Category Archives: things that work

Listen up, retailers and retail employees!

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You know you can’t afford to lose customers these days. We’re having an economic situation/blip/slowdown/downturn/recession/crisis/depression, ah––cut to the end: when the train finishes pulling into the station, it’ll be “Economic Disaster”.

Businesses spend money and effort on advertising, but often are oblivious to how they treat the customers themselves. When I walk into the tiny local florist to send condolence flowers and the person greets me coolly, asks only “How much do you want to spend?”, has no prices posted on anything, and no pictures or samples to show me, does it seem likely I will return? If there’d been another similar business within 15 miles I’d have walked out and gone elsewhere.

This subject has been on my mind for a few years, because my experience at the florist is far from an isolated incident. I fantasized about making my million with a company issuing videos and doing workshops about how to treat customers. But that’s not likely, and American business needs this now, so I’m going to write a little about it. Maybe it’ll be worth more than the traditional value of free advice.

Keep in mind, much of what I will say may seem obvious. It is. But if you work with the public and you aren’t practicing this, you need to hear it. And more than just hear it; consciously work at it and get some sort of feedback on how you are doing. My plan for teaching “customer service” included video illustrations of right and wrong; role-playing; and finally videotaping “students” for them to see themselves, because in all aspects of life we need a mirror, an objective reporter, to show us what we really do and say, as opposed to what we believe we do and say. Think about how true that is of other people you know. And it is just as true of you. And me.

Attitude

If you are going to work with the public, in a gas station, a library, a restaurant, a retail store, behind any sort of service desk, accept these basic realities:

  • No customers, no job.
  • Every customer advertises you to people they know, with praise, condemnation, or silence.
  • Making a repeat customer is like gaining a new customer without the expense of buying ads or running special deals.
  • You’re “on” every minute.
  • Customers get to act tired, cranky, stupid, and demanding, but you do not. You must be polite, helpful, inoffensively cheerful, and competent.

These are habits of thought and action like any others, and you can learn them and make them mostly unconscious and routine. Even virtue, Aristotle said, is a habit.

If you absolutely can’t accept and act on these realities, then public service/retail is the wrong place for you. You won’t be effective or happy in your job. And eventually it may catch up to you, as your boss decides you don’t add anything to the business, or your own business fails.

Attentiveness and Greeting

If you’re otherwise engaged when a customer arrives, you must show that you know he or she is there. Maybe you’re on the phone or helping someone else when Joe walks up to the counter. Make eye contact with Joe, smile, return to what you are doing.

Don’t keep him waiting more than a couple of minutes unless it is clear to him that your current transaction has a clear end coming up, as for instance ringing up the customer ahead of him. (This doesn’t apply to a grocery checkout line, or other situations where customers know they are waiting and know their place in line. Although even there, send a smile to the customer who’s waiting behind that person sorting through a zillion coupons, and it will be appreciated.)

If your transaction may go on and on, use your judgment; probably you should say to the customer in front of you, “Excuse me just a moment,” turn to Joe, and say “Hi, can I answer a question for you?” He asks whether your store has Acme Widgets in stock, you tell him yes (and where they are) or no (adding, but if he can wait a moment, we have something very similar) then turn back to your current customer. Or if there is another employee available, get that person over to help Joe. Joe doesn’t walk out thinking you don’t care about his business, and you may have a customer.

On the other hand, don’t let attentiveness to the newly arrived customer make you abandon the one you were working with. Same with phone calls; that’s what the Hold button is for. Fairness is important to us humans, and the person who was there first can reasonably expect you to finish his or her transaction before going on to another. If Joe’s “quick question” turns into something longer, you must gently interrupt and promise to help him just as soon as you’ve finished with the other person’s business.

[Supervisors, take note: should your sales desk people really be answering all the incoming calls, too? You think you’re saving money but it means someone who is right there with money to spend has to wait while the clerk answers questions and routes calls.]

Do not do personal business in front of customers. Everybody needs to make a phone call at work sometimes, or talks to other employees during a slow period about non-work stuff, but make it a rule: never when a customer is present. Tell your babysitter you’ll call right back, quit discussing the weekend, the hot new clerk in Shipping, or the prospect of layoffs. Even if the call or conversation is really work-related (informing another staff member that the new shipment of extra-large widgets hasn’t arrived yet so we don’t have any on the shelves right now), the customer needs to come first. Make eye contact (as above) and end the other matter at once.

Each customer should feel that they have been noticed, that they will have your attention soon, and that during that time they will be your primary focus.

Helpfulness

All of us have had the experience, on the customer side of the counter, of being either smothered with attention or wandering lost and alone. We want someone to pick up on our signals and act appropriately.

