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Q&A with Maia Szalavitz: Going Beyond Victims and Pushers for Pain Stories

Q&A with Maia Szalavitz: Going Beyond Victims and Pushers for Pain Stories

After I wrote a series of posts about some of the ethical issues surrounding pain management, journalist Maia Szalavitz contacted Reporting On Health with a complaint: "How come you guys never cover the other side in the pain issue?" She was right. Antidote has written repeatedly about painkiller addiction, pill mills, and, most recently, ethicists being investigated for their ties to the pharmaceutical industry. But we haven't written much about some of the issues she raised after asking that question.

Currently a writer for Time, Szalavitz also has written for the New York Times, Huffington Post, Psychology Today, Mother Jones and other major publications. She has authored and co-authored five books, including Born for Love: Why Empathy is Essential – and Endangered; Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids; The Boy Who Was Raised as a Dog: And Other Stories from a Child Psychiatrist's Notebook--What Traumatized Children Can Teach Us About Loss, Love, and Healing; and Lost Boy. I interviewed her via email. The interview has been edited for space and clarity. The first part is below. The second part will run next week.

maia szalavitz, chronic pain, reporting on health, addiction, william heisel
Q: You have written about what you see as an epidemic of media stories about painkiller addiction and a scarcity of stories about the ways opioids can bring relief to chronic pain patients. What makes you say that?

A: First of all, how many times do you see pain patients who aren't addicted represented in the coverage? That's actually the majority of patients on these drugs, one that is silent. Secondly, virtually all of the coverage portrays the situation as though doctors and drug companies are "making" patients into addicts and therefore, that cracking down on use of opioids for chronic pain will fix the situation. The real problem is that young people want to get high on opioids-even then though, only around 15% get addicted and for adults in middle age without a prior history of addiction, the rates are less than 1%, according to a review of research on over 2,500 chronic pain patients.

But the media likes innocent victims and evil drug pushers- and the drug companies have done some terrible things; I'm not defending them. However, just because drug companies may be evil doesn't mean they can't sometimes be right- and just because some pain patient advocates may have naively taken money from them doesn't mean they are just insincere and deluded dupes whose perspective should be discarded. The crackdown is making pain patients suffer, and it isn't even an effective way of fighting addiction.

Q: But those who support the crackdown claim that we don't even know if opioids actually help chronic pain.

A: Those claims are disingenuous at best. Because the FDA requires only short-term data on drugs for approval, long-term data doesn't exist for most commonly used drugs. This is not unique to opioids. Of course more data is needed always, but humans have a centuries' long history of using opioids for pain relief and most importantly, for many people, there are no alternatives that help. Do they work for everyone?  No. But they very clearly do work for many people and to ignore this is to condemn them to life in agony, even if they don't work perfectly.

Because of human diversity, it's rather like the antidepressant debate. Not all antidepressants are placebo. Antidepressants don't make all people who take them suicidal or homicidal. Nor are antidepressants a miracle cure for everyone. But all three are true for some people, and this makes the data really difficult to interpret. That shouldn't mean we say absence of evidence is evidence of absence.

Q: Are you taking issue with all the government reports – state and federal – documenting the rise in painkiller abuse?

A: I'm not saying that there hasn't been a rise in misuse of painkillers (abuse is a stigmatizing term that, research shows, actually pushes medical professionals to prefer punishment to treatment).

Nonetheless, this hasn't been driven by doctors turning patients into addicts. Most misusers of pain medications are pre-existing drug addicts. For example, a 2007 study in The American Journal of Psychiatry found that 78% of those addicted to Oxycontin had previously been in rehab and the same percentage never had a legit prescription for the drug. The same is true for people who overdose. A 2008 study in the Journal of the American Medical Association found that 95% show clear signs of drug misuse and addiction, like snorting or shooting drugs meant to be swallowed or the presence of street drugs in their systems. Most teens using the drugs don't get them from doctors:  Over 80% get from family or friends. And most pain patients aren't teens. They are middle-aged, and if you haven't become an addict before middle age, the odds of doing so are vanishingly low.

Q: I'm not sure we can just take people with addictions out of the equation. They are patients, too, and deserve a broader approach to treatment than just a stack of pre-signed prescription forms, which is what medical boards have found in some pain doctors' offices during investigations. These addictions may have started with an attempt to self-medicate a mental illness or a pain problem years ago. Why should we discount their experiences?

A: I'm not saying we should discount their experiences- I'm an ex-addict myself!

However, the "treatment" we're offering instead actually increases harm. Typically, when doctors discover that addicts have been scamming them for pain medications, they throw them out of their practices. This is not addiction treatment!  Indeed, a study in North Carolina found an increase in overdose deaths when they put a pill mill out of business. It is assumed that cutting off an addict's supply will cure the addiction or that punishment will. Data does not support either contention. Even in prison, addicts get drugs. Pain patients are the ones who suffer when legitimate supplies are cut off.

The irony is that the treatment with the best evidence for efficacy for those who are addicted would actually be a prescription for an opioid, either buprenorphine or methadone, and often for long term maintenance depending on severity.

