Recently, the FDA indicated it would be increasing the level of restriction on many opiate drugs. Now, I work in both emergency medicine and addiction medicine; I’ve used opiates and believe strongly that they are a valuable, even crucial tool in the armamentarium of the physician or other health care provider. But I’ve also seen what opiates can do if left unrestrained. I’ve seen teens, twenty-somethings, fathers and mothers of small children on my gurneys in the ED, beyond my help because they had overdosed where no one could find them and were, in EMT parlance, DRT – “Dead Right There”, no need for them to be brought to an emergency department but for the need for a physician to say they were dead.

So today we see a letter to the editor in the Boston Globe. In it, the author decries the FDA action, as it will , in her opinion, leave pain patients (I prefer the term “patients with pain”, myself; the other term seems to me to denote patients who are a pain, not, I suspect, what the author had in mind) with fewer options, and thus, more pain.

The author claims, among other things, that opiates cause so few deaths that the lives saved are not worth the cost to patients with legitimate pain. I’m not going to get into the debate about the worth of a human life; people who say that no value can be assigned ignore plain economic fact (life insurance companies, for instance, assign value to human life regularly. NICE, the clinical effectiveness people in the UK, used to value human life at approximately $30,000 per “quality adjusted year”; they never said so outright, but the number could be derived from other portions of their well-written analyses. Look it up; I’ll wait). But the fact is that the letter writer plays a little fast and loose with the actual facts, as follows, in my reply to her letter:

“Let’s take at least one claim in this letter apart: “But those figures also show that only 29 percent of these deaths involved opioids alone; the rest involved alcohol, benzodiazepines, and other drugs. Yet it’s opioids — like the legitimate pain patients who need them — that get vilified.” The key word here is “alone”. As far as it goes, the sentence is accurate. Opiates alone can kill you, but in general, it’s combinations of drugs which tend to kill people. Many of the other deaths involved alcohol, benzodiazepines, and/or other drugs-usually in combination with opiates. It’s very, very difficult to die from overdosing on benzodiazepines; it can be done, but requires a lot of them. Dying from the combination of benzodiazepines and opiates is common. The same goes for alcohol, and “other drugs”. Opiates are almost always a factor in those deaths too.

The fact is that opiates are a weapon; they’re a lot like guns, actually. They’re legitimately a weapon in the fight against pain, as Ms. Foreman notes. But they’re also a weapon which, if not carefully controlled, will kill people. The FDA believes the balance between access and control is currently tipped too far towards access; as an emergency physician, and as a physician who has worked in the substance abuse field (I am technically still the research director at SECAP) I agree. I have no desire to see people in pain left without a treatment that works, and opioids work. But I am tired of seeing people fall into addictions that they could have avoided but for the easy availability of opiates during vulnerable times; adolescence in particular. The presence of too many twenty-somethings in my clinic tell me the FDA is right to rein opiates in.”

So, that. Opiates are useful, even crucially so. But damn, they cause vast amounts of pain and suffering, on a par, I would argue, with the pain and suffering caused by, well, pain and suffering. So before we say how evil the FDA is, let’s make sure the balance has all the factors on it. It’s not just deaths; it’s crimes done to get money for drugs, it’s children unfed because their parents sold their food stamps to get money for drugs, it’s the pain of the people with the addictions (do you think the people who commit the crimes or sell the food stamps *like* themselves after they’ve done those things? I am here to tell you they do not; they hate themselves unmercifully. Some of the drug related deaths are not accidents). There’s the money spent on rehabilitation; I believe that’s money well spent, but damn, rehabilitation is *hard*, people. Not just the physiology; the psychology of drug addiction is hard to clear up-people want to be clean, but they want to not have the suffering that comes with being and staying clean-the cravings, the withdrawal symptoms, the need to make amends with friends an family-all of those things are hard, and before you condemn the people who must eventually do these things by saying it’s their own fault, consider that none of these folks woke up in the morning and decided to become addicts. Each one has a story, and each story starts with some variant of “I didn’t mean for it to get this far”. So there’s pain on both sides, and to neglect to tell the whole story does an injustice to everyone in this discussion.