Editorial Comment 5/21: Fear
Editorial Comment: Fear
1. Even for this periodical, the variety of topics included today is unusual. The We Rise project in the Los Angeles, alcohol use in pregnancy, the impact of psychostimulants on opioid use and mortality rates, alcoholism and emotional responsiveness, major national policy initiatives, and the adverse effects of early discontinuation of opioids in those on long-term management are among these. A week seldom goes by without this periodical including a piece that reflects the concerns of physicians about governmental restrictions placed on either opioid analgesia or pharmacologic management of opioid addiction; so noting that frequency leads to the following overview.
2. Life is a projective test; and sometimes the perceived projection leads to anxiety, and fear. The heating-up of the opioid endemic (sic) has raised several sources of fear for physicians. The obvious one is the consequences of the Harrison Tax Act of 1914, which led to 25,000 physicians being indicted and 2,500 imprisoned by the early 1930s for attempting to treat those with opioid use disorder (heroin and morphine addiction, at that time)*. As regulations are increasingly creatively-interpreted by authorities, many physicians are justly worried that through an act of professional responsibility, in seeking to care for the addicted patient, a physician will be found in violation of some more rigid interpretation of the methadone or buprenorphine prescribing statutes. This seems a reasonable fear, given history.
But a second source of fear, of anxiety at least, is subtler, perhaps even less-than-conscious. It proceeds from the experience of seeing so many patients, with so many illnesses, in pain. Leaving aside the role of pain in identifying injury or illness, supposedly as a protective factor in evolution, there is the effect of pain as a source of impairment. Not merely does pain interrupt one’s capability, it robs the individual of dignity. Dignity, not merely of the sort associated with a “stiff upper lip” and the willingness to endure adversity; but dignity in the sense of having a function, of being able to perform the things for others and things for oneself to which we were once accustomed. Dignity in that sense of having a role or purpose is a mainstay of our professional identity; and as those reading this know well, professional and personal identity in medicine are usually co-mingled.
So, one of the greater fears for us – for me, anyway, this is the projective test - is that no one may be able to provide for our pain when it occurs. And fear impels severe reactions. Who knows, perhaps this was an unconscious motive at the outset of the era of over-prescribing? Not everyone’s chronic pain will derive from an obvious source, or be excused as a result of progressive cancer or known, irremediable, progressive, disabling illnesses. We want the solution for pain in extremis to be available, even should the better choice not commonly be an opioid. At the same time that I may have an addiction which compels careful and judicious management, or may be at hereditary risk for development of compulsive use, I should like some common sense to prevail: when I fracture my femur, or have my inferior myocardial infarction, I don’t want to find that we have proceeded so far down the line of opioid prescriptive restriction that I will hear the words, “I’m sorry, but you have reached your limit.”
* William L. White, in David LL. Musto, One Hundred Years of Heroin, 2002
- William Haning, MD, DFAPA, DFASAM