This article, in a slightly edited form, first appeared in the Salt Lake Tribune on May 20, 2021.
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 had chosen to end his unremitting pain with a gun. I live with 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, and for how long, and to whom. Opioids can kill. But so can under-treated pain. Opioid use and chronic pain are deeply intertwined. But today, one is being 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 in doing so was to share my professional knowledge about opioids and addiction, and also to give voice to the many people in pain I treated for years. I didn’t realize the documentary had a different agenda.
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. Unfortunately, some of them successfully end their own lives.
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, dishonest marketing practices of opioid manufacturers and the human toll that took over the last 20 years, the picture presented is woefully incomplete. This is my fundamental problem with the documentary.
We are facing a far more nuanced and 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? 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 rewind 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 don’t blame them. But we should hold decision makers accountable when they are seduced by a moral panic, and when they swing and miss at a deep-seated societal problem.
Years ago, my pain clinic was raided by the DEA which later declined to pursue a case against me. I was named in a host of anti-opioid lawsuits, from which I was released. Patients under the care of my team died not because of treatment, but despite it. I successfully treated thousands of patients, and have devoted my life to identifying safe and effective alternative pain therapies.
Jack’s suicide weighs heavily on my conscience, and most physicians undoubtedly have wrestled with similar, no-win dilemmas. 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.