Sunday, August 28, 2011

Good Grief

I didn't want to clutter up Abbie's place with a discussion on something that's entirely off topic. To that end, here's the comment to which I'll be writing a response:

The reason that so many doctors are hesitant to write for controlled-substance pain medications is that the DEA has been keeping a closer watch on them. The reason that the DEA is cracking down is because there's been a big increase in opiate addiction rates and hospitalizations from opiate overdoses. And a large part of that increase has been due to a few bad apples (that is, some of these "pain clinics" that have been popping up all over the place, where they just sell prescriptions for controlled substances to the patients without even seeing them, or otherwise prescribe without a genuine medical need or doctor-patient relationship).
It sucks, but there is a good reason for it. About the only thing that could be done for it would be to remove or reduce the restrictions on controlled substances, which (while it *may* lead to a reduction in abuse over the long term) would result in a large short-term spike of abuse, likely including quite a few people dieing from overdosing.
I will say, though, that even with the restrictions and the hesitancy of doctors to write for them, hydrocodone-containing pain relievers are almost certainly the top-selling medication in my area, and oxycodone-containing pain relievers aren't far behind them. Granted, that is almost certainly related in part to the reason why hydrocodone has been nick-named "hillbilly heroin" ... I'm in Appalachia, which has had quite an epidemic of opiate addiction.
However, even nationwide, codeine medications are the #2 selling therapeutic class when measured by prescriptions written, with hydrocodone/acetaminophen combinations being the most widely sold prescription product in the nation by a fair margin:
And then some links to websites showing the relative breakdown, I assume, of prescriptions written for which class of drugs. That's not relevant, so I skipped it.

First, Woden, I understand that medical practitioners are trying to serve a lot of masters with perfect success all the time. I am unsympathetic to say just about the least of it. If the difficulty in providing medically indicated treatments because of having to perhaps justify them during a diversion audit is remotely inconvenient for physicians, they should perhaps choose a different line of work. We all have people to whom we report who ask/demand explanations from time to time on what we do.  For what physicians make per year, I can't begin to care that some laws annoy them. Particularly since the medical/pharmaceutical lobbies are exceptionally strong. With respect to the central point I wish to take on, I'll direct your attention to this segment:

The reason that the DEA is cracking down is because there's been a big increase in opiate addiction rates and hospitalizations from opiate overdoses. 
It sucks, but there is a good reason for it.
Second, I understand the reasoning used to justify the legislation and why this is an issue. However, there isn't a good reason for it.  In particular, addiction to substances has two distinct flavors: physical and psychological. Anyone who's on opiates for any considerable length of time becomes physically dependent on them. This is easily treated, and it has a 100% cure rate:  ween the person off of the relevant medication over a period of time. Psychological addiction is dicier, but as pertinent here this is irrelevant.

For the purposes of medical care, it is immaterial whether a person is a known opiate addict or not. Even if someone has a heroin addiction, say, the use of opiates are not contraindicated for medical intervention. This may well provide a physician a reason to more closely the monitor the rate at which a patient is going through a prescription, but it is not a sufficient reason to counsel against providing medically indicated treatment.  It is, indeed, in my state malpractice. But that has nothing to do with leglislation.

Third, for a society that is supposedly free, there should be a compelling reason to proscribe any conduct. That some people will be harmed by abuse of an available commodity is no argument at all that said commodity requires any greater attention. It's entirely possible for people to die from antibiotics, and yet these are far easier to procure than a silly old opiate. For that matter, there's a more important reason to make antibiotics harder to get than they are already:  eventually, they'll be almost entirely useless, and there seems to be a rather hard limit on the horizon to how many different ways we can make them. Opiates, therefore, aren't a threat to society-at-large.

Lastly, yes, people do bad things while on heroin, say. They do bad things to procure more of it. Were it freely available at the local store, the heroin addicts could get whatever fun they want, and a great deal of suffering could be reduced. All without requiring potentially thousands of dollars in medical bills for a person to decide that, you know, accidentally skewering their hand hurts bad enough they can medicate themselves. Or that a sprained ankle is sufficiently painful to warrant picking up some vicodin on the way back from the gym. Or a headache. Or a toothache. Or whatever. It's no one's business but that person's and his/her family and health provider what evil things s/he is doing to his/her body.

All of the stock arguments about people abusing drugs are wholly unconvincing. It is clearly not the case that having them available is detrimental to society, even though a few people here and there will die from them for lack of control. That's their decision, not the government's. I fail to see a single reason that demands these drugs specifically require so much tax money to be wasted investigating. What? Are we in such a state of affairs we have the money to burn to investigate if someone is having too much fun? If someone's broken finger is really broken enough?

What is, one wonders, this "good reason" of which you speak.


Woden said...

I think you misunderstood my position on the issue; I'm generally in favor of legalization. The "good reason" I was speaking of was from the perspective of the current system, not my own perspective.

However, even though I acknowledge that legalization is generally the better option, there does remain the fact that legalization has often been followed by a period of heavy abuse, which is something that does likely make lawmakers less inclined to decriminalize drugs.

Justicar said...

Legalization might well presage a period of heavy abuse. Again, so what?
You say I misunderstood your position. Perhaps. But you said that there existed some good reason. Now you're saying because some instances of heavy abuse might come on the heels on legalization that, at least, some lawmakers will be less inclined to decriminalize drugs.

I hate to return to the point, but I think I must: I see precisely no good reason that 300 some odd million people are presumed, by law, to be incapable of determining when they're in pain or not because of the poor judgment of a couple of thousand people.

It almost sounds like you're saying a 'good reason' is whatever some legislators somewhere decide is their reasoning for doing something.

I'm not trying to conflate your 'personal opinion' with the issue. I am trying to take stock of what you wrote, which is that there exists some 'good reason' which justifies the current system. Sorry, I still fail to see it.

Brad said...


Would you consider yourself a pragmatist or a neo-pragmatist?

I was reading the above and it struck me that your point echoes some aspects of Richard Rorty's thinking.

I call myself a pragmatist but I'm not on board with everything he said so I guess I'm just asking if you're familiar with his work?