by Michael Greger, MD and United Progressive Alumni
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From an excellent article in the magazine Reason:
Pain is woefully under-treated in this country. This tragic state of affairs, which has devastating consequences for individuals, families and communities, is rooted not so much in technology as in ignorance and persistent prejudice about pain, opioids, and addiction. Pain is needlessly perpetuated and suffering prolonged when, in the name of drug control, or for the ostensible purpose of preventing drug addiction, a pain medicine specialist is stripped of the power to pursue his or her vocation for actions taken in the exercise of sound medical judgment and in conformity with generally accepted standards of practice.
Torture, despair, agony, and death are the symptoms of 'opiophobia,' a well-documented medical syndrome fed by fear, superstition, and the war on drugs. Doctors suffer the syndrome. Patients suffer the consequences.[915]
The Reason article, written by J. Sullem, documents the true story of Mr. David Covillion:
Covillion finally got relief from his pain with the help of Jack Kevorkian.... The pain came from neck and back injuries Covillion had suffered in April 1987, when his station wagon was broadsided by a school bus at an intersection in Hillside, New Jersey. The crash compounded damage already caused by an on-the-job injury and a bicycle accident. Covillion, a former police officer living in upstate New York, underwent surgery that Fall, but it only made the pain worse.
Along with a muscle relaxant and an anti-inflammatory drug, his doctor prescribed Percocet, a combination of acetaminophen and the narcotic oxycodone, for the pain. The doctor was uneasy about the Percocet prescriptions. In New York, as in eight other states, physicians have to write prescriptions for Schedule II drugs - a category that includes most narcotics - on special multiple-copy forms. The doctor keeps one copy, the patient takes the original to the pharmacy, and another copy goes to the state. After a year or so, Covillion recalled in an interview, his doctor started saying, 'I've got to get you off these drugs. It's raising red flags.' Covillion continued to demand painkillers, and eventually the doctor accused him of harassment and terminated their relationship. 'Then the nightmare really began,' Covillion said. 'As I ran out of medication, I was confined to my bed totally, because it hurt to move.... At times I'd have liked to just take an ax and chop my arm right off, because the pain got so bad, but I would have had to take half of my neck with it.'
He started going from doctor to doctor. Many said they did not write narcotic prescriptions. Others would initially prescribe pain medication for him, but soon they would get nervous. 'I'd find a doctor who would treat me for a little while,' he said. 'Then he'd make up an excuse to get rid of me.' Eventually, Covillion went through all the doctors in the phone book. That's when he decided to call Kevorkian.
The retired Michigan pathologist, who has helped more than 40 patients end their lives, was reluctant to add Covillion to the list. At Kevorkian's insistence, Covillion sought help from various pain treatment centers, without success. He called Kevorkian back and told him: 'I'm done. I have no more energy now. I just don't have the fight. If you don't want to help me, then I'll do it here myself.'
Kevorkian urged him to try one more possibility: the National Chronic Pain Outreach Association, which referred him to Dr. William E. Hurwitz, an internist in Washington, D.C., who serves as the group's president. The day he called Hurwitz, Covillion was planning his death. 'I had everything laid out,' he said. 'I got a few hoses and made it so it would be a tight fit around the exhaust pipe of my car. I taped them up to one of those giant leaf bags, and I put a little hole in the end of the bag. All I had to do was start the car up, and it would have filled the bag right up, pushed whatever air was in there out, and it would have filled the bag up with carbon monoxide. Same thing as what Dr. Kevorkian uses. And then I had a snorkel, and I made it so I could run a hose from the bag full of gas and hook it up to that snorkel, and all I had to do was put it in my mouth, close my eyes, and go to sleep. And that would have been it. I would have been gone that Friday.' But on Thursday afternoon, Covillion talked to Hurwitz, who promised to help and asked him to send his medical records by Federal Express. After reviewing the records, Hurwitz saw Covillion at his office in Washington and began treating him.
