Friday, April 22, 2011

Standing By My Principles

I was reading Burt Prelutsky's most recent article on drug legalization when I realized I had a bit of a moral dilemma.

Having thought about the matter at great length, I know in my heart that the war on drugs has done far more harm than good. And, even if it has done good, it has, as von Mises pointed out, done quite a bit of harm simply by enshrining the principle that it is the role of the government to tell people what is good for them and protect them from bad decisions. Not just that, but it has also harmed any number of innocent people, as I can attest first hand.

As a sufferer of nervous disorders I suffer from horrendous pain, but, due to the war on drugs, doctors are very reluctant to prescribe pain killers in adequate quantities. In one year, due to changing DEA rules and doctor fears, I went through opiate withdrawal three different times as various doctors worried that I was using "too many" pain relievers, at the same time I was suffering excruciating pain. Johns Hopkins, a noted research center, is reluctant to prescribe pain killers as the DEA accused some departments of overprescribing (or so I heard unofficially). In addition, I have had many times faced a doctor who was convinced that I was a "drug seeker" who was exaggerating pain to get opiates. In fact, that may be one of the worst outcomes of the war on drugs, creating an almost adversarial relationship between doctors and patients, where doctors need to suspect the motives of their patients, while at the same time afraid to prescribe pain killers for fear of DEA prosecution. (Nor do I exaggerate, several doctors have recently been prosecuted on the basis of DEA claims that they "should have known" their patient was "doctor shopping".)

So the thought that the war on drugs only harms drug users is absurd, people who suffer from pain also suffer due to some of the excesses of the war on drugs as well.

However, much as I think the war on drugs should be ended, I can't say in good faith that we should legalize drugs on a federal level.

Why not?

The answer is quite simple. As I have thought more and more about how the nation should be run, I have come to the conclusion that the founders knew best, and we would benefit most form a truly federal system, rather than the almost omnipotent central government we have now. So, no matter how much I feel that drug legalization would benefit us, I can't honestly say we should legalize it federally.

No, to legalize federally is just as bad as prohibiting federally, both have all the bad results of any national action.* Instead, much as it worries me that many states would continue the current prohibitions, I think the ideal solution is simply to do away with all of our federal rules, eliminate the DEA, and return this, as we should all criminal questions, to the individual states.

If we leave the drug questions to the states we may not have 50 perfect solutions, but it is much more likely at least one good solution will arise out of the 50 choices, than that the single federal solution will be right. Why not take 50 shots at the right answer rather than saddle ourselves with just one?**

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* I will not bother here to reproduce my earlier arguments on the benefits of federalism for the war on drugs. For those who are interested, you can read my thoughts here.

** And if you disagree with me, and think legalization will produce nothing but harm, then why not allow a federal solution where we can compare 50 different sets of laws? If legalization is truly harmful, then it will be obvious when we can compare drug-free states with legalized drug states. So, if you are right, and legalization is a bad idea, federalism will help settle the question once and for all. Otherwise, we have only one solution, nothing with which to compare it, and the debate will continue forever, with no easy way to resolve the question.

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UPDATED 02/09/2008


I realized after I wrote this that I had not adequately described the degree of deception the war on drugs introduced into the doctor-patient relationship, but, as the server appeared to have some problems overnight,  I have not been able to update until  today.

To understand how artificial the process of treating pain has become, we need to think of an ideal situation, without any legal considerations. In that situation, a patient would tell a doctor how much pain he suffers, the doctor would consider the drugs available and the side effects, and prescribe appropriately. If the medicine did not relieve the pain, the patient would tell the doctor, and the prescription would be revised.

Our current system is nothing like that, though it pretends that is still the model. However, instead of an honest assessment of treatment, the top two concerns of the doctor are to not be seen as "over prescribing" and not to allow anyone to receive opiates to which they are not "entitled" according to the state. The patient, on the other hand, is first and foremost concerned with not being labeled a "drug seeker", as, once that label enters his records, he risks being sentenced to permanent pain. (I know, as I have records I cannot provide to other doctors thanks to a very unpleasant neurologist's assessment of me.)

So, rather than the ideal above, the current procedure goes as follows:

The patient very cautiously tells the doctor he has some slight pain. he cannot honestly state the degree of pain, as he will seem to be fishing for drugs, so all patients must always underplay the degree of their pain. The doctor responds by offering a variety of useless non-opiate solutions such as aspirin, gabapentin*, etc. or even patently silly solutions, such as trying to cure nerve disorders with physical therapy. The patient must try these for a sufficiently long period, regardless of ineffectiveness, and suffer through his pain for several weeks before returning and saying "they didn't entirely work." (The patient has to pretend these solutions provided some relief, no matter what the truth, or else risk being labeled a drug seeker.)

At this point the doctor can reluctantly offer a minute amount of opiates, though he has to do so with many warnings and with a great show of reticence. The patient has to make the same gestures as well, and explain at great length that he doesn't want opiates and only accepts them reluctantly and for a short time until the doctor finds a better solution.

Of course, the amount initially prescribed is wholly ineffective, so the patient has to suffer another month or two with inadequate relief until the next appointment, at which time he can again say something along the lines of "I sometimes have some small break through pain", even if he is suffering constant agony. After this the doctor, again with a great show of reluctance, can offer a small increase in medication.

This continues for months until the patient, if he is lucky, and plays the game right, finally reaches a dosage which relieves his pain. Unless, of course, the doctor at some point decides he is taking "too much" or is really a drug seeker. Or maybe the DEA decides the doctor is over-prescribing, prosecutes him, revokes his prescribing privileges, and the patient has to start over again with anew doctor.

And before anyone accuses me of exaggeration, until I found my current very good pain doctor, the story above was my life for the past 2 to 3 years. I have gone through at least 3 withdrawals, been called a drug addict to my face, had records declare me a drug seeker, been told by an emergency room doctor that they could not give me any pain killers, and any number of other indignities. I spent over a year without a diagnosis, undergoing lumbar punctures, MRIs, nerve conduction tests, and so on, at the mercy of doctors' (and the DEA's) whim as to whether or not I would have pain relief, and subject at a moment's notice to, not only having that pain relief withdrawn, but also being forced to undergo the discomfort of opiate withdrawal.

So, again, I do not want anyone to tell me that calling for drug legalization means one just wants to smoke weed, or that the war on drugs harms only addicts. I am just one of many innocents who have been horribly mistreated due to the war on drugs.

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* Gabapentin may or may not work. In my case, I suffer from severe adverse reactions to a wide range of medications, so it did very little for me. In fact, excepting opiates, antibiotics, some few antispasmodics, and aspirin, I can think of few medications which agree with me. So if gabapentin has been of use to any reader, I am quite glad, but in my case I often told doctors that medications such as gabapentin, cymbalta, and lyrica had side effects (photosensitivity, nocturnal vomiting,  distended stomach, an inability to digest food,sleep apnea, confusion, depression, temporary deafness, etc.) only to be told I had to try them anyway. That is, if I was lucky. Some doctors didn't believe me at all, and though I was just making up adverse reactions to get opiates. Again, the war on drugs turns many doctors into judgmental petty tyrants, who, unfortunately control access to necessary medication.

Originally Posted in Random Notes on 2008/02/08.

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