Suspicion and Control

An FDA panel recently recommended lowering the maximum recommended daily dose of acetaminophen, a measure intended to decrease the number of accidental overdose related liver failure. They also recommended other things, among them to withdraw acetaminophen combination narcotics like Vicodin and Percocet from the market, as one study indicated that most such overdoses involved these types of drugs. Despite an estimated 10% of accidental overdoses leading to death being caused by over-the-counter medications, such as cold and flu meds, the panel did not recommend that these be removed from the market.

So let me get this straight… according to the article, approximately 56,000 people are seen in emergency rooms with acute liver damage related to accidental overdose. That's a lot of people. On the other hand, as a percentage of the entire US population of approximately 350 million - and please correct me if my math is wrong, because it's entirely likely it is, as math makes my brain hurt - it represents .016%. Hmmm. The number of fatalities is estimated to be 450. Hmmm…

So instead of educating people about what their medication contains, what acetaminophen can do to your liver and in general empowering them to be responsible in medication use, we're going to pull pain meds that enable people to live their life. But we're not going to pull acetaminophen itself, despite over-the-counter meds like Tylenol not coming with the kind of educational package that happens - or should happen - when a doctor writes a prescription for Vicodin or Percocet. We’re also not going to pull cold and flu meds, which is a good thing, isn't it, because "[m]anufacturers could have lost hundreds of millions of dollars in sales if combination drugs were pulled from the market. Total sales of all acetaminophen drugs reached $2.6 billion last year, with 80 percent of the market made up of over-the-counter, according to IMS Health, a health care analysis firm."

How much of this decision of what to pull and what not to pull do you think was if not based, then certainly influenced by, that consideration? Because pharmaceutical companies are a force to be reckoned with, but the very small percentage of people taking Vicodin or Percocet for really big pain is not.

"But addiction!" you say. Well, you probably don't, but somewhere out there, the stereotype of pain patients automatically becoming addicted to narcotics is increasingly influencing decision-making. Because now, people who have chronic pain and are being seen by pain specialist or a pain clinic will be required to sign treatment agreements. By signing such a document, you agree to take the medication exactly as prescribed, agree to random drug testing (no, I'm not kidding), use only one pharmacy and agree to the doctor and pharmacist exchanging information about you (what kind of information?) and a whole bunch of other things. As well, should you do anything that goes against this agreement - like e.g., take less medication than prescribed for a day or two - you will fail the drug test, be terminated from the program and no other doctor will prescribe opiates for you.

WTF??? Most people who are prescribed narcotics for severe chronic pain do not develop an addiction. Yes, some do, but most do not. As I’ve mentioned before, you do become dependent on the drugs in the way that without them, you couldn't live your life and be a productive member of society, but if you look at it that way, I guess a diabetic is addicted to the insulin, too. However, I'm pretty sure diabetics don't have to sign treatment agreements, because needing insulin is not suspicious. And maybe it's because blood sugar levels can be verified in a blood test, but pain levels has to rely on subjective reports of the person in pain and we all know how much credence the medical profession usually gives to patient experience, but regardless of all of that, this? This is some of the most offensive crap I've heard in a while.

So because a small number of people on narcotics get addicted, we are going to treat everyone who need the big painkillers for chronic pain as suspect, subjecting them to random drug trials as if they were criminals on parole. This reminds me of when Mike Harris (a pox upon his name) and his conservative party got elected to govern Ontario based on an election platform with a major focus on popular stereotype that every welfare recipient is out to milk the system. Once elected, they reduced welfare rates significantly, to such a point that nobody can live on it. I heard from a reliable source that the amount of fraud in the Ontario social assistance program ranges from 5 to 12%, which apparently is the amount of fraud that can be expected in any system, not just the welfare system. Of course, nowhere was it mentioned that 88 to 95% of people receiving assistance do so because there is a genuine need. And that's one of the things that bugs the snot out of me, this focus on where the system is abused or doesn't work, because they never flip it, do they? They never look at how many people are able to live happy productive lives because of a responsible use of narcotics. And what's going to happen to those people now? How well do you think those treatment agreements will work in real life? So you have to call your doctor for approval every time you need a bit more or a bit less medication - how often do you think the doctor is available? And what happens if you get food poisoning and throw it all up? Or any of the other examples in that article. If you have too much medication in the system, it's assumed that you're an addict and if you don't have enough medication in your system, it's assumed that you're selling it to somebody else.

And it's making me really grateful that I live where I do because although there are restrictions on and supervision of narcotics, the Canadian system - at least where I live - assumes to a greater extent that you are an adult, reasonable, rational and responsible person who, after receiving proper education by your doctor, will take your medications in a reasonable and responsible manner. My prescription of codeine is labelled "take as needed". And I do - some days, I hardly need any, other days (like the last three weeks where I've been nursing this damn neck injury), I take more. Of course, if I suddenly started coming back to my doctor every month for a new prescription of 100 tablets without changes in my health instead of as I do now every 4-5 months, I might get flagged as potential drug seeking. But I am presumed responsible until proven otherwise, not the other way around.

And the saddest thing of all is what Karen Lee Richards said in her piece about treatment agreements: "[b]ecause there are so many people out there who do abuse drugs and who have become experts at cheating the system, those of us who need stronger medications to control our very real pain, are forced to abide by these highly regulated restrictions in order to receive the treatment we need" and there's a real sense that this is just what you have to do. But these are not just "highly regulated restrictions," these are invasions of privacy and a level of suspicion and control unheard-of in the general population, but targeted on you because you have chronic pain. That is your only infraction. And you're supposed to just accept that and find it reasonable. Because if you want the meds that’ll enable you to live, you have no choice.

I say again… WTF???