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Artillery Row

The problem with prescriptions

Concerns about over-prescription should not be trivialised or problematised

In Empire of Pain, Patrick Radden Keefe’s history of the Sackler family and the US opioid crisis, there’s a particular section that leapt out at me. Dr Russell Portenoy, paid by Purdue Pharma to promote sales of OxyContin, has to find a way to override the public’s wariness of it. “Portenoy,” writes Keefe, “described the fear of opioids as a kind of hysteria. He gave it a name, ‘opiophobia’”. 

This tactic — a shaming one, positioning misgivings about a drug as an irrational fear — is later paired with a form of mock social justice activism. Efforts to limit the distribution of OxyContin are, according to former Purdue chairman Richard Sackler, “a clear attack on the pain movement”. Critics, it is implied, are allowing their “opiophobia” and hatred of “Big Pharma” to hurt the most vulnerable — chronic pain sufferers, who desperately need more, not fewer, pills. 

When it comes to the role of the Purdue and the Sackler family in causing the US opioid epidemic, I suspect most people today would be unwilling to accept these arguments. They are self-serving, devious attempts to equate criticism of the Sacklers with criticism of those from whose suffering they profited. The excuses don’t work, at least not any more. They do, however, remind me of other, perhaps more complex scenarios. 

Last week, for instance, saw the publication of a report by the Beyond Pills All Party Parliamentary Group. The title is “Shifting the Balance Towards Social Interventions: A Call for an Overhaul of the Mental Health System”. Already, I can imagine the response this will provoke in many people who take any form of psychiatric medication (indeed, the response I might once have had). Isn’t this just stigmatising mentally ill people? What’s wrong with taking pills, anyways, if they make you feel better? Couldn’t this, in fact, be a backdoor way to invalidate mental illness, at a time when sufferers are already being threatened with the loss of personal independence payments? 

I, too, am concerned about all of these things. Nevertheless, here, too, I think the distinction between defending a treatment due to its ultimate efficacy and due to a fear of “shaming” those who use it gets quite blurry. SSRIs and neuroleptics are not the same sort of thing as opioids. The risks and consequences of use are different, as are the motivations of those prescribing. Even so, there is much in the “Beyond Pills” report that ought to ring some alarm bells.  

 “Mental health outcomes,” it argues, “have not improved despite substantial investments in services and research, with rates of poor mental health worsening in the general population and the mortality gap widening between individuals with severe mental health problems and the general population”:

The dominant biomedical model of mental health care has led to over-reliance on psychiatric drugs and neglect of effective social, community and relational approaches. This approach fails to address the underlying social, economic and psychological determinants of mental distress and is contributing to worsening outcomes.

As the sibling of someone with a severe mental illness diagnosis — someone who almost died as a consequence of known side-effects of medication — I can recognise this. It is not that efforts to address underlying issues are being openly disregarded. The “biopsychosocial model” implies that there is a social element to be addressed. It’s just that usually this isn’t happening. Meanwhile, criticising medication — even decades-old medication, promoted using constantly shifting marketing messages and justifications — feels very much taboo. Finding a biological root to mental disorders — or at least believing there is one, even if you never find it — has become tied to “de-stigmatising” mental illness in such a way that expressing concerns over a drift towards a purely biomedical model can lead to charges of not taking sufferers seriously at all. 

For both mental illness and gender dysphoria, there is the same pressure to “validate” conditions by viewing them as innate and unchangeable

In this, I think there are enormous similarities with the politics surrounding the treatment of gender dysphoric children. As both the Cass Review and Hannah Barnes’ Time to Think have shown, so-called “gender affirming” medicine has long been able to hide behind social justice sloganeering — and the very real suffering of patients — in order to deflect criticism. Just as Portenoy argued for the Sacklers with regard to critics of opioids, critics of puberty blockers and the over-prescription of SSRIs can be positioned as irrationally “phobic”. For both mental illness and gender dysphoria, there is the same pressure to “validate” conditions by viewing them as innate and unchangeable; the same belief that “social, community and relational approaches” have already been tried and are in any case ineffective; the same insistence that anyone who (even remotely) doubts the treatment doesn’t believe in the suffering; the same claim that the treatment itself is “fighting stigma”; the same vilification of whistleblowers; the same false binary between the current treatment and a dismissive “just get over it” approach. 

Above all, there is the same suspicion that because any real alleviation of suffering requires time, investment and tremendous social change — “implementation will be difficult,” admit the authors of the “Beyond Pills” report — those calling for it cannot be doing so in good faith and must simply want to withhold help in the here and now. One of the key messages of Time to Think was that clinicians in the Tavistock’s Gender Service simply did not have the resources to do anything other than put vulnerable patients on a pathway to lifelong, potentially harmful medicalisation. In such a situation, wanting better is so difficult it is tempting to pretend there is no “better” at all. 

I have sometimes wondered why some feminists — who often, like me, have no particular medical background — feel very confident criticising “gender-affirming” care, but are far more reticent about critiquing psychiatric over-prescription. Similarly, I wonder why some critics of the latter see no issue with the former. To be clear, I am not saying “trust nothing – medical responses are never effective!” I am saying that when it comes to the social context of distress, we should at least recognise continuities in categorisation and response (for instance, when it is suggested by feminists that one wouldn’t affirm anorexia in the way that gender dysphoria is affirmed, I often want to point out that we are not really in the clear with anorexia, not least with efforts to over-state biological causes and the emergence of “terminal anorexia” diagnoses). 

The isolation and social exclusion of those who are suffering from chronic pain, mental delusions or gender distress need to be alleviated. What this should not mean is that any form of treatment becomes beyond criticism because by questioning it, one is supposedly “attacking” the isolated and excluded themselves. I do not necessarily think that “Beyond Pills” has all the answers (and the report itself does not condemn the use of medication in  all cases). Nonetheless, there is a need for a more open discussion about what works and what does not. Most people are not “phobic” and caring about consequences should never be a source of shame.

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