By David Nagel, M.D.
“Those are rare who fall without becoming degraded; there is a point, moreover, at which the unfortunate and the infamous are associated and confounded in a single word, a fatal word, Les Misérables.”
—Victor Hugo, Les Misérables, Vol III, Book VIII, Chapter V
Jean Valjean still ranks as one of the great characters of literature. As the protagonist of Victor Hugo’s Les Miserables, Valjean finds a way to triumph over the evil of his fellow man — and in so doing he becomes a true hero, one who takes the gifts he has been born with, develops them, and then uses them to help all those around him better the world.
Idealistic French literature? Maybe. But there’s nothing completely abstract about this story; it happens every day in our country, just in a different form. In 1862 Hugo wrote: “So long as there shall exist, by reason of law and custom, a social condemnation which, in the midst of civilization, artificially creates a hell on earth…so long as ignorance and misery remain on earth, there should be a need for books such as this.”
Are we any different? I love my country, but we are not without sin. We lament our past injustices to Native Americans, African Americans, women, homosexuals, Jews, and others. We seek to fix the sins of the past, but there are others still who remain persecuted — and our social policies of the last hundred years have made an unnecessary living hell for both those who experience chronic pain and those who suffer from addiction. Currently, 35-40 million Americans suffer from what has been referred to as “high impact” chronic pain. Two and a half million Americans suffer from some form of “opioid abuse disorder.” For most of the past century they have all been treated like criminals, imprisoned by an ignorant system lacking mercy and falling decidedly short of justice. The social policies designed to help those addicted only harm those in pain, and what is needed is a change in perception — a cultural transformation, even — to de-stigmatize the stigmatized.
State and federal authorities’ stance towards opioid use and abuse has harmed many pain patients. I see the results every day in my office. The reality is that our options for treating pain are limited, and opioids are an important tool in this battle. So, the question needs to be posed to these authorities: if you are limiting access to opioids, what steps are you willing to take to help develop other options for care? This is not a new question, and perhaps it will receive greater emphasis as a result of the opioid crisis. It has been my observation that in colloquial terms, pain management and opioid prescription are too often viewed inter-changeably. It is also alarming that the needs of treating and preventing opioid abuse supersedes that of those who suffer from chronic pain, even though the ratio of those who suffer from high impact chronic pain to those who abuse prescription and non-prescription opioids approaches 20:1.
But hope is on the horizon.
The National Pain Strategy is an extraordinary document that seeks to correct these problems. It acknowledges the issue of opioid abuse, points out the deficiencies in our ability to care for those who suffer, and offers a six point strategy for remedying these deficiencies by addressing: 1) population research, 2) prevention and care of chronic pain, 3) disparities, 4) service delivery and payment, 5) professional education and training, and 6) public education and communication.
What is also exciting is that for the first time in my career, patient advocate groups are standing up for their rights. The Chronic Pain Advocacy Task Force has outlined four core beliefs which are being accepted by other groups including the National Pain Strategy. Moreover, the creation of state policies for medical cannabis is a direct challenge to failed federal drug guidelines. Cannabis and cannabinoids have great potential as therapeutic agents for pain, and at least 15 percent of pain sufferers risk government reprisal by illegally obtaining them for self-medication.
Much is happening — finally — but much still needs to change. Pain patients are treated as pariahs by doctors, who often refuse to care for them. They are treated like criminals in a court system that views them as guilty until proven innocent. They are discriminated against in a workplace that sees them as a potential risk, or even just an extra cost. They are the targets of unsavory snake oil salesmen both in medical and non-medical settings. The list goes on.
In my book Needless Suffering: How Society Fails Those with Chronic Pain, I outline sixteen social institutions and how the behavior of each adversely affects the lives of those who suffer from chronic pain. More importantly, I offer solutions for these pervasive social and medical problems. My goal is to broaden the social discussion on chronic pain beyond just opioids and return a sense of dignity to those who suffer. As both a doctor and an author, I would like to see an end to the legion of Valjeans who suffer needlessly as a result of myopic policies. In doing so, I hope, like Valjean’s bishop savior, to provide mercy to the needy and a sense of hope to the hopeless.
I welcome you to join this journey.