First do no harm. Immediately our minds turn to physicians when we read or hear this phrase, yet the reality of “Pill Mills” in our cities and neighborhoods is one factor fueling the present crisis of faith in our health care system for many people. We are a nation that labels and stereotypes with great abandon, and with the numbers of criminals using an MD degree to illegally provide narcotic prescriptions for the price of an office visit, the negative label on the entire pain management profession was no doubt inevitable.
I was guilty of supporting that label, myself. For sixteen years I lived in a region where in the beginning, alcohol and marijuana were the primary recreational drugs. Over the years, however, I saw many beautiful, bright and charming young people become addicted to narcotics, and the drugs became easier and easier to obtain even in that isolated part of the country. A few years back, I learned about growing numbers of pain clinics in the region, and that students were “safely” obtaining legal prescriptions for their recreational drugs. The words “pain clinic” became anathema to me.
After I retired and moved close to a city several hours from where I had worked, my back pain was so severe and disabling that my primary care physician told me he was going to refer me to a pain management physician. I was stunned, then just plain mad. “No, thanks!” I told him, and he may have understood the unspoken question “Have you lost your mind,” though I tried to hide it. It took some time for him to convince me, first that the physician in question was highly skilled in interventions like epidural nerve blocks for the pain, and second that he was completely legal. Even so, I did not hesitate to inform said pain management specialist that I did not need his services except for the epidurals.
I like to think that I am a fairly open-minded person, and six months later (and in much better health largely as a result of the care received from my pain management physician) I am now a patient in the pain management clinic, where my physical intolerance of narcotics and other medications is taken in stride. That is to say, I finally remembered my sociological training (to say nothing of my own teaching on the subject) and realized that no matter what my experience was in my former place of work, it did not come close to describing an entire branch of medical expertise and practice.
First, do no harm. But physicians are not the only group that should make decisions with this caveat in mind. I, for one, had to accept that the caveat applied to me, as well. How much harm did I commit in my righteous indignation over the felonious pill mills? I hope not as much as our legislators and law enforcers have done by tarring innocent physicians and patients with the stereotypical labels of pill pushers and drug seekers.
Legislators can bring about costly changes in the way that laws are made and enforced, resulting in potential harm to many people. The current “war” on opioids is a prime example.
Lawmakers are subject to pressures from the press, from their financial supporters, and their colleagues. Faced with the need to satisfy so many groups with vested interests, to first do no harm often seems to be the farthest thing from these officials’ minds. However, a few states have passed legislation designed to protect both patients with chronic pain and the physicians who prescribe for them. Indiana is one such state.
In 2012, an Indiana Senate committee introduced a bill that would become IN SB246. The final version of this bill http://www.in.gov/legislative/bills/2013/SB/SB0246.2.html was passed in 2013, based on advice from a panel that included physicians and the Medical Licensing Board. The Medical Licensing Board then enacted an Emergency Rule effective on December 15, 2013 http://www.IN.gov/mlb . The Emergency Rule established standards and protocols for physicians who prescribe controlled substances for the treatment of pain.
You will note in reading the rules that there is a clear separation between medical license regulations, and activities termed felonious that must be prosecuted. The law covers the latter category only, and leaves control of errors in staying within the bounds of regulations to the proper authority: the Medical Licensing Board. This is precisely where many other state, local and federal government bodies have gone overboard, causing unnecessary pain and grief – even loss of life—to innocent persons by including professional regulations with actual laws. As a result, people have been needlessly targeted – “profiled,” to be exact—as living outside the law. People such as respectable physicians, living within the law, as well as persons who have been non-addicted, chronic pain sufferers, trying to manage their suffering “just enough to cope,” to remain productive. All have suffered needless, devastating, harm.
To some, the Indiana Emergency Rule seems very strict. However, given the reality of drug abuse, illegal drug trafficking, accidental and purposeful suicides using opioids, and the growing number of people misusing a medical degree to set up “pill mills,” I choose to defer to the wisdom of the Indiana Senate and the advisory committee that worked with them. I believe they tried to first do no harm. In actuality, the Emergency Rule does not prevent physicians from prescribing opioids for chronic pain patients. Both physicians and chronic pain patients are protected when both groups stay within the parameters of this legislation. Anxiety over the new rules should be lessened as prescribers become familiar with the details.
If we are to be successful in striking the balance between battling drug abuse and providing effective pain care, we must begin with education, followed with continuous reassessment of the results of our words, our laws, and our practice of medicine. Succumbing to the hysteria currently surrounding the prescription of opioids for pain care will take away the hope that chronic pain sufferers might find pain relief “enough to cope.” This will propagate a great deal of harm to millions of our fellow citizens. Laws that lead to the arrest of compassionate physicians, who are genuinely attempting to help their patients, create a situation in which great harm could befall upon innocents.
Thanks are due to those state legislative groups who have not bowed to the hysteria that would ban these pain relievers. Thank you, Indiana Senate, for thoughtfully drawing up a law that does not harm the citizens of our state. We can only pray that other states will follow your example; perhaps even improve upon it. As long as they also…
First, do no harm.