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Part 1: The Man Comes
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 1986, Russell Portenoy and Kathy Foley publish a paper in Pain, a medical journal, concluding that “opiates themselves were not inherently addictive.” They cite the 1980 Porter and Jick paragraph published in the New England Journal of Medicine. The Pain paper asserts that addiction is dependent on a patient’s history: for example, if a patient has a history of drug abuse, they are more likely to develop an opiate addiction than a “seventy-plus-year-old woman with bleeding ulcers” is.
Portenoy and Foley leap to a big conclusion when they state that “opiates themselves were not inherently addictive.” The reader should recall that Jick’s 1980 paragraph that apparently claimed that few patients grew addicted to opiates used data from patients who were administered opiates in the hospital and were thus closely monitored by medical staff. In contrast, doctors prescribed OxyContin in the 1990s and 2000s in circumstances where patients were free to use and abuse the painkillers outside of hospitals.
Themes
The paper makes a big splash, and Portenoy is largely demonized in the U.S., which continues to stigmatize opiates. Other doctors do support Portenoy and Foley, however, and such support continues to grow over the 1980s, particularly in Salt Lake City, which holds monthly meetings to discuss management innovations in pain. One idea to emerge out of these meetings is that “pain counteract[s] opiates’ euphoric effect and thus reduce[s] the risk of addiction,” a view that is promoted on the American Pain Society’s website. Another view to come out of this period is that pain should be treated “as a vital sign.” By the late 1990s, both the Veterans Health Administration and the Joint Commission for Accreditation of Healthcare Organizations deem pain a “fifth vital sign.”
Portenoy and Foley’s call for the more liberal prescription of opiates is seen as revolutionary at first, but it quickly grows to be accepted by the larger medical industry. In general, America’s growing support of opiates is founded in exaggerated and sometimes erroneous information. For example, pain can’t exactly be treated “as a vital sign” because, unlike other vital signs, like blood pressure and respiration rate, it cannot be measured objectively.
Themes
Russell Portenoy is later made director of the Beth Israel Medical Center’s Pain Medicine and Palliative Care department, where he pushes for further destigmatization of opiates—with the help of funding from drug companies.
Portenoy’s well-intentioned push to destigmatize opiates would eventually be exploited by the drug companies, like Purdue, that funded his research.
Themes
Pediatric nurses Donna Wong and Connie Baker, of Tulsa, create the Wong-Baker FACES scale in the 1980s to help assess pain in children, and the scale is later expanded and adapted to assess pain in adults, too. In the 1990s, “Press Ganey surveys,” or surveys that assess patients’ satisfaction with their doctors, enter into use in US hospitals.
“Press Ganey surveys” emphasize patient satisfaction over doctor discretion and they normalized the harmful “patient is always right” philosophy in the medical industry, creating an industry that valued customer satisfaction over medical integrity.
Themes
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Each of these implementations—which unfold quickly, over about the span of a decade—foster a culture that values patients’ views and “rights” regarding their care more than the discretion of their doctor. Press Ganey patient surveys, which were designed to protect patient rights, are increasingly used to coerce doctors into writing more prescriptions in order to keep their patients happy and thus keep their jobs.
Implementations that were originally intended to help patients were corrupted when doctors became more concerned with the economic implications of patient rights: it was a wiser business investment for doctors to have happy, satisfied patients than to have appropriately treated, healthy patients.
Themes
Another early issue with the pain movement is the lack of long-term studies on the addictiveness of painkillers. Doctors have no way to gauge which patients to whom they should or shouldn’t prescribe opiates. Still, the pain movement gives doctors confidence in painkillers, fueled both by “a quasi-religious fervor” of pain researchers like Russell Portenoy, as well as pharmaceutical companies like Purdue, who fund their research.
Quinones seems to suggest that proponents of the pain movement were so swept away by their “quasi-religious” belief in opiates as “Holy Grail” methods of treating pain that they failed to accept that the “heavenly” immediate pain relief opiates provided might be followed by a “hell” of addiction.
Themes
