A Swing Too Far

It has been difficult to avoid the news this past year or so—with the ongoing opioid epidemic in the USA and the hysterical swings authorities, of various stripes, have been taking to fix the problem. In typical American lore, there is always someone to blame for anything that does not go right. Thus, first it was the over prescribing doctors, then the drug companies over marketing their wares, then the over prescribing pain clinics, then the Mexican heroin cartel bringing in cheaper-than-prescription-opioid heroin. Lost in all this has been the fact that drug use has been escalating over many years in the USA, and as long as there is a market for the product, illegal proliferation of one drug will always occur. So, where is there the realization that for real drug addiction to occur? There must also be the mental attitude of the addict. There is little question that prolonged use of opioids will cause physical habituation and unpleasantness when the drug is suddenly stopped, but that is very different than addiction, which is a complex syndrome definitely involving a strong mental component producing drug seeking behavior.  I have had many patients necessarily on long-term opioids and when the necessity is over, I cannot recall any patient drug seeking, other than those who already had a history of such behavior prior to their latest problem.

The major situation with opioid-use is that there are very few viable options to ease chronic pain in so many patients and the problem has been blown out of all proportion as to the cause and effect. And, if an otherwise stable patient with genuine severe chronic pain does become dependent upon prescription opioids, what ultimately is the great harm? This is especially true of patients who have a painful terminal illness with limited life span where opioids remain the only substance available to ease their suffering. I do not wish to get into the argument of the dysfunctional attitude of the US and other governments to the use of opioids, but there are some alarming consequences for which I have some personal vignettes.

I was in France when medical heroin was legal and being used in oncology centers. It is an amazing drug and nothing comes close to its effect in pain relief and production of some euphoria for terminal patients. During my stay there, under pressure, the French government finally followed the US in outlawing the drug, which was discarded, much to the detriment of the patients whose suffering was so ameliorated by it. Now it is being timorously suggested that heroin be pharmaceutically available again for patient use.

In another instance, in Saudi Arabia, that bastion of dark age religion and laws where the sentence for drug offence is beheading, doctors in the outlying areas of the country would not prescribe opioids, period. As a result, cancer patients had to travel up to 600 miles by air to return only for the purpose of obtaining a month’s prescription of opioids to be prescribed by the urban cancer hospital for their pain relief.

In the US and to some extent Guam, suddenly everyone is an expert and has their own method of control. So, most pharmacies have stopped carrying most or all opioids and have stringent screening; insurances will only allow prescriptions not to exceed a week’s supply and must be pre-approved, and many doctors have stopped all opioid prescriptions lest they fall victim retroactively to some politician’s benighted answer to the problem, as in California. With the myopia that is endemic to hysteria, the terminal cancer patients in pain has been caught up in the conflagration. Belatedly, the CDC and then the FDA have come out with statements that their marvelous solutions should not include cancer patients, but the harm has already been done. Many cancer patients have to travel far to obtain opioid prescriptions as their local rural pharmacies stopped carrying these drugs. There was even a block at the wholesale level for a time and we, at Cancer Center of Guam, had to borrow opioids from the much-appreciated Naval Hospital until the supply chain eased. And local insurances, after some arguing, begrudgingly exempted cancer patients from the restrictions of other patients.

There is no question that there is a drug problem in the US and many deaths are the result of this. But the solution is not to have the needy patient suffer in the shotgun approach to a problem that has long been escalating and only very tardily recognized, and at that, considerably with vision askew.