As a salesperson (or library assistant, waitperson, etc.) you can learn to read minds. Yes, it can be done. Offer initial assistance, then ask if you can help; if the answer is “No, I haven’t quite made up my mind,” or the old standby “I’m just looking around,” then say “Just let me know when you’re ready” or “Let me know if I can help you find something.”

And then, you don’t forget about this customer. If I sit staring at the menu for ten minutes maybe I need to be asked, “Would you like to hear about our specials today?” or “Can I tell you more about any of these lunches?”––and not in a tone of “Would you please get on with it!” Restaurant staff are usually much better at this than retail staff, since turning the tables over in restaurants is so important. In a store, people searching the shelves or aisles in vain for what they need have a certain look, which you don’t have to be a master of human expression to recognize.

Make your interchanges genuine. What you say, how you say it, body language, all can have a positive or negative effect. One of my pet peeves is the “drive-by wait-person” who asks, while rushing past our table, “Everything okay here?” And if it’s not? If my hamburger is raw inside or I need more water, do I have the impression that this person has time to care? Waiting table can be a high-stress job with a lot of things to juggle at once, but if you’re going to talk to me, please stop, face me, make eye contact, and then talk.

At the store’s cash register, as you are asking me whether everything was okay, and did I find what I needed, same thing: make eye contact, take that extra 5 seconds to see me, and then listen and respond to what I say. I like it better, and you may get valuable information: there’s no ground beef left at the meat counter, I couldn’t find what I came in for and am heading elsewhere for my main purchase, the directional signage is wrong and I’m ticked off, somebody spilled coffee all over your bin of blue widgets.

When there’s “nothing to do”

Most jobs have slow times: no customers, no calls, waiting for a part to arrive or for someone else to do something. In work that’s mentally or physically demanding you need little bits of rest. But, especially in retail or public service, there really are things to do even when––especially when––the store or restaurant is quiet and the phone isn’t ringing. This is your chance to make the coming busy times easier for yourself, and improve the service you are able to offer. Some of it’s obvious: fill the condiment containers, put away the unsold merchandise that has made its way to the counter, check your supplies, replace the cash register tape, tidy things up. That’s the kind of thing a boss will be pleased not to have to remind you about.

There’s more that’s not as obvious: you need to know a lot about whatever goods or services you are in charge of, so look over the stock, check out the new stuff, notice that you now have some of those special items someone asked about last week, ask the cook about today’s soup (or even taste it!). Find the answers to questions you haven’t been able to answer, and next time you won’t have to consult someone else or confess ignorance. Have the answer that will help the customer, and result in a sale. “I need something for a baby shower, but she already has 2 kids.” “How do you use this chutney stuff, can I use it for a marinade?” “All these dry dog foods are confusing, what are the differences?” “Can I do my taxes online here at the library?” “What’s a good flowering plant for a shady location?” “I need some left-handed scissors.” This can be an enjoyable part of your job, learning more to help people toward what they are looking for.

And if your store hasn’t got those left-handed scissors, or your restaurant doesn’t have a wide vegetarian menu, you’ll earn the customer’s gratitude by being able to suggest an alternative, or even another place that has what’s needed. I had to return a plastic lap desk (for a laptop) to an office store because it just wasn’t adequate, and nothing else they had was any better. I won’t forget that the staff person recommended a big book store to me as a good place to look; I would never have thought of going there and was getting tired of the search. I followed the tip and found what I wanted. Now, I think of that office store as a more helpful place, and I’m more likely to go there instead of to their competitor. An interchange can be very successful (in terms of your business) even if it doesn’t result in a sale.

Personal Satisfaction

This is the part about what’s in it for you, if you change your attitude and behavior so customers leave feeling good about their experience in your workplace.

Now, it’s obvious that you are very likely to increase your own chances of success at work by doing this, whether you own your own business or are an entry-level employee someplace.

What if your boss is an SOB who only cares about the bottom line, treats customers and staff poorly, and is never going to die or retire in time for you to benefit? Sounds like a good place to move on from, and if you understand and can express good principles of customer service, you have an advantage in the coming job interviews. The surly or spaced-out shirker isn’t at the head of anyone’s hiring list.

Deciding to look for ways to be better at what you do is not equivalent to resigning yourself to being at your present job forever. Just the opposite, in fact; bad attitude and bad performance are not attractive to potential new employers. Nor are they conducive to promotion (except in the financial industry and high-level corporate management).

