Why Do Democrats Become Anti-Choice When It Comes to Pain?
A few weeks ago, Senators Kirsten Gillibrand and Cory Gardner proposed a bill that would limit initial opioid prescriptions to 7 days for acute pain, as an attempt at treating the opioid epidemic. Never mind that opioid deaths have continued to rise as prescriptions have fallen, or that the majority of opioid deaths are from street drugs, like heroin cut with fentanyl.
Cory Gardner is a Republican with a fairly lousy record regarding https://adapt.org/press-release-national-adapt-confronts-senator-cory-gardner-for-refusing-to-cosponsor-the-disability-integration-act/, so it makes sense that he has no issues getting in between patients and their doctors. But Kirsten Gillibrand is strongly pro-choice. Her Senate website states, “Senator Gillibrand believes that a woman’s medical decisions should always be made between her, her family, and her doctor — not by politicians.” But not, apparently, if the woman has major surgery and needs a week and a half’s worth of Percocet to get her through her recovery period.
A law with a hard, fast limit on the length of initial opioid prescriptions, no matter how thoroughly researched and carefully written, is a blunt instrument, and a poor substitute for the judgment of an individual doctor who’s seen both the latest research and the actual patient. A reasonable first prescription for a healthy 30-year-old with a broken ankle might look completely different from a reasonable prescription for a 70-year-old after heart surgery who can’t take NSAIDs due to stomach problems. Likewise, a doctor might be more cautious if a patient has a history of substance abuse, but prescribe a longer dose if they’ve had opioids after surgery previously with no issues.
A doctor can also talk with a patient about their ability to actually get to the follow-up appointment and prescribe accordingly. They might prescribe more conservatively for someone who lives on a bus route that passes the doctor’s office than for someone who’s already rescheduled their surgery twice because they don’t have a reliable ride. A specialist in a large city might even schedule a telemedicine consult rather than an initial in-person follow-up for patients from far-flung rural areas. (I’ve traveled a hundred miles one way to see a specialist before; I can’t imagine doing that on a weekly basis after major surgery.)
Additionally, a law limiting opioid prescriptions to seven days flies in the face of the concept of informed consent. Patients are supposed to be able to discuss pros and cons with their doctors and consent to a decision. But such a law requires that the risk of opioid addiction, even if it’s negligible for a specific patient, take priority over a patient’s primary concerns. Focusing on the long-term risks of addiction at the expense of current agonizing pain makes little sense for many patients. If an 80-year-old is facing heart surgery, try telling them with a straight face that you’re really concerned they might become addicted to opioids in 5 or 10 years. Likewise, a patient who’s already attempted suicide because they can’t bear the pain they’re in today isn’t likely to respond well to focusing on a future they might never see at the expense of their present. While the proposal does make exceptions for cancer and palliative care, it doesn’t take into account age or other factors that either reduce the risk of opioid addiction or make it a moot point. Again, this is why individual doctors need to treat individual patients, well, individually. No law or guideline will ever carve out every necessary exception.
One incredibly important political reality that Democrats should have learned from both abortion and voter suppression is that you don’t need to outright ban something to prevent people from doing it. The harder you make it, whether financially, logistically, physically, or emotionally, the more people you’ve prevented from doing it, whatever “it” is.
On its face, a seven-day limit doesn’t prevent any doctor from keeping a patient on opioid pain meds for a month or three if they think it’s warranted. They just have to see the patient in the office every week and give them a new prescription. Then the patient just has to get that prescription filled. But an awful lot of obstacles are hiding behind that “just.”
First, the doctor has to actually have an available appointment and schedule the patient for it. If doctors weren’t already following up every single week with every single patient on opiods, this is going to clog up their schedules, and not everyone will get an appointment within a week. If the doctor in question already has a packed appointment calendar, patients may already be waiting weeks or months for an appointment. So, some people are likely run out of meds before they even get to that first follow-up. If doctors don’t have appointments available, they may refer patients to pain specialists after routine surgery. Doctors who specialize in pain management are already in high demand with long waits for appointments, so adding more patients to their schedules makes it even more likely that people in pain won’t be able to get the treatment they need in a timely fashion.
