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Unquestionably, people who take a narcotic for a long period will become physically dependent on the drug. But researchers have learned that dependence is not the same biological phenomenon as addiction. Most patients don't become addicts that easily, perhaps because they lack the addictive body chemistry, perhaps because they take the drugs in a social setting different from that of illicit users. "When addicts use drugs, they become less functional, more isolated, and they move away from the mainstream," says Dr. Richard Patt of the M.D. Anderson Cancer Center of Houston. "When pain patients use drugs, they become more functional, much less isolated, and they move toward the mainstream." And when they no longer need the drugs, Patt says, they have, almost without exception, no difficulty gradually eliminating their intake.
That doesn't mean a doctor can prescribe narcotics with impunity. For one thing, this can be hazardous to one's career. Medical-review boards in some states, notably Tennessee, West Virginia and New York, are notorious for singling out physicians who prescribe a lot of narcotics and yanking their licenses. "I tend to underprescribe instead of using stronger drugs that could really help my patients," a West Virginia doctor admits. "I can't afford to lose my ability to support my family."
A physician who nearly did lose her license is Dr. Katherine Hoover, formerly of Key West, Florida. In December 1993, Hoover got into trouble with Florida authorities because she had treated the chronic pain of seven of her 15,000 patients with narcotics. A pain specialist testified at her 1995 hearing that she was practicing within accepted guidelines. But the review board censured her anyway--a decision that was reversed on appeal. Says Hoover, who now practices in West Virginia: "There is a belief that anyone who prescribes narcotics is a bad doctor."
In no field of medicine is the controversy more intense than in the treatment of children. Dr. Kathleen Foley, head of the pain service at Memorial Sloan-Kettering in New York City, remembers an adolescent who was terminally ill. "The father didn't want his son on morphine because he was afraid the boy would become an addict," Foley recalls. In his grief over the imminent loss of his son, it seems, the father failed to see the absurdity of worrying about long-term addiction in a child who is dying in pain.
Of course, narcotics are not the answer for everything. Nor should doctors prescribe any medications, opiate or otherwise, just to placate their patients. But studies have shown that when physicians take their patients' suffering seriously--and do all they can to relieve it--the patients respond by getting better faster and staying better longer. Asked why they want to die, most people who seek physician-assisted suicide respond that it's because they can no longer stand the pain. But when their pain is relieved, most would-be suicides suddenly find they are a lot more interested in living.
--Reported by Sam Allis/Boston, Deborah Fowler/Houston, Jeanne McDowell/ Los Angeles and Dick Thompson/Washington