Pain (33 page)

By the late 1990s, other studies found that pain relief echoed other forms of social discrimination; patients who received treatment at outpatient cancer clinics serving minorities were three times more likely to be undermedicated with analgesics than patients in other settings. Researchers could only speculate about the origins of such disparities, listing the possibilities: “inadequate prescribing of analgesics for minority patients may result from many factors, including concern about potential drug abuse in minority patients, fewer resources with which to pay for analgesics, greater difficulty in accessing care and in filling prescriptions, and greater difficulty for the physician in assessing pain in minority patients because of differences in language and cultural background.”
⁴⁹
Reforming such a system that produced hidden, rather than explicit and articulated, forms of discrimination (including both overtreatment and undertreatment) was a perplexing problem, akin to the battle against what critics called “institutional racism.”

Gender differences in pain assessment were also obvious. According to one influential scholar, women were more likely to be sedated for pain. Discussing her findings at a 1997 Capitol Hill breakfast briefing on pain
management (sponsored by Iowa Democratic senator Tom Harkin and hosted by the pharmaceutical company Bristol Myers-Squibb), Christine Miaskowski, professor of nursing at the University of California, Berkeley, noted that pain's undertreatment was a “major public health problem.” In some contexts, women seemed to receive dramatically better pain relief. A few years later, Miaskowski's studies found an even more complex gender story in pain: women were more likely to complain about pain, were less stoic, and were also less accurate in reporting their pain than men. Women were more expressive in describing their pain, she argued, yet they were also better at coping with pain than men. Men were less likely to be sedated for pain, but they were more likely to receive pain medications like OxyContin. The findings, of course, echoed and informed broader gender stereotypes—or as a 2003 article on pain in
Good Housekeeping
noted, pain followed a “clear gender gap.” Women were “more inclined than men to describe their symptoms emotionally, they [were] also more likely to have their problems downplayed by doctors … or dismissed as purely psychological.”
⁵⁰

That pain should have a gender and racial politics is not a new observation; the meanings assigned to anguish, complaint, and identity had always been a perplexing question in culture and politics. As historian Martin Pernick has noted, at the birth of modern anesthesia in the 1840s, a vibrant discussion flourished about pain, race, gender, and difference. The well-to-do, women, and Anglo-Saxons were said to have a higher sensitivity to pain, while Native Americans, the poor, and blacks were characterized as constitutionally less sensitive to pain.
⁵¹
For Mark Zborowski, writing in 1969, pain expression told the story of different ethnic groups—Anglo-American stoicism, Jewish suspicion and complaint, and so on. For Reagan in the 1980s, disability pain in those seeking government support was deeply suspect; “fetal pain” was real. These attitudes toward the pain of others evolved with the political milieu, informed by prevailing attitudes and by a broader politics of belonging and citizenship. In the 1990s, the new question was how these issues of identity could drive overtreatment for some and undertreatment for others. The answer was that minority people in pain and women in pain (depending on their context) were subject to an extra level of surveillance, because to provide pain relief was still, as it was in the nineteenth century, an act of policing boundaries of acceptable behavior and identity.

Disparities in pain relief thus shed light on a fragmented society where the undertreated and the overmedicated were both microcosms of a growing trend in American society where the gap between the poor and wealthy had grown; gaps in pain and relief merely reflected the social divide. This political atmosphere explains how undertreatment (and the image of physicians as denying of care) became a hot-button issue for some, as HMOs and private insurers came under withering criticism for their efforts to limit access to care, while overmedication vexed others. Disparities existed in many places—in the Los Angeles and Atlanta emergency rooms, in chronic cancer care in Wisconsin, in the sickle-cell disease clinics of New York City, and also at the local pharmacy. “We Don't Carry That” ran the title of one study in the
New England Journal of Medicine;
it pointed to yet another problem, “the failure of pharmacies in nonwhite neighborhoods to stock opioid analgesics.”
⁵²
Researchers in the 1990s saw these racial disparities in relief, but they were ill equipped at the time to see that these differences between the haves and have-nots had deep origins in the social, political, and economic relationships of the time.

