“Pain must be regarded as a disease… and the physician’s first duty is action–heroic action–to fight disease.” –Benjamin Rush
The impetus of this post originally came from the very brave and truthful comments posted by Dr. Robbins in regards to opiate medications for chronic pain, and the difficulty legitimate pain patients face in receiving appropriate treatment for their pain, mainly owing to drug abuse by non-pain patients. I shared his post, as I do many of his wonderful insights on my Facebook page, and a person responded with a comment that really struck a nerve with me. The author of the comments (who shall remain anonymous for obvious reasons) had made previous statements, which led me to conclude that they were addicted to illicit drugs before trying to illegally obtain narcotic pain medication, and I stated as much in my response to them. The person responded again with the following comments:
“You were correct in stating I was on other drugs before I began abusing pain medication, yet it was perscribed to me by a Gen. Practitioner. He perscribed me 40mg of Methadone a day for stomach pains he could not identify. In his defense he did send me to other specialists, and ran many test. I also will admit that I was a GREAT actress. I will concur and say it is not fair to those with legitiment pain. And those who are abusing the medication should be the most penelized. Yet. this is not a perfect world. And laws are not made to meet individual needs. I feel docters need laws of this nature to proctect the amount of blood on thier hand. I realize thats a little dramatic sounding, but RX meds is the #1 cause of death in the US (or at least in the top 5). I can only imaigen how frustrating is, ecpspecially if you are a victim in this case, yet we must do whatever ever it takes to protect people that obviously cannot protect themselves, or dont’ know how to protect themsleves, and even those that don’t want to protect themselves.” [sic] (Emphasis in bold added by me)
Now if you are a doctor that is trying to treat legitimate pain patients or you are a chronic pain patient, then those comments probably make you as upset as they did me. The biggest problem I have with these comments is that they are simply not true. It may sound true, especially if you are only gathering your information from the media, but there is not one iota of truth in these claims. Not one.
The fact is that narcotic medication is not the number one cause of death in the US. It is not even in the top five, nor the top ten. It is not even in the top fifteen, and it has never been the case in all of US history. As a species on the whole, we tend to rely too much on group-think and media sound bites in order to form our opinions and ideas, and then these falsehoods are repeated and spread over and over again throughout our society like a virus, and it is almost impossible to cure. The hardest thing to cure in our existence is not a bacteria or a virus; as we can take a round of antibiotics for the bacteria and a vaccination for the virus. The hardest thing to cure in our existence, across all of humanity, is an idea, especially a bad one.
The truth is that more people die every year in the US from NSAIDs like Advil, Aleve, Toradol and aspirin than die from narcotic medication, whether a doctor is involved or not. In fact, if the deaths from NSAID medications were tabulated by themselves in the same Centers for Disease Control (CDC) vital statistic reports, they would rank as the 15th leading cause of death in the nation. (1-7) Furthermore, those mortality statistics do not even include the NSAIDs that were bought over the counter, and thus the total amount of deaths and hospitalizations should rank even higher. The truth is that more than 107,000 patients are hospitalized annually for gastro-intestinal bleeds and complications as a result of using NSAID medication exactly as recommended. That means there have been more people hospitalized for using NSAIDs than casualties suffered in all American wars combined in our nation’s history. (5-7)
The highest number of deaths related to opioid analgesics was in 2008, and in that year a total of 14,800 people died due to overdose. (1-4) Compare that figure with numbers cited by The American Journal of Medicine, which stated the following: “Conservative calculations estimate that approximately 107,000 patients are hospitalized annually for nonsteroidal anti-inflammatory drugs (NSAID)-related gastrointestinal (GI) complications and at least 16,500 NSAID-related deaths occur each year among arthritis patients alone.” (5)
In other words if we just count the patients being treated for arthritis, more of them will die each year due to NSAIDs than in the highest year of deaths attributed to narcotic pain medication in our nation’s history. Another way to look at it is that more people die from NSAID medications each year than die from AIDS, cervical cancer, asthma, and Hodgkin’s Disease, and that is just the numbers from one category of patients being treated for arthritis. Imagine if we had the numbers for every type of malady that NSAIDs are used to treat, and then you get a better understanding of how illogical the war on pain medication and pain patients has become. (1-7) How many of you remember the AIDS epidemic scare? Now how many of you remember the NSAID scare? Exactly, you have never heard of an NSAID scare, and neither have I.
How about the H1N1 swine flu scare the media was bleating and baying about for months- did any of you rush out in a panic with the millions of other people to get vaccinated in order to protect yourself? My educated guess based on the numbers indicates that all of these people had an NSAID medication in their purse or medicine cabinet. Would it surprise you to know that according to the CDC that four times as many people die each year from NSAIDs than swine flu? (1-7) It shouldn’t surprise anyone who is paying attention and using evidence and reason to make decisions about health care, rather than media hype and “Drug War” propaganda. And yet millions of people rushed out to get vaccinated for swine flu, and all the while they were four times as likely to die from the NSAIDs in their medicine cabinet.
