The War on Drugs, the War on Doctors, and the Pain Crisis in America
-
Eighty Years of Naked Emperors
--------------------------------------------------------------------------------
by Alexander DeLuca, M.D., June 4, 2004

Submitted to Professor Michael Sparer, Ph.D., Health Care Policy, Mailman School of Public Health, Columbia University, New York City.
Originally posted: June 5, 2004.  Last minor revisions: June 17, 2004.
--------------------------------------------------------------------------------
Introduction

There is a Pain Crisis in America. Its primary manifestation is the routine and widespread under-treatment of pain, especially chronic, non-cancer pain. Other manifestations include a severe and growing shortage of physicians willing to prescribe morphine and related opioid analgesics, the widespread use of more toxic and less efficacious classes of medications in an effort to avoid opioids, and the profound distortion of medical education and of the doctor-patient relationship.
How large a problem is under-treated pain in America? In a 2001 article in the Journal of the American Medical Society (JAMA), Brian Vastag reports on the work of Richard Brown and colleagues who stated, at a National Institute on Drug Abuse (NIDA) symposium in April 2001, that there was widespread acknowledgment that both acute and chronic pain are undertreated. Brown estimated that more than 17% of Americans have serious chronic pain and that many go untreated and many more are undertreated. [Vastag, 2001] This is the pain crisis in America.

In an attempt to gauge the extent of the problem, these researchers developed a survey that measured the prescribing practices for benzodiazepines (Valium and related sedatives) and for opioid analgesics by different groups of physicians in response to variations of a single presented case. The physicians’ prescribing decisions were then compared with recommendations from a panel of pain management experts. The findings were stark:

While the expert panel recommended that virtually all patients with [common idiopathic back pain] who do not respond to other treatments be given an opioid analgesic, only 20% of physicians said they would actually write that prescription… "It suggests there's a lot of unnecessary suffering," said Brown. To combat the problem, he called for increasing the amount of medical school education devoted to pain management, from the typical 2 to 4 hours to 16 or 20.  [Vastag, 2001]

None of this is new.  For decades, researchers have noted this discrepancy between how chronic pain should be treated and the dismal state of the art as practiced in the U.S., and they commonly call for more and better education of physicians. But is the pain crisis in America simply a problem of the acquisition and application of medical knowledge? And if so, why have the impressive and consistent educational campaigns directed at this problem in recent decades failed to yield the expected changes in medical practice in the U.S.?

The historical record strongly suggests a deeper and far more disturbing root cause of our current pain management predicament. In the years after 1914, the Narcotics Division of the Treasury Department, progenitor of today’s Drug Enforcement Agency (DEA), brought a series of test cases against physicians under the Harrison  Act. Through the courts, drug prohibitionists achieved the criminalization of drug users and of the doctors who would treat them as patients and as human beings worthy of the same individualized medical care as any other sufferer in a free society. This wide scope of law enforcement responsibility was far beyond that legislated by Congress when it passed what appeared to be a tax act in 1914. [King, 1953]

This historical period marks the invention of a perpetual national drug crisis which has ever since been claimed as the special national interest justifying the regulation of opioid analgesic medications and other ‘dangerous drugs’ by a federal