Poor, Sick…and in Pain
Recently, two very nice physicians that I know said essentially the same thing…
“People who are extremely poor are not good candidates for pain treatment with opiates. They will be tempted to sell their medication.”
Both doctors work with the uninsured and chronically ill. Neither is a monster. Both would be considered compassionate. Neither saw anything objectionable about the comment. To them, it was a simple fact. A person who is poor and needs money for rent or food will obviously consider selling drugs illegally. Obviously. And therefore, a prudent doctor will not give that person the chance to become a prescription drug dealer, no matter how severe the person’s pain. It is the doctor’s obligation to the public, to help fight the rising tide of prescription drug abuse. By assuming that every poor person is a drug dealer until that person proves herself worthy of the doctor’s trust.
I think I may have to ask my husband to build me a wall, so that I have something to bang my head against at times like these.
Before you tell me that our state needs a patient’s bill of rights guaranteeing them the right to pain relief, I must tell you that we already have one. However, doctors exercise their clinical judgment. If they believe that a patient is malingering, they do not treat their symptoms. If they believe that treatment will cause more harm than good, they do not treat. And while doctors are warned against being paternalist, paternalism is the middle name of many physicians—even the women.
By the way, “Trust” is one of the core values that most medical institutions (claim to) embrace. So is “Mutual Respect.” Usually those are right up there at the top. “I will protect you from becoming a criminal” is not typically one of the core values, though certainly no doctor wants to contribute to a patient’s incarceration. That’s why we warn them not to drive under the influence of certain sedating medications like antihistamines and pain pills.
A person who is too poor to eat will do a lot of things. He or she might, conceivably, pawn or sell their possessions, including their medication. But the Viagra that a man receives free of charge from the manufacturer as part of a patient assistance program of the uninsured can be sold just as easily as hydrocodone---and no one has ever said to me “The poor should not be on Viagra. They might sell it.” The albuterol inhalers that they get at the public health clinic pharmacy could probably fetch $15 or $20 on the streets since they cost about $45 at the pharmacy. Birth control pills, hormone replacement therapy, antibiotics, non-benzodiazepine psychiatric drugs---some of which cost up to $20 a pill---all have a “street value”. So, why the rush to deny the poor treatment for their pain? Why do some doctors seem so proud of the fact that they are protecting their poor patients from the temptation of having a bottle of hydrocodone at hand?
The doctors who are reading this will say “It’s the DEA’s fault. The docs are afraid of being audited and shut down.” But, at a public institution for the uninsured, practitioners seldom get in trouble for doing too much for their patients. They are much more likely to be censured for doing too little. Witness the VA scandal.
I have some theories. But I am still puzzled. After all the efforts in recent years to increase physicians awareness of patients right to pain treatment---it is actually on the list of most Patients Bill of Rights that you see posted---why would two seasoned doctors assume that every poor person is a potential drug dealer? I am sure that they have met a few drug dealers. I have a sneaking suspicion that they did not recognize the drug dealers who were white, middle class, conservatively dressed, polite, well educated. And that they may have harbored some false suspicions about others whose only crime was being Black or unkempt (it’s hard to stay groomed when you live in a car) or in need of mental health services that were not available. Because if you enter an examination room with a preconceived notion---like everyone in a “free” clinic is a malingerer who is here to feed his drug habit or get some product to sell—that is what you are going to see.
On the other hand, if you take a step back and consider how that person came to the “free” clinic, if you remember that he once had a job and once had insurance and once paid taxes, until a truck backed over him—on his job---fracturing his cervical vertebrae---and that his employer weaseled out of his Workman’s Comp obligation throwing the patient into bankruptcy and onto the mercy of the public health system, and that while he can walk, he has constant, disabling pain from the bone and joint injuries and from nerve injuries and is going to live with that pain---and the poverty and disability---for the rest of his life through no fault of his own---maybe you can remember that the so called “poor” are people just like you and me---and by “me” I mean the well dressed, well fed, well paid doctors who would be absolutely outraged were anyone ever to tell us “Sorry, but I can only give you Motrin for your pain. You might abuse hydrocodone. The stresses of being a physician in America right now are so high. I must protect you from yourself.”
“A way has to be found to enable everyone to benefit from the fruits of the earth, and not simply to close the gap between the affluent and those who must be satisfied with the crumbs falling from the table, but above all to satisfy the demands of justice, fairness and respect for every human being.” (Pope Francis, Address to the Food and Agricultural Organization, 6/20/13)
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because it is very hard for them to pay to see a doctor, very hard for them to get a prescription (for the reasons I describe above) and they are always in pain and never know when it will flare up and they will not have the money to go to the ER. Poor people are much more likely to be the ones spending $5 or $10 to buy some middle class, insured person's Hydrocodone than they are to sell their own for the simple reason that they have no access to health care and they may need the medication so that they can stay on their feet for 8 hours at their minimum wage job so the kids don't get tossed into the street.
Hi, Towlie!