What confuses me is why I don’t hear people clamoring for Advil or Aleve to be removed from the shelves or that the makers of these drugs should be held accountable for “the blood on their hands.” I assume because it is not discussed with the same hysterical hyperbole as used by mainstream media or the Drug Enforcement Administration (DEA). The truth is too boring for most people, and thus it rarely makes headlines or generates advertising revenue. Because of the tendency of most people to use group-think instead of using evidence and reason to make decisions, pain patients have ended up in the no-win situation we are facing, and unfortunately, very capable, honest, and trusting doctors are right there with us. Paint patients are degraded, treated as criminals and drug addicts, under-treated or not treated at all, and in the vast majority of cases this happens to the patient without one shred of evidence to support these assertions or discrimination. It is beyond immoral and illegal that we have reached this stage in our country, it is a crime against humanity.
Why do I read about “bad” doctors who should be sanctioned, and those that have been arrested and suffered criminal penalties due to the DEA inquisition against doctors, and yet I have not read about even one DEA raid against a Walgreens or Wal-Mart for the distribution of Advil? I have not seen the DEA recommend scheduling of NSAIDs, and yet they kill and hospitalize more people than narcotic medications ever have in our history. Where is the reason and logic in this? How are doctors expected to work in an environment where science and evidence is not even used to make rational, empirically based medical decisions?
Here are the actual ranking of causes of death from 1999 to 2009, as reported by the agency charged by law with tracking and providing research on this information to the government; the CDC vital statistics reports. (1-4)
1. Diseases of heart
2. Malignant neoplasms
3. Chronic lower respiratory diseases
4. Cerebrovascular diseases
5. Accidents (unintentional injuries)
6. Alzheimer’s disease
7. Diabetes mellitus
8. Influenza and pneumonia
9. Nephritis, nephrotic syndrome and nephrosis
10. Intentional self-harm (suicide)
12. Chronic liver disease and cirrhosis
13. Essential hypertension and hypertensive renal disease
14. Parkinson’s disease
15. Assault (homicide) *Bearing in mind the CDC does not count the deaths from NSAIDs
Just as there are laws in place to prevent drug addicts from obtaining cocaine and heroin; in the same vein, there were already laws in place to prevent people from obtaining pain medication that they do not need and were never prescribed. The problem is that drug addicts don’t care about laws, nor do these laws thwart drug addicts from obtaining narcotics illegally. They simply modify their behavior to circumvent those laws and get the drugs anyway. They will lie, manipulate, violate the law, and are “GREAT actresses” in order to get their fix.
And yet these same people who game the system and use fraud and deceit to get high are the same ones that claim, “Laws protect those who don’t want to or cannot protect themselves.” In reality everyone is hurt because of their actions, and the laws passed as a result. The addict gets hurt by either overdosing or ruining their lives due to drugs, the doctor gets hurt by lawsuits or criminal sanctions or perhaps loses their license to practice medicine, but further, the only people who are not able to protect themselves are the legitimate pain patients who need the medication to improve their quality of life and stop the excruciating pain that they legally, morally, and justifiably should not have to suffer. The legitimate pain patients are hurt the worst and they are also completely innocent of any crime or wrongdoing.
The drug seekers and professional patients have the ability to protect themselves, and they certainly have the knowledge, they just don’t care about the repercussions to everyone else or themselves. Now the doctor who has been duped will be less likely to prescribe the medication to his cancer patients, AIDS patients, patients with spinal injuries, people needing the medication for “end of life care”, and patients like migraine and cluster patients who need the medication to treat one of the most painful, and incurable diseases to ever exist.
They don’t call them “suicide headaches” because they are an enjoyable experience, they call them that because patients suffering from the genetic, hereditary, neurovascular disease that causes the “headaches” are not properly treated, and they end up committing suicide because of the incomprehensible chronic pain they must needlessly endure. The patient’s quality of life is destroyed, and their existence becomes unbearable. If you will look up, you will see that suicide was the 10th leading cause of death in the US, and narcotic pain medication was not even listed. In regards to the comments posted on my Facebook page, the doctor didn’t violate a single law or ethical requirement in this instance, the drug addict did. I find it difficult to believe that this person was prescribed methadone on a first visit, especially by a general practitioner, and I suspect that we may not be getting all the information in this instance. However, even if this was the case, the doctor may have had a reason to prescribe the medication as he truly believed that the patient was suffering. He ordered all the proper tests, did a complete examination, and sent the patient to specialists in order to help find the cause of the pain. What more can a doctor do to prevent people from breaking the law besides be given a crystal ball along with their MD? It was the drug addict that violated every law and ethical requirement on the books concerning obtaining pain medication, and not one of those laws stopped them, and they never will. No matter how many laws are passed, the only people that laws affect are people that actually follow them.
