Advances in the conquest of pain are underway, we are told, in Europe, England and the U.S. Pain clinics and pain specialists are increasing, as are hospices and pain-management courses in medical schools. This sounds wonderful, but the reality does not seem as wonderful as the labels. Our check into these facilities and their methods indicate that they seem dedicated more to teaching people to endure pain than to efforts to alleviate it. Europe, an older and more sophisticated culture, may take a less rigid position than is adopted here --- for we are a nation of extremists --- but that's only an assumption. The fact is that medicine has never really regarded pain as important, although pain is what sends people to doctors in the first place.
When Jeffrey Bernard, the famous columnist in London's Spectator, smitten with pancreatitis and suffering "phantom" pains from an amputated leg says about physicians, "most of all I hate them for their meanness and narrow-mindedness about dispensing pain relief," we hear a transatlantic echo of the American situation.
Our physicians are not, of course, either sadists or monsters. They are hapless semi-victims of our immense Drug War, which is being conducted like a real war. It rides roughshod over Constitutional rights, treats everyone as a potential enemy --- and as a possible dealer or addict, or both. Physicians, who are caught in the middle in this War, are constantly suspected of trading with the enemy. They are, therefore, subjected to close controls and monitors, forced to make detailed reports of all painkillers they prescribe to whom, when and why, and are harassed in countless ways.
If they prescribe too many drugs, their licenses are in jeopardy. Who rules when a doctor prescribes too many painkillers? The list is extensive, and does not always include medical practitioners. Physicians are subject not only to the restrictions of the Drug Enforcement Agency, but also to private insurance firms and their "adjustors," to police authorities of more variety than can be easily or quickly listed, and a swamp of arguments about the nature of addiction, drug-use, human nature, and behavior.
These are all immense subjects beyond the power of words to contain. One paramount point, however, seems nearly lost in the subject of narcotics. They were hailed on their first arrival as blessings that can release mankind from pain. To forbid their use in this regard is to condemn people to suffer. That does not seem either Christian or sane. But wars have a way of escalating, and creating suffering on all sides far beyond their purpose. As many a well-intentioned person has discovered, doing good is a very treacherous and uncertain matter. Forcing an entire nation to behave is a very complex task, and our success in this effort is among the worst in the civilized world.
More than one person has pointed out that we have, as a nation, gone down part of this road once before, when we tried to prohibit the use of alcohol as a beverage, a painkiller, a social solvent, a vice, a comfort --- whatever. Prohibition, created by a Constitutional Amendment in 1919* was repealed in 1933, only two generations ago. One would expect that even as ahistorical a nation as ours would be able to remember the lessons of that failure, but it appears that it has not. Despite the ignominious collapse of Prohibition, the government has created a new Prohibition of Narcotics, on an even larger scale. Its intended targets are addicts and those who supply them; its unintended targets (and they are numerous) include everyone in pain who needs painkillers.
Perhaps the reasons the lessons of Prohibition are not remembered is because they have not been taught or even, generally speaking, discussed. What Prohibition did was to outlaw an industry in all its branches and suppliers. That meant not only distillers, bottlers, labelers and advertisers, but the curtailment of the supplies of that industry. The wheat and corn markets were affected, the barrel-makers and wagon-makers and horse breeders and furniture trade, the malt and hops market. The police had to be expanded, and the tax authorities were directly affected. The Bureau of Alcohol, Tobacco and Firearms was created as an arm of the Treasury during Prohibition, because bootlegging and its ramifications involved evasions of taxes.
Prohibition spread corruption, cynicism, lawbreaking on a national scale and the nation's first true black market. Our tax records and governmental evaluations have never really recovered control of the facts of our national economy. In a moral and traditional sense, the people have never recovered. Neither have the police, the government as a whole, the courts, the theater or the culture. The effort to enforce Prohibition led the BATF into battering down doors, shooting people and making numberless arrests. In Michigan, a fourth violation of the Volstead Act meant life in prison. The nation polarized on the issue, deadly gang wars flourished, and Chicago became a worldwide synonym for murder in the streets and rampant racketeering.
In the end (if there can be said to have been an end, because dry counties remained until recent years) a great moral crusade introduced immorality on a scale never before known in the land. Prostitution, gambling, tax evasion, corruption in high places: all the ills with which we are now familiar, rose like fumes from a dunghill during Prohibition.
The drug laws, launched in 1915 against opium in Chinatowns and marijuana among jazz musicians and fringe groups, took longer to mount into fortresses and barbarities. Narcotics, as part of national decay in the West, really seemed to take root in Europe first amid the ruins of World War I. Narcotics in Berlin and Paris fueled a black market, prostitution, and a sort of hedonistic despair to a spectacular extent. (This was a facet of the Weimar Republic which its admirers seldom stress in their current histories.) Drugs and an atmosphere of vice was part of an immoral scene that Hitler was quick to inveigh against, and had much to do with the fall of the Weimar Republic.
