In Pain: An Aberration Story

May 01, 2009

I saw the tremendous lack of education on the intersection of law and medicine related to controlled substance prescribing ...

According to leading medical, legal, and psycho-social experts in the field of pain medicine, mainstream media has failed to accurately portray the rising US tide of addiction to prescription pain medications. The media has blamed seedy clinicians, as well as dangerous medications and their associated greedy manufacturers. Experts in the field of pain believe the media has overlooked the critical points that (1) addiction is a major genetic disease to be appropriately understood and monitored, and (2) that pain is real and unending for many Americans who need power-packed drugs to maintain a bearable quality of life.

Consider this scenario: twelve people sit around a table all night drinking wine with their dinner but only one is an alcoholic. Alcohol, restaurants, and wineries do not an alcoholic make just as physicians, pills, and big pharma do not a drug addict make. So if clinicians or pharmaceutical companies are off the hook, who the hell is at fault? To begin combating the current epidemic of abuse and diversion, we must first determine where the insidious truth lies. Only then can we, as a society, begin to properly dissect the issue and address root causes.

These highly regarded experts gathered on March 21st at the New York Marriott Marquis to speak at a symposium on emerging practices in opioid prescribing for chronic pain. As a consultant, I sat in the audience representing a small specialty pharmaceutical company based in the UK. My nearly twenty years of pharmaceutical industry experience and science degree provided the appropriate amount and type of brain cells necessary to fathom both the specific messages of each engaging presenter and the overarching battle cry to their own kind—clinicians and attorneys must pull together in new ways to not only help protect patients and society, but also to protect themselves.

It just so happens that I’m also a writer. The following points not only amazed me but also sent my writing wheels into a major spin as I sat wide-eyed, nursing my complimentary Starbucks coffee and cubed cantaloupe. By show of hands, the alarming number of clinicians who:
  • did not have solid educational exposure to specialty of addiction medicine,
  • did not consistently use standard assessment tools for identifying patients who may be at high risk for abuse or diversion,
  • felt they could identify a risky patient simply by looking at them—counting tattoos, bling, and other such markers,
  • did not include or fully consider familial and/or environmental patient aspects when assessing abuse and/or diversion risk,
  • did not have a solid comfort level with the science and practice of risk management.
Like addicts, you can’t identify a snarly physician based on looks; however, the Marriott clientele surrounding me appeared to be bright, sincere folks from all over the country. Most seemed suited for a Norman Rockwell. Okay, so one guy had tattoos. But this was generally not an audience filled with evil, devious doctors on the make. Their collective voice reflected a sincere need to know and understand more about the cornucopia of narcotics they channel through our neighborhoods, towns, and cities with the genuine intent of helping those who suffer. The group as a whole did not wear the smell and edge of drug dealers, blatant nor subtle, yet they were just the kind of super nice professionals who risk getting handcuffs slapped around their wrists every day due to an alarmingly poor understanding of the law and art of addiction medicine.

Jennifer Bolen, Esquire, brave and bold with an edgy sharp voice and wit, was there to inform them about the laws around prescribing controlled substances. Bolen was a prosecuting attorney for many of the landmark cases against clinicians that established the laws they now must dance around. She also happens to suffer from chronic pain. Oh, how the writer wheels turned as I watched her energetically shout at the dumb-struck geniuses eager for her every word. I could easily picture her intimidating a crumbling witness in one of the many Supreme Court cases that molded the laws used against the very folks she now advocates for. And to top it off, her smile was contagious!

I couldn't resist inviting Jennifer to join the Aberration Nation. After all, I'm addicted to great stories.

When you first developed your chronic pain, how did you cope?

I just kept going and tried not to think about the pain in my body. Over time, however, the pain was so distracting that I could not focus on my work and my relationships. I have a pretty strong personality and belief in God, so I asked for strength and began figuring out a way to get help.

As an attorney, you are devoting your time to helping education physicians and attorneys about the history and current laws around prescription pain medications. How did you become so involved in this effort?