The undertreated (their numbers, their alleged character, their deservedness) inspired political wrangling and new alliances, as drug companies strategically sided with them. The marriage of patients in need and drug company self-interest had become a regular part of the political landscape since the 1980s. Activists groups such as the Drug Reform Coalition Network insisted that the undertreatment of chronic pain was “one of the saddest and least noticed consequences of the war on drugs,” with the problem stemming from physician ignorance and fear on one hand and law enforcement threats on the other. For them, “the enemies in the battle for pain relief [were] state medical boards and the Drug Enforcement Administration.” They had allies in government, singing from the same script. Presenting the case at the 1997 Capitol Hill meeting sponsored by Senator Harkin and paid for by Bristol Myers-Squibb, all could agree with the spokesperson for the National Institute of Nursing Research who saw the problem as far reaching. “In 1987, 90 million Americans were living with chronic conditions, with direct health care costs of $272 billion annually.” By 1995, the number had risen to 99 million. The cost of relief ran to $479 billion annually and was expected to grow. By 2030, it was estimated that 148 million people would have chronic
conditions, with an annual cost of $798 billion. Here was another byproduct of the OxyContin era, as elected officials from the left, pain reformers, and industry agreed that “pain is our nation's silent public health crisis” and that physician prosecution and “legal myths” about pain relief undermined patient care.
⁵³

Advocates for liberal relief charged that many of the undertreated were becoming pseudoaddicts, a new term expressing their frustration with the perverse effect of a surveillance-oriented drug policy. The Reagan years had brought renewed attention to illegal drugs, with heightened prosecutions of drug offenders, the “crack” cocaine scare, and a new push for mandatory minimum sentences—all of which cast a shadow over the pain market and pain drug consumers. Coined in 1989 by pain specialists D. E. Weissman and J. D. Haddox, “pseudoaddiction” described the behavior of a patient in real chronic pain whose pain was not adequately relieved with the prescribed opiate analgesic regimen. Chronic undertreatment forced the person to try to procure more medication. “In such cases,” experts who adopted the term noted, “the drug-seeking behavior ceases once pain is well controlled.” Advocates for pain reform used the term to highlight the failure (indeed, the counterproductive failure) of the war on drugs. The behaviors of patients who were not adequately relieved by their prescriptions could easily be confused with that of drug addicts. As this new theory of pain behavior suggested, not all drug-seeking behavior was criminal or suspicious, and moreover denial of pain relief actually
created
the criminal behaviors.
⁵⁴

Amid such obvious overmedication and troubling undertreatment, Americans grappled with where and how to intervene in such a broken relief system—how to do surveillance while showing compassion. One avenue (the law-and-order approach) embraced aggressive federal and state prosecutions of “pill mills” (a new term in the late 1990s associated with rogue doctors, new pain-management clinics, and online pharmacies allegedly pursuing profits through excessive prescription writing) and fraudulent users. Another route (the bureaucratic path) involved new hospital regulations, pushed by organizations like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to promote better pain monitoring.
⁵⁵
Yet another pathway (the surveillance approach) involved enacting prescription drug surveillance systems in state law enforcement to monitor and identify doctor shopping before it became
a problem. As some reformers saw it, a fourth reform, industry regulation, involved stricter regulatory control and prosecution of deceitful pharmaceutical marketing and advertising practices. Yet others advocating a more libertarian approach pointed to the problem of untreated pain, the lack of options for many people, and the need for more, rather than fewer, pain remedies. For them, California's medical marijuana law was the model to follow—encouraging “compassionate” relief for people with HIV, wasting diseases, and other painful conditions. But for those critiquing American consumerism, the public's overreliance on pills for all their ailments had become not a solution but the new problem.