Beyond that though, is another realm of benefit entirely. It actually is true that if you work at doing your job well you are very likely to feel better about it. That is not a falsehood spread by the capitalist bosses, it’s a psychological fact. If you don’t think your own job is worth doing well, then you are telling yourself that every moment at work is a waste of time, something to be resented and avoided. In other words, “Over half of my waking life is worthless.” If you don’t have any sense of satisfaction except when you manage to work as little as possible, you go home feeling pretty crappy about all those hours and effort, and about yourself.

And now, a word to the “capitalist bosses”

Most of what I have written has been addressed more to employees, but it is employers who set the tone of their businesses, and they have a lot to lose if staff are providing poor customer service. If that is the case at the business you run, don’t blame your the people who work for you––train them, encourage them, and set a good example including in your behavior to the employees themselves.

This may only be possible in small businesses, since larger ones get drawn astray by greed, ego, and isolation of management from the product and customers. Management starts to think that the end product is money, and they start viewing everyone else in the world as either tools or fools. Employees are tools to be used, customers are fools to be scammed. But we always hear that small businesses generate most of the new jobs in the US, so if they can accept a model based on good products, good customer service, good treatment of employees, then that will be a significant change.

Our current economic debacle can be directly traced to poor practices on the part of those in charge, whether they were causing bad loans to be made, or failing to listen to consumers when designing cars. Greed is always a pyramid scheme: it pays off only if you bail out at the right time. A risky business model, that: it’s really just gambling (with other peoples’ money).

If you’re in business, you have customers. Act toward their greater satisfaction, strive to do what you do better than anyone else, take a long-term point of view, keep your debt down, and invest in your employees. You may not end up with the biggest widget company in the world, but you are likely to be still operating when the big guys have vanished in debt and disgrace.

Free books for kids at the Food Pantry

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“Free Books for Kids” says the sign that I put up every week at the local food pantry. The boxes of books, and two small folding tables, live in the back of my old Explorer.

This,

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quickly becomes this

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When I began several years ago I was thinking it would be like a library or book exchange: kids would return the ones they chose last time and get new ones. It didn’t take long to understand the shortcomings of that model. Mostly, there’s too much turnover and uncertainty. Families are only permitted 12 visits a year to the food pantry (a state or federal limitation); they might come three weeks in a row and then not return for months. Some live in cars, campgrounds, or at a series of friends’ houses. And families vanish, moving elsewhere for various reasons or (we hope) experiencing an improvement so that they don’t need the food pantry any more. Kids forget to bring things back. I can’t turn away needy kids that want books; my desire is only to get books into the hands of young people, from infants to high schoolers.

So now my little “Book Bank” (like a “Food Bank”) is as simple as can be. Free books for kids whose families come to the food pantry. Period. I say, “You can bring them back whenever you’re done, or keep them forever.”

That’s the only way it will work, and it also gives kids books of their very own. A dozen favorite books don’t take up much space and may be a help to children who move a lot, and live with constant change and uncertainty.

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I had expected my “customers” to be kids and parents, but grandparents have turned out to be an important group too. Some care for grandchildren regularly (or are raising them), some have kids staying over in summer, visiting on weekends, or just dropping in. A few aunts and uncles come by also. Occasionally these books are given by the adults as birthday or Christmas gifts to the kids.

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I’ve expanded to include workbooks (printing, arithmetic, shapes and colors, word recognition, etc.) and flash-cards.

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This isn’t the Baby Einstein scene, grooming kids for prep school or to impress the parents’ rich friends; the parents and grandparents want their kids to be ready for school, and to do well there. Despite all the worries a family has when they need to come to a food pantry, most of these adults are actively working to help their children succeed in school. And I know the parents read to the children because the kids themselves tell me so.

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Cardboard books for infants and toddlers are popular. These sturdy books have bright simple illustrations; parents can point out colors, shapes, animals, noses and ears as the babies are learning language (long before any actual words come out). Children learn how to hold a book right way up, turn the pages, and be comfortable with a book in hand. They get a positive association with books and reading, to go along with the good feelings of being read to from all sorts of books––as well as from being sung to, talked to, and all those other forms of language that flow between adults and young children.

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The books are arranged by age of likely readers: in addition to the bins of cardboard books and workbooks, there are two big plastic boxes: one for picture books and simple books, another for longer books with longer words. “Chapter books” (a new term that I learned from the kids, who ask for them that way) go in a smaller box; these are short to medium-length novels for readers up through high school.

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Except for the workbooks, I regularly read books from all of the categories while I am sitting alongside my display. There’s some very good writing, and of course the illustrations are often wonderful. Kids’ books must be putting bread in the mouths of quite a few artists. That’s a good thing especially with art in schools having been virtually eliminated; at least children get to see paintings, drawings, and photographs with artistic merit and heart.

