And People Say Libertarians Lack Empathy

People live every day with excruciating pain that is untreatable with current medications, either because the medication has nasty side effects or they have built a tolerance or both.  So I would have thought the prospect of a new medication to help these folks would be an occasion for good news.

But not according to Chris Hawley of the Associated Press.  I first saw this story in our local paper, and was just staggered at its tone.  The article begins this way:

Drug companies are working to develop a pure, more powerful version of the nation's second most-abused medicine, which has addiction experts worried that it could spur a new wave of abuse.

And it goes on and on in that vein, for paragraph after paragraph.  Through it all there is all kinds of over-wrought speculation, with nary a statistic or fact in sight.   This is not atypical of the tone:

"It's like the wild west," said Peter Jackson, co-founder of Advocates for the Reform of Prescription Opioids. "The whole supply-side system is set up to perpetuate this massive unloading of opioid narcotics on the American public."

or this gem:

Critics say they are troubled because of the dark side that has accompanied the boom in sales of narcotic painkillers: Murders, pharmacy robberies and millions of dollars lost by hospitals that must treat overdose victims.

Recognize that murders and robberies associated with narcotics are almost always due to their illegality, not their basic nature.  These are a function of prohibition, not the drug itself, which in fact is more likely to make users docile than amped up to commit crime.

It is not until paragraph 11 that the article actually acknowledges there might be some folks who benefit from this new medication.  And even this is a dry discussion of side effects by some doctors -- how about heart-rending quotes from pain sufferers?  Newspapers love to include these, except in articles on pain medications where I have yet to see one such quote.

But then the author quickly goes back to arguing that pharmaceutical companies are purposefully addicting patients as part of the business model

"You've got a person on your product for life, and a doctor's got a patient who's never going to miss an appointment, because if they did and they didn't get their prescription, they would feel very sick," said Andrew Kolodny, president of Physicians for Responsible Opioid Prescribing. "It's a terrific business model, and that's what these companies want to get in on."

That's a pretty ugly way to portray this.  Couldn't you argue the same thing about, say, medications that suppress HIV?  What these opponents never discuss is that they are basically proposing to consign people who have chronic pain to life-long torture.   They are saying "better in pain than addicted."  Really?  I will take the addiction.  Hell, by the same logic I am addicted to water and air too.

The notion that we should force a person to live in lifelong pain because some other person makes choices we don't like regarding their own narcotic use is just awful.  Seriously, these are the same folks who say that libertarians have no empathy.

Postscript.  Only after her death have I really learned about the contributions of Siobhan Reynolds, who died the other day after years of fighting to bring the interests of pain sufferers into this debate.  Radley Balko has a memorial, but this AP article is about all you need to understand what she was fighting, and how easily the plight of pain sufferers is ignored in these discussions.


  1. Dan:

    Great post - thanks. I'm currently suffering intense pain due to a herniated disc, and am taking vicodin. I understand this drug has the potential for abuse, but without it, I'm home curled up in a ball feeling like I'm going to die instead of sitting here at my desk at work wasting time responding to a blog post rather than working!

    This reminds me of airport security. Because there are a few deviant people who want to bomb airplanes, all the rest of us law-abiding people are treated like potential criminals and subject to long delays getting onto a plane. People with chronic pain shouldn't have to go through hoops to get their medication just because there are deviants who want to abuse it.

  2. Fred from Canuckistan:

    "Through it all there is all kinds of over-wrought speculation, with nary a statistic or fact in sight"

    A journalist wrote the article so why would you expect anything else?

    Just like in AGW, fear mongering and hysteria sell newspapers.

    The truth, not so much.

  3. me again:

    Two years ago I spent all of March, April, and May in abject pain because of a neck problem. Chronic pain saps the life out of you and I wouldn't wish it on Mr. Hawley, but I would drop a little fist to the face pain on him.

    Dan - good luck getting through the pain. I found a neurologist who took the time to figure out what was wrong. He did a one hour procedure on my neck and when I woke up from the surgery I knew he had fixed me. I hope you can find the same result!

