Wednesday, January 4, 2023

The Opioid Conundrum

Pushing out opioids leads to abuse, but curtailing them has its own problems (NY Times):

Anne Fuqua keeps a list of suicide deaths. She’s chronicled hundreds of cases of chronic pain sufferers who have killed themselves after losing access to opioid medication since 2014. Recently, she almost became an entry.

Ms. Fuqua, a former nurse, has an incurable genetic disorder that causes ‌agonizing spasms and shaking. She can only function when she takes opioids. She’s one of the estimated five million to eight million Americans with chronic pain who regularly rely on them. But in November, her doctor’s license to prescribe controlled substances was suspended by the Drug Enforcement Administration — marking the second time she’s been left to fend for herself to avoid pain and withdrawal because of law enforcement action against a pain clinic.

Between the mid-1990s and the early 2010s, the number of opioid prescriptions written for Americans roughly doubled, driven by dishonest pharmaceutical marketing campaigns and unscrupulous entrepreneurs who opened so-called pill mills to sell drugs. Medical guidelines, legislation, law enforcement and other measures have since returned painkiller prescribing to pre-crisis levels. But because people who lose access to medical opioids are rarely provided with immediate treatment (whether they are experiencing pain or addiction or both), the result has been more overdose and suicide deaths, not fewer.

I wrote here a few years ago about a case in which a man sued a doctor for prescribing the opioid pills that got his wife addicted and helped lead to her death. He was furious at the doctor, but one of the witnesses for the defense was the dead woman's mother, who said that she had been so crippled by pain that to have been given a few years of better life was a blessing even if the drugs eventually killed her. Opioids are bad for you, but so is chronic pain.

The US government recently reduced the amount of opioids that pharmaceutical companies are allowed to produce by 5%, and there are reports of shortages and people not being able to get their prescriptions filled. It is of course possible that some of these people would be better off cutting back on pills and pursuing other approaches to pain management, but randomly cutting 5% off cold turkey seems like a cruel way to run the experiment.

I don't think anything about chronic pain or opioids is simple, and I get irritated with people who want to blame everything on evil pharmaceutical companies. As I have written before, I have a sense that our struggle with chronic pain has strong psychological and sociological components, but I don't see how "let's build a better, less lonely world" is much of a policy. People are suffering, and every effort we make to reduce addiction means some people are not treated for pain. Many of them turn to illegal suppliers, which is one reason for the spike in Fentanyl deaths. 

Finding the balance is hard.

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