Where do the books come from? and other details

Most come from the bookstores operated by Friends of the Library, at local branches and also in Portland (OR). Locally I pay 25￠- 50￠; Portland has higher prices but a huge selection. Twice a year I go there and buy maybe a hundred books, stocking up on the ever-popular dinosaur picture books, ones on science and nature, and others that are hard to find. Then there are garage and yard sales where sometimes kids’ books go for a few bucks per cardboard boxful. Once in a while I find suitable new books at the Dollar Store, where I buy all the workbooks and flash-cards. And occasionally people (at the food pantry or elsewhere) donate books outgrown by their children. I could be more active in soliciting such donations, something to work on.

After I acquire books I do a little processing. I wash the covers and spines with a damp rag and 409 to remove grime and make the books look shiny and more appealing. A few may need a bit of mending, for which I use clear packaging tape. Then I stamp each one inside the back cover: “Free Books for kids/at Ruch Food Pantry./To donate kids’ books/or $ pls call xxx-1234.”

One reason for the stamp is to help books come back, although few do. I have an informal arrangement with the local branch library: if books with my stamp arrive in their bookdrop, they save them for me. That offers a much more accessible return location than the food pantry which is only open 3 hours a week.

Our food pantry is a small one; we average 20 to 25 households each week, though lately it has been getting busier. There are many households that don’t include children. There are times when I go home without having given out a single book, and days when I have half a dozen eager customers. When people arrive I haven’t seen before, I go over and introduce myself; even if there aren’t any children accompanying them, there may be kids at home, or grandchildren in their lives. If kids hang back shyly I talk to them and their parents and invite them to come and look. A lot of these kids are quite wary of how much things cost, so they need reassurance that yes, all the books are free (even though some have old price stickers from the places where I got them). And I let my customers know how pleased I am that they came, which is just the truth.

And when someone comes over to tell me that the books have made a difference—their grandchild is reading better, their kids are enjoying the books or benefitting from the workbooks, do I have more books about horses or dogs because their daughter just loves to read them—well, you can imagine how good that is!

And now, why did I write this?

Only one reason: I’m hoping someone may read it and decide to do something similar. The Food Pantry connexion is a good one, and the project doesn’t take a lot of time. Your Food Pantry or similar organization would probably welcome this addition to their services. “Food for the mind, as well as the body,” was my pitch, but the idea didn’t really need a “pitch” to be accepted. Or perhaps you just have books your kids have outgrown: consider giving them to the local women’s shelter, where women and children often arrive with nothing but the clothes on their backs, and may stay for weeks. Library Friends’ bookstores always welcome donations, and offer cheap books to the community (with proceeds used to support library activities and services). And libraries or schools may need volunteers to read with kids or to kids.

If you’re looking for an organization to get involved with, there seem to be a lot of them. Maybe your area has one like SMART (Start Making A Reader Today) in Oregon that pairs adult volunteers with early readers, to improve children’s ability and their love for reading. There are many local and national groups concerned with kids and reading; I googled “kids reading organizations” [do not use quotation marks if using this as a search term] and came up with a bunch. Look for evidence of actual work done, not just raising money and promoting “awareness of the issue”.

“Give me a place to stand, and I can move the earth.” So said Archimedes, who did not invent the lever but gave the “earliest known rigorous explanation” of how it worked. There are many such places to stand, for anyone who wants to change the world a bit. The promotion of reading for kids, in a direct personal way, is one of them.

Dr. House’s writers betray pain patients

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As a chronic pain patient who took methadone for years, and experienced a lot of misunderstanding from medical professionals and laypersons about addiction, I greeted the House series with hope when I first saw it. It’s smart and interesting as tv goes, and Hugh Laurie is a fine actor who has done well with the unusual role. But beyond that, I thought having a chronic pain sufferer as a main character presented a great opportunity to break the stereotype that “taking pain meds longterm = addiction”. Dr. Gregory House is certainly well-informed about medical science as opposed to drug war hysteria, and no one can deny that he’s assertive!

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Source unknown, appears only on generic odd picture sites. Found with Google image search.
House’s halo may fade as you read on.

However, the writers and producers are promoting the familiar hackneyed clichés about addiction–––worse, these clichés are false and are no longer accepted in current medical thought. And House, of all people, is represented as knowing no better, and accepting the label of “addict”.

