I am grateful to Des Spence for highlighting the issue of drug diversion in his recent piece.1 The redirection of legally acquired medications into illicit channels undoubtedly perpetuates drug culture in society and causes significant harm to the individual: emotional, physical, financial, and otherwise.
However, I feel he is misguided in suggesting that this issue is driven by the widely held idea that ‘pain is what the patient says it is’, or more specifically by prescription practices based on this tenet. Though he rejects it as ‘unscientific and false’, to me this simple statement neatly conveys the notion that pain is a nebulous phenomenon, occurring without the tangible anatomical or biochemical substrate that might allow it to be measured objectively.
The corollary of Spence’s view is then surely that pain is not always what the patient says it is; but it is hard to see how this stance would be useful, or indeed workable, in clinical practice. It implies a need for doctors to distinguish the genuine from the fraudulent. Not only is this impossible, given pain is subjective and unquantifiable, but it also welcomes prejudice. How might we identify would-be drug diverters? Do they really look or behave in the stereotyped manner that Spence portrays? I would argue that mispronouncing a drug’s name has poor positive predictive value in this respect.
Allowing doctors to become the arbiters of their patients’ pain is not a credible solution to the quiet epidemic of drug diversion. Under-treatment of valid pain will beget unnecessary suffering and it is easy to conceive that sufficiently determined patients will contrive increasingly elaborate, disingenuous methods to acquire the prescriptions they seek.
- © British Journal of General Practice 2017