  4. NL_:

    Of course, the dependence on doctors for prescriptions is a function of the prescription system. Doctors and pharmacists like a system that requires their constant involvement and consultation. If he wants to free patients from the tyranny of regular appointments, then he can start a group that believes in freedom from the prescription requirements.

  5. Pakkinpoppa:

    I agree.
    I had two hernias and two thyroid surgeries. Most painkillers didn't do a darn thing for me.
    Whatever is in Tylenol 4 did for my 2nd hernia and while I recognized the reason people might abuse it, I also recognized it as almost the same (not quite) sensation one got when drinking, smoking a left hander (ahem...from what I've been told, of course), so of course there's potential for abuse.
    People can abuse anything. Does that mean we make life illegal? I sure hope not.

    As for the abuse side...well, it makes a handy excuse that "the doctor got me hooked on pain pills" I'm sure.

    I have seen people who claim prescription painkillers are the gateway to heroin. And for some people, I'd bet it was.

    I had a personal story to tell about somebody addicted to painkillers, someone I knew, but I don't blame the drugs. And decided not to tell. (No, not me, but somebody I was close to for a while. May she find peace, but I couldn't help her.)

  6. Dan:

    Thanks, Me Again. Glad it worked out for you. I'm optimistic that somehow, I can get relief. Trying an epidural injection in early Jan. I feel too young to be dealing with this. As soon as I hit 40, this happened, and I've been in lots of pain since. Hope this isn't a sign of how middle age and old age is going to be for me.

  7. Johnathan:

    There's another dimension to this that the article touches on briefly, but doesn't go into detail. There is no "pure, more powerful version" of hydrocodone, there is just hydrocodone, which is synthesized to the requisite pharmaceutical purity as part of its manufacture. However, it is then combined with acetaminophen (APAP) when put into pill form.

    Why is this done? Is it because there is some synergistic effect of hydrocodone and APAP? No. APAP has a very low therapeutic index, which means that the toxic dose is not much higher than its therapeutic dose. Thus, increased doses of this compound drug become toxic more quickly than would hydrocodone if dosed alone. This is intentional (and required for FDA approval), and is a way to "discourage" recreational use. It also means that patients who have become tolerant to hydrocodone's pain-killing effect risk liver damage if they increase their dose to compensate before they can visit their doctor to change their prescription.

    What kind of person thinks it is okay to require a patient to choose between pain and liver damage?

    The formulation in the article you quote is a new time release mechanism for hydrocodone that both provides extended duration pain relief as well as a lower potential for addiction (related to the rate of increase in concentration of the drug in the blood.) That is why it contains "10 times more" drug than Vicodin. But the reporting around this has been even worse than usual.

    I don't know, but I'm willing to bet the delay in bringing this to market is to satisfy FDA requirements that the extended release is difficult to "bypass" by dissolving the pill in an appropriate solvent to separate the hydrocodone from the inert ingredients. Making this type of pill formulation is difficult and expensive, so this also increases the costs to the patients and insurance companies that will pay for the medication.

    I can't think of a single aspect of this that is improved by any of the numerous state interventions on display here.

  8. Paul:

    Good job deconstructing this pathetic excuse for journalism "reporting" about a new form of an old drug which will soon be available to treat chronic pain. Speaking as a health care provider and prescriber, I know that most patients use their narcotics responsibly; only a few become addicted to where they escalate their use beyond that needed to control their pain. There are ways to structure the patient/health care provider relationship when treating chronic pain with narcotics to keep abuse to a minimum.

  9. David:

    I have chronic pain due to infection (treating, but it'll be a while), and then had a very painful injury (testicular torsion- I don't recommend it) and needed some even more serious meds for a while. I think these puritans must not have ever actually been in severe, not-going-away pain, or else they'd sing a different tune.

  10. el coronado:

    Good comments all, & I'm a chronic pain guy myself. But in comments on this article and many many others like it, I never see anyone bring up the *real* issue. It's not whether or not the DEA should have a say in how much painkillers docs prescribe, or how easy they are to abuse, or any of that.