'The last three years I've been all right,' he said in a July interview. 'I have a life.' Yet Covillion was worried that his life would be taken away once again. On May 14 the Virginia Board of Medicine had suspended Hurwitz's license, charging him with excessive prescribing and inadequate supervision of his patients.
At the time Hurwitz was treating about 220 people for chronic pain. Some had been injured in accidents, failed surgery, or both; others had degenerative conditions or severe headaches. Most lived outside the Washington area and had come to Hurwitz because, like Covillion, they could not find anyone nearby to help them. Dr. Sidney Schnoll, a pain and addiction specialist who chairs the Division of Substance Abuse Medicine at the Medical College of Virginia, observes: 'We will go to great lengths to stop addiction - which, though certainly a problem, is dwarfed by the number of people who do not get adequate pain relief. So we will cause countless people to suffer in an effort to stop a few cases of addiction. I find that appalling.'[916]
Russell Portenoy, director of analgesic studies at Memorial Sloan-Kettering Cancer Center, told the Times, 'The undertreatment of pain in hospitals is absolutely medieval.... The problem persists because physicians share the widespread social attitudes that these drugs are unacceptable.' He added that 'many physicians fear sanctions against themselves if they prescribe the drugs more liberally.'[918]
There exists an attitude of "stingier than thou." The Reason article cited a recent survey in which 203 out of 353 patients at a Chicago hospital said they had experienced "unbearable" pain during their stay. More than half were in pain at the time of the survey, and 8 percent called the pain "excruciating" or "horrible." Most of the patients said nurses had not even asked them about their pain. The same study found that nurses were dispensing, on average, just one-fourth the amount of painkiller authorized by physicians.
Quoting from an article in the Journal of Medical Humanities entitled "A Legacy of Silence," "The treatment of cancer pain, clearly, is still not based solely on scientific fact but draws on ignorance, fear, prejudice, and on an invisible, unacknowledged moral code expressing half-baked notions about the evil of drugs and the duty to bear affliction." According to John Bonica, the first president of the International Association for the Study of Pain, no medical schools have a pain curriculum.[920]
[Researchers have] estimated that less than one percent of patients treated with narcotics in a hospital become addicts. Although they urged better training in pain treatment, they concluded with a prescient warning: 'For many physicians these drugs may have a special emotional significance that interferes with their rational use.' Subsequent studies confirmed that patients treated with narcotics rarely become addicts. In 1980, researchers at Boston University Medical Center reported that they had reviewed the records of 11,882 hospital patients treated with narcotics and found, 'only four cases of reasonably well documented addiction in patients who had no history of addiction.' A 1982 study of 10,000 burn victims who had received narcotic injections, most of them for weeks or months, found no cases of drug abuse that could be attributed to pain treatment.[921]
From an article entitled "When Patients Know More": "Because pain is hard to verify objectively, the conflict between drug control and pain relief is inevitable.... The existential dilemma of pain management... is that we can never know more about our patient's pain than our patient does."[922]
So what happened to David? An attorney filed a federal class-action suit against the Virginia Board of Medicine, the Department of Health Professions, and the DEA on behalf of herself and Hurwitz's other pain patients. David Covillion was not a party to the suit. He killed himself that September.[923]
[915] Sullum, J. "Who'll Stop the Pain?" Reason 1997(January).
[916] Ibid.
[917] "Brief of American Pain Society and American Academy of Pain Medicine Amici Curiae." Supreme Court of Mississippi. No. 97-CC-01410.
[918] Sullum, J. "Who'll Stop the Pain?" Reason 1997(January).
[919] Ibid.
[920] Rich, BA. "A Legacy of Silence." Journal of Medical Humanities 18(1997):233-259.
[921] Sullum, J. "Who'll Stop the Pain?" Reason 1997(January).
[922] Gesensway, D. "When Patients Know More." American College of Physicians' Observer 1997(May).
[923] Sullum, J. "Who'll Stop the Pain?" Reason 1997(January).