Pain policy is not drug policy. If society wants to improve the lives of people in pain and compress the terrible inequalities in its diagnosis and treatment, we have to tailor policy to the root causes driving our problems in treating pain humanely and equitably. In the United States, we do not. Instead, we have proceeded to conflate drug policy with pain policy, relying on arguably magical thinking for the conclusion that by addressing the drug overdose crisis, we are simultaneously (...) addressing the pain crisis. This is a category error, decades of commitment to which have resulted mostly in a worsening of both public health problems. Disentangling our problems in treating pain fairly and equitably from our problems with drugs and substance use is the only path to humane and ethical policy for each. (shrink)

This essay explores the long Western history of anxieties about feigned illness connected specifically to social policy. There is a remarkable consistency of such anxieties across time, as they appear in almost every major historical period in the West since the Middle Ages.

Prescription opioid policies too often reflect over a century's worth of moralizing about the nature of opioid use disorder, the value of pain, and the meaning of suffering. The social and legal penalties to prescribers run in one direction—avoid overprescribing, however defined, at all costs. The lack of shared definitions is problematic for formulating and evaluating opioid policy. For example, the variant definitions of “misuse,” “abuse,” and “addiction” complicate estimates of morbidity. There are also no widely accepted definitions of misprescribing (...) and overprescribing. I offer here a modest attempt at the categorization of misprescribing: inadvertent overprescribing, corrupt overprescribing, qualitative overprescribing, quantitative overprescribing, multiclass overprescribing, and underprescribing. (shrink)

The observation that neurological illnesses follow recurrent hits to the head was tempered by the terms that first called the diseases into scientific existence: “punch-drunk,” “slugnutty,” “slaphappy,” “goofy,” “punchy,” and a host of other colloquialisms accompanying class identities. Thus the discovery of disease and its medicalization ran straight into a countervailing belief about losers—losers in boxing, losers in life, losers in general. To medicalize such individuals was to fly in the face of a culture that made them jokes. Yet a (...) subculture began to emerge around pathological understandings: first in medicine, then in journalism, then in the courts, and finally with patient accounts about illness. (shrink)