Prince, Chronic Pain, Opioids & Why Dependence is Not a Pathology

Prince, Chronic Pain, Opioids & Why Dependence is Not a Pathology May 9, 2016

On April 21, when my alarm clock radio blasted “Raspberry Beret” at 5:30 a.m., I let it play for a minute before turning the radio off. The familiar tune was an unexpectedly pleasant start to my day. Several hours later, I learned that Prince, the musical genius behind that song and so many others, was dead at age 57.

My initial fond remembrance of Prince’s place in the soundtrack of my high school and college years has since been replaced by annoyance, anxiety and anger over how the news media are framing Prince’s life and death. Prince was apparently taking opioid medications for chronic hip pain, and planned to meet with a so-called “addiction specialist” the day he died. Dozens of news stories are discussing chronic pain, addiction and opioids—and largely getting things wrong.

The most common inaccuracy confuses and conflates the terms “dependence” and “addiction.” In a May 5 New York Times article, for example, Jan Hoffman toggles between the two terms in a way that suggests they are synonyms, that someone dependent on opioids is addicted to opioids. This is wrong. As I discussed in my Salon essay on opioids, anyone who uses opioids long-term will become physically dependent, which means they need regular doses of opioids to avoid becoming sick with withdrawal symptoms. Addiction, in contrast, is a brain disease involving dependence and certain behaviors, including compulsion, loss of control, and continuing to take a substance in excess despite negative consequences for one’s health and life. Hoffman points out that Prince didn’t have many risk factors for addiction, but seems to conclude in any case that he was addicted.

The physician Prince planned to meet the day he died, referred to as an “addiction specialist” in much news coverage, was actually a chronic pain specialist. Dr. Howard Kornfeld and his son Andrew run a San Francisco recovery center that helps chronic pain patients dependent on opioids such as oxycodone and hydrocodone explore other options. The Kornfelds advocate medication-based treatment using buprenorphine—a less addictive opioid that quiets cravings and withdrawal symptoms while also relieving pain and avoiding the “high” that tempts people to take too much—along with comprehensive pain-management strategies such as exercise, diet, and mental health support. As a colleague of the Kornfelds has pointed out, “Seeking help from Kornfeld does not mean that Prince necessarily had an addiction problem. Instead, he could have been trying to avoid one. It could imply he’s having a pain management problem and was worried about becoming dependent.”

In other words, Prince could have been a lot like me—searching every possible avenue for living a full life with chronic pain and concerned about drug dependence for many reasons other than addiction. That possibility has gotten lost in the flood of alarmist, confused, and misinformed journalism about Prince’s life and death. Some media accounts go beyond conflating “dependence” and “addiction” to present a skewed understanding of the very idea of dependence.

For example, David A. Kessler, former head of the Food and Drug Administration, takes our confusion around dependence to an absurd conclusion in an op ed titled “The Epidemic We Failed to Foresee,” published in the May 6 New York Times. Kessler’s op ed includes legitimate concerns about the rise in opioid overdoses, how effective opioids really are for some types of chronic pain, and physicians who prescribe opioids too readily for routine surgeries and injuries. The op ed, however, also includes this claim:

Some patients will make heart-rending pleas that they cannot live without their opioids. But we have failed to see this for what it is, the signature of addiction: “I need it. I can’t get better or normal without it.”

Kessler is, in other words, arguing that dependence on a medication, in which a patient insists that s/he requires it to feel “better or normal,” equals addiction. Think about that for a minute, about what it means to pathologize someone’s need for medication or something even more basic to feel “normal.”

A depressed person who needs an SSRI to feel normal? Addicted.

A diabetic who needs insulin to feel normal? Addicted.

A hungry person who needs food to feel normal? Addicted.

These comparisons—particularly the last—may appear ridiculous. But the comparisons hold, maybe especially the last.

When someone on psychiatric medications goes missing, the plea for help in finding them often includes the fact that they left behind medications that they need. Many psychiatric medications produce withdrawal symptoms when a patient stops taking them suddenly. People on psychiatric medications will feel worse—both psychologically and physically—and unable to function well if they stop taking them. They are dependent. Yet we don’t call them addicted.

We are all physically dependent on food to feel “better and normal.” When we go without food for too long, we feel sick with stomach pains and headache, and we can’t function well. When we ingest more food than we need, however, we also feel sick and fail to function optimally—just as someone who takes to much opioid medication compromises her health and struggles to function. We are physically dependent on food such that someone who is starving will beg for it. Yet we don’t call the starving person addicted. We recognize that overeating and addictive behavior around food (such as eating in response to anxiety or boredom) cause serious health problems for individuals and our society. Yet we would never suggest that withholding food from those who need it is the solution to these problems. We recognize that food—when ingested in healthy kinds and amounts—can enhance well-being. Yet experts like Kessler refuse to consider that opioid pain medication—when taken in prescribed amounts for certain types of pain that respond well to opioid treatment—can enhance well-being. Such experts refuse to recognize that dependence on these medications is not addiction, but an effective way for some people living with debilitating conditions to feel “better and normal.”

