My first panic attacked occurred in the middle of a volleyball match. I was 21, the players all U. S. Army, the location a remote island in the Aleutian chain. We were all there to eavesdrop on the evil Soviet Empire, but today we’d taken a break from our duties to relieve the boredom of routine.
It happened this way:
Early in the game, I leaped up at the net to deflect a strike from the other side when, with no warning, I was seized by panic: a powerful hand squeezed my chest, another gripped my throat. I gasped for air, my legs turned rubbery, my body trembled, my heart beat erratically. I collapsed to my knees and felt the world contract, time suspended in this vacuum. Dread, like a black rose, blossomed inside me.
Fast-forward fifty-plus years. I am perched on an examination table in the clinic approved by my insurance company. A very young female doctor—call her Dr. K—has just advised me that, given the excellent results of blood tests over the past year and a half, I can stop taking my diabetes medication. And, by the way, she asks, what about getting off your paroxetine and bupropion–the very drugs that keep panic at bay? Try counseling, perhaps?
Ah, yes, behavioral therapy. Just what the doctor ordered.
“I’ve been fighting panic attacks since I was 21,” I explain to her in a voice that is more rebuff than reason. “I spent thirty-some years controlling my attacks with pure willpower.” I saw no reason, I told the doctor, to return to that battle when my prescription drugs were already working as advertised, keeping all hints of panic at bay. Nipping that evil flower in the bud, so to speak.
End of conversation, as far as I was concerned. Dr. K must have sensed my determination because she didn’t contest my decision, only suggested that I think about it. This was not the first time I had run into Dr. K’s resistance to prescribing medications.
About a year earlier, I had injured my back, probably a seizing-up of the muscles, a problem I had experienced at irregular intervals since wrenching my back in my first job out of the army. Nevertheless, it was extremely painful and debilitating, and “walking it off” was off the discussion table: I could barely stand, let alone put one foot ahead of the other.
What I really needed, I told Dr. K, was a prescription for a painkiller like hydrocodone that I could take just before bed; otherwise, I would get no sleep and little rest. Which also meant I would have little energy and stamina for rehabilitating my back through exercise. I also reminded her of the well-known side-effects of high doses of ibuprofen or naproxen—I was especially worried about its effect on my liver. Finally, I told her, decades of experience with painkillers proved that I was not going to become addicted to hydrocodone. I had no desire to live my life in a blissful fog.
Likely motivated more by my intransigence than my logic, Dr. K was finally driven to seek the advice of the clinic director. I was more than a little curious and anxious about how her consultation would go.
Moments later, in walked the director–call him Dr. Big. He was there, I was sure, to size me up. In the diminuitive exam room, he seemed oversized. He was a big, affable guy. Big hands, big smile. We shook, smiled, made small talk. Drug seeker or hapless old man? he must have been asking himself. Our brief encounter over, he left the exam room with Dr. K in tow.
When she returned, Dr. K passed me a prescription for the lowest dose of hydrocodone with acetaminophen, a combination that is supposed to discourage overdoses, I read somewhere.
Over the next week, I used the hydrocodone sparingly, usually breaking one tablet in half in the evening before bed. It was enough to take the edge off the pain, let me fall asleep. And knowing that Dr. K probably would never again prescribe a narcotic painkiller for me, I was conserving my 30-day supply for the inevitable next episode of wrenched back.
* * *
Getting patients off medications is playing out less like a fad than a crusade these days. A crusade supposedly launched in the patient’s interest. Out of, I could say, an abundance of caution—except it’s a principle little applied in the United States unless it meets some political objective. Indeed, little attention is given to any problem unless it serves a political purpose.
In the case of drugs, the drive for a drug-free America is brought to us by our old friends at the Drug Enforcement Administration and all its government and non-governmental minions–starting with the DEA’s Office of Diversion Control and the National Institute on Drug Abuse to the International Narcotics Control Board, the National Association of Boards of Pharmacy, the National Association of State Controlled Substance Authorities, and the Federation of State Medical Boards; as well as, of course, the American Medical Association.
Its “war on drugs” having been flagged a failure by many in the fields of drugs research, medicine, and even law enforcement, the DEA could only have licked its chops at the chance to reinvigorate a dying campaign.
