Exposing a Dangerous Myth: Pain Patients Aren’t 'Drug Users'

If you don’t know Laurie Engel’s harrowing story, you should read her heart-wrenching interview with Dr. Josh Bloom. Ms. Engel underwent 25 knee surgeries, a double mastectomy necessitated by breast cancer, then resigned herself to hospice care after contracting acute myeloid Leukemia. She used prescription opioids without becoming addicted for over 25 years, until she was admitted to hospice and her medication regimen was changed seemingly without cause. As she told Dr. Bloom:

“Two days later a new nurse showed up and informed me, they were replacing my OxyContin with MS Contin (a time-release morphine pill). I told her I had previous experience with MS Contin and that I could not tolerate it and asked to speak to the admitting physician. I was told, ‘No she won’t talk to you; her mind is made up.’”

After switching hospice facilities, she was allowed to continue taking OxyContin and is living out her remaining days in relative comfort. The terrible treatment she received nevertheless prompted me to ask a question during a recent episode of our Science Dispatch podcast: 

• Why does the medical establishment deny chronic pain patients access to opioids while support grows for harm-reduction schemes that endorse recreational drug use? 

The answer is that America’s drug policies are shifting from prohibition to normalization, one extreme to the other, while inexplicably neglecting pain patients. The real solution lies between these polar opposites. We should give legitimate pain patients access to prescription opioids and discourage recreational users and addicts from consuming illicit drugs—even if legalization is the goal.

A user is a user?

Many drug policy reformers reject this perspective, of course. Pain patients, some of them argue, don’t have a more legitimate reason to use drugs. A user is a user, whatever their particular justification happens to be, and the real problem is society’s lingering stigma toward all drug use. Some addiction specialists have even chastised pain patients for rejecting this one-size-fits-all framing of the issue.

It’s a convenient argument, but it denies several obvious and important distinctions between pain management and recreational drug use.

Treatment vs pleasure

The most important distinction is that pain patients take opioids to lead a relatively normal existence. In Engel’s case, for instance, “My doctor’s goal was to give me as much quality of life as possible as well as the ability to live independently,” she explained in her interview with ACSH. 

That’s not the case for many people who use drugs outside a medical context. A 2022 study published in the American Journal of Public Health gives us some insight here. The researchers surveyed 40 participants in a safe-supply pilot program in Ontario, Canada, that was designed to reduce overdoses by providing “people who use drugs (PWUD) with pharmaceutical-grade alternatives to illicit drugs.” 

Not only did the program fail–33 out of 40 participants continued to use illicit substances on top of the prescribed narcotic–it highlighted the contrast between pain management and recreational use. Consider the case of Mark, who was only described as “a 28-year-old White man.” He continued to use street drugs because the prescribed opioid (hydromorphone) was

“… just f****** boring. I don’t really feel the rush. . . . It’s like having ******* cereal with no milk. It’s just like j****** off with no busting a ***. You know what I mean? It’s not the same. . . . You know what I mean? It’s not the same. There’s nothing there. . . . It’s no comparison.”

In other words, the “high” itself is the motivation for these individuals, and they are clearly distinct from patients who, for instance, have to choose between chronic pain management and a leg amputation. Harm-reduction researchers commonly acknowledge this point, too, albeit in less colorful language.“There is a need to account for pleasure in the design and implementation of safe supply approaches,” the pilot study authors concluded. Other harm-reduction experts have made the same argument.

The fact that researchers are crafting interventions around “subjective benefits” (their words) like pleasure further illustrates the difference between pain management and drug use. Pain patients take opioids to alleviate debilitating suffering; recreational users take them because they want to or because they're addicted and can't stop, even if they want to. 

One possible criticism here is that drug users don’t owe me or anyone else an explanation for their habits. That might be true if we lived in a libertarian paradise where our individual decisions didn’t affect anybody else, but that’s not where we reside. In fact, many harm reductionists actually demand that society accepts collective responsibility for the consequences of recreational drug use. 

Psychiatrist Theodore Dalrymple, who spent years treating addicts in a low-income area of London, recently recounted an amusing example of a Scottish harm reduction group displaying this attitude:

“A petition to the Scottish Assembly from a campaign called ‘Help Not Harm’ … asked that [drug] testing kits be made available free of charge (that is, free to their users) in all public places …The response to the petition quoted a passage from a report of the Scottish Drug Deaths Taskforce … ‘Change is needed, but it will only be possible when we accept that this is everyone’s responsibility … Any person can save a life. They can do so through direct action like carrying and using naloxone [an overdose reversal drug] and challenging stigma whenever it is seen.’

“This seems to imply that every citizen should walk around with naloxone in his pocket in case he comes across someone who has overdosed. Further, he must never think, even in private, that heroin addiction could be partly the fault of the addicted, for that would be stigmatizing.”

