Shaming Med Use Kills

In the last several weeks, there have been several news articles relating to opiate use and changing definitions regarding drug classification and how doctors can prescribe. As usual this has brought a lot of the stigma surrounding medicine use to the limelight. Whenever these conversations get sparked again, a lot of people start talking about over-prescription, abuse of narcotics, and how big bad pharma creates fake conditions in order to sell drugs. People start talking about patients who abuse the system and end up addicted. These conversations are usually had by people who have no personal experience with chronic pain or the type of conditions being discussed. These same arguments then get used to discredit conditions like Chronic Fatigue Syndrome, Fibromyalgia, and ADHD.

The shaming inherent in a lot of these arguments not only make life more difficult for patients, but they are actually an example of how “a little” knowledge is a dangerous thing. Take, for example, the frequent argument that ADHD is often over-diagnosed and an excuse to medicate children. Some people have gone so far as to claim that ADHD meds are the shut up and sit still drug and that ADHD itself doesn’t exist.

The first half of the argument is based on two problematic ideas: the lie of more-diagnoses which I discussed in a previous article, and a tendency by certain studies to limit their focus on white males. While there is some indication that ADHD may be over-diagnosed in white boys, in every other category girls, people of colour, and so forth, the opposite appears to be the case.

In white children misbehaviour is believed to be pathological, whereas in the case of children of colour, it is believed to be genetic and inherent. When behaviours that are believed to be disruptive appear in class, white children are often send to counselors and psychiatrists, while black children in particular are punished. We’ve seen this discussed when activists and studies discuss the school to prison pipeline. In many cases the behaviours being punished are the same that are said to be caused by ADHD in white children.

In the case of girls versus boys, girls often present with Neurodivergence differently than boys, while the standard for diagnosis is based on boys. More and more studies are coming out showing how most women don’t get diagnosed with conditions such as this till adulthood. I, myself, wasn’t diagnosed until I was 25. Behaviours that are indicative of ADHD in girls, like chattiness, get instead blamed on their gender. Not being diagnosed until adulthood can have a serious impact on a person’s ability to thrive in schools. It creates antagonism between frustrated teachers who just want kids to pay attention and frustrated students who physically can’t. It takes away the opportunity to use therapeutic strategies to counteract the difficulties than can present themselves when it comes to studying and meeting deadlines, processing information in classrooms, and so forth. By preventing diagnosis in Children of Colour and in girls, society puts these children at an unfair disadvantage.

The statement that ADHD meds are the Shut up and Sit Still drug is also a fundamental understanding of how ADHD medication works. For one thing, they are a stimulant. In people who don’t have ADHD or who are on the wrong drug, the result would be increased energy and an inability to keep still. It is people with ADHD who would react by being better able to focus.

Shaming however works to discourage people who would benefit from medicine from actively receiving medication. Women and People of Colour who already have a harder time getting taken seriously by doctors have to fight against doctors own societal biases towards these medications. I’ve had one doctor claim that the only reason to get treated for ADHD in adulthood was to abuse the drug, while another tried me on a different medication first since the one discussed had a higher street value. Doctors are no more immune to societal bias as the rest of us, but they have a greater ability to impose that bias on those of us struggling.

Where this becomes especially dangerous is because untreated conditions can have impact on other conditions. It’s been found for example that untreated ADHD can make treating depression more difficult. That without being paired with ADHD meds as well, anti-depressants on their own do not work as effectively if at all.

It can also be dangerous when doctors become so afraid of potential addiction, that they risk patients’ lives in order to get them off the medication faster. Like what happened to me when rather than wean me off the medication gradually, doctors opted to put me in opiate withdrawal post admission, leading me to almost having a heart attack.

What many of the articles and discussions surrounding illegal use and abuse of medications and prescriptions ignore is the way some patients are forced to go through less than legal means in order to secure adequate treatment. Faced with doctors who cannot prescribe the needed dose for pain control as a result of restrictive laws may find themselves needing to rely on the black market or multiple prescriptions in order to get the full dose that would have otherwise been prescribed. Patients who have a hard time securing pain medication from doctors might have to rely on illegal acquisition for any hope of relief or assistance.

Consider for example the recent studies that have shown that black people are less likely to receive treatment for chronic pain and that as many as 10% of students at prestigious US law schools believe that black people and People of Colour feel pain less than white people. This idea is a call back to stereotypes as far back as the slave era, where torture of slaves was excused because “they couldn’t feel it anyway. That you had to whip a slave hard, or it wouldn’t have an effect.” It is racist.

