pain: a class issue

"He's gonna step on you again..."

Tina Rosenberg is an uneven writer – she wrote an excellent first book, about violence in Latin America, but since then her record is spotty – she wrote a very goofy piece on DDT a few years ago that swallowed every libertarian canard ever manufactured – as is well known, libertarian canards can be dangerous to your health. However, she is still hopping down the chemico-neural trail, and the result this time is better.

LI is an old fan of recreational percocet use, although now that we exist in the economic basement, we are content to groove on the lows procured from almost any storebought infusion of confusion. This here American culture is always coming up with more and more drugs to wipe out experience (the experience of wrinkles and impotence, for instance, which seem to truly bug your average householder), while at the same time we get bristly about pain pills – all of which points to what is at the root of the American soul: alcoholism. The only legitimate stupors are beer, wine, whisky or religion, and all else is hocus pocus that has to be justified by shrieks and years of organic damage.

Of course, given the inequality in the country, LI needs to modify this: the killing of pain, like anything else, is distributed in this country in a pattern that follows money. For the poorest, there are doctors like the central one in Rosenberg’s article, Ronald McIver - who is “a doctor who for years treated patients suffering from chronic pain. At the Pain Therapy Center, his small storefront office not far from Main Street in Greenwood, S.C., he cracked backs, gave trigger-point injections and put patients through physical therapy. He administered ultrasound and gravity-inversion therapy and devised exercise regimens. And he wrote prescriptions for high doses of opioid drugs like OxyContin.

McIver was a particularly aggressive pain doctor. Pain can be measured only by how patients say they feel: on a scale from 0 to 10, a report of 0 signifies the absence of pain; 10 is unbearable pain. Many pain doctors will try to reduce a patient’s pain to the level of 5. McIver tried for a 2. He prescribed more, and sooner, than most doctors.”

Eventually, playing near the edge, he fell in:

Some of his patients sold their pills. Some abused them. One man, Larry Shealy, died with high doses of opioids that McIver had prescribed him in his bloodstream. In April 2005, McIver was convicted in federal court of one count of conspiracy to distribute controlled substances and eight counts of distribution. (He was also acquitted of six counts of distribution.) The jury also found that Shealy was killed by the drugs McIver prescribed. McIver is serving concurrent sentences of 20 years for distribution and 30 years for dispensing drugs that resulted in Shealy’s death. His appeals to the U.S. Court of Appeals for the Fourth Circuit and the Supreme Court were rejected.

Caste crime is severely punished in this land of jails. If McCiver had been treating a higher caste of patients, he would, of course, still be practicing like a pain djinn.

“But with careful treatment, many patients whose opioid levels are increased gradually can function well on high doses for years. “Dose alone says nothing about proper medical practice,” Portenoy [chairman of pain medicine and palliative care at Beth Israel Medical Center in New York] says. “Very few patients require doses that exceed even 200 milligrams of OxyContin on a daily basis. Having said this, pain specialists are very familiar with a subpopulation of patients who require higher doses to gain effect. I myself have several patients who take more than 1,000 milligrams of OxyContin or its equivalent every day. One is a high-functioning executive who is pain-free most of the time, and the others have a level of pain control that allows a reasonable quality of life.”

There is one law for high-functioning executives and another law for you, reader.

As a drunk among nations, America is inclined, when sober and headachey, to resolve on radical cures. It’s best cure is always prohibition. Its an ace resolve, all the better because – of course – it is impossible to implement. Thus it can continue the cycle of sin and guilt, which is the whole point:
“Several states are now preparing new opioid-dosing guidelines that may inadvertently worsen undertreatment. This year, the state of Washington advised nonspecialist doctors that daily opioid doses should not exceed the equivalent of 120 milligrams of oral morphine daily — for oxycodone or OxyContin, that’s just 80 milligrams per day — without the patient’s also consulting a pain specialist. Along with the guidelines, officials published a statewide directory of such specialists. It contains 12 names. “There are just not enough pain specialists,” says Scott M. Fishman, chief of pain medicine at the University of California at Davis and a past president of the American Academy of Pain Medicine. And the guidelines may keep nonspecialists from prescribing higher doses. “Many doctors will assume that if the state of Washington suggests this level of care, then it is unacceptable to proceed otherwise,” Fishman says.”

"He'll stamp out your fire/he can change your desire/don't you know he can make you forget you're the man"


Scruggs said…
Whence this calculated, smirking mercilessness, Roger, this fascination with torturing people -- keeping them alive, forcing them to stay alive and keeping them in pain? It crosses our country's nominal ideological boundaries to an extent I'd call pathological. Only the minority ideologies oppose it, officially (among them the libertarians).
Brian said…
All part of the Culture of Life, Mr. Scruggs. The Culture of Life.

Hey, roger: thanks for getting rid of that awful scrambled text coding to post. I am, after all, only an Artificial Intelligence Entity and was stymied at times by the wierd patterns!
roger said…
Brian, actually, that was North's suggestion. Although I should claim it as an act of administrative genius on my part!

However, my own opinion on Mr. Scrugg's question is that ... I'm not sure where fear of not keeping patients alive, the "forcing them to stay alive and keeping them in pain" thing comes from. I think we are living in a medical environment nobody has ever encountered before. At the same time, the old extended family is gone, which means that those living in the highest pain and mortality zone - the aged - are living on their own. I'm not saying this as though it were a bad thing - it is just a thing - but there is an awful lot of guilt attached to it. As the apes who punish themselves, we've all learned to associate pain with punishment - there is a sort of synaptic jump which occurs when one has a pain to 'what did I do to deserve this", which is all about that pain-punishment connection. I could get all Nietzschian about this, but then Mr. Scruggs would have to shoot me.

However, I believe that the pain-punishment association is built into the floating guilt around these issues. That's why it seems, sometimes, as though America is the drunk among nations - we have that same cycle of binge and regret, with regret codified in legislation and law enforcement agencies that are more than happy to force regret down your throat. In the article I referenced, there are a number of accounts of people in so much pain they can't do things, like sleep. The obvious question then becomes: why is it worse to be addicted than to be in constant pain?
On a more surface level, of course, Rosenberg's article is just another proof that as soon as the DEA appears, in any way, to get involved with any issue, everything goes to shit. It will be a small triumph for civilization when the DEA is abolished.