As with the predictable and avoidable costs, including lethal epidemic, of the opioid crisis generated by inappropriately prescribed opioid pain medications for an entirely non-medical condition – similarly the fabricated “disease” (medical, “hijacked brain”) model of addiction continues to drive a worsening national substance use epidemic despite its invalidation by all lines of evidence and outcomes. But centralized chronic pain and substance use are not the only non-medical conditions medicalized with predicted resulting harms, and it’s not just adults being harmed.
Stopping and reversing the predictable harms and public health crises from medical scope of practice and competence assaults requires facing not just the history and outcomes of the disasters, but understanding the driving cultural, psychological and historical forces underneath them. It will require dismantling and correcting the fabrications that are messaged by powers with the cultural capital to message them, and the false sheen of decency, authority, and truth covering the useful, profitable fictions.
Constructed fictions that sociologist Pierre Bourdieu termed
Doxa is what is accepted and understood as fact, not because it is fact, but precisely because it has never been publicly and openly scrutinized, examined, never subjected to A Critical Discourse.
Chronic pain and its treatment have played central roles in runaway over-prescription of opioid pain medications and the opioid crisis. Understanding how we got off track with chronic pain is crucial considering the costs that include: key role in etiology of the opioid crisis and projected mortality and morbidity and, for example, an estimated $90 billion annually in wasted healthcare expenditures for inappropriate biomedical treatments just for lower back pain.
But none of that is new – Decades of mutually-supporting research and understanding – of the psychogenic nature of chronic pain; of placebo effect and its meaning; of why CBT works and provides durable relief for chronic pain – establish that centralized chronic pain should never have been treated as a medical condition.
And the use of opioid medications for chronic pain was indicated against all along.
As documented and linked to research in an initial post, from the beginning, well prior to explosion of runaway, widespread use of prescription opioids for centralized chronic pain, all lines of evidence pointed against and contraindicated their use. There was never support for their safe, effective use due to longstanding:
1) lack of research evidence for effectiveness long-term
2) evidence for the potential for hyperalgesia – increased sensitivity to pain
3) established addictive potential of opioids
4) understanding of the psychogenic nature of centralized chronic pain
5) evidence for cognitive behavioral therapies (CBT) as the indicated treatment for chronic pain
Because the evidence – all lines of relevant evidence – was there all along, indicating against use of opioids for chronic pain on the bases of safety and effectiveness, explanations for the pathological results force us to face and correct the systemic abdication of responsibilities of institutions and professionals in positions of pubic trust to protect the public from harm, abdications of accountability, professional competence, nonmaleficence (“do no harm”), and of scientific and ethical reasoning.
The weak excuses of the medical industry do nothing to explain and account for the harms in ways that would identify and describe the failures and provide understanding of the distortions that created them.
The problems are systemic and point to pathological deficits in healthcare industries and institutions responsible for oversight and protection of the public, deficits that allow public heath and medical “knowledge” to be arbitrarily constructed, as fiction, by interests with the cultural capital to construct those fictions for gain, in an ethical and scientific vacuum, without open scrutiny or discourse – healthcare industries that are functionally embedded in a criminal economy that continues to assault public health in order to further enrich and empower a very small owner class and its institutional operatives.
There’s been no accounting for the social and institutional pathologies creating the opioid crisis, and in that vacuum no learning or correcting changes to avoid the same systemic generation of ineffective public health policy due to medicalization of non-medical problems.
In the rush to respond, manage the harm, and attempt to re-establish the appearance of competence and effectiveness in management of chronic pain, opioid use and related risks, the managed healthcare/medical industry has invested in a type of harm reduction strategy rebranded “Medication Assisted-Treatment”. In MAT the manufactured, prescription opioids methadone or buprenorphine (brand names Subutex, Suboxone) are dispensed and intended to provide the assisted part of Medication-Assisted Treatment, assisting by creating conditions for patients to basically feel and function better, in order to effectively access and benefit from the “treatment” part = effective (“evidence-based”) behavioral health therapies (the subject of multiple Posts).
But – in a repeat of the abdication of critical and ethical thought and of responsibility to avoid public harm – the universal support and implementation of a medical fix, Suboxone, for the non-medical problem of compulsive use of opioids, is not supported by the evidence, with research pointing to failed outcomes and pointing to those failures due to the inappropriate medical fix distracting resources and attention away from the indicated, evidence-based psychosocial supports and therapies established as effective for problem substance use.
In addition to the relevant research pointing to failed outcomes when suboxone is seen as and provided as a “treatment” or “fix” for the opioid crisis, longstanding research and evidence related to the nature of substance use problems and return (“relapse”) to problem use predicts those failures.
As with the ineffective and invalidated use of Nicotine Replacement Therapy (NRT) for tobacco use , the provision of buprenorphine (Suboxone) in medical settings with focus on medical visits and monitoring provides directly and indirectly the message to patients that use of Suboxone serves as a type of treatment, a medical treatment for a medical condition, the disease of addiction. To the extent that actual evidence-based treatments for a substance use disorder (psychotherapies like Motivational Interviewing (MI), Cognitive Behavioral Therapy (CBT), Community Reinforcement Approach (CRA) – which addresses environmental problems and provides support for employment and other psychosocial supports – and others are messaged as secondary or not provided at all, treatment failure is predicted.
