EDITOR’S NOTE: Points is delighted to welcome Kim Sue, a previous contributor (check out her earlier posts here and here), medical anthropologist, and dual degree MD/PhD candidate at Harvard University. On the heels of Points’ recent posts about the difficulties of reconciling clinical and scholarly perspectives on addiction treatment and the media frenzy about the recent prescription opioid epidemic, Sue offers a historical and ethical reflection on having the power to dispense prescriptions.
I first met Anita in the Boston jail where she was doing time for passing bad checks related to a prescription opioid addiction. She had first been introduced to opioids after giving birth to her first child several years earlier. “I was prescribed percs [percocets] for pain related to the delivery,” Anita explained. “I just remember taking them and being high and cleaning … I took four or five at a time.” Anita’s drug use spiraled out of control, as her physiological tolerance to the opioids increased and she needed to buy more and more pills to get the same effect. One day, Anita’s dealer offered her heroin, and off she went.
Ethnographers and historians of drug use are all too familiar with stories that resemble Anita’s. As an anthropologist who studies prisons and addiction treatment, I find it relatively easy to point the finger at doctors for their professional complicity in “epidemics” of opioid addiction.
But as a medical student in my final year, destined to start residency in July in an internal medicine-primary care program, I also worry I won’t be able to refuse prescriptions for opioids for patients presenting to me in distress and pain.
Historians of medicine and drug use have detailed how physicians—whether they wanted to or not—became central to the distribution and administration of opioids in the United States. In the wake of the Harrison Narcotics Act, addicts had to obtain prescriptions for their drugs, and so-called “dope doctors” would provide them for cash. The alternative to the dope doctor was the street druggist, the so-called “pusher.”
Doctors and opiates have a long, complex history. In the era of magical formulations, Dr. Thomas Syndenham compounded laudanum by mixing “two ounces of opium and one ounce of saffron dissolved in a pint of Canary or sherry wine” with a “drachm of cinnamon powder and of cloves powder,” as historian Richard Davenport-Hines noted in his history of the subject. At the time, opiates (plus or minus alcohol) were among the few medicines that were actually effective pain relievers (working at the μ pain receptors in the brain). They were instrumental in bolstering the medical profession’s emerging reputation for dispensing effective interventions rather than simply bearing witness to suffering. Indeed, enterprising pharmacists and doctors alike created their own patented formulations of various narcotics marketed as cure-alls– a mix of magic, profiteering, and chemistry.
Doctors prescribed opiates frequently at the turn of the twentieth century, especially to women for their essentially painful physiological conditions (e.g. menstruation, childbirth). Harper Lee’s Miss Dubose in To Kill A Mockingbird was a quintessential “medical” addict, an elderly woman addicted to morphine at the hands of her physician. Famous addicts like William S. Burroughs recount cycling between doctors in pursuit of prescriptions in the 1940s and 1950s. His advice to others in his novel Junky: “You need a good bedside manner with doctors or you will get nowhere.” Throughout the twentieth century, drug addicts were increasingly defined as “medical” or “nonmedical” users. Medical users had a “legitimate” reason: their addiction, as in the case of Miss Dubose, was perhaps a harm that was a necessary fact of treatment. Those who were deemed “nonmedical” drug users were increasingly criminalized, stigmatized and incarcerated.
Since court decisions between 1915 and 1922 made it difficult for doctors to prescribe opiates for addicts as maintenance medications, medical users increasingly turned to the street. But physicians continued to supply a steady stream of opiates for “diversion,” causing the Federal Bureau of Narcotics and the Drug Enforcement Administration to pursue and arrest “dope doctors” and pharmacists who would prescribe opiates to patients in a manner regulators deemed indiscriminate. Doctors teetered on a fine line between “respectability and infamy,” wrote historian David Musto.
Physicians still toe this line. The DEA has aggressively cracked down on small numbers of unscrupulous modern-day “dope doctors,” especially in Florida around the so-called “pill mill” clinics (doctors in Florida purchased 41 million oxycodone pills in the first six months of 2010 than providers in all other states combined, according to the DEA). This year, Dr. Stan Xuhui Li, in his pain clinic in Flushing, Queens, famously saw over 80 patients a day and took cash for prescriptions. He was convicted of 195 counts including two manslaughter charges. Dr. Moshe Mirilishvili made headlines for writing over 13,000 prescriptions for oxycodone (1.2 million pills) in Washington Heights with a $200 cash price tag for a prescription for 90 tablets of 30mg oxycodone; the DEA special agent on the case claimed, “These defendants are drug dealers playing doctor.”
There are certainly doctors who, like Li and Mirilishvili, just want to make a buck. They make a mockery of the doctor-patient relationship that so many of us view as the core of our professional identities. They nakedly expose the fact that healthcare is a business, and they trade cash for prescriptions.
As a profession, we are expected to police ourselves and each other– but we can’t.
Physicians are actively debating our complicity in this issue. Anna Lembke recently published a controversial piece about why doctors continue to prescribe opioids to patients they know have addiction in the New England Journal of Medicine. Lembke’s article gets to the heart of how difficult it is to truly assess pain, and it suggests that doctors are one important, integral part of a dysfunctional, fragmented healthcare system. Physicians teeter cautiously between under- and over-treatment of pain. We struggle with patients’ cultural mentality of the quick-fix—a point of view that aligns with the pharmaceutical sector’s goals of selling pills and profiting from social distress (for more on the topic, see Barry Meier’s muckraking book on Oxycontin and Purdue Pharmaceuticals). Prescription drug abuse takes place within a healthcare system that underfunds addiction and mental health treatment and funnels people with drug use to prisons and jails.
Increasingly, clinics and states are coming up with rules and regulations such as pain contracts; warning individuals about the downside of opioids (i.e., addiction); and counseling patients that opioids are only one part of comprehensive treatment for painful conditions, and should not seen as a permanent or long-term solution. There are new best practices and state Prescription Drug Monitoring Programs. But they are underutilized in practice. The reality of the situation is that I have fifteen minutes to see you, and you are in pain.
Doctors have been burdened with the responsibility of meting out pills that are medicines on the one hand, and poisons on the other. On the one hand, we want to effectively treat pain (the ethical principle of beneficence), and on the other hand, we want to be stalwarts of public health and do no harm (the ethical principle of nonmaleficence). With opioids, physicians’ interpretations of the ethics vary widely: Treat the pain! Never give oxycodone or benzos! Believe the patient! The patient is faking!
The historical complexity and contemporary contradictions surrounding opioid prescribing leaves me wondering: will I be a dope doctor when I grow up?