But this means that People of Colour with chronic pain conditions might be left without any treatment for their conditions. A state which is dangerous in and of itself. Left untreated, pain and chronic pain can lead to conditions like fibromyalgia. It can cause all sorts of chronic problems and negatively impacts overall health. For their own safety, they may have no choice but to buy on the streets what they should have been given by a doctor. It gets even worse when you factor in the devastating impact that inaccessible healthcare has. When it is unaffordable, when it is not available to certain people, and so on.

It says a lot that states that have legalized marijuana have had a significant drop in opiate deaths as people who were required to use opiates can either take mmj instead of opiates. Alternately they can take it in addition to opiates, allowing them to take lower dosages with the same effect.

The shaming of med use also has an additional impact in actually limiting the development of certain types of meds and how they are available. For example, if people consider ADHD to not be something that is essential to treat, there is no pressure on pharmaceutical companies to develop different ways of administering the medication. People like me are left in the lurch, where instead of having the options of a quicker digesting method like chewable or non-digestive method like a patch, I have to hope that I’m actually digesting that day. If not, then I can swallow all the pills I like, but all I will get is a stomach ache but no help with focus.

Shaming the use of meds creates a culture that makes life difficult for patients and not for addicts. Time and time again we’ve seen that legislating and making drugs illegal does not work as well as legalization and treating addiction as the medical condition it is. Meds are important. Their prevalence is not a sign that something is wrong with the world, but rather a sign that we have a healthcare system that is constantly evolving, discovering, and working to help people. The solution to opiate abuse isn’t making it harder for patients to get pain medication but actually making it easier for them to access a variety of types of medication so that opiates aren’t the only choice. It’s about making it possible for doctors to evaluate each case individually rather than through generalizations that often exclude the very people most likely to need regular access.

The decision of whether or not to medicate is one that should be left to the patient and to the doctor and not up to society and every Sam, Dick, and Mike who believe they understand things that don’t affect them and think they’re experts because they have a 101 understanding of the subject.

Shaming Med Use Kills

9 thoughts on “Shaming Med Use Kills

  1. 1

    One probably minor point about opiates: If a person is “addicted” to opiates, that is, needs to take them daily to function normally and will go into withdrawal if they don’t have them, but at the same time they can function well with them, are not requiring escalating dosage, and are pain free or in as little pain as possible…so what? What’s different about needing opiates to function versus needing exogenous insulin to function?

    Marijuana looks promising as a treatment for chronic pain. For one thing, it appears (in mice) to reverse the hyperalgesic effect that chronic opiates can produce (in which chronic use of opiates can make the nerves more sensitive to pain resulting in worse pain and escalating need for opiates…which, of course, continues the cycle). It also appears to have pain relieving effects in its own right, probably synergistic with opiates. And reverses some of the side effects, such as nausea, that can be associated with opiates. It’s about time we started looking at marijuana as a serious source of potential medications and dropped the idiotic laws making it illegal.

    Wasn’t there a racial component to the illegalization in the first place? I have the idea that marijuana was the drug of choice (rather than alcohol) for Zapata’s troops and that freaked the US out. But I could easily have that wrong.

    1. 1.1

      I made the so-what point in my marijuana post about addiction. One thing people misunderstand about addiction itself is that is has to have a negative psychological component. Withdrawal and needing it to function are not always enough. Consider that someone in severe pain might need it to function not because of addiction but because functioning while in pain is extremely difficult. Moreover, withdrawal symptoms come up regardless of whether you are addicted of not. I experienced withdrawal after the hospital.
      Interestingly the fact that my body could go into adrenal crisis if I don’t taper the dose is never used as proof that I’m “addicted” to prednisone.

      1. Good point re addiction and psychological consequences. I should really have noted that it’s dependence, not addiction when someone is perfectly functional but needs opiates to continue functioning. Which makes it no different from any other drug in any other situation. As you noted, you’re dependent on steroids. My functioning would be considerably damaged if I stopped taking SSRIs, but I’m never lectured on that either.

        Even with true addictions, alcoholics are given benzos to ease the withdrawal symptoms when they are hospitalized. Smokers are given nicotine patches. Why shouldn’t people who are, say, addicted to heroin get a dose of opiates which will keep them functional and out of withdrawal during a hospitalization? (Yes, of course it would be better for them to get detox treatment, but it would also be better for the smoker and drinker to quit.)

