Journal of the California Cannabis Research Medical
The Undertreatment of Pain Crisis
by Frank B. Fisher, M.D.
By Frank B. Fisher, M.D.
Chronic pain is the largest single cause of disability in America,
exceeding both heart disease and cancer. Tens of millions are afflicted,
and those who suffer from the severest form of the disease are the
least likely to find satisfactory treatment.1
This is the case because when the disease has progressed to this stage,
treatment with opioid analgesics, which are categorically safe2 —and
for pain sufferers, non-addictive— is usually the only therapeutic
modality bearing the potential to bring the disease under control.
Paradoxically, while the streets are awash in illicit analgesic medications,
pain sufferers are the only group within society who can’t adequately
access these substances.
The undertreatment of chronic pain is a public-health disaster for
which there is a workable solution close at hand. The whole mess is
a consequence of prohibition law in the form of the Controlled Substances
Act, and is driven by the collapse of medical ethics within the discipline
of academic pain medicine.
The most fundamental principle of medical ethics is the physician’s
solemn obligation to put the interests of his patient ahead of all
An examination of the interplay between medical ethics and prohibition
law illuminates the nature of the problem. The most fundamental principle
of medical ethics is the physician’s solemn obligation to put
the interests of his patient ahead of all other interests. This is
the foundation of the physician/patient relationship. The Controlled
Substances Act of 1970 attempted to preserve the physician/patient
relationship by creating an exception to drug prohibition so that physicians
might legally prescribe controlled medications in the course of their
Despite the apparent good intentions of its authors, the law is fatally
flawed in that it requires law enforcement to determine which physician
conduct is professional practice, and which is illegal drug distribution.
Naturally, physicians take measures to avoid criminal sanction and
thus, the physician/patient relationship stops serving the interests
of the patients and instead becomes an expression of law-enforcement
The leadership of academic pain medicine has adopted drug-war values
with alacrity. Ignoring a wealth of scientific data informing them
that addiction to opioids among chronic pain sufferers is vanishingly
rare,3 they have devised an elaborate pseudo-science they believe protects
them from prosecution. They call this endeavor “aberrant” drug-
related behaviors, and they use the observation of these behaviors
as a means for selecting out, and excluding from treatment, patients
whose medical needs expose the physician to increased risk of law enforcement
These behaviors, for the most part, are conduct in which patients whose
pain is poorly controlled are likely to engage. For example, complaining
of uncontrolled pain and asking for a larger prescription, is a common “red
flag.” When this occurs, the physician is required to impose
sanctions against the offending patient. These range from suspicion
and heightened scrutiny to termination of treatment “justified” by
destructive comments in the medical record warning other physicians
not to treat the patient again.
The withholding of pain treatment, when a physician has the means
at hand to control pain, is torture.
The withholding of pain treatment, when a physician has the means
at hand to control pain, is torture. This form of torture, delivered
by the medical profession, is widespread and systematic. The result
is unimaginable suffering and countless suicides.
Pain-treating primary-care physicians have little choice but to comply
with the pseudo-science of “aberrant” behaviors because
if they fail to do so, the government will have no problem securing
the testimony of an academic physician to testify against the targeted
doctor in criminal court.
The government’s hired gun will assert that the primary-care
physician’s behavior lay outside the boundaries of professional
practice, and was in fact illegal drug distribution. Coupled with the
testimony of former patients eager to diminish prison sentences garnered
for selling their medications on the street, the presentation is devastating.
Unfortunately, the threat these prosecutions pose to physicians in
the community is not remote. On a daily basis, a physician faces such
criminal charges somewhere in the United States.4 And because of “get-tough-on-drugs” mandatory
sentencing laws, many American physicians are currently serving what
are, in essence, life sentences in prison.
The Pain Relief Network, led by pain control advocate Siobhan Reynolds,
has worked efficiently and with increasing success in recent years
to publicize the pain crisis in the national media. At the same time,
established “drug-policy-reform” groups have raised money
on the pain issue —as if they had been doing the heavy lifting!— and
effectively diverted funds from the admirable PRN.
Historically, whenever medical ethics have been systematically abrogated
in deference to political demands, physician conduct has been atrocious.
Physician conduct around the pain crisis has proven to be no exception.
When society finally comes to terms with what has occurred here, the
conduct of academic physicians and their willingness to collaborate
with the government’s purposes will likely come to be understood
in the same light as war crimes.
The reality of the pain crisis is so disturbing that most prefer not
to acknowledge that this could happen in the United States of America.
There is, however, some good news. PRN has recently devised a Constitutional
challenge to the Controlled Substances Act, which promises a solution
to the problem. A white paper pointing the way toward a due process
claim on behalf of the millions of Americans in untreated pain can
be found on the front page of
The immediate problem at this point is securing funding for the legal expenses
1 Chronic Pain In America: Roadblocks To Relief. Available @
2 The Use of Opioids for the Treatment of Chronic Pain: A consensus statement
from American Academy of Pain Medicine and American Pain Society. Approved
by the APS Executive Committee on August 20, 1996. Available at: http://www.ampainsoc.org/advocacy/opioids.htm
3 Friedman DP. Perspectives on the medical use of drugs of abuse. J Pain Symptom
Manage 1990; 5(1 Suppl):S2-5.
Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl
J Med 1980; 302: 123.
Medina JL, Diamond S. Drug dependency in patients with chronic headaches. Headache
1977; 17: 12-14.
Kanner RM, Foley K. Patterns of narcotic drug use in a cancer pain clinic.
Ann NY Acad Science 1981; 362: 161-172.
Schug SA, Zech D, Grond S, Jung H, Meuser T, Stobbe B. A long-term survey of
morphine in cancer pain patients. J Pain Symptom Manage 1992;7:259-66.
Perry S, Heidrich G. Management of pain during debridement: a survey of U.S.
burn units. Pain 1982; 13:267-280.
Portenoy RK, Foley KM. Chronic use of opioid analgesics in nonmalignant pain:
Report of 38 cases. Pain 1986; 25: 171-186.
Zenz M, Strumpf M, Tryba M. Long-term oral opioid therapy in patients with
chronic nonmalignant pain. J Pain Symptom Manage 1992; 7: 69-77.
Moulin DE, et al. Randomized trial of oral morphine for chronic noncancer pain.
Lancet 1996; 347: 143-147.
Brookoff D, Palomano R. Treating sickle cell pain like cancer pain. Ann Intern
Med 1992; 116: 364-368.
Chapman CR, Hill HF. Prolonged morphine self-administration and addiction liability:
evaluation of two theories in a bone marrow transplant unit. Cancer 1989; 63:
4 Ziegler S Lovrich N. Pain Relief, Prescription Drugs, and Prosecution: A
Four-State Sureby of Chief Prosecutors. Journal of Law, Medicine & Ethics
Why Do They Hate You?
“Once in Chicago while performing with Buffalo Bill Cody’s
Wild West,” writes Roxane Dunbar, “Sitting Bull spoke through
his translator to the huge crowd of ragged white men, women, and barefoot
children: ‘I know why your government hates me. I am their enemy.
But why do they hate you?’”
Robert Altman’s great movie “Buffalo Bill and the Indians” depicts
the context. It’s the dawn of the age of hucksterism, when corporations
were first exerting their power and influencing American culture. Paul
Newman plays Buffalo Bill, who runs and is the star attraction of a
traveling show. One of the “acts” on display is laconic,
brilliant Sitting Bull.
The Sioux leader’s image and his profound question —“Why
do they hate you?”— comes to mind with each example of
the U.S. government’s willingness to see its citizens suffer
and die in pursuit of corporate interests.
The examples are coming at us in a sandstorm these days. Exhibit
A is the attempt to occupy Iraq on behalf of the oil companies. Exhibit
B is the gov-ernment’s complicity in approving and actually promoting
pharmaceutical drugs and with harmful side effects while prohibiting
the safest pharmacological agent known to mankind —cannabis.
Hardly a day goes by without news of the government seeking to justify
corporate practices that are literally killing us. To protect the
beef producers the feds won’t allow thorough testing for Mad Cow disease.
To protect the poultry producers they tolerate high levels of salmonella
in chicken, and even 500 ppb of arsenic! (See “Teflon Kills,” page
Here at O’Shaughnessy’s we’ve had an example of endangerment-by-corporate-arrogance
hit home. Tod Mikuriya strongly suspects that Lipitor, Pfizer’s
blockbuster statin drug, had a damaging effect on the lining of his
biliary tract. Mikuriya was put on Lipitor three years ago to lower
his cholesterol following coronary bypass surgery. He has had three
patients who attribute similar adverse effects to Lipitor, including
itching, a feeling of cold, and digestion problems.
A lawsuit filed this Spring by a Teamsters health-insurance fund
charges that Pfizer execs unethically promoted sales of Lipitor.
they’ve sold $46 billion worth, including $12.1 billion last
year, making Lipitor the world’s best-selling drug.)
The suit, according to the Wall St. Journal, “cites internal
Pfizer marketing documents, Pfizer-funded studies and physician-education
programs that encourage doctors to use Lipitor early in treatment,
despite the risk of side effects in some patients. Pfizer says side
effects with Lipitor are generally mild, such as stomach upset, but
the drug has been associated in rare cases with muscle damage and
Rare cases” of a drug taken by millions equate to thousands of
individual catastrophes. The pharmaceutical manufacturers claim that
the benefits their compounds confer on the many far outweigh the damage
they cause a few. (The Journal asserts that Lipitor “has helped
millions of people avoid or manage coronary artery disease, including
heart attacks and strokes.”) The sanctity of the individual —which
the Wall St. Journal proudly invokes in opposition to collectivist
regimes— couldn’t stand up to cost-benefit analysis.
The corporate decision-makers relate to us as customers, not as people.
Their ad campaigns are folksy and friendly, as if they’re “good
neighbors” concerned about our health —but they’re
really stock owners intent on maximizing their profits. They’re
willing to endanger our health to sell their products.
That’s not the way you treat people you respect and love. It’s
more akin to contempt and hate. And therein lies the answer to Sitting