Pain and prejudice

In his work as a pain management pharmacist, Dan Arendt has seen some of his patients stigmatized as “drug seekers” or blamed for their use of opioids rather than being acknowledged as a person who is suffering from a severely painful condition. 

Arendt said these stigmatizing judgments are not reserved only for his pain patients. In fact, he argues that the stigma surrounding opioids is negatively affecting both patients with pain and patients who struggle with opioid use disorder. 

Arendt, PharmD, assistant professor in the University of Cincinnati’s James L. Winkle College of Pharmacy and co-chair of the pain stewardship committee for UC Health, said the stigma that is affecting his patients is not new. In fact, he explains, many of these narratives date back hundreds of years, yet they still remain prevalent today.  

In a recent editorial published in the Journal of the American College of Clinical Pharmacy, Arendt discusses the racist origins of United States drug policies that continue to have an effect today and proposes a strategic way forward with pharmacists taking the lead in the fight against the opioid epidemic.

Historical context

Arendt details that racist motivations for drug policies can be traced back to 19th century America, when anti-Asian discrimination and racial fear mongering that portrayed Chinese immigrants as savages led to the banning of the practice of smoking opium, even though other forms of opioid consumption remained legal. 

Similarly, southern states, initially resistant to federal drug regulation, ultimately came on board so long as the regulation would additionally include cocaine. This change of heart, largely based in fear, was at least in part due to false (and racist) reports describing a “negro cocaine fiend” who supposedly didn’t feel pain, had superhuman strength and had no regard for human life.

Systemic racism continued to play a part in national drug policy through the 20th century, epitomized by the 1986 Anti-Drug Abuse Act that authorized penalties 100 times harsher for crack, which tended to be more popular in communities of color, than cocaine, despite these substances having no pharmacological differences. 

Despite historically similar rates of illicit drug use across racial lines, the response to the opioid epidemic in the early 2000s was characterized very differently than drug epidemics of the past. Much of the media narrative presented addiction as a novel issue, finally worth paying attention to because its victims were white, Arendt said. 

Notably, the criminal justice approach to drug use shifted alongside this change in public perception. For the first time, the individual drug users were being viewed as victims, rather than criminals.

Arendt said he believes it is important to recognize the history of how racism has affected drug policy in order to provide context for the present day. 

“I think when people hear others say that current policies are discriminatory or racist, some try to dismiss it. They have the old, ‘racism is over’ mindset,” he said. “But those same people are more open to recognizing the impact that racism played in developing the policies of the past. When you share with them how those policies and narratives were racist, they’re more willing to accept it, and then when you show them how those later developed and morphed into what we see today, I think you’re more likely to make headway.”

Looking to the past also shows that a criminal justice approach to drug policy is not very effective, whether it targets individual users or larger systems like pharmaceutical companies. 

In the past decade, Arendt notes, opioid prescription rates have declined sharply, but opioid overdoses are higher than ever. In addition, patients with real, severe pain are not getting the treatment they need and there is still not adequate access to treatment for those  with opioid use disorder.

Arendt said he hopes that a good understanding of historical context will allow people to move beyond a single idea of what pain treatment, addiction services and drug policy has to look like. 

“We don’t have to choose between treating pain or preventing and treating addiction. We can do both,” he said. 

In addition to expanding treatment access, Arendt has been a strong local advocate of distributing naloxone, fentanyl test strips and sterile syringes to increase harm reduction efforts.

“I think that the more people understand the context behind our policies, and the state of the crisis, the more they will open up to harm reduction and other evidence-based methods that really help people who are struggling,” he said.

A way forward

Specifically, Arendt said he believes that pharmacists are in a unique position to lead the way in developing new strategies to combat the opioid epidemic. Pharmacists are often some of the most accessible health care workers to the general public, and they also know these drugs the best, Arendt said.

“Opioids are incredible medications that are saviors for many, but they also can be a destroyer of lives. Working to maximize how many people receive effective pain control, while minimizing the negative experiences, is like walking a tightrope,” Arendt said. “That’s what pharmacists do. That’s exactly what we are trained for. It’s the reason the profession makes such a difference, not because we know the answers when things are black and white, but because we are able to walk that tightrope when clinically, things may be in the gray area.”

In the editorial, Arendt lays out three key strategies that can be led by pharmacists in an effort to change practices and provide more equitable care for all patients. He advocates for a reevaluation of programs and policy, the expansion of education and support for patients and increasing the accessibility of treatment and harm reduction services.

“The key strategies really are born out of what a lot of other incredible health care providers are seeing and doing. They come from lived experience,” he said. 

While working to increase the availability of harm reduction resources, Arendt said he has encountered many obstacles and red tape. 

“​​You work hard every day, and yet someone with power can dismiss you just like that and destroy weeks or months of your work, simply because they haven’t taken the time, or refuse to take the time to learn about these issues,” he said. “The public doesn’t always understand either, thinking you are ‘enabling’ or a ‘shill for big pharma.’”

Going forward, he said the health care industry needs to make it easier to develop policies and programs that help patients. Although the work is frustrating at times, Arendt said he is inspired to continue by his patients and colleagues who are battling every day to create a more equitable future and fight the opioid epidemic.

“To see others do that gives me so much hope,” he said. “It makes me believe in the goodness of others and the value in doing things for others, even when doing them makes things harder for you. That’s why I became a pharmacist in the first place, to have a position where I can advocate for the patients that haven’t historically been given a voice. That keeps me going.”