Like the National Rifle Association, the DEA has little use for objective research. Much as the neo-conservative club in Congress forbids any research on guns that might reflect badly on the gun industry or suggest possible effective measures to contain gun violence, so any report on illicit or regulated drugs, based on DEA-funded research, begins with the premise that a negative finding must be the result. [Anyone who doubts this statement should look up the DEA’s most recent finding that marijuana continues to be a dangerous drug—a policy of self-promotion over good science that flies in the face of evidence that cannabis has caused precisely zero deaths, ever.]
Handing over, or ceding by default, control of a drug campaign to the DEA guarantees more trouble ahead. President Richard M. Nixon set the tone for the modern effort to eradicate drug abuse when in June 1971 he gave it the self-important title “War on Drugs”.
Even statistics on opioid use are driven by law enforcement reports, which amass data designed to scare us just enough to justify more money and a larger headcount for the DEA. Only the Department of Homeland Security has a bigger claim on fear as a motivator and justifier of massive spending, personnel, and intrusiveness. Add ineffectuality to that list in both instances.
The trouble with DEA’s control of the opioid epidemic, as the CDC has declared it, is its limited supply of tools to bring opioid abuse under control. In the DEA’s hands, all such tools add up to coercion. Taking drug makers to court, raiding pharmacies, putting physicians on trial—such highly publicized stunts by the DEA have left primary care physicians, like my Dr. K, extremely leery of finding themselves on the agency’s blacklist. Loss of license and all that goes with that loss may scare doctors, but it has little impact on the problem.
That’s because so much of the pain-killer epidemic is fed by the passing of drugs from one patient’s cabinet to a friend or relative. This is certainly the case with teenagers, according to the National Institute on Drug Abuse.
Meanwhile, older patients living with chronic pain may find their supply of painkillers cut off. Doctors will recommend (as mine did) a host of non-drug therapies for pain, from exercise to meditation. Some of these “multi-modal” approaches to pain management can, in fact, reduce the pain elderly people experience.
But here’s the catch: most insurance companies, including Medicare, do not cover the cost of these alternatives. Catch 22. And some patients will still need opioid pain relief in conjunction with these alternative modalities.
When they do, writes New York Times columnist (The New Old Age) Paula Span, “[They’ll] get more questions, hear about more about alternatives—and take home fewer pills” [“New Opioid Limits Challenge the Pain-Prone,” 6/6/16.] Online.
And it’s our age cohort that needs pain relief most. In that same Times column, Span notes: “Older patients are more apt than younger ones to hurt from musculoskeletal disorders like arthritis, from nerves damaged by diabetes or shingles, from cancer, from multiple causes all at once. They have more surgery.”
At the same time, traditional over-the-counter (OTC) pain relievers “like ibuprofen and naprosen,” she notes, can cause “bleeding, elevated blood pressure, reduced kidney function.” These two OTC drugs are the ones suggested by my Dr. K.
Even if an older patient manages to get a prescription for an opioid, these days her physician won’t be able to call in a refill. The patient, no matter how debilitated, will have to make an office visit to have her needs evaluated by her doctor–every month. “Those can be onerous requirements for older people in pain,” Span writes.
In short, DEA dictates have brought to a standstill the campaign to overcome decades of under-prescribing for pain. So the Agency has brought us seniors and others back to square one. Not because caution in prescribing couldn’t be balanced with the need for pain control–something most doctors have been doing for decades–but because a regimen based on criminality, including midnight drugs raids, incarceration of users and doctors, and other draconian measures, sends doctors and patients scurrying for cover and makes the street trade in drugs flourish as a private enterprise.
As we “senior citizens” become an increasingly larger share of the U. S. population and the voting public, perhaps Congress will be forced to end its funding of the senseless war on drugs, which the non-governmental Drug Policy Alliance reports added up to 51 BILLION federal and state dollars in 2015. Legalize and regulate drugs and begin to funnel those funds into programs that deal with drug over-use as a public health issue, rather than as a crime.
Meanwhile, we must ask, how long before the Congress and the American public realize the drug war is a dead end?