So, why aren't these doctors allowed to simply say, "Let's be real. You have an addiction problem." They could then prescribe an opioid for them, referring them for counseling and additional services elsewhere if needed, though research shows that adding these services actually doesn't improve the results from simply prescribing!

There's a bizarre disconnect between what we do and what we know would help people, and it comes down to the fact that we don't look at this problem at all rationally.

Next: How to do your homework when writing about pain medicine

Q&A with Maia Szalavitz, Part 2: Understanding Addiction Through Science - and Personal Experience

Comments

There's more to consider with opioid use than abuse and addiction. Opioids certainly do help reduce pain sensation. But studies show opioids lower your pain threshold, meaning you need increasingly higher doses and addiction becomes inevitable even for those with no history of addiction. There's also evidence that opioids increase the spread of tumors, meaning there may be life-threatening health consequences to their sustained use. As with the antidepressant example, even when drugs work, they work at a cost - and not just in dollars and cents. If the relief for your chronic pain is a shorter life due to opioids' potential cancer-promoting effects, you may reach an entirely different conclusion about using them and be more aggressive in finding drug-free alternatives that may help you manage your pain, not eliminate it.

There is a tendency in the media to vilify medication. Ms. Szalavitz's point about antidepressants is right on. I'm not as well-versed in the pain medicine debate to say that about the other points she made, but I did find them interesting and important to consider. I wish there were more articles like this and more balanced reporting out there. Bravo to you, Mr. Heisel, for writing this, and to you, Ms. Szalavitz, for speaking out.

There's more to consider with opioid use than misuse and addiction. Opioids certainly do help reduce pain sensation for many people. But studies show opioids lower your pain threshold, meaning you need increasingly higher doses and addiction becomes inevitable even for those with no history of addiction. There's also evidence that opioids increase the spread of tumors, at least in cancer patients - meaning there may be life-threatening health consequences with their sustained use. From the medicinenet.com report: "Morphine can increase tumor cell proliferation, inhibit the immune system, promote the growth of new blood vessels (angiogenesis) that feed tumors and decrease barrier function. In cancer patients undergoing surgery, decreased barrier function may make it easier for tumors to invade tissue and spread to other parts of the body, while increased angiogenesis helps tumors thrive in a new location." As with all drugs, even when they work, they work at a cost - and not just in dollars and cents. If the relief for your chronic pain is a shorter life due to opioids' potential cancer-promoting effects, you may reach an entirely different conclusion about using them and be more aggressive in finding drug-free alternatives that may help you manage your pain, not eliminate it. This doesn't mean we should deny the use of opioids in appropriate situations like hospice care, but their use for chronic pain relief in non-terminal patients should be seriously circumscribed given their possibly lethal complications.

The evidence that opioids cause"hyperalgesia" or increase pain in some people is problematic. For one, this seems to affect only some types of pain, if you look at the studies, some tests show increases while others show no effect. The type of pain affected — the pain from sticking your hand in a cold bucket— is not clearly relevant to real world experience for most people. Secondarily, we've had thousands and thousands of people taking steady doses of methadone for decades for addiction— their doses don't infinitely escalate or produce increasing illegal opioid use as they would if they were causing increasing pain. In fact, illegal use goes down over time. But note my analogy to antidepressants: clearly, some people do get worse and I'm sure it's the same with opioids. That doesn't mean some don't get better. Regarding cancer, this is very new data and there is no evidence that methadone patients are particularly cancer prone (beyond the lung cancer from smoking and the cancers linked to their early life stress), nor is there any evidence that since we've expanded access to opioids for cancer patients, cancer is getting worse. The opposite is true. It's worth studying, especially because it could lead to tumor blocking agents — like drugs currently studied to treat opioid-linked constipation— that could capture this mechanism for use in treatment. But without more data, it's not something that should be part of the debate over compassionate access.

I have always been amazed at what "journalism" picks on when reporting about pain medication.  More amazed still at how too many doctors prefer punishment rather than prescribing adequate pain control for many patients.  No one should be able to walk into a doctor's office and ask for opioids, but when a doctor has been seeing a patient over time - or has access to his/her medical records - and there is no history of use, misuse, abuse or whatever of either drugs (as prescribed medications or not) and alcohol, there is no reason to leave people to suffer.  When I read John Lynch's comment, I have to say this:  Here in Québec, we have had a commission on dying with dignity.  I prepared a paper and presented my views and can tell Mr. Lynch that if I were a cancer patient not treated for pain being offered pain relief but for a shorter life span, I would jump on the occasion. 

Suffering is not necessary and it is unproductive.  My experience with chronic pain which is totally unstable and with many acute peaks has made me appreciate the days when there is lesser pain.  My doctor does not understand much about pain, and it is impossible to change doctors here when one third of Québecers have no family doctor.  Just recovering from the gastro-enteritis that is the sum of all such gastros experienced in 63 years, a funny thing has happened which Inoticed at the lastmilder gastro:  of course, when this happens, taking pain meds is useless because... this is so violent.  It is so violent that all other sites of chronic pain just quieten down.  Not having had pain meds in four days hasn't made me stark-raving mad and twitching and all.  Addiction happens with SOME people who take drugs for a good reason, but for most people with chronic pain, although there can be habituation, it is NOT addiction. 

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