    The question nobody asks is how is it that Congress is allowed to tell full-grown adults acting entirely of their own free will what they may or may not ingest/inject/smoke/eat? Whatever happened to 'keep your laws off my body'? Also, as government-supplied "healthcare" (LOL) continues to expand, does anyone think the problem of undertreating pain is gonna get better, or worse?

  11. Ted Rado:

    I am 83 and have had quad bypass surgery, heart attack, kidney stone, diverticulitis, knee surgery, backache, etc. I have known a number of people who got hooked on painkillers and am terified of that happening to me. When I was recovering from my various surgeries and problems, I frequently turned down offers of painkillers from nurses out of fear. Perhaps this was a mistake and I suffered unnecessarily.

    The bottom line is that we are each responsible for our own behavior. If one allows oneself to overuse painkillers, whose fault is that? Each of us must determine the optimum balance between pain and risk of addiction and then deal with it. The results are our own doing.

  12. dr kill:

    these might be the most reasoned comments in the blogosphere. well done.

  13. el coronado:

    @ Ted -

    FWIW, you may be suffering unnecessarily. As noted earlier, I'm a chronic pain guy, but it's off-and-on pain. Sometimes, Heaven smiles on me, and the hurt switches "off". When that happens, I go off the pills. Twice in the last 5 years, I have cold-turkeyed off a 80-to-100 mg./day Vicodin regimen. If you believe the movies and the media, I should have undergone agonizing withdrawal symptoms, massive sweats, pain, gone berserk looking for "a FIX, man!", all that.

    Didn't happen.

    What happened was 3-5 days of a most uncomfortable restlessness: couldn't sit still, couldn't sleep longer than 20-min stretches, felt like my skin was suddenly 2 sizes too small. Don't misunderstand me, here - it was exactly *zero* fun, and not something I'd really want to do again. But compared to all the pain I (didn't) have thanks to the Vicodin, it was....a piece of cake. A trade I'd make any time, any day. And it lasted all of 5 days, max. I'm not saying folks don't get addicted to painkillers; I've been told I have a higher-than-norm tolerance to them; your mileage may vary. But what I went through was MUCH MUCH better than pain, Ted. Even if you have to undergo a withdrawal 10x worse than mine, I think you'd still be coming out way ahead. But hey, don't take MY word for it: Theodore Dalrymple is a Brit prison doc & shrink, who's done extensive work with jailed "addicts". He's written articles in which he says that (paraphrase) physical addiction is a very unusual thing. He quotes several heroin (!) addicts who'd admitted to him that 'they didn't NEED a hit, they just WANTED one'. Based on my experience and others I know, I'd say that's about right. Also, no offense, but at 83, who gives a crap if you're "hooked" on pain meds? You've paid your dues, and you don't owe anyone anything anymore, right? Unless it's straight morphine, it's not going to ruin your brain or make you stupid or jump out a window because 'you think you can fly!'. At most, it'll make you somewhat sleepier. If you're in the level of pain it sounds like you're in, that would actually be a **bonus**, would it not?

    There is no Glory, or Honor, or Wisdom to be gained by being in long-term pain, Ted. I expect you know this to be true. So from one pain guy to another: TAKE THE PILLS!!, and get your life back. Best wishes, and good luck.

  14. ParatrooperJJ:

    What they are doing with the new time release drugs is encapsulating Narcan in a nondissolivable coating along with the time release encapsulated narcotic. When one takes the drug normally the Narcan capsules pass thru your system without being absorbed and the narcotic works normally. Whan an addict tries to grind up the pill the Narcan capsules are ruptured thereby allowing the Narcan to block the opoid receptors preventing the narcotic from working.