Once an appointment is on a doctor’s calendar, the patient has to make it there. Remember, this is someone who has just had an acute pain event for which opioids have been prescribed. While Kirsten Gillibrand tweeted that no one needs 30 days of opioids for a wisdom tooth extraction, acute pain patients also include victims of severe accidents, people having knees or hips replaced, and people who’ve had open heart surgery. Many of these people are probably not driving a week after their injury or surgery. They will likely need to rely on a friend or family member, or there might be some public transit available. (Whether that public transit is inaccessible if the patient is in a wheelchair, or excruciatingly painful because of their surgery, is another matter.)
At this point, it’s worth remembering that the US is still one of the few wealthy countries without some form of socialized medicine, so the patient also has to pay for every one of those weekly appointments. If they’re lucky, they have decent insurance, and they met their deductible with the event that caused them to need opioid pain meds in the first place. But a lot of people don’t have insurance, or have catastrophic plans that cover next to nothing. Even with insurance, a specialist co-pay might be $50 or $100 every week, before the patient even pays for the meds. This may be a serious hardship for patients who are also losing time at work due to their illness or injury.
And then, the patient has to actually get the pain medication. If you haven’t been prescribed opioids in the US lately, you might not be aware of what a hassle it is to get those prescriptions filled. With most meds, a doctor can fax a prescription to the pharmacy or use the pharmacy’s electronic system. The pharmacy then contacts the patient when it’s ready, and the patient picks it up. But opioid prescriptions have to be hand-written and physically delivered to the pharmacy.
You might wonder why that’s an issue, since someone has to go to the pharmacy to pick up the meds either way. Here’s the problem. Many pharmacies don’t stock opioids, or only stock a small supply. Because of concerns about theft, a pharmacy won’t tell patients over the phone whether they can fill an opioid prescription. With other prescriptions, you know when you walk in the door that they have your meds waiting for you, but with opioids,a patient shows up at a pharmacy with no idea whether the pharmacy can fill the prescription at all. If they can’t, the patient can try another pharmacy, but might not fare any better there. Chronic pain patients often devote a whole day each month to trying to get their meds. Making this weekly instead of monthly for many people will only exacerbate existing issues.
All of this takes time and money. Gas for the car or fares for public transit. Not to mention that co-pays for the drug itself may be higher if you refill it a week at a time. The time and effort are also significant. If the patient is doing this running around themselves, it might be more activity than is recommended for the stage of recovery they’re in. They might also be missing doses of their meds in order to drive. If a caregiver, friend, or family member is tasked with this pharmaceutical scavenger hunt, they may be missing work or other responsibilities during that time. At best, that’s time that could be better spent actually taking care of the person recovering from surgery or an injury.
So, even when every person involved in the pain patient’s care is doing their job compassionately and competently, there can still be massive logistical hurdles to getting a pain prescription filled every week after a serious injury or a major surgery. And that baseline assumption that pharmacies and doctors’ offices will do everything right doesn’t always mesh with reality.
I believe that most people in medicine get into the field because they want to help people, and they’re usually doing their best. But that doesn’t mean there aren’t screw-ups, failures of empathy, or careless mistakes. If you more than triple the number of times a patient needs to interact with their pharmacy and doctor’s office for a month’s worth of pain pills, you’ve tripled the opportunities for those mistakes to occur.
Any number of mistakes can prevent someone from getting a prescription filled, particularly an opioid prescription that can’t be faxed or submitted electronically. A doctor can write the prescription incorrectly, or forget to provide it. A receptionist can write down an appointment date or time wrong, meaning the patient isn’t seen and therefore cannot get a prescription. In addition to innocent mistakes, a doctor can also dismiss the concerns of a patient or decide they must be drug-seeking if they want pain medication refilled, even after surgery. Pharmacists can do the same, refusing to fill a prescription if they don’t believe the patient needs it. There’s tremendous pressure on prescribers and pharmacies to avoid contributing to opioid addictions, and they often respond to that pressure by treating patients with suspicion.
If you want to see the worst that medicine has to offer, check out #DoctorsAreDickheads on Twitter, a hashtag focused on medical mistreatment, or First Do No Harm (https://fathealth.wordpress.com/), which collects stories of prejudice against fat patients that adversely affects their care. The #ChronicPain hashtag, while it’s more general in nature, also chronicles the difficulties chronic pain patients already have in getting their pain adequately treated. Also, check out Ana Mardoll’s description of xer harrowing experience in the ICU after surgery. Think about all this dysfunction and needless suffering, and then consider the ways in which a seven-day limit on opioid prescriptions will add to that.
