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Spring 2006
O'Shaughnessy's
Journal of the California Cannabis Research Medical Group

Commentary

The Undertreatment of Pain Crisis

by Frank B. Fisher, M.D.

By Frank B. Fisher, M.D.
Chronic pain is the largest single cause of disability in America, exceeding both heart disease and cancer. Tens of millions are afflicted, and those who suffer from the severest form of the disease are the least likely to find satisfactory treatment.1
This is the case because when the disease has progressed to this stage, treatment with opioid analgesics, which are categorically safe2 —and for pain sufferers, non-addictive— is usually the only therapeutic modality bearing the potential to bring the disease under control.
Paradoxically, while the streets are awash in illicit analgesic medications, pain sufferers are the only group within society who can’t adequately access these substances.
The undertreatment of chronic pain is a public-health disaster for which there is a workable solution close at hand. The whole mess is a consequence of prohibition law in the form of the Controlled Substances Act, and is driven by the collapse of medical ethics within the discipline of academic pain medicine.

The most fundamental principle of medical ethics is the physician’s solemn obligation to put the interests of his patient ahead of all other interests.

An examination of the interplay between medical ethics and prohibition law illuminates the nature of the problem. The most fundamental principle of medical ethics is the physician’s solemn obligation to put the interests of his patient ahead of all other interests. This is the foundation of the physician/patient relationship. The Controlled Substances Act of 1970 attempted to preserve the physician/patient relationship by creating an exception to drug prohibition so that physicians might legally prescribe controlled medications in the course of their professional practices.
Despite the apparent good intentions of its authors, the law is fatally flawed in that it requires law enforcement to determine which physician conduct is professional practice, and which is illegal drug distribution. Naturally, physicians take measures to avoid criminal sanction and thus, the physician/patient relationship stops serving the interests of the patients and instead becomes an expression of law-enforcement ethics.
The leadership of academic pain medicine has adopted drug-war values with alacrity. Ignoring a wealth of scientific data informing them that addiction to opioids among chronic pain sufferers is vanishingly rare,3 they have devised an elaborate pseudo-science they believe protects them from prosecution. They call this endeavor “aberrant” drug- related behaviors, and they use the observation of these behaviors as a means for selecting out, and excluding from treatment, patients whose medical needs expose the physician to increased risk of law enforcement attention.
These behaviors, for the most part, are conduct in which patients whose pain is poorly controlled are likely to engage. For example, complaining of uncontrolled pain and asking for a larger prescription, is a common “red flag.” When this occurs, the physician is required to impose sanctions against the offending patient. These range from suspicion and heightened scrutiny to termination of treatment “justified” by destructive comments in the medical record warning other physicians not to treat the patient again.

The withholding of pain treatment, when a physician has the means at hand to control pain, is torture.

The withholding of pain treatment, when a physician has the means at hand to control pain, is torture. This form of torture, delivered by the medical profession, is widespread and systematic. The result is unimaginable suffering and countless suicides.
Pain-treating primary-care physicians have little choice but to comply with the pseudo-science of “aberrant” behaviors because if they fail to do so, the government will have no problem securing the testimony of an academic physician to testify against the targeted doctor in criminal court.
The government’s hired gun will assert that the primary-care physician’s behavior lay outside the boundaries of professional practice, and was in fact illegal drug distribution. Coupled with the testimony of former patients eager to diminish prison sentences garnered for selling their medications on the street, the presentation is devastating.
Unfortunately, the threat these prosecutions pose to physicians in the community is not remote. On a daily basis, a physician faces such criminal charges somewhere in the United States.4 And because of “get-tough-on-drugs” mandatory sentencing laws, many American physicians are currently serving what are, in essence, life sentences in prison.
The Pain Relief Network, led by pain control advocate Siobhan Reynolds, has worked efficiently and with increasing success in recent years to publicize the pain crisis in the national media. At the same time, established “drug-policy-reform” groups have raised money on the pain issue —as if they had been doing the heavy lifting!— and effectively diverted funds from the admirable PRN.
Historically, whenever medical ethics have been systematically abrogated in deference to political demands, physician conduct has been atrocious. Physician conduct around the pain crisis has proven to be no exception. When society finally comes to terms with what has occurred here, the conduct of academic physicians and their willingness to collaborate with the government’s purposes will likely come to be understood in the same light as war crimes.
The reality of the pain crisis is so disturbing that most prefer not to acknowledge that this could happen in the United States of America. There is, however, some good news. PRN has recently devised a Constitutional challenge to the Controlled Substances Act, which promises a solution to the problem. A white paper pointing the way toward a due process claim on behalf of the millions of Americans in untreated pain can be found on the front page of
PainReliefNetwork.org.
The immediate problem at this point is securing funding for the legal expenses involved.


