Sue, a friend of mine, has been living with pain most of her adult life. Hence chronic. And chances are she’ll live with pain for the rest of her life. Hence refractory.
Such a debility tends to cloud your outlook. Like many people with chronic pain, Sue’s condition is accompanied by bouts of enervating anxiety against a backdrop of relentless major depression. She was born with scoliosis, a misalignment of the spine, so her long association with pain began with her back. Eventually she earned a diagnosis of fibromyalgia, which physicians grant to women who must be hysterical hypochondriacs because, No, doctor, I’m still in pain and nothing you’ve done seems to help.
You can almost hear doctors’ eyes rolling when a woman with fibromyalgia walks into the office. Docs are reluctant to treat, delighted to refer, and oddly willing to blame fibro patients for their own malady. This latter is true despite clear evidence that, in addition to a psychological component, fibromyalgia has genetic, neurobiological, and environmental causes. Not to mention that blaming the patient is acceptable almost never.
Sue’s constellation of symptoms is surprisingly common. Depression, anxiety, and pain are a vicious amalgam having no well-defined cause-and-effect or chicken-and-egg relationship. Although pain treatment guidelines exist, the reality for many people with chronic pain is a long course of medical care that is bewildering, inconsistent, and often ineffective. More than 100 million Americans suffer from chronic pain, with treatment costing the nation up to $635 billion annually. The total cost of pain treatment exceeds that of any other diagnosis.
One and all, people in pain are…well…in pain, and their circumstance speaks to basic human compassion as well as to the very heart of medicine. I mention Sue’s case because people with fibromyalgia, with its psychological sequelae, may be especially ill-suited to adhere to prescribed therapy in the current environment. In her case, prescribed therapy is hydrocodone, an opioid narcotic. The current environment is here and now, where heroin addiction has rocketed and the war on drugs rages with plenty of collateral damage.
In recent years American medicine has been on an estimable quest for increased quality of care—an effort encouraged by the Affordable Care Act, which tied reimbursement levels to outcomes. Part of that effort was identifying areas of deficiencies, and one of the identified areas of deficiencies was pain management. In general, patients were being allowed to remain in too much pain too long. Medicine responded with a more liberal application of pain meds and loving grace. That’s a good thing.
Since 2007, combination hydrocodone-acetaminophen has become the most-prescribed drug in the United States—surpassing ACE inhibitors, cholesterol-lowering statins, and beta-blockers. In 2012, that came to more than 135 million prescriptions, or one prescription for every 2.3 men, women, and children in the country. That’s neither good nor bad. It just is.
The bad thing about opioids is that, while they are the most effective drugs against pain, they are also the most addictive and abused of the prescription drugs. In 2011, drug overdose was the number one cause of injury death in the United States, killing more people between ages 25 and 64 than motor vehicle accidents.
In October 2014, the Food and Drug Administration reclassified hydrocodone from a Schedule 3 to a Schedule 2 drug. The change creates more restrictions around hydrocodone prescriptions—for example, only written prescriptions are accepted, so docs can’t call or fax in a prescription; written prescriptions are limited to a one-month supply, and may not include refills; and patients must present a photo ID and pick up prescriptions themselves.
Here’s another bad thing for patients in pain, especially patients like Sue with long-standing fibromyalgia for whom hydrocodone is the sole effective treatment—something that makes life bearable, worth living. Physicians and other health care providers, pharmacists and pharmacy staff, and insurance companies and their patient-facing representatives, all of them without exception have been taught to provide opioid pain killers like uncaring, suspicious dolts.
Here’s Susan: A well-educated, law-abiding, 50-something female professional with a demonstrated failure to find relief from pain and depression in any other way, including electroconvulsive therapy (ECT), a regimen of 8 to 12 visits to a state-of-the-art neurology department to sit through frightening electric zaps to the brain. Undergoing ECT is not drug-seeking behavior. Sue is the lady standing at the pharmacy counter or in the doctor’s waiting room, crying, totally humiliated, forced to change doctors and pharmacies by an insurance company that has also changed, having to make her case over and over again. That’s very bad.
A big question both Sue and I have is, given the current environment of suspicion and red tape, how do prescription opioid narcotics like hydrocodone get in the hands of people who would take or use them illegally in the first place? It would be funny if it didn’t hurt so much. Literally.
And here’s another unfunny thing: People with heart problems or diabetes or numerous other conditions routinely are prescribed drugs they and everyone around them know they’ll need to take for the rest of their lives. Addiction becomes irrelevant. It’s all about survival, and these people, like many of us, are addicted to life and wish to repeat it every day.
So, world, I’m begging you: Give a law-abiding, prescription-following person with chronic pain a break. And if you’re up for it, a smile or a hug. They’re doing nothing wrong, everything right, and could be your mom, sister, daughter, wife, aunt, or just a fine human being you happen to love. And love is very good.