However, these laws do stop the majority of legitimate pain patients from receiving proper treatment as doctors are now afraid of the same thing happening to them that happened to the doctor in the case above, and they are afraid of being hounded by the DEA and medical boards for behavior that is out of their control. Thus a majority of doctors now treat every patient that needs pain medication as a drug addict that needs psychological help and possibly criminal sanctions, instead of prescribing them the medication that the addicts have no trouble obtaining on the street. The addicts who wantonly, knowingly, and purposely abuse the drugs; and violate the ever increasing laws are the ones causing legitimate paint patients to suffer, as well as their doctor, and you cannot stop them by stacking redundant laws on top of already redundant laws.
Further, the majority of the studies that espouse the idea that legitimate pain patients are becoming addicted or overdosing are not studying pain patients at all, they are studying drug addicts. For one example, out of many, a study on overdose deaths in West Virginia from 1999-2004 found that 63.1% of the deaths occurred in persons who had never actually been prescribed an opioid, and had either stolen the medication or bought it from a drug dealer.(9) This study and others with the same methodology all fail to recognize the fact that pain patients are not the problem, and yet they are cited numerous times by media, law enforcement, and even doctors as a reason to never prescribe pain medication. The laws in place did nothing to stop these deaths or deliberate drug abuse, and a doctor was not even involved in over 63% of the cases. Even if the doctors had prescribed these people (not patients) medication, no doctor can control the behavior of the patient once they leave their office.
The same study found that 79.3% of the deaths were a result of people who had a “multitude of other medications”, including illegal drugs in their system when they died. In short, this study which is used to “prove” the dangers of treating legitimate pain patients with opioid pain medication are not even discussing the legitimate pain patient, they are discussing drug addicts who obtained the medication illegally, and were never prescribed the medication in the first place. Further, 80% of the people that supposedly overdosed due to pain medication were actually mixing the medication with other drugs, which nobody ever bothers to mention. (9)
Neither the addict nor society can blame what happens to the drug abuser on the doctor or the legitimate pain patient, as it was the drug addict’s fault, every single bit of it. I understand that the popular notion of addiction is recognized as a disease, but I have a hard time accepting that line of reasoning, as the behavior began with sober intent. Cancer is a disease, malaria is a disease, muscular dystrophy, migraine and cluster headaches are a disease, and all of these are completely out of the patients control. However drug addicts deliberately chose to start using drugs, and they used fraud, deceit, manipulation and broke the law so that they could get high, and caused great injury to the doctors and legitimate patients that need the medication to live in the process. The blood is not on the doctor’s hands, it is on the people that abuse the system, break the law, and violate the trust of doctors to the detriment of society and specifically legitimate pain patients.
To the regulatory authorities and doctors that refuse to look at the actual data, and thus deprive legitimate pain patients from the essential and often live saving treatment they need, I say you are violating the very oaths and principles you swore to uphold. If you simply refuse to allow legitimate patients the opportunity to try and relieve their suffering and lead some life of value, what do you expect them to do? I’ll say that again: What do you expect us to do?
“It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.” -Mark Twain
by Jeff Poleet, Chronic Migraine Patient
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5. Singh Gurkirpal, MD, “Recent Considerations in Nonsteroidal Anti-Inflammatory Drug Gastropathy”, The American Journal of Medicine, July 27, 1998, p. 31S
6. Wolfe M. MD, Lichtenstein D. MD, and Singh Gurkirpal, MD, “Gastrointestinal Toxicity of Nonsteroidal Anti-inflammatory Drugs”, The New England Journal of Medicine, June 17, 1999, Vol. 340, No. 24, pp. 1888-1889.
7. Edward J. Frech and Mae F. Go, “Treatment and chemoprevention of NSAID-associated gastrointestinal complications”, Therapeutics and Clinical Risk Management, 2009, pp. 65-73
8. Congressional Research Service: American War and Military Operations Casualties: Lists and Statistics, http://fas.org/sgp/crs/natsec/RL32492.pdf
9. Hall AJ, Logan JE, Toblin RL, Kaplan JA, Kraner JC, Bixler D. et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities.. JAMA. 2008;3002613-20
DISCLAIMER: The views and opinions expressed herein are those of the author and do not necessarily reflect those of Dr. Robbins or the Robbins Headache Clinic. I am not a healthcare provider, and I do not provide any medical advice, diagnosis or treatment. The information presented here is designed for general informational purposes and discussion only, and is not intended to replace a physician’s judgment about the appropriateness or risks of a procedure, medication, product or diagnosis. Always consult your doctor about any medical questions or conditions you may have.