References
1 Chronic Pain In America: Roadblocks To Relief. Available @
http://www.ampainsoc.org/whatsnew/conclude_road.htm
2 The Use of Opioids for the Treatment of Chronic Pain: A consensus statement from American Academy of Pain Medicine and American Pain Society. Approved by the APS Executive Committee on August 20, 1996. Available at: http://www.ampainsoc.org/advocacy/opioids.htm
3 Friedman DP. Perspectives on the medical use of drugs of abuse. J Pain Symptom Manage 1990; 5(1 Suppl):S2-5.
Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med 1980; 302: 123.
Medina JL, Diamond S. Drug dependency in patients with chronic headaches. Headache 1977; 17: 12-14.
Kanner RM, Foley K. Patterns of narcotic drug use in a cancer pain clinic. Ann NY Acad Science 1981; 362: 161-172.
Schug SA, Zech D, Grond S, Jung H, Meuser T, Stobbe B. A long-term survey of morphine in cancer pain patients. J Pain Symptom Manage 1992;7:259-66.
Perry S, Heidrich G. Management of pain during debridement: a survey of U.S. burn units. Pain 1982; 13:267-280.
Portenoy RK, Foley KM. Chronic use of opioid analgesics in nonmalignant pain: Report of 38 cases. Pain 1986; 25: 171-186.
Zenz M, Strumpf M, Tryba M. Long-term oral opioid therapy in patients with chronic nonmalignant pain. J Pain Symptom Manage 1992; 7: 69-77.
Moulin DE, et al. Randomized trial of oral morphine for chronic noncancer pain. Lancet 1996; 347: 143-147.
Brookoff D, Palomano R. Treating sickle cell pain like cancer pain. Ann Intern Med 1992; 116: 364-368.
Chapman CR, Hill HF. Prolonged morphine self-administration and addiction liability: evaluation of two theories in a bone marrow transplant unit. Cancer 1989; 63: 1636-1644.
4 Ziegler S Lovrich N. Pain Relief, Prescription Drugs, and Prosecution: A Four-State Sureby of Chief Prosecutors. Journal of Law, Medicine & Ethics 2003; 31:75-100.


Why Do They Hate You?

“Once in Chicago while performing with Buffalo Bill Cody’s Wild West,” writes Roxane Dunbar, “Sitting Bull spoke through his translator to the huge crowd of ragged white men, women, and barefoot children: ‘I know why your government hates me. I am their enemy. But why do they hate you?’”
Robert Altman’s great movie “Buffalo Bill and the Indians” depicts the context. It’s the dawn of the age of hucksterism, when corporations were first exerting their power and influencing American culture. Paul Newman plays Buffalo Bill, who runs and is the star attraction of a traveling show. One of the “acts” on display is laconic, brilliant Sitting Bull.
The Sioux leader’s image and his profound question —“Why do they hate you?”— comes to mind with each example of the U.S. government’s willingness to see its citizens suffer and die in pursuit of corporate interests.
The examples are coming at us in a sandstorm these days. Exhibit A is the attempt to occupy Iraq on behalf of the oil companies. Exhibit B is the gov-ernment’s complicity in approving and actually promoting pharmaceutical drugs and with harmful side effects while prohibiting the safest pharmacological agent known to mankind —cannabis.
Hardly a day goes by without news of the government seeking to justify corporate practices that are literally killing us. To protect the beef producers the feds won’t allow thorough testing for Mad Cow disease. To protect the poultry producers they tolerate high levels of salmonella in chicken, and even 500 ppb of arsenic! (See “Teflon Kills,” page 40.)
Here at O’Shaughnessy’s we’ve had an example of endangerment-by-corporate-arrogance hit home. Tod Mikuriya strongly suspects that Lipitor, Pfizer’s blockbuster statin drug, had a damaging effect on the lining of his biliary tract. Mikuriya was put on Lipitor three years ago to lower his cholesterol following coronary bypass surgery. He has had three patients who attribute similar adverse effects to Lipitor, including itching, a feeling of cold, and digestion problems.
A lawsuit filed this Spring by a Teamsters health-insurance fund charges that Pfizer execs unethically promoted sales of Lipitor. (Since 2001 they’ve sold $46 billion worth, including $12.1 billion last year, making Lipitor the world’s best-selling drug.)
The suit, according to the Wall St. Journal, “cites internal Pfizer marketing documents, Pfizer-funded studies and physician-education programs that encourage doctors to use Lipitor early in treatment, despite the risk of side effects in some patients. Pfizer says side effects with Lipitor are generally mild, such as stomach upset, but the drug has been associated in rare cases with muscle damage and liver problems.”
“ Rare cases” of a drug taken by millions equate to thousands of individual catastrophes. The pharmaceutical manufacturers claim that the benefits their compounds confer on the many far outweigh the damage they cause a few. (The Journal asserts that Lipitor “has helped millions of people avoid or manage coronary artery disease, including heart attacks and strokes.”) The sanctity of the individual —which the Wall St. Journal proudly invokes in opposition to collectivist regimes— couldn’t stand up to cost-benefit analysis.
The corporate decision-makers relate to us as customers, not as people. Their ad campaigns are folksy and friendly, as if they’re “good neighbors” concerned about our health —but they’re really stock owners intent on maximizing their profits. They’re willing to endanger our health to sell their products.
That’s not the way you treat people you respect and love. It’s more akin to contempt and hate. And therein lies the answer to Sitting Bull’s question.
Fred Gardner

 

O'Shaughnessy's
O'Shaughnessy's is the journal of the CCRMG/SCC. Our primary goals are the same as the stated goals of any reputable scientific publication: to bring out findings that are accurate, duplicable, and useful to the community at large. But in order to do this, we have to pursue parallel goals such as removing the impediments to clinical research created by Prohibition, and educating our colleagues, co-workers and patients as we educate ourselves about the medical uses of cannabis.
 
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The Society of Cannabis Clinicians (SCC) was formed in the Autumn of 2004 by the member physicians of CCRMG to aid in the promulgation of voluntary standards for clinicians engaged in the recommendation and approval of cannabis under California law (HSC §11362.5).

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