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Part 1: All About the 501s
Themes
Key
LitCharts assigns a color and icon to each theme in Dreamland, which you can use to track the themes throughout the work.
Pain Management and the Normalization of Narcotics
The Drug Business
Stigma, Shame, and the Opiate Epidemic
Community as a Remedy to Addiction
Summary
Analysis
In a way Dr. Hershel Jick couldn’t have predicted, his 1980 letter to the editor in the New England Journal of Medicine gains traction and fuels America’s pain revolution with Kathy Foley and Russell Portenoy citing the letter in their 1986 paper in Pain. As Jick’s letter continues to be used to validate treatment with opiates by proclaiming opiates’ nonaddictive qualities, advocates ignore one critical piece of information: Jick’s data applied only to hospitalized patients who were given drugs that were carefully, precisely monitored. Such careful regulations are not, in other circumstances, being followed by doctors and researchers who advocate for increased use of opiates in all patients. Opiate destigmatization enters into the mass culture; in 2001, Time magazine publishes a story called “Less Pain, More Gain,” which calls Porter and Jick “a landmark study.”
Again, Quinones emphasizes how pain researchers overlooked crucial pieces of information in their overzealous quest to find a “Holy Grail” painkiller that could relieve pain without causing addiction. The Porter and Jick letter was only a one-paragraph letter to the editor, yet it was repeatedly misconstrued as a “landmark study” that gave the absolute go-ahead for doctors to confidently and legitimately prescribe opiates to their patients. Once the destigmatization of opiates entered into the mainstream via widely-read publications like Time, patients, too, could rationalize taking prescription opiates.
Themes
Russell Portenoy continues to be a leading voice in pain management, working at Beth Israel, serving as editor in chief at the Journal for Pain and Symptom Management, as well as an editor at Pain. By the mid-1990s, it is accepted that opiates are only destructive for addicts: for pain patients, in contrast, opiates help to improve one’s quality of life. Increased reliance on opiates causes a decrease in “multidisciplinary” treatment plans for pain patients. Therapy takes more time and effort than pills, which are viewed as “an easier solution.” Multidisciplinary clinics closed as insurance companies increasingly refuse to cover their treatments.
The idea that opiates were only dangerous to “addicts” stigmatizes addiction: it suggests that some people can handle narcotic painkillers and others cannot. In this way, the destigmatization of opiate painkillers inadvertently resulted in the stigmatization of opiate addicts. Insurance companies’ decision to cover pills over multidisciplinary approaches to pain treatment shows how they valued cost-efficiency over the actual effectiveness of treatments.
Themes
Prescription practices begin to change. If a patient claims that a painkiller isn’t helping, doctors up their dosage; in years prior, this never would have happened. In a 1989 Pain article, Drs. J. David Haddox and David Weissman coin the term “pseudoaddiction” for patients requesting a larger dose. They claim that doctors should honor pseudoaddicted patients’ requests and “increase the dose of opiates until pain [i]s relieved.” The concept of pseudoaddiction provides doctors with the go-ahead to increase doses of opiates, as it handily distinguishes between “true” addiction and circumstantial, pseudoaddiction.
The concept of “pseudoaddiction” perpetuates the erroneous idea that an addiction to “legitimate” opiate painkillers like OxyContin is somehow less destructive than an addiction to illicit opiates like heroin. The lack of stigma associated with prescription painkillers and prescription painkiller addiction allows the opiate epidemic to expand and worsen unchecked.
Themes
