By Richard Dobson, MD, Guest Columnist
The war on drugs is so frustrating and confusing! Why are people in pain forced to suffer? It just makes no sense!
I often see those comments from people who suffer from diseases or injuries that cause severe pain. I often feel the same way. But after years of bewilderment, I have come upon a clinical description that seems to describe the plight of people who suffer from chronic pain. Let me try to simplify this complicated and mystifying condition.
First, a brief overview of the current situation. There are five basic groups of people involved in the opioid crisis:
1. Pain Patients
These are the people who have medical conditions that cause them to suffer daily with torturous, disabling chronic pain. Many have found that opioids have given them a new lease on life, reducing the pain and enabling them to have some quality of life.
Then the CDC prescribing guideline came along and formalized a process in which these valuable pain medications were often withheld and pain sufferers were shunned by doctors.
Doctors and other healthcare providers who prescribed opioids to treat chronic pain became targets of regulatory and legal sanctions. Some were forced out of practice by the suspension of their licenses. Others went to prison under the guise that they “overprescribed” opioids with no medical justification. Those who were not targeted chose to eliminate opioid prescribing or discharge patients who would benefit from opioids.
3. Drug Abusers
These mystifying actions occurred against a background in which an epidemiologically distinct group of people were becoming addicted and dying in increasing numbers. This group includes those who abuse opioid prescriptions, although most are using illicit substances such as methamphetamines, cocaine, heroin and fentanyl.
4. Drug Dealers
The suppliers of illicit substances, including those who produce fake pills and lace them with deadly poisons derived from fentanyl. The Drug Enforcement Administration has labeled them “illicitly manufactured opioids” (IMF) and they are now responsible for about 3 out of every 4 opioid overdoses. In Massachusetts, IMF’s are involved in an astounding 90% of overdoses.
5. Regulators, Insurers, Politicians and Media
The regulatory and enforcement agencies from federal, state and local governments, as well as politicians, insurers, news media and addiction treatment advocates, have all promoted actions that target chronic pain patients and the dwindling number of doctors who treat them. It is this group that has the ultimate power to take effective action and disrupt the deadly supply of IMFs.
Diversion of Blame
Here is the basic scenario which entails a massive effort involving diversion of blame.
The drug abusers in Group #3 are dying in record numbers, even as opioid prescriptions have declined. These alarming deaths are caused primarily by poisons illicitly produced and distributed by the drug dealers in Group #4. But the regulators in Group #5 remain virtually silent about the IMF market and instead chose diversion of blame, targeting patients and doctors in Groups #1 and #2.
The consequences are horrible. People in Group #3 continue to die at escalating rates. People in Group #1 suffer horrible enhanced torture and many are having suicidal thoughts. And doctors in Group #3 are being driven out of pain management.
It is truly a bizarre scenario! But there is an actual medical condition that would help explain or at least describe these events. You have to keep an open mind and try to look at things with a perspective that is not warped by old, preconceived ideas. But here it is.
Munchausen Syndrome by Proxy
What if, instead of pain patients in Group #1, there were a group of children? And what if, instead of regulators and enforcers in Group #5, there were parents and caregivers? Ignore the other groups for the time being.
The same scenario -- only involving children, parents, and caregivers -- becomes a classic case of Munchausen Syndrome by Proxy. Those in a position of power (parents and caregivers) are imposing a factitious disease on children.
The official name for this condition is Factitious Disorder Imposed on Another (FDIA), a psychiatric disorder in which a person repeatedly and deliberately imposes an illness on someone else, even though they are not really sick.
In the case of pain patients, it is the regulators and enforcers who have FDIA and erroneously portray patients as responsible for the increasing number of overdose deaths. Patients are made to look like they have some disease that they do not have.
In the pain community, I believe there is no argument about this falsification and diversion of blame. Most people who take opioid medication are not drug addicts, just as most doctors who treat them are not drug dealers. Most pain sufferers and doctors have no idea how to even obtain IMFs.
While FDIA is classically used to describe the abuse of a child by a parent, the diagnostic criteria are not limited to child abuse. The criteria apply equally well to the abuse of people with chronic pain: The imposition of a factitious disorder (addiction, drug diversion) on a group of people who do not have that disorder (falsification of the medical condition) by someone in a position of power (the cohort of regulators, insurers, politicians, news media, and the addiction treatment community).
Factitious Disease Imposed on Another is both a perfect metaphor and a diagnosis for the ongoing diversion of blame in the opioid crisis -- the culprit that enables the medical torture of patients and perpetuates the rising overdose death toll.
Looking at the opioid crisis as another form of FDIA would give society a formal platform to make a more realistic assessment of pain patients who are falsely labeled as addicts and drug dealers. It could also serve as a framework to end the diversion of blame and redirect it towards more effective and constructive action.
Richard Dobson, MD, worked as a physician in the Rochester, New York area for over 30 years, treating and rehabilitating people suffering from chronic pain, mostly as the result of work or motor vehicle accidents. He is now retired.
The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.