Pain, addiction and The War on Drugs

Pain and addiction are two complex phenomena whose presentation and management in the acute setting are further complicated by synergies between symptoms and biological dependence, as well as by comorbid psychiatric and organic pathologies. Such interactions and the concomitant pitfalls that plague physicians are abundantly described in the medical literature and discussed in clinical situations. In particular, it is the highly subjective specificity of these interrelated forms of suffering that have resulted in quite a bit of attention on the part of outpatient clinicians and psychiatrists--both of whom are afforded substantial time and space, relatively speaking, to explore the affective and moral contexts of individual patients' lives. If there is any credence to the "humanistic" notion that the depth and quality of interpersonal engagement can be as or more important than frequency, the emergency physician's relative lack of familiarity with the anthropological specificities of context could be seen to hamper acute management. A salutary corrective to this potential disadvantage, I think, would be to approach patients in acute pain and addiction/withdrawal from a perspective informed by historical and social context.

When an attending bluntly opines that, "I don't give these people [alcoholics] anything because they just go out and overdose on Ativan, go on another binge and the whole thing starts again," wouldn't it be appropriate to critically examine the alternatives faced by alcoholics and other drug users once they leave the ER? If, as the same attending admitted, "people tend to hate Haymarket," doesn't the abandonment by the public sector of our addicted and withdrawing patients---who, after all, are usually in the ER because their money (or luck?) ran out---place a burden of responsibility on us? If I were homeless, unemployed and physiologically addicted, I'm not sure that being denied the means to pharmacologically manage my symptoms on the street would improve my chances of recovery.

But, mere empathy aside, there are broader considerations that might humanize the approach to acute care for "pain-seekers"---and reveal the violent contradictions of such epithets. As demonstrated by Ethan Nadelmann, JD PhD of the Drug Policy Alliance, histories of xenophobia, racism and classism have driven the contradictions and vacillations in anti-drug policy, from the outlawing of opiates with the influx of immigrant Chinese to the west coast, the illegalization of marijuana in response to fears of migrant Mexicans in the midwest, and the crackdowns on alcohol production and "public drunkenness" due to the "less White"--that is, poor, non-Protestant--communities of Eastern European and Irish refugees that took hold in American cities throughout the 19th and 20th centuries. Of even more contemporary relevance is the pernicious effects of the War on Drugs. Since its inception, this "War" has been highly racialized, with its differential repression and litigation of crack vs. cocaine, for example. It has also been made manifest in ways that are profoundly classist--again, as exemplified by differential treatment of "possession" (for personal consumption) vs. "intention to deliver" (for economic gain), as well as by the unconstitutional levels of police surveillance and resultant risks of incarceration in neighborhoods inhabited by a preponderance of young people of Color. The "War," as Nadelmann explains, has been central to the criminalization of drugs, transferring responsibility and power from the positive social institutions of public health and medicine, to the negative formations of courts and prisons.

It is a little known fact that William S. Halsted, the famed surgeon who was appointed Chief at Johns Hopkins in 1890, who developed the inguinal hernia repair and radical mastectomy, and who published 180+ scholarly articles during his career, was chronically dependent on cocaine--which his friend and colleague, William Osler, treated and managed through a chronic regimen of morphine injections. It is important to consider such precedents and contexts to avoid adding to the stigmatization and marginalization of our desperate--and often sick, poor and "pain-suffering"--patients who present acutely in the ER.