  15. Nevada Doctor:

    The palpably false pseudoscience of human alchemy is a formidable opponent to physicians.
    On the one hand you're Sir Isaac Newton that brings the tool of calculus to the world. Yet at the same time, you're the Dr Jekyll Newton who believes that base metals can be synthesized into gold. Even worse, you're the Mr Hide Newton who believes that better humans can be hammered out by using the anvil of prohibition and forced social engineering.
    There is nothing more damaging than acting adversarily against your fellow man based on false ideas. Indeed, it is the chief occupation of mankind.

  16. el coronado:

    You may want to back off on the Vodka & Absinthe there, Doc. That post was a somewhat trenchant and semi-wise analysis of the human condition, but you kind of lost control of it there right about after....oh....the first couple of words or so. Simpler and more accurate to say there's nothing more damaging to one's fellow man than 1)mistaken assumptions 2)regulatory & law enforcement mission creep and 3)stupidity.

    That plus, of course, every word the 'drug war military and industrial complex' spouts is a damn lie. If it was *their* mom, or wife, or kid suffering or in terrible pain, rest assured they'd be out there scoring doobies or oxy or dilaudid right there with the rest of the "druggie scum" they hunt, for fat paychecks and even fatter pensions. (Which they frown on us mentioning. "Heroes", doncha know.) May God's curse light upon them all; may their daughters become skanky toothless crack/meth whores; and their sons do long horrific prison terms for drugs planted on them in routine traffic stops by cops who grin & smirk while lying under oath in court.

    Bitter? Me? I came by it fair & square, believe me. Any cops out there who care to defend this ongoing (and accelerating) travesty?

  17. Sam L.:

    Some are so afraid of one outcome--addiction--that all other outcomes are just not worth it. For anyone. For any reason.

  18. I Got Bupkis, Fomenter of "small-l" libertarianism:

    >>> Whan an addict tries to grind up the pill the Narcan capsules are ruptured thereby allowing the Narcan to block the opoid receptors preventing the narcotic from working.

    LOL, I can already see how to crack this one, you just need to put the pills in water or whatever, something ingestable, which breaks down everything but the Narcan. Duh.

    I grant, it takes a bit of patience and forethought, but someone's gonna do it.


    I'm with the sensible people -- if you're going to abuse drugs, you're going to abuse drugs (and that opinion comes from observed experience) -- stop someone from getting one drug, they're going to go after an alternative.

    And most of the people who claim to be addicted are mentally so, not physically so. They just WANT it. And I'm not even saying it's not a powerful kind of want. So some people should suffer just because other people are weak-willed? Who the eph thinks THAT makes any sense?

    I've had serious back pain, and anyone who's had that knows you have a choice of either being utterly useless and in agony or possibly becoming addicted. I'll take the latter risk any day.

  19. John Hatchett:

    I'm a palliative care physician. Pain and symptom management is one of my specialties. A long acting oxycodone is sorely needed, just as long acting morphine has been helping suffering patients for decades. It is another tool to use in a field of great complexity and individual nuance.
    Addiction is a complex syndrome of genetics, social, and psychological makeup that is actually uncommon. Most people, if they have no pain, don't want to take these drugs. But even the addicted have pain and deserve compassionate care, albeit under close supervision, with well-understood parameters of use.
    This will be another advance in pain management which, for the right patient, will make all the difference.

  20. the other coyote:

    Isn't this "all for me, but none for thee" the same reason DDT is banned?

    In other words, an (incorrect, as it turns out) belief that some birds might have their eggshells thinned is directly responsible for the deaths of millions of Africans from malaria. Because God forbid a bird should suffer a population setback.

    Off topic - Coyote, there was a piece on NatGeo (I think) about some Eastern Coyotes (which appear to be a wolf / Western coyote cross) who attacked and killed a hiker in Canada. Very interesting program on a "super predator" with the smarts, resourcefulness, and adaptability of the coyote mixed with the bravery (in that they will go after prey as big or bigger than them) and cooperative hunting abilities of the wolf. These Eastern Coyotes have blockier heads and shorter, wider, more wolf-like muzzles than the beautiful specimen pictured in your masthead.

    My local coyotes feed mostly on mice, voles and barn cats, which is good considering how I'm old and slow.