That orientation to medical setting, model and “treatment” is predicted to directly increase probability of return to problem use of opioids and to decreased retention in MAT programs as related to two primary predictors of relapse based on the research: 1) belief in the falsified disease model of substance use and 2) the correlated factor of diminished sense of self-efficacy – the sense of having ultimate agency, competence, and potency in making important changes including the ability to stop use of a substance by choosing to and making the critical behavioral, cognitive, and life changes to support cessation. Dependence on continued use of a medication and medical visits works against strengthened sense of self-efficacy and instills self-defeating beliefs in the disease model of substance use.
These factors, established by research, predicted the negative outcomes of reliance on buprenorphine as a “treatment” in controlled studies and in the decades-long natural experiment in France.
Unsupported medicalization of 1) chronic centralized pain and of 2) the problem compulsive opioid use it largely created has resulted in predictable failed outcomes at high costs to public health.
The medicalization of substance use in general is associated with a steadily worsening national substance use epidemic and with diversion of public funds for decades away from established evidence-based therapies for substance use disorders to research and support for a fictional medical model of substance use, with no evidence of gains provided, instead false promises of a cure just around the corner.
Promoting a medical cure to emerge, just around the corner, for a non-medical condition is indicative of deeper social and cultural distortions and pathologies.
The reductionist medical model that attempts to understand and treat human ailments and complaints generally as physical or biomedical seems to know no bounds and seems to be immune to benefitting from insight and accountability, and correction, based on harms done, even public health crises.
In upcoming posts, we’ll explore additional areas of human and public health conditions and illness that are psychosocial in nature and in indicated treatment yet have been coopted by medicalization, with failed outcomes.
We know a lot about depression – that it is grounded in distorted beliefs that are inaccurate and self-defeating, that it is tied to early experiences including trauma and ACE, and is influenced strongly by social and other environmental losses and stressors. We also know, from the field of evolutionary psychology, that the behaviors associated with depressed mood seem to have a function and represent an adaptive signal to the organism to respond to an important loss in ways that are healing, protective, re-organizing, and help-seeking.
If I have a tooth ache due to dental decay, one “treatment” approach might be for my medical provider to place me on opioid pain medications long-term, enough to manage the pain. The symptom disappears. But that’s not treatment at all, and worse, distracts from and robs me of motivation to make changes that would address the underlying cause of the symptom, that underlying cause worsening or at least not healing.
More on that later.
Perhaps the most underappreciated, unrecognized, and potentially potent and effective, preventative, approach to public heath problems that range from depression and anxiety, to substance use, to obesity, to heart disease and diabetes centers on the strong and established links among generation of these large-scale health epidemics to assaults against the developing child early in life – Adverse Childhood Experiences, or ACE – experiences that affect brain development, stress hormones, core beliefs about self and the world, ability to regulate mood, ability to self-soothe emotionally versus soothe with substances or other harmful behaviors.
In any proactive, socially just, and effective use of social resources to promote social well-being and health ACE would be addressed in an intensive public health campaign of prevention, one that might marshal resources that have been squandered on fictional medical models for non-medical conditions like chronic pain and substance use – like the $90 billion dollars annually wasted on biomedical interventions for chronic back pain.
The prevention and treatment of ACE effects are fundamentally and almost entirely psychosocial – that is, dependent on effective behavioral health therapies and interventions, like family therapy, work on regulation of emotions and anger, and substance use interventions for parents struggling with those problems. That’s because the effects of ACE – setting kids up for high risk of mental health and physical health problems through their lives – are created by the disturbing and potentially traumatizing effects of dysfunctional and emotionally damaging behaviors of parents. There’s no way around that, no shortcuts, no medical interventions.
That’s a psychosocial, not a medical or physical problem, right?
In any reasonable world, any rational and ethical culture, yes.
But not ours, not in a culture that allows powerful industries to create, against all evidence, a lethal opioid crisis.
Allows those same industries, driven by profit and power, to generate worsening substance use epidemics while shilling for decades false promises for a magic pill, a cure just around the corner.
We know that ACEs are forms of stress and create baseline anxiety, that stress-eating is driving a childhood obesity epidemic, obesity driving a looming diabetes crisis, and those effects partly caused and worsened by nicotine, which directly contributes to risk of diabetes and is delivered in e-cigarettes, booming in popularity with kids.
Prevention of ACE is the key, something we’ve known for a decade or so.
In the Pacific Northwest, driven by managed care, there are efforts to better serve kids, for example, through the Oregon Pediatric Improvement Project (OPIP), identifying kids with signs of developmental challenges and getting them to effective services.
but the vast majority of children with signs of early problems are struggling due to effects of ACE, including abuse, neglect, more commonly exposure to frightening adult behaviors like drug use and aggression – psychosocial issues demanding family and psychosocial – not medical – assessments, treatments and interventions. The inappropriate medicalization and medical treatment for another non-medical problem, chronic pain, is what gave us the opioid crisis.
Vulnerable population . . . managed care . . . business model healthcare system . . .. . . medical model . . . for non-medical problems . . .