Yes, that dress. The one that blew up social media and had the world squinting over laptops, accusing friends, co-workers, and family members of color blindness as they asked: ‘so, what color is this dress?’ While I would like to believe we as a global community have bigger fish to fry than the color of a party dress, it is an interesting example of how people can legitimately perceive two entirely different versions of the same reality and how divisive this difference of perception can be: those who see the dress as blue-and-black are positively incredulous of those who see it as white-and-gold, and vice versa.
It is certainly not the intent of this post to suggest a fashion dilemma in any way equates to a very real and deeply troubling healthcare problem. Instead, the goal is to consider how the metaphor of the dress, and the differing perceptions surrounding it, can offer some insights in to the on-going debate regarding pain management in our country.
Recently I listened to Attorney General Maura Healey discuss her commitment to stopping prescription opioid abuse in the state of Massachusetts. Healey has labeled this effort her ‘top priority’ and it is a key rallying cry of Governor Baker’s political platform. While Healey and Baker’s goal to eradicate opioid overdose deaths is laudable, their strong anti-prescription opioid rhetoric makes me uneasy. It assumes a ‘white-and-gold dress’ view of the problem that leaves little room for the possibility of an equally accurate ‘blue-and-black dress’ reality. It is certainly true that opioid medications carry risks, and prescribers most definitely have an obligation to educate patients and their families, while taking precautions to minimize the risk of diversion and misuse of these powerful drugs. But it is also equally true that most opioids are inexpensive and amazingly effective in treating difficult pain, and, in fact, are considered the gold-standard pain therapy for patients with moderate to severe cancer pain. Opioids are not the right drug for every patient, but for many patients suffering with serious and terminal illness, they are simply the best, most effective, and sometimes the only, therapy we have to offer.
As an oncology palliative care provider I have seen both sides of the equation, both the ‘blue-and-black dress’ and the ‘white-and-gold dress’ version of the problem. I have seen methadone* prescribed almost cavalierly to patients who had safer options available, and then in the next room watched a man riddled with cancer writhe and pant in pain because no one would order a reasonable dose of morphine for fear of causing respiratory depression. Prescribing of pain medications for non-cancer patients can be equally baffling. A friend of mine—a quiet, mild-mannered, graduate student—had minor outpatient surgery; upon discharge she was given an unnecessarily hefty supply of Percocot (oxycodone with Tylenol). I was shocked and, frankly, so was she. No one thought to ask about her serious major depression, the strong history of alcoholism in her family, or the fact her brother had died of a heroin overdose. No one took the time to squint a bit more carefully and ask themselves the medical equivalent of: ‘so, what color is this dress?’
We as healthcare providers, healthcare systems, politicians and regulators seem to swing wildly back and forth on this pendulum of pain management—alternately over-correcting in either direction, but unable to find the middle ground. Unacceptably high percentages of patients – even those with advanced stage cancer – still suffer in preventable agony. Unacceptably high percentages of people die from prescription opioid abuse. At the 2012 Oncology Nursing Society Research meeting, my mentor and colleague Professor Susan Beck wisely referred to this disturbing scenario as a ‘dual epidemic:’ a concurrent epidemic of drug abuse and an epidemic of undertreated pain. In other words, the problem is both a blue-and-black dress, and a white-and-gold dress.
These debates and discussions take on a very different dimension when one considers the state of pain management in the majority of the world. Consider: roughly 70% of the world’s cancer deaths occur in low-and-middle income countries and an equally large percentage of patients (about 80%) in these countries present with advanced stage disease and in desperate need of pain relief. For a host of complex reasons, but primarily due to a labyrinth of outdated regulations that prioritize reducing abuse and diversion over ensuring legitimate access to pain medications, millions of the world’s poorest patients suffer and die in unthinkable agony. In many countries in the world basic pain relief, such as short-acting morphine, is simply unavailable in the hospital, in the pharmacy, or even the country.
The Pain & Policy Studies Group has been a pioneer in advocating for balanced access to opioids, and has created a morphine consumption metric to gauge the degree of pain relief available in a particular country. Check out this graph that depicts the stark disparity between morphine consumption (in milligrams/per capita) for medicinal purposes between the United States and a sampling of lower income countries.
This powerful map shows the size of countries adjusted for their consumption of opioid medication per death from cancer or HIV/AIDS. Notice that high income countries consume 93% of the world’s morphine supply, despite the fact that the majority of the world's cancer deaths occur in lower income countries.
The dire situation of lack of access to basic pain relief in low and middle income countries is increasingly being framed as a violation of human rights. Despite this growing awareness, anti-opioid conversations in the U.S. have the potential to have a profound ripple-effect in the developing world, creating even more barriers for the millions of vulnerable and impoverished patients with advanced cancer and other terminal illnesses who already struggle to obtain basic pain medication. Shouting at the world that it is a white-and-gold dress makes it far less likely people will appreciate that it can also be a blue-and-black dress.
What can be done? Just as our policies governing opioids must be balanced, so must our conversations. Language matters: Pain killers. Narcotics or opioids. Drugs versus medications. Addiction confused with physical dependence and tolerance. We must choose our words carefully, as they are the architects of perception. Fueling ‘opioid-phobia’ by contributing to the disproportionate fears and myths surrounding opioid therapy serves no one. The ‘blue-and-black dress’ and the ‘white-and-gold dress’ camps must work together to see the problem more accurately and fully. Those advocating for increased opioid regulations must be informed of the large body of research documenting the global epidemic of untreated pain and the very real barriers that contribute to unmanaged pain. Oncology and palliative care providers cannot put their heads in the sand and ignore the realities of opioid misuse and diversion, nor be naive about the potential risks of opioid therapy—issues that may be especially salient as cancer patients live longer with serious, chronic illness. Clinically relevant training and education about opioids is essential, not only for healthcare providers, but also for patients and family caregivers. Continued research is needed so we better understand the complex dynamics of pain, mood, genetics, substance use and addiction. Practical and effective ways to risk-stratify and screen patients for potential opioid misuse must be consistently implemented to help ensure safe and effective pain care.
Pain is the number one reason patients present for healthcare, but ironically it is one of the least resourced aspects of our healthcare system. No ethical healthcare provider wants to contribute to the epidemic of opioid abuse, but we should be equally concerned about the epidemic of unmanaged pain. At the end of the day, whether you see the dress as blue-and-black or white-and-gold matters far less than being willing to acknowledge that others may perceive it differently, recognizing both as legitimate views, and working together to get as complete a picture as possible to solve the problem.
*Methadone can be a very effective opioid medication for cancer pain, but it is pharmacologically complicated and requires vigilant monitoring by experienced prescribers.