The Pill Doctor

Puttering around the porch this weekend I found a damp New Yorker from May 5, the cover torn, the corners of the pages stuck together. Prying the pages apart I found a fascinating article by Rachel Aviv about a doctor in Wichita, Kansas who was prosecuted for over-prescribing opiates. The doctor, Stephen Schneider, comes across as a decent man who got caught up in the crossfire of our contradictory attitudes toward pain medication. On the one hand there is a whole movement of people who insist that they have a right to aggressive treatment for pain, and on the other we still have our vindictive attitude toward drug users and even more toward drug "pushers." I thought the confusion was best summed up in the case of a woman who died after Schneider prescribed large doses of opiates. Her husband sued Schneider for malpractice, but her mother appeared as a witness for the defense, saying that the woman had lost her life to pain until Schneider's drugs restored some sort of sanity and control.

Schneider's practice is also a good case study in the kind of care poor people get in America. Many of Schneider's patients were on Medicaid, and other doctors refused to see them because the reimbursements in Kansas are so low. To make ends meet Schneider's clinic had to limit appointments to 10 minutes, even for patients with complex histories of pain and medication. Under those circumstances the easy thing to do was to give the patients the prescriptions they wanted, and after all drug company reps were always pushing on Schneider and his colleagues studies showing that their medications were safe.

As for the patients, it is hard to know what they were really suffering from. Aviv interviewed Mark Sullivan, a psychiatrist, who said

that in poor, rural regions doctors are using opioids to treat a "complex mixture of physical and emotional distress." He said, "It's much more convenient for both patient physician to speak in the language of physical pain, which is less stigmatized than psychological pain." Some of these patients could be said to be suffering from what his colleague calls "terribly-sad-life syndrome." "These patients are at a dead end, life has stymied them, they are hurting -- the want to be numb." He believes that doctors are inappropriately adopting a "palliative care mentality" to "relieve the suffering of people who have had very tough lives."

It is a sad, sad story. Millions of people in America lead grim lives dominated by pain of one kind or another. Even for people with good health insurance, real help is hard to come by; those without it are largely on their own. I have written here before that I think many people with chronic back pain and so on have problems that are fundamentally spiritual -- what they need is hope, meaning and a bit of excitement more than pain pills. But where can they look for those? In America we are short on love, community, togetherness, meaning, and hope, but we have lots and lots of drugs.