It started in the Garden. When God punished Eve for tempting Adam he decreed that she and all women would suffer pain in childbirth.
Ever since, it seems, human beings have been ambivalent about pain. Certainly we don't like it. But something in the back of our minds keeps hinting that we deserve it, that it's somehow good for us.
That ambivalence toward pain has influenced many of our attitudes toward illness and bodily distress. Unfortunately, it has had a particularly sinister effect on our understanding of prescription drugs -- and that confusion has led to bad public policies in several states.
So far, Maryland has avoided these mistakes, but a number of public officials -- including the governor's Prescription Drug Commission -- are championing them anyway. More ominous still, there are attempts in Congress to establish these policies on the federal level.
In its most familiar form, the controversy goes under the name "trip scrip," referring to a system under which physicians must record in triplicate any prescriptions for "Schedule II" drugs -- pain-killers such as morphine that have medical uses but a high potential for abuse. The triplicate form allows authorities to monitor prescription patterns. Presumably this will allow them to prevent physicians from creating addicts or, worse, diverting drugs to the illicit market.
Computers have allowed the development of less cumbersome versions of this monitoring system, but the problems still remain -- as do privacy questions about violations of the patient-physician relationship.
Despite the alarms raised by drug enforcement officials, there is little evidence that abuse of prescriptions provided by doctors is an important factor in the country's drug problem -- or, more important, that trip scrip and its derivatives could have any significant effect on prescription drug abuse. Illegal laboratories can always fill the gap.
In 1989 New York state extended its trip scrip law to include Schedule IV prescriptions (drugs that control anxiety). Initially, there was a shortage of these substances on the streets, and a sharp increase in the price. But the benefits were short-lived. Now, a tablet of Valium is as easy to buy on the street as it was in 1988 -- and the price has dropped.
Far more disturbing is the evidence that these regulatory efforts cause problems for people who genuinely need medications. When physicians know they are being watched, they are more reluctant to prescribe these drugs. This chilling effect has been documented in states that have adopted prescription monitoring programs.
In fact, there is substantial evidence that the medical community's real problem with narcotics is under-prescription. To cite one glaring example, unmedicated and under-medicated cancer pain is a serious health problem.
In a case that could have wide-reaching effects, a jury in North Carolina last year handed a well-regarded nursing home what was thought to be the highest malpractice penalty in the state's history. The crime? Willful failure to relieve the pain of a cancer patient.
According to Dr. Robert L. DuPont, who from 1973-1978 served as the first director of the National Institute on Drug Abuse, much of the problem stems from a confusion between drug addiction and a benign physical dependence.
Addiction, Dr. DuPont says, always involves two characteristics. First is a loss of control in which the addict's life becomes unmanageable. Second, addicts deny their addiction, lying to themselves, to their families, co-workers and friends.
In contrast, many people can develop a dependence on a drug that does not qualify as an addiction. If, for instance, a patient were given strong painkillers after an operation or injury, he may suffer withdrawal symptoms if the medication were abruptly halted. But the drugs serve an important purpose. Good medical care would not condemn that person to days ruined by pain, but rather wouldwithdraw the drugs gradually as the need subsides.
Prescription monitoring programs represent a misplaced moralism that lumps all pain together and reckons that, somehow, we deserve it. But not all pain is equal. Some kinds of pain serve an essential warning function in the human body. Without these signals we would ignore problems and do a great deal of damage to ourselves.
But many kinds of pain serve no useful or ennobling function. In fact, research is showing that pain can be a destructive force in the human body, actually working against recovery or even survival. What does it say about a society that refuses to recognize this distinction and seeks to make it more difficult for suffering people to find the relief they need?