This marks another contrast between pain patients and drug users. The former simply want access to healthcare they’ve been denied by law enforcement and public health bureaucrats; the latter want you to endorse their habit, pay for their needles and quit asking why homeless people use drugs on street corners as your children walk by on their way to school. 

Recreational risks vs medical benefits

Perhaps the most important difference is that recreational drug use carries serious risks that pain management typically doesn’t. It’s widely recognized that America’s overdose epidemic began more than four decades ago and is significantly driven by nonmedical drug use linked to “Sociological and psychological ‘pull’ forces … such as despair, loss of purpose, and dissolution of communities,” a 2018 paper explained. 

In contrast, medical use of opioids has little to do with the overdose epidemic. Patients prescribed these drugs for pain management generally don’t abuse them. In one 2007 study of more than 27,000 OxyContin addicts, 78 percent said they were never prescribed the drug for a medical reason; 86 percent reported use of the drug to “get high or get a buzz,” and 78 percent reported receiving prior treatment for a substance use disorder.  There is a large body of research that confirms this conclusion.

Many drug policy reformers will counter that the solution to the ill effects of drug abuse is legalization. Paired with references to the failure of alcohol prohibition, this all-purpose salve (we’re told) will help ensure a safe supply of drugs for everyone, reducing overdose deaths, addiction and disease transmission.

Prohibition can have terrible consequences, but this argument in the context of illicit drug use deserves more skepticism. For one, it downplays the reality that legalizing these substances will almost certainly expand their use and thus the risks they carry. The nonmedical abuse of FDA-approved opioids (read: “safe supply”) facilitated by pill mills and unethical doctors was legalization in action, addiction specialist Sally Satel has noted.

We’ve also seen some evidence of this in states that have legalized recreational marijuana use. A 2023 systematic review identified multiple studies showing that legalization facilitated an increase in the use of cannabis-related emergency services, unintentional ingestion (particularly in children under age 12) and cannabis-involved pregnancy-related hospital admissions. 

The same likely applies to other illicit drugs. In a detailed piece advocating an end to the drug war, the progressive outlet Vox nonetheless conceded that

“... A 2014 study by Jon Caulkins, a drug policy expert at Carnegie Mellon University, suggested that prohibition multiplies the price of hard drugs like cocaine by as much as 10 times … Caulkins estimates that legalization could lead hard drug abuse to triple, although he told me it could go much higher.” [my emphasis]

In a subsequent 2018 paper, Caulkins observed that use of the most popular substances–heroin, marijuana, methamphetamine and psychedelics–began to accelerate during the 1960s before law enforcement turned significant attention to drug prohibition:

“Documenting how little energy was devoted to drug enforcement before 1965 is hard.  Statistics on drug control spending in [the] 1950s, for example, are not recorded, perhaps precisely because it was a relatively minor concern.”

The drug war was a response (admittedly a bad one) to the negative externalities of often legal drug use promoted by the counterculture. As the father of two young children, the downstream effect I find most troubling is the experimental teenage user driven deeper into addiction and homelessness by harm-reduction programs that prioritize safer use over treatment—an approach Satel calls “benign neglect.” 

Present-day examples abound. San Francisco broke its record for overdose deaths in 2023 despite officials “leaning into harm reduction” for years, according to the SF Chronicle. Surely a city moving toward legalization shouldn’t be “one of the epicenters'' of a worsening overdose crisis. But it is, and it’s not the only one. 

Portland, Oregon, saw equally miserable results from its three-year experiment with decriminalization, record homicide rates and overdose deaths among them, and recently re-criminalized drug possession, with an emphasis on getting addicts into treatment. [1]

Conclusion

There are thoughtful scholars who have argued that things in Portland would have improved with time and even more liberal drug laws. The city’s residents and businesses didn’t want to run that experiment, and parents of addicts in San Francisco were equally skeptical of policies “too steeped in harm reduction.” 

If these challenges can be resolved with some pathway to drug decriminalization or legalization, one that stresses treatment and  law enforcement as necessary to ensure public health and safety, that's fine. Portugal's decriminalization approach may offer a blueprint here. 

Whatever the solution, pain patients shouldn’t be forced into the broader fight over drug policy. Their access to health care must not hinge on any government’s ability to supply safe drugs to recreational users. Veterans shouldn’t be driven to suicide because their opioid prescriptions were tapered thanks to the CDC’s inane guidelines.  [2]

Sick people are entitled to treatment because they need it. No other factor should determine which medicines they may use.

[1] See this study and this one for examples of effective treatment programs. Satel cites additional evidence here. 

[2] The agency's 2016 Guideline for Prescribing Opioids for Chronic Pain, which established artificially restrictive prescribing recommendations, is a key reason why so many patients are deprived of medically necessary pain management. See this article by Dr. Bloom to learn more.