The war on drugs and the doctor-patient relationship

The first time I became aware of the criminalization of disease was in high school, when I found out that there are two kinds of glaucoma, and with one of them you can go blind a little more slowly if you smoke marijuana.

There are doctors out there willing to quietly look the other way while a patient in their care uses marijuana to treat something like glaucoma or the nausea from chemotherapy, appetite loss from hepatitis C, anxiety, seizures, insomnia, anorexia, back pain from muscle spasms, gastrointestinal issues, post-traumatic stress disorder, HIV, or a lot of other things because they see doing what works as part of patient care or their duty to their patients is paramount or the war on drugs should be fought somewhere other than their office.

Unfortunately, our government does not agree and is more than happy to fight the war on drugs pretty much wherever, regardless of whether that is appropriate or conducive to other goals. Think for a moment about who you want making decisions about your healthcare, a trained and licensed medical professional who knows about your condition and personal history and who has the appropriate critical thinking skills to diagnose and treat you, and who is concerned about your health and welfare and what the best outcome is for you, or a cop, who has a degree in criminal justice, a gun, a baton, handcuffs, and a mandate to win the war on drugs.

What’s a cop going to do if I have cancer, arrest it?

It’s messed up when doctors have to break the law or conspire to break the law in order to treat their patients, to have to tell their patients that the only treatment is illegal, that our government has decided that the war on drugs is more important than their health.

Doctors are under increased pressure and regulation due to the war on drugs. Most of this is couched in terms of preventing substance abuse. It’s common for clinics that treat chronic pain to require contracts that lay out the terms of treatment, to require drug tests from their patients, ensuring that they are taking only what is prescribed, and to insist that no other care providers will prescribe pain medication. Patients caught violating these terms are discharged, regardless of how much pain they are in. Because the pain of people who break the law doesn’t count.

This creates a divide between doctors and patients. Rather than just having the obvious legitimate concerns about addiction and appropriate care, doctors now have to worry about being prosecuted for overprescribing or prescribing to the wrong person. This also pushes doctors toward prescribing less effective or less appropriate medications for pain. Patients who want to ask for more effective treatment are then caught between pain and the fear of being denied and classed as drug-seeking. This is particularly aggravated in patients who do not have health insurance.

A fair few people who do not have health insurance end up going to the emergency room for care. The ER is a pretty stressful environment. It’s supposed to be for emergencies, but with huge numbers of Americans uninsured and for those unable to afford a visit with a primary care provider, that has changed. The emergency room is a place where they can see a doctor, so when they really need one that’s where they can go. Understandably the emergency room is not happy about people who want to see them for low cost general care especially when they are trying to deal with actual emergencies, but if that’s where you can go, that’s where you go.

In case you haven’t had to go recently, a trip to the emergency room is time-consuming. You will probably have to wait several hours. If you go at a busy time, like on a Friday night, or to a hospital that has a lot of traffic, you will wait even longer. When you do go in, the doctor will not be thrilled to hear that you want a refill on a prescription, that you’ve been taking medication for chronic back pain and you can’t get by without it and you’d call your doctor’s office but it’s Friday night so they’re closed and someone stole your pills today while you were at work. And maybe this is true and maybe it isn’t and you’re just some asshole who wants to get high. Maybe you really do have pain. Maybe you’ve had pain and you’ve become dependent on the medication as a side effect of treatment, and now you have to deal with that on top of whatever else is going on.

So after you’ve had this terrible day and no pain relief and having to wait so long, you will probably be pretty irritable, which the doctor will like even less – not only are you coming in for something your primary care provider should take care of, but you’re taking it out on them. And then you ask for your medication by name and dose amount, and maybe they give it to you. Maybe they explain to you that you need to see your PCP for this. Maybe they decline and write in your record that you were irritable and drug seeking, because knowing what relieves your pain is a sign that you are an addict.

The war on drugs has not recognized that the dangers of not having medication far outweigh the dangers of self-medication, preferring to criminalize people who suffer from chronic pain or other conditions.

Of course this hits hardest people who do not have much in the way of economic privilege, people without money or insurance or access to affordable care, people who have disabilities and can’t work but haven’t been able to get Social Security yet, or people who have disabilities that they are able to keep under control and continue working through only if they have access to care and medication.

And when people do get out of this a little, when they get a job with health insurance or get on disability and get Medicare, their new PCP gets these ER records that say they’re drug-seeking and it’s harder for them to develop a relationship of trust with their doctor, and when the patient sees their doctor take the ER records from a really terrible day more seriously than what they say or any prior records of treatment it’s harder for them to be honest and tell the doctor everything and so the doctor/patient relationship is further undermined and the cycle continues. The war on drugs is not won.

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Some citations for people who want article links:
Here’s a 2007 Washington Post article about Dr. William Hurwitz and the reduction of his sentence.

Here’s a 2004 article on the adversarial relationship between doctors and the DEA.

NORML’s intro page on medical marijuana. Whatever you think about NORML’s goals, this has a ton of citations to other sources and they seem to have a solid legal team.

The stuff I’m finding on glaucoma says that marijuana works but not necessarily better than other medications, but what the other medications are or how much they cost or other issues around the studies isn’t specified. I’m also not finding a lot that says what the state of this was 20 years ago, so I’m really hoping that what this means is that treatments for glaucoma have advanced. Here’s a link to a National Eye Institute report on marijuana for glaucoma last reviewed in 2009, and a link to a medical marijuana site where they talk about glaucoma treatment with marijuana being a part of a larger overall plan of treatment.

Here’s a link and another link to some American Medical Association articles about issues they were having with the DEA.

I pulled a bunch of links from Democratic Underground’s messageboard. The comments may be illuminating if you don’t know a lot of people who have chronic pain.

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