Many years ago, I took on an unforgettable patient (“Jack”) who was on a high dose of physician-prescribed opioids. He wanted me to continue his high dosage.
But I was unsure whether the benefit of doing so outweighed the potential harm. I also worried that, if he died from a natural cause, his death would be attributed to the opioids and, ultimately, I would be blamed. Given that, and despite his objections, I tapered his medication.
Days later, I received a call from his daughter. She said he chose to end his unremitting pain with a gun. I live with the question of whether he might have lived if I had continued to prescribe the medication he believed he needed.
As a pain specialist, I carry the burden of deciding how many opioids to prescribe, for how long, and to whom. Opioids can kill. But so can under-treated pain. But today, one is intensely scrutinized while the other is largely ignored.
After months of corresponding with the producer of HBO’s new documentary, “Crime of the Century,” I agreed to be interviewed. My interest was to share my professional knowledge about opioids and addiction, and also to give voice to the people in pain.
After viewing the documentary, some people may conclude I am an advocate for opioids. On the contrary: I strongly believe that opioids must be replaced as a first-line method of pain treatment.
That said, it remains clear that a subset of the population does respond to certain opioids without incidence of abuse or addiction. People in this category typically have no other option. They are tortured by their daily pain, and they often see suicide as a means of escape. While the number of suicides in the U.S. continues to climb, studies show that people with chronic pain are at least twice as likely to report suicidal behaviors.
It’s a shame that the documentary allowed America’s complex chronic pain crisis to be reduced to greed by opioid manufacturers. While the documentary rightly shows the aggressive marketing practices of opioid manufacturers and the human toll over the last 20 years, the picture presented is tragically incomplete and hopelessly distorted. This is my fundamental problem with the documentary.
We are facing a far more nuanced, complicated predicament than the documentary conveys. Its objective is to tell a riveting story, with heroes and villains. It doesn’t aim to include all the salient facts. What happens, for example, when politicians and regulators, ranging from well-intentioned to cynical, begin to practice medicine? What happens when they restrict access or, worse, ban entire classes of opioids from people who desperately need individualized treatment? What happens when people with addictions are criminalized or unable to find treatment. Very simply, we swap out one crisis for another.
We’ve seen this story before. In the 1990s, “getting tough on crime” was the favorite sound bite of politicians, both Democrat and Republican, culminating with President Bill Clinton’s signing the 1994 crime bill into law. What resulted was the mass incarceration of a generation of primarily Black males. Now, a criminal justice reform movement has bipartisan support and aims to undo the war on crime’s excesses. One crisis traded for another.
If people have a genuine change of mind about complex issues after careful evaluation, I cast no blame. But we should hold decision-makers accountable when they are seduced by a moral panic that leads them to use a broad sword on a deep-seated societal problem when a scalpel is needed.
I treated thousands of patients and devoted my life to clinical research to identify safe and effective alternative therapies to opioids. At the same time, my pain clinic was raided by the DEA, a case the DEA later declined to pursue. I was named in a host of lawsuits along with the opioid manufacturers and distributors, from which I was released. Patients under the care of my team and I died not because of treatment, but in spite of it.
While my experiences are my own, the dilemmas inherent in some of them are not. Most physicians undoubtedly have wrestled with similar, no-win dilemmas as mine with Jack. If better policy solutions do not replace the status quo, Jack’s story may be well on its way to becoming the next crippling national crisis.
Lynn Webster, M.D., is a retired pain physician and clinical researcher. He lives in Salt Lake City, Utah.