Furthermore, our culture is profoundly uncomfortable with the notion of dependence on anything. As I discussed in my Salon piece, our cultural norms lead many people to feel a “generalized sense of shame over taking medication at all. A friend who takes antidepressants says that every day, she asks herself if she really needs that little blue pill, or if she is taking the easy way out. Our current cultural climate exacerbates the stigma of taking medication for conditions, including psychiatric illness and chronic pain, that some people perceive as character flaws instead of medical problems. My Facebook and Twitter feeds are populated by rants against Big Pharma and profit-focused doctors alongside uplifting stories about people who take a DIY approach to health —the woman with multiple sclerosis who claims she is still able to walk because of her self-engineered diet and exercise program, the nutritionist who offers sour cherries and other anti-inflammatory foods as a remedy for back pain, the blogger who shares his regimen of daily runs, extra-high doses of Vitamin D, and a diet cleansed of grains, dairy, and sugar as a surefire way to send wintertime depression packing. In a culture distrustful of experts and authority figures, and partial to sloppily constructed arguments favoring the ‘natural’ over the human-made, ongoing dependence on any kind of medication is questionable. Dependence on opioids— a substance often abused and at the root of severe social ills—is seen as not merely misguided or uninformed, but deeply suspect.”

And it’s not just dependence on medications and doctors that are suspect, but dependence on anything and anyone. Cultural norms emphasize personal preference, customized experience, and do-it-yourself everything, fostering independence over dependence. We follow limited diets that eradicate certain kinds of food (e.g., grains or dairy) or most food itself (extremely low-calorie diets)—limitations that lead us to prepare and consume food independently instead of with others. Many factors have contributed to the rise of religious “nones”—people unaffiliated with a particular faith—including values (such as engagement with the natural world) that religious institutions would do well to take seriously. But one factor in decreasing religious affiliation is that independently cobbling together one’s own spiritual practices frees people from conforming to the schedules, expectations, and ethical norms of a faith community, from the responsibilities and limitations of dependence on a communal expression of faith.

As independence frees us to embrace our own preferences—not necessarily a bad thing— it also limits our reliance on communal resources that have traditionally helped human beings thrive. As Guardian columnist Will Hutton wrote recently about a rise in anxiety disorders, particularly in teenagers, Western cultures prize individualism and freedom of choice over dependence and interdependence. We prefer managing on our own to relying on one another. Critics of individualism “usually focus on the exterior consequences, ranging from heightened inequality to weakening rates of innovation, investment and productivity. They are right, but there is another less frequently made criticism—what this worldview is doing to our mental lives,” writes Hutton. “Happiness can never result from the exercise of choice alone,” he continues, for “we are social beings, and the building blocks of happiness lie in looking out for each other, acting together, being in teams and pursuing common goals for the common good.” He argues that “the doctrine…that the quest for a common good—in schools, in unions, in the delivery of public services—should be trumped by the expression of choice [has resulted in] the anxiety epidemic.”

Medications to treat this anxiety are one response to the epidemic, but the most effective responses are likely to be comprehensive, addressing social isolation and cultural norms that focus on individual achievement at the expense of emotional and relational health. The most effective responses to chronic pain are also comprehensive, addressing a pain patient’s emotional, psychosocial, and physical needs while providing various kinds of medications to lessen pain.

For the past few months, I’ve been putting together a comprehensive chronic-pain plan that includes physical therapy, exercise at home and in the pool, mental health support, and altered home routines (e.g., we hired someone to clean the house so I don’t expend limited energy and invite injury doing it myself), along with opioid medications. I began exploring a more comprehensive plan in part because I don’t like being dependent on opioids; I fear withdrawal should I be without medication for reasons beyond my control, I dislike the logistical hassles involved in getting these increasingly regulated medications, and I experience stigma and shame—sometimes from within, but also in response to careless and callous comments, including from the pain specialists I see who have chosen to make patients like me the focus of their practice.

I have no idea whether Prince was addicted to opioids or, like me, had become dependent on opioids to relieve his pain, didn’t like being so dependent, and wanted to explore a more comprehensive approach. I do know that human beings are created with needs—for nourishment, for relationship, for engagement with the world. In the biblical narrative, these needs—our dependence and interdependence—were part of the human story from the very beginning. When our physical or mental health is not sufficient for such basic needs to be met, then we need other things, from equipment and caregivers to therapy and medication. Pathologizing certain kinds of needs because meeting them is complicated and variable is a failure of imagination and compassion. Journalism that pathologizes dependence while reinforcing damaging assumptions and misinformation about pain and opioids fails to honor Prince’s life and death, and the lives of all of us committed to living full and functional lives with chronic pain.

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