The lessons of Prohibition and of Weimar, occurring largely in the same decade, deserve more concentrated, in-depth attention than they have received. But both periods were immediately swamped by immediate events: the Depression and New Deal at home, and the rise of Hitler abroad. This century has barely had time to reflect on its lessons; they have been buried beneath wars and upheavals so vast that objective commentators have hardly had time to digest their causes.
Our historians, for instance, tend to treat Prohibition as a passing phenomenon; an example of religious fanaticism. In reality, it was more than that: it was an unprecedented effort by the government to curtail individual liberties, to control the people for their own good, with a minuteness de Tocqueville anticipated. "Such a power does not destroy," he said, "but it stupefies a people, till each...is reduced to nothing better than a flock of sheep, of which the government is the shepherd." Prohibition was such an effort, launched for the good of the people, that irreparably distorted the spirit of the nation.
By not recognizing the depth of that damage, we have stumbled in little more than a dozen years after our escape from Prohibition and a release from wartime controls (and a renewed wartime black market and more corruption) into --- step by step --- the Drug War: Prohibition on a larger, more fearsome scale. This one makes the first Prohibition seem, retrospectively, naïve and innocent. This one is threatening to wash away all our liberties.
The physicians are fearful that if they prescribe narcotics to persons in pain who need painkillers, they will create addicts. They are also afraid that they will lose their licenses to practise medicine, because the regulations restricting the use of narcotics for even medical reasons have grown so numerous, so complex, so restricting that most physicians find it safer to let patients suffer. Suffering, after all, is not a life or death matter. And the rationales, the separation of real from psychological pain, have been well developed. These allow physicians to argue, with a good conscience, that pain is better than addiction.
Unfortunately the subject of addiction, which is central to the Drug War, is one that remains mysterious. Everybody who drinks does not become an alcoholic. Everybody who tries drugs does not become an addict. Nobody, in either case, knows why. Persons in pain, however, who have been prescribed narcotics, almost never become addicted. (One can never say never, but in these cases one can say almost never.)
Meanwhile the World Health Organization newsletter has issued a report on the Second International Conference on Cancer Pain, issued by the Memorial Sloan-Kettering Cancer Clinic and their chiefs Dr. Kathleen Foley and Dr. Jan Sjernswaard, of the organization's Cancer Unit.
"Undermedication," they state, "continues to be THE major problem in the Unites States, despite excellent studies showing that the psychological dependence characteristic of addicts almost never develops in pain patients. Patients with cancer pain easily discontinue their drugs when the source of their pain is removed through treatment.
"Nevertheless, drug use and drug abuse are so inextricably linked in the public mind that even physicians continue to believe opiates have the power to transform...patients into addicts. Over the past 15 years, researchers at Memorial Sloan-Kettering and centers everywhere have gathered an impressive body of data showing that effective pain control, far from causing addiction or heavy sedation, permits many patients to function better."
In the United States, regulations have had an unintended impact upon patients in pain. For example, Dr. Foley is forbidden by law to write a prescription that will provide a month of pain relief to some of her New Jersey patients because the amount they require exceeds the state's legal limit for oral morphine. The law demands a new, freshly signed form, entailing an otherwise unnecessary appointment at MSK. "Ironically, it has never been shown that oral morphine has much value as a street drug," Dr. Foley noted.
The Drug War, in other words, has created such a threatening climate for physicians that they are allowing even patients with diagnosed cancer to suffer agonies, rather than prescribe painkillers. If this is true for patients with terminal cancer (what threat of addiction is involved here?), what about other patients in pain?
Michael Fitzgerald, a columnist for The Stockton Record, to cite only one case out of many, last fall described the instance of Alma Herrington, who fell and injured her spine. After her fall, doctors discovered Herrington had a ruptured disc. They performed a spinal operation, then an operation on her back, and then four more spinal operations. Each was designed to ease pain; none succeeded. She lives today on disability in constant pain. Her doctors have refused to prescribe painkillers.
Dr. Sandon Saffler, medical director of San Joaquin General Hospital, says, "Physicians in general have taken a very conservative approach to prescribing narcotics for chronic long-term pain sufferers who are not terminally ill." "Narcotics may addict patients," Saffler said. "Doctors also worry that large, sustained doses will increase a user's tolerance until the painkiller becomes ineffective. Certain narcotics," he added, "poison the liver. The best approach may be to send the sufferer to a pain clinic where various treatments can be tried to see what works best." Unfortunately, we know what this means. The clinics try acupuncture, massage, sometimes hypnosis --- and lots of "counseling." They employ a team of doctors, and the patient is shifted from one to the other to the other. Most are dedicated to the theory that pain can be endured, and that painkillers are dangerous.
The columnist also noted that Dr. Saffler "was mindful that doctors who prescribe too much painkiller can be censured and prosecuted. 'You lose your license and you're not going to be able to care for anybody,' he said."
California State Senator Greene considered that outrageous. He said, "Quite frankly, I am outraged by the unwillingness of the medical profession to wake up and join the 20th century." Acting upon that indignation, Greene authored a new law that lifts the threat of punishment from doctors who prescribe painkillers for persons with intractable pain problems.
