Saturday, October 30, 2010

Pain Relief Without Addiction: Walking the Tightrope

[Originally published on on 29 Oct. 2010]

Roger T., a middle-aged systems analyst, showed up at a LifeRing recovery support group looking for help with addiction to painkillers.  Years earlier he had been a passenger in an auto collision which left him with chronic pain in his lower back and hips.  His doctors had prescribed the standard opiates, and this had provided him with some relief, but over time he needed larger and larger doses.  He said he had been taking 300 Vicodins® per day.  He knew he had to stop the drugs -- but he couldn’t live with the pain.  

Not only patients but also their physicians have to walk a tightrope between pain and addiction.  A hot case in point is the jury trial involving Dr. Sandeep Kapoor, the 42-year old Hollywood internist and physician to celebrity model Anna Nicole Smith.  Smith died of a drug overdose in 2007.  Dr. Kapoor and two other defendants were not charged in her death -- this was ruled accidental -- but were charged with conspiracy to provide her with excessive quantities of pain medications while knowing she was an addict.  

In other words, Dr. Kapoor was charged with crossing the line from medical helper to drug pusher.  It’s an issue that inflames hundred-year old wounds on the U.S. medical community.  With the passage of the Harrison Act in 1914 and regulations and court decisions shortly thereafter, the federal government severely limited physicians’ professional freedom to prescribe analgesic medications.  They could prescribe opiate painkillers only in tapering doses, and their good faith professional medical judgment was ruled irrelevant.  

In the following decades, the US Treasury Department indicted more than 25,000 physicians for prescribing opiates; some 3,000 went to jail, and more than 20,000 were forced to pay fines.  It was a shameful period, and it has left enduring scars on modern medical practice.  The California statute under which Dr. Kapoor was charged is a direct descendant of this period.  These laws have chilled physicians’ treatment of patients with chronic pain problems.  

The Harrison Act rested on paranoia about anarchists, radicals, criminals, and foreigners -- especially Chinese -- who were (wrongly) seen as the typical opiate users of their day.  Scratch any subscriber to what passes as public opinion in the US today and you’ll find, not far beneath the surface, a similar identification of drug users with social undesirables.  

All of that goes on the scrap heap when a celebrity is involved.  As everyone familiar with the criminal justice system in the U.S. must be aware, celebrities are above the law, particularly the law of addictive substances.  Lindsey Lohan, Mel Gibson, Paris Hilton ... all would be locked up for years if their names were Smith, Jones, and Johnson.  And so here.  With Anna Nicole Smith, a genuine neon blazing celebrity at the center of the trial -- even more dazzling a presence in death perhaps than in life -- the judge found ample justification for her possession, post mortem, of more than 1,500 pills.  In a phrase that will reverberate in courtrooms for years, Judge Perry T. Fine admonished the jury, "The number of pills is not a determinative factor in this case. Please keep that in mind.”  

The jury did.  After 13 days of deliberations it returned yesterday a verdict of “not guilty” for Dr. Kapoor.  It found, in other words, that Ms. Smith was not “addicted” and that Dr. Kapoor’s prescription of opiate painkillers was medically justified in view of her many and severe symptoms of pain and anguish.  

Dr. Kapoor still faces a lengthy process of rehabilitating his reputation and defending possible attacks on his medical license.  But he will not go to prison.  

With this courtroom victory, physicians who specialize in the difficult art of pain management -- a small and endangered species -- will breathe a long overdue sigh of relief.  

Most of these physicians are members of the American Society of Addiction Medicine (ASAM), a highly respected and conservative professional body of providers who more or less successfully navigate the tightrope of giving pain relief without enabling addiction, every working day.  

But  there is also a fringe element of medical opportunists who will prescribe whatever the patient asks for, so long as the check is good.  And there are well-intentioned general practitioners with zero schooling in addiction medicine whom the experienced opiate addict plays like a violin.  

There are no easy answers to pain.  I have had conversations in LifeRing meetings with a number of people like Roger T. who suffer from chronic pain, medically managed with conventional opiate-based pharmaceuticals.  They tell me that they have learned to recognize when they are crossing the boundary from pain relief into seeking euphoria.  Unfortunately that insight came only after multiple boundary crossings with harmful consequences.  I have also talked with chronic pain sufferers who have found relief through hypnosis, meditation, special exercises, nutrition, and other alternative approaches.  Pharmaceutical research is also hinting at new types of analgesics that do not involve the classic addictive brain circuits, as the opiates do.  

Obtaining pain relief without falling into addiction is one of the most difficult challenges for professional and patient alike.  One thing seems certain.  There will be more progress if this problem is left in the hands of providers and patients, without massive interference from uninformed legislators and political appointees, frequently with demagogic motives.  To that extent, the jury’s verdict freeing Dr. Kapoor is an important step forward, and Judge Fine deserves recognition for a well-reasoned set of jury instructions.

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