All of these problems, from transportation issues to doctors who don’t believe them, fall disproportionately on the people already underserved by our current medical system. Racial minorities, disabled people, women, the LGBTQ community, and people in multiple categories facing intersectional oppressions. Those are both the people less likely to be able to make it to, and pay for, a weekly doctor’s appointment and the people whose medical issues probably haven’t been handled appropriately to begin with. And so these problems snowball. Black patients, black women in particular, tend to have a much harder time getting treatment for pain. Doctors don’t believe them, or prescribe lower doses than they would for a white patient. In many cases, this medical mistreatment can be fatal. Even when it’s not, Black women whose pain has been ignored by multiple doctors for years may end up with more severe issues that require a longer course of pain meds if the problem is finally addressed, and will be more negatively affected by a requirement to come back every 7 days.
Some of those black women will be doubly or triply impacted when this rule collides with other racism that they and their families already experience. One might have a teenage son who’d be happy to take her to her appointments, but he’s sitting in jail for weed possession, while a white kid caught with the exact same amount got off with probation. Another has been passed over for a promotion in favor of a white coworker with lower qualifications, so scraping up the money to pay for those appointments is harder than it should be.
It’s worth noting that a law preventing doctors from prescribing more than seven days’ worth of opioids at once is a *maximum.* Remember the pressure on prescribers I mentioned earlier. Doctors are highly unlikely to prescribe the maximum opioid prescription allowed by law unless they can really justify it, to avoid suspicion that they’re prescribing inappropriately. Because of the number of biases already existing in healthcare, this might mean that a white cis man gets seven days’ worth of pain meds after surgery, a white woman with the same condition gets five, a black woman gets three, and a trans women of color gets Tylenol.
Democrats seem to understand these systemic issues this when it comes to abortion. They understand that waiting periods for abortion are intended to double the time, expense, and hassle of getting an abortion and ensure that fewer people can have them. They get it when it comes to voter suppression. They understand that closing polling places in black communities depresses black voter turnout, especially when many of those same black voters are already working multiple jobs or don’t have reliable transportation.
They should get it when it comes to pain. Particularly when precedents established in one area of healthcare legislation are always open to be used (and abused) in others. If Congress can set the maximum length of an opioid prescription, rather than the CDC or professional organizations or individual doctors, they could also set any number of other burdensome limits. Ana Mardoll discussed Gillibrand and Gardner’s proposal extensively, and xie pointed out how thoroughly it would upend the lives of people who can get pregnant if birth control needed to be refilled daily or weekly. Xie also noted that promoting aggressive government meddling in medical care is a massive gift to right-wing pundits.
This anti-choice tendency is profoundly concerning from Democrats, because adequate medical treatment is a human right. When anti-abortion fanatics rant about pregnancy as an inconvenience and people who have abortions as lazy and selfish, it becomes pretty clear that they see women more as incubators than as people. (Not everyone who can get pregnant is a woman, of course, but anti-choicers also tend to believe in a strict gender binary.) So, do Democrats pushing crack-downs on opioid meds fully see the patients they’re harming as people? In the conversation on Twitter, I witnessed a couple people accusing chronic pain patients of caring more for their “convenience” than for an addict’s life, making their views on people who are suffering crystal clear. And Senator Gillibrand’s glib comments about wisdom teeth show a similar level of casual disregard. One would expect the population of Congress to have more compassion than Twitter trolls, or at least, one would have before a walking comments section was elected to the highest office in the land. Today it’s more of a faint hope than a de facto expectation.
To her credit, Senator Gillibrand did, eventually, listen to the massive criticism and pushback from chronic pain and disability advocates, who understand how detrimental this would be to patients. It remains to be seen whether an updated proposal will effectively take those concerns into account, or whether her meeting with disability and pain advocates in DC served more as a photo op and a shield against future criticism than as an impetus for a more effective means of addressing opioid addiction.
Why Do Democrats Become Anti-Choice When It Comes to Pain?
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