My Aunt sent me a copy of Dopesick, by Beth Macy, 2018. "Dealers, Doctors and the Drug Company that Addicted America".

I am 96 pages in, in two days. Well written. Lots of references. But I don't think she's read Manchild in the Promised Land. That book was a huge influence for me, as well as realizing that my father was an alcoholic. And then how much my mother enabled. I went to medical school after college and working for five years. I already had some strong ideas about addiction and one was that opioids are addictive.

The "pain as a vital sign" campaign hit when I was in residency, 1995. I thought it was monumentally and spectacularly stupid. I wrote Vital Signs I and Vital Signs II and when I handed someone a prescription for an opioid, I said, "These are addictive. Try to get off them as soon as possible. Try not to take them around the clock." I was strict. I did urine drug screens way before they were a thing.

Dopesick says that more people have died under age 50 from opioid addiction then from HIV and AIDS. That is impressive, don't you think? Age 20, 24, 16, 29, 38.... I really do not have a very large patient group of addiction folks or chronic pain folks: approximately 20 of each. Some are really really difficult and time consuming and heartbreaking. And I have at least one person a year leave the practice and that I hear is dead within a year. A 55 year old dead on his kitchen floor from alcohol and opioids. And younger ones.

Dopesick gives a history too: the waves of opioid addiction that have swept through the US. Not just one. A wave of morphine, after the Civil War. A wave of heroin, over the counter, in cough medicine for babies and children and adults, "safer than morphine". And I look in her index and she doesn't even have kratom in the index. I wonder: are they checking for it in overdose deaths yet? I just started checking in send out urine drug screens. My addiction patients are the honest and calm ones here: "Oh, yeah, I tried that back when I was on heroin." Not everyone has heard of it. But the chronic pain patients are the ones actively using it now, not all, but more than one. So are they opioid overuse aka addiction patients now? And the head of UW Telepain states he's never tested a patient for kratom. Does he even ask? What the hell? Don't ask, don't tell?

I don't trust pain specialists. Don't ask, don't tell, head in the sand, ostriches that got us in to this mess. Don't trust them. I have NEVER put a patient on methadone and I don't think I ever started anyone on oxycontin. I have sent them to pain specialists who put them on methadone or oxycontin, but I really try not to. Don't fall into their clutches. Long term opioids make pain worse.


And so what do we do about pain? Stop using substances to escape: speak up, listen to each other, open our hearts.

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