There is something captivating about watching other people struggle or deal with pain.
My favorite childhood TV show revolved around watching a Black family’s struggles. The landmark TV show, Good Times was about one family’s joy and pain. Heralded for daring to show an unbroken Black family with a strong, tender, chauvinistic and loving father in the home. It was launched on CBS in 1974. It’s honest depiction of Black life made the show and it’s cast members iconic.
So many little boys and girls walked around like skinny Jimmy “JJ” Walker, saying “dy-no-mite.” He was the silly son who teased his sister. We watched his mom and dad, Thelma and James, love and protect their awkwardly built son who was a gifted artist. One show in particular demonstrated the dangers he faced coming of age in the infamous Cabrini- Green Homes, a Chicago public housing project, in the 70’s. Before I knew she could dance, I watched Debbie Allen play JJ’s love interest, Diana, in two episodes. JJ was so in love and they wanted to elope. However, his young fiancé had a secret, Diana was addicted to heroin; she was a junky. Heroin is an opioid and ever since the end of the Vietnam War, the Black community has suffered from the plague of mass drug addiction, it gripped the housing projects of major cities like Chicago and destroyed young lives.
In two episodes, Good Times, demonstrated the signs of drug addiction: the agitation, the shakes, and the wide-eyed look; the person gets the fix then there is the nod. Diana’s desperation was a dose of reality. About a decade later, the crack epidemic took hold of Black communities in the 80’s. Destructive like heroin, crack coming into the housing projects and urban cities gutted Black communities even more. A cheaper form of cocaine these addicts were stimulated. Crack is more than just whack; the short intense high makes these addicts restless, irritable and violent. Early in my career as an emergency medicine physician, I have cared for both of these types of addicts-the heroin addict with track marks and nonhealing sores on the arms and legs and the crack addict presenting with chest pain or altered mental status. Most times they left against medical advice (AMA). They left to get another fix. Good Times, the show, not medical school, taught me what to expect. They were ill and would be back.
Heroin and Crack addiction while heavily concentrated in urban cities like Atlanta, Chicago, Philadelphia, and New York also made its way into rural areas. Drug addiction was something that was aligned with being poor and Black. It was our problem and the criminal justice system sought to solve it by giving long sentences to many people often Blacks and Hispanics who battled drug addiction. Although, far more men than women are in prison, there is the disturbing statistic of a 700% increase of women incarcerated from 1980 to 2019. (sentencingproject.org). The imprisonment rate for Black women is the highest of all ethnic groups and their crimes are often drug related. Like urban public health hospitals, prisons experience a revolving door from these offenders.
On June 18, 1971, President Richard Nixon declared drug abuse as “public enemy number one.” His war on drugs policy had three goals, eradication, interdiction and incarceration. After fifty -years of trying to prevent new addicts, today we are faced with a growing opioid crisis, this time from prescription pills, such as oxycodone. Doctors are warned not to be a part of the drug problem in America; We risk losing our ability to practice medicine and prison. As the gatekeepers of pain medications, we have to discern if a patient’s pathology or injury requires pain medication and if so, how much.
The documentary called, The Pharmacist on Netflix, exposed the perils of the opioid crisis. The lives of a White pharmacist and a Black physician, Dr. Jaqueline Cleggett, who used her pain management clinic in New Orleans as a pill mill collide after his son was killed over drugs. The drugs she was prescribing in large amounts made their way into the streets of the city. Her patients would get the holy trinity (Soma, Xanax, and oxycontin) in illegal amounts. This physician was not only addicted to the money but ultimately proved to be using her supply. According to the “12 Crack Commandments” by Biggie Smalls, that was a big no-no. When the Drug Enforcement Agency, finally caught up with her, she had lost both her moral compass and her ability to practice medicine. By 2002, the stern warning was out for young physicians, like me, to not overprescribe narcotics or risk being flagged by a pharmacist and subsequently investigated by the DEA. The threat of decades of prison time like Dr. Clegget was sentenced to is a real possibility for the distribution of controlled substances.
Due to overdoses and deaths from prescription drugs, the medical community has been exploring alternative ways to treat both acute and chronic pain from common painful conditions and cancer. Mindfulness medicine and medicinal marijuana are gaining in popularity as ways to help curb the need for prescription pain killers (e.g.,synthetic opioids) that can make it into communities and cause deaths from drug overdoses.
While this sounds good and necessary, racial bias is well demonstrated in pain assessment and treatment. Dr. Kelley Hoffman from the University of Virginia found in her study that a substantial number of White laypeople, medical students and physicians in training hold false beliefs about the biological differences between Black and Whites. Furthermore, these beliefs predict racial bias in pain acknowledgement, resulting in Black patients receiving less treatment for pain. The connection that Black patients are systematically undertreated for pain whether the complaint is a broken leg, cancer or labor pain because of unchallenged myths about darker skin is unfathomable. To test her hypothesis, Dr. Hoffman’s team created a list of fifteen items about biological differences, some true and some false. Her White subjects were to rate on a six- point scale the truth ability of statements such as “Black people’s nerve-endings are less sensitive than White people’s nerve endings.” Clearly this is a false statement as were eleven other statements, however 73% of her subjects endorsed at least one false statement about Black bodies.
Dr. Hoffman’s statements seem simple, but they are crafted to remind us that prominent Southern physicians made their careers by researching and writing about the biological differences of Black and White patients. The 19th century physician, Dr. Samuel Cartwright, wrote that Blacks bore a “Negro” disease (making them) insensible to pain when subjected to punishment. The rise of the Black Lives Matter movement has given birth to the removal of symbols of slavery across the South, the seat of the Confederacy. These physical statues of White men who led the fight to keep slavery can be taken down, but racism in medicine is proving to be a momentous legacy.
Dr. Susan Moore, the Black physician who died in an Indianapolis hospital of COVID-19, documented her treatment by her White doctor. She looked into her camera on Facebook and told us how she was being denied pain medications and made to feel like she was a drug addict. She left us a testimony about racism, pain and medicine. The pandemic is illuminating the map of health disparity, racism, and poverty in America. The ability to access and manage pain while fighting an opioid crisis has the same topography. As our public health system flails on the pandemic front with growing cases particularly in the southern states, vulnerable patients who are often Black and poor with acute and chronic pain conditions are at risk of suffering under the guise of our war on drugs.
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