"We don't find anybody is becoming a drug addict and we've seen thousands of cases," Greene said. "The problem is that the doctors are too concerned with insurance and the state medical agency. They're money machines." He now wants to fine or sentence doctors who refuse to provide pain relieving medicine. Herrington is, of course, very cheered. "It's not just me," she said. "There's thousands of people like me out there. We are dehumanized, stripped of all pride and dignity."
Greene's charges against physicians were, of course, hyperbole. Once a campaign of the size of the Drug War gets underway, with its use of the armed services and a wide variety of governmental agencies on all levels --- and especially when the Drug Prohibition has created billions of tax-free dollars rolling through the economy --- there is more than one reason involved: there are fortunes, careers, corruption, and danger.
Physicians are part of the entrapped. The practise of medicine is under the control of nonmedical groups, who have far more on their minds than healing the pains of the sick. The benefactors include the bootleggers, the dealers, the hit men, the police (who benefit by added jobs, duties and expanded authority), the ambitious prosecutors building political careers, the Bill Bennetts entrusted with sweeping powers whose rhetoric was like gasoline on flames. "I would behead the dealers," he said at one point.
These various forces, operating under loud shouts about saving the people, have added nearly a million persons to the prisons --- many under life sentences, and many for minor drug possessions. They have added to our racial difficulties by providing Farrakhan with an issue on whether the possession of crack deserves more punishment than the possession of pure cocaine, which he charges illustrates the differences in the treatment of ghetto drug users and white collar users. (Note that we do not say addicts, because all users are not addicts. Some users simply like to defy the law.)
We are enduring, on a grander scale, another and much fiercer Prohibition. Because of our towering international position we have drawn other nations into our effort. Manufacturing narcotics for the American and West European market is now a highly lucrative, complex worldwide industry with factories, transport, salesmen, guns, carriers, and distributors. It is undermining entire nations, such as Colombia, and to a large extent our own.
The medical profession has lost its centuries-old independence from the supervision of medically-untrained persons. Physicians, under present regulations, might as well be sitting in government departments. Mandated health plans are discussed over their heads, as though they are creatures to be regulated --- or unregulated --- by legislators, bureaucrats, policemen, insurance firms, and clerks. In that, they have joined accountants, who can keep no secrets from the government, and taxpayers who are also warned against holding any transaction private.
The legal profession, which has helped devise many of these rules, is not exempt either. The courts have ruled, long since, that lawyers must report fees accepted in cash, and return such fees if their clients are found guilty of drug offenses. The Drug War is sweeping through the liberties of all. De Tocqueville's warning that a democratic government, which treats everyone alike, "covers the surface of society with a network of small complicated rules, minute and uniform...." is proven.
The Drug War, almost universally applauded as necessary and essential to maintain a civil and safe society, is actually the vehicle that is unhinging our society. The example was clear in our first effort at Prohibition in our fathers' generation; it is strange that its repeat is not universally recognized as constituting the same evil solvent.
Do physicians recognize the full impact of the Drug War upon their profession? Apparently not. Mexico makes a fine border living from treating desperate Americans not seeking liquor, as in the old days, but medical relief from the new prohibitions. Natural foods, vitamins, "health" brochures, miracle cures, tons of patent medicines, and nearly universal "workouts" are efforts to stay healthy, to remain strong --- at all costs, to stay away from doctors.
To allow physicians, afraid of the government or the police, or both (the two are becoming indistinguishable), to take refuge in antiquated, obsolete, and ignorant theories about "imaginary" pains when people are in visible agony is to abandon them to Kevorkian and his supporters.
The doctors, in other words, believe that pain (like the poor) will always be with us. Most doctors prefer to leave pain to the patients themselves, or to priests, or to nurses, while the surgeons perform heroics and the rest turn their attention to more important issues like life or death.
In reality, Kevorkian's "patients" would not exist were it not for the cavalier attitude of some physicians toward pain. All Kevorkian's pitiful clients --- people who preferred death to life in pain --- had been through uncaring hands. Kevorkian is, of course, openly practicing euthanasia --- and has entire groups applauding his efforts, while the courts pretend there are no laws to restrain him.
If the medical profession in this land is to ever regain the respect of the people, it will have to show much more courage vis-à-vis the politicians, and more concern for the suffering of the sick, than it does now. Medicine should restore sanity to the nation on the issue of drugs, and lead the reaction against the excesses and ignorance of our increasingly destructive Drug War.
Otto Scott is the editor of Otto Scott's Compass, a monthly commentary on contemporary issues of modern civilization as seen from a historical perspective. It is published by Uncommon Media, P.O. Box 69006, Seattle, WA 98168, 800-994-2323. A longer version of this article appeared in Otto Scott's Compass, Vol. 6, Issue 65, January 1, 1996.
Originally published in the Medical Sentinel 1998;3(4):141-143, 148. Copyright © 1998 Association of American Physicians and Surgeons (AAPS).