I was working as a federal prosecutor and took my responsibilities very seriously. I saw the tremendous lack of education on the intersection of law and medicine related to controlled substance prescribing, and I began lecturing at the invitation of several key physicians who have served as my mentors through the years. I decided that the government's approach to placing investigations of physicians and pharmacists with the basic drug lawyers was misplaced and, at times, tantamount to the criminalization of negligence, so I left to strike out on my own and join forces with the physicians who wanted to achieve balance in pain management by treating pain and using medications where indicated and, at the same time, taking reasonable steps to prevent abuse and diversion. I have never looked back.

One of your children has issues with substance abuse. How has this impacted your opinions about prescription pain medications, and your professional work?

I see both sides of the balance scale. When I adopted my son, he came with a genetic predisposition to alcohol abuse and began struggling with this problem late in high school and again after returning from Iraq. As a US Marine, he was hurt and his pain problem became chronic. His mixture of alcohol and controlled medications is very disheartening, but he has taken the very brave step of asking for help in his own way. I do not go easy on him, and I expect that there will always be hurdles for him and our family. He's a human being with a tangled medical and mental health history. His medical caregivers need to recognize this and set boundaries and enforce consequences if he cannot be responsible with his medication. His challenges encourage me to remember the multifaceted nature of the under treatment of pain in our country, and the tremendous difficulties clinicians face in identifying and treating substance abuse problems. Our current health care system does not really support medical professionals in the way it should in this area. And, more governmental involvement is not the answer--in my opinion.

Do you feel that there is a stigma associated with taking prescription pain medications, and if so, do you believe this is a fair for those who truly need them?

Yes, there is. You're using the phrase "prescription pain medications." I use the phrase "controlled medications." Most health care professionals, including pharmacists, use the term "narcotics," which is a law enforcement term used to define the effect that a certain class (opioids/opiates) of controlled medications has on an individual. This tells you a great deal about the stigma. I have to sign an agreement to take my medicine properly before I can get my controlled medications. Yet, I do not have anyone really bugging me about my noncontrolled medication usage patterns and my compliance with the treatment plans surrounding them. I take a blood thinner, coumadin, which can be dangerous to others and to me. No one seems to care about that, but there is a greater likelihood of me experiencing a problem with my blood thinner (blood too thin = brain bleed; blood too thick = more clots) than with my pain medication--at least for me because of my medical history.

With regard to your own struggle, has being forced to live with chronic pain brought you growth or expanded understanding of the world around you? Despite the pain, how has it changed your life for the positive?

I do not think like this. I do not think of myself as a pain patient or someone forced to live with chronic pain. I'm getting better at taking care of myself, and I'm happy most days. I use the "down days" to think of ways I can do something to make a difference, or to just stand (figuratively) for a bit.

I have learned not to fight myself over the little things--so what if I cannot wear heels; so what if I cannot ride horses as much as I used to--I can still train them from the ground and still teach other riders and be with them; so what if I have to use a cane from time to time to assist me with standing for long periods or just walking through an airport. I'm still me. I'm still alive and kickin' and very thankful for this.

If you could say anything to those struggling with chronic pain, what would you say?

Be true to and with yourself about your pain condition and treatment needs. Make sure you address the emotional aspects of pain with your healthcare professionals and be very, very careful that you do not use your pain medication to treat your feelings. I have never done this, but I understand how hard it is to feel down and want to do or take something to stop the downward spiral that follows some days. Be very honest with yourself and your healthcare professionals, and remember that as patients we have a tremendous responsibility to handle our medications responsibly--in the way we use and store them. There are many very good healthcare providers who will treat pain, but they have a great responsibility--legally and professionally.

We need to ensure that we do not do anything to present barriers to their continued involvement in our care or the care of others like us.

Of note, next week Jennifer and I will both be attending the 28th Annual American Pain Society Meeting in San Diego.

Comments

Anonymous

Anonymous said:

I really enjoyed this particular post. As someone who deals with pain issues, I appreciate the importance to address the emotional needs as well as physical needs. Thanks for sharing.

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