In 2003, Limbaugh's lawyers asked the judge in his case to see the radio star as a victim twice over; it was an unlikely legal argument for the conservative provocateur, but it accurately captured the tenor of the times. His lawyers claimed that Limbaugh had been victimized, in this instance by a drug that had been falsely offered to physicians as safe and nonad-dictive. He was a victim, that is, of the boom and bust market in painkillers that accompanied his rise to fame. Second, his lawyers alleged that—once charged—he was now victimized again, this time by excessive state surveillance and enhanced police powers as prosecutors seized his medical records in Florida (a regional locus of pill mills) and California. These actions, his lawyers said, amounted to a violation of privacy by state governments that had grown too enamored of surveillance at the cost of doctors' and patients' rights. In December 2003, the Florida judge dismissed Limbaugh's privacy argument, but his attorneys appealed and the costly debate over state power moved up the judicial chain.
⁵⁶
With the political clout, media platform, and financial resources to defend himself (using these libertarian claims), Limbaugh's court battles increasingly focused not on his pain or right to relief but on intrusive government power and its expansive surveillance.

The debate on pain medication, including Limbaugh's case, reflected a broader debate in the 1990s and 2000s on regulation and deregulation, market freedom and government control. The OxyContin promise distilled many ideals of the era into one drug: the promise of fast relief without
dependence; the promise of a return to an active lifestyle with pain suppressed without deficits in functioning; the promise of few, if any, side effects; the promise of liberal end-of-life care without opioids; and the promise to remedy enduring gaps in access to care among underserved populations. But pharmaceutical companies' claims of fast relief, like conservatives' claim that markets function as elixirs for social pain, proved to be deeply flawed and dangerous to the body politic. Pain medication was not just a sideshow in the era's political theater, it was a major site for political maneuvering and policy formation—and OxyContin powerfully revealed not only the problem of pain relief but many of the social tensions and anxieties that defined the 1990s.

OxyContin grew out of conservative market policies, but the product also grew out of liberalized relief, riding the desire to extend relief to the chronically undertreated. Although blame for overmedication was obviously shared among doctors, patients, and pharmaceutical companies, it is clear that companies like Purdue Pharma had
especially
taken advantage of the political environment created by both liberals and conservatives.
⁵⁷
Only later, in 2010, would it be disclosed that Purdue had funded the pain awareness groups who had lobbied aggressively for the undertreated, supporting such organizations as the American Pain Society and others pushing for reform. By 2012, advocates for liberal pain relief admitted that they had been so keen on the mission of pain reform that they had not looked skeptically enough at the company's claims. A leader of the reform effort, Russell Portnoy, who had been a prominent adviser to the FDA in OxyContin's early years, was also a paid speaker for Purdue Pharma and many other companies with pain drugs to sell. Ten years later, the breadth of those payments to liberal pain relief groups became much more clear.

In a scathing letter to the American Pain Foundation, the American Academy of Pain Medicine, and other reform groups, Senators Max Baucus (conservative Democrat from Montana) and Charles Grassley (moderate Republican from Iowa) laid responsibility for OxyContin at the feet of liberal advocacy groups as well. The painkillers actually killed “more people than heroin and cocaine combined,” they alleged. They denounced “extensive ties between [drug] companies that manufacture and market opioids and non-profit organizations such as the American Pain Foundation, the American Academy of Pain Medicine, the Federation
of State Medical Boards, the University of Wisconsin Pain and Policy Study Group, and the Joint Commission”—all of which depended on pharmaceutical industry subsidies. Using industry funds, such groups had produced thinly researched “guides for patients, journalists, and policymakers” that played down the risks and exaggerated drug benefits.
⁵⁸

Just after the Limbaugh OxyContin story appeared in 2003, the columnist Clarence Page noted that Limbaugh's views on drugs had evolved. Page hoped that, in the wake of his long-term abuse, Limbaugh might become a “powerful voice … on behalf of other non-violent drug abusers who could benefit from treatment instead of incarceration.” “He could make a very good conservative argument,” said the columnist. But this hope was, of course, a liberal's dream. Portraying himself as a victim in court, Limbaugh struck a defiant pose on the air. He was unapologetic, politically combative, and partisan when he announced his addiction: “The Democrats still cannot defeat me in the arena of political ideas,” he said. “And so now they're trying to do so in the court of public opinion and the legal system. And since I'm not running for office … they're going to seek the occasion of this event in my life to see, to find out if they can do any damage.”
⁵⁹