        In short, I’m not actually disagreeing with you on any point. I’m mostly grumbling about the problems of treating pain. I’m not currently in practice, but I used to treat a lot of people with sickle cell disease. Talk about the problems at the intersection of race, poverty, and sickness as it relates to inadequate pain control! The problem is that there is no way to provide adequate pain control for a lot of people with sickle–some patients reach a point where adding more opiates does flat out nothing to further relieve pain. This is one reason I’d really, really like someone to take up serious clinical trials of marijuana as a pain reliever. In the state where I worked, I wasn’t allowed to mention the data that marijuana might relieve pain (though I was allowed to say that I wasn’t allowed to say that there were data suggesting that marijuana could relieve pain and that pubmed was allowed to show anything that had been published in a medical journal), which meant there was little choice but opiates. Well, and semi-effective adjuvant meds, but they only work for a minority of people. It was very frustrating.

  2. 2

    People start talking about patients who abuse the system and end up addicted.

    I suppose those people are also vehemently campaigning for the reintroduction of prohibition, right? Because clearly alcoholics exist and alcohol serves no “legitimate” purpose other than fun.

    In the case of girls versus boys, girls often present with Neurodivergence differently than boys, while the standard for diagnosis is based on boys.

    Tell me about it. I had my daughter tested for autism and while we got a diagnosis the therapist could also have decided not to.
    Standard testing here involves several tests where you need a certain “score”. She scored in the “on the spectrum” range in two or three of the tests, but the one where she presented as “neurotypical” was the questionaire I had to answer with the questions being asked by the therapist in a standardised way. I never had a more frustrating experience in my life. When I was finished I sat in my car and fought against tears for about 10 minutes.
    Those questions were clearly geared towards your stereotypical autistic boy and there were none that would accurately describe the ways her neuodiversity presents.
    There were often questions “Does the child XYZ?” And I would be “No, but….”, only there’s no room in those things for a but, for a different version of the phenomenon.
    What actually made the therapist diagnosing her was him being aware of the gender bias in the diagnosis.

  3. 3

    There is also an age bias – doctors tend not to proscribe medication to younger patients, a language bias (do you have an accent? then you’re out of luck!) and so on. Pretty much the only people that would get a quick and decent diagnosis are the doctor’s doppelganger, preferably with a matching bold spot.

    As bad as various laws are (particularly in USA) the real problem is in doctor training. Their training actively (especially for surgeons) seeks to dehumanize the patients into a set of symptoms, rather than human beings.
    I’ve heard numerous doctors complain about tests in pharmacology and the like, but I haven’t heard a single complain about a test in ethics because there isn’t one! There isn’t even a course in ethics (actually there is, but it’s optional and is almost always neglected for more “useful” courses), let alone anything that would teach the doctor to examine their biases (a common problem in all academic fields, but that’s a different matter). Usually their only exposure to ethics is one or two optional lessons at the end of the year.

    Until this changes nothing is going to improve care-wise. The saddest part is it seems that even government drug policy is easier to change than medical education. That’s probably the most conservative field in all of academia.

    1. 3.1

      I’m not sure medical education is _quite_ as grim as that, though I agree that the lack of ethics education is problematic. When I was in med school (the early 1990s, so dated information), there was, indeed, only one ethics class and that was optional. There were, however, several lectures in other classes that discussed ethics. As I recall, patient autonomy and ethics of clinical trials were a bigger focus than bias. Also, anyone involved in clinical trials is required to take training in ethics of clinical trials and HIPPA requirements every few years. Tuskegee is overtly discussed.

      Recently, mandatory training in “cultural sensitivity” has become fashionable, though I’ve found the classes I’ve attended to be rather superficial and sometimes misleading. But at least it’s a start: a required class that directly addresses the problem of cultural differences and how they effect care.

      The training to depersonalize patients is a problem because it’s necessary. Honestly, I want to be patient #34,362, routine and boring surgical procedure of the day #6, to a surgeon. A surgeon who is too emotionally involved with her patients is more likely to make a mistake. In principle, this training could be used to decrease prejudice: gall bladder #12,821 is gall bladder #12,821, no matter what gender identity, genitalia, skin tone, etc are attached to the gall bladder in question. Unfortunately, it somehow doesn’t end up working out like that. I’m not sure why.

      1. Dianne

        I’m not sure medical education is _quite_ as grim as that

        It could be that local medical school is worse than the norm for Western schools. It’s actually very likely considering our head of the chief forensic institute boasts about his collection of human organs. He is particularly fond of tattooed skin.
        Yes, really.

        It great that the schools in your country are taking steps forward!

  4. 4

    I’m young, I’m White, I’m obviously disabled, and I’m inadequately medicated with Naproxen for pain levels that range from a 4 on a good day to a 7.5 on a bad day.

    Fortunately, up here in WA, we have legal-according-to-state-law-(fuck-the-feds) marijuana!

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