Two of the doctors House works with (his boss Cuddy and his friend Wilson) say frequently that House’s professional and personal abilities are being damaged by his “addiction” (his everyday use of vicodin for constant severe pain in his leg), and this conflict has played out in many episodes in the first three years. [We never seem to watch the Fox channel, so we see House in reruns on other channels; if there has been a drastic change in the last season I wouldn’t know about it. But I doubt there’s been a change in a theme which has been used so often.]

I was moved to write this by seeing again the old episode titled “Detox” (episode 11, season 1, 2005). Cuddy challenges him to go a week without vicodin to “prove he’s not an addict”. House accepts the challenge, his prize being a month of no clinic duty, and he also accepts the premises: that if he shows signs of physical withdrawal it means he is addicted. He does show these signs, though he tries to hide or deny them, and he also suffers greatly increased pain. Feeling nauseated, he’s told that it’s withdrawal, and replies “No, I’m in pain. Pain causes nausea.” Maybe so, but withdrawal from opioids does too. Finally the pain and withdrawal symptoms make it impossible for him to function as his usual professional self: hyper-smart and intuitive diagnostician. A patient is depending on him, and so are his diagnosticians-in-training, and one of the latter gives him some vicodin and tells him to take it because he’s not able to do what needs to be done.

At the end, asked what he has learned, House says (close paraphrase): I’m an addict….But I’m not going to quit…I pay my bills, I work, I function.

His friend Wilson says, You’ve changed, you’re miserable and you’re afraid to face yourself…Everything’s the leg, nothing’s the pills?

House: They let me do my job, and they take away my pain.

So, House won’t abandon the vicodin because he cannot function without pain relief, but he caves to the notion that he is an addict.

There are so many things wrong with this, and the writers of a medical show ought to know better.

Addiction Versus Dependence

The refusal to distinguish between these two terms has cursed our management of pain for fifty years or more. But in the last couple of decades medicine has, at last, officially separated the two. Here is a discussion of the terminology from an authoritative source, a Consensus Document issued jointly by The American Academy of Pain Medicine, The American Pain Society and the American Society of Addiction Medicine, called Definitions Related to the
Use of Opioids for the Treatment of Pain. [I quote at length, so it will be clear that this represents exactly and completely the sense of this document. Emphasis is added.]

BACKGROUND

Clear terminology is necessary for effective communication regarding medical issues. Scientists, clinicians, regulators and the lay public use disparate definitions of terms related to addiction. These disparities contribute to a misunderstanding of the nature of addiction and the risk of addiction, especially in situations in which opioids are used, or are being considered for use, to manage pain. Confusion regarding the treatment of pain results in unnecessary suffering, economic burdens to society, and inappropriate adverse actions against patients and professionals.

Many medications, including opioids, play important roles in the treatment of pain. Opioids, however, often have their utilization limited by concerns regarding misuse, addiction and possible diversion for non-medical uses.

Many medications used in medical practice produce dependence, and some may lead to addiction in vulnerable individuals. The latter medications appear to stimulate brain reward mechanisms; these include opioids, sedatives, stimulants, anxiolytics, some muscle relaxants, and cannabinoids.

Physical dependence, tolerance and addiction are discrete and different phenomena that are often confused. Since their clinical implications and management differ markedly, it is important that uniform definitions, based on current scientific and clinical understanding, be established in order to promote better care of patients with pain and other conditions where the use of dependence-producing drugs is appropriate, and to encourage appropriate regulatory policies and enforcement strategies.

RECOMMENDATIONS

The American Society of Addiction Medicine (ASAM), the American Academy of Pain Medicine (AAPM), and the American Pain Society (APS) recognize the following definitions and recommend their use:

ADDICTION

Addiction is a primary, chronic, neurobiologicneurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

PHYSICAL DEPENDENCE

Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist…

TOLERANCE

Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time.


DISCUSSION

Most specialists in pain medicine and addiction medicine agree that patients treated with prolonged opioid therapy usually do develop physical dependence and sometimes develop tolerance, but do not usually develop addictive disorders. However, the actual risk is not known and probably varies with genetic predisposition, among other factors. Addiction, unlike tolerance and physical dependence, is not a predictable drug effect, but represents an idiosyncratic adverse reaction in biologically and psychosocially vulnerable individuals. Most exposures to drugs that can stimulate the brain’s reward center do not produce addiction. Addiction is a primary chronic disease and exposure to drugs is only one of the etiologic factors in its development.

Addiction in the course of opioid therapy of pain can best be assessed after the pain has been brought under adequate control, though this is not always possible. Addiction is recognized by the observation of one or more of its characteristic features: impaired control, craving and compulsive use, and continued use despite negative physical, mental and/or social consequences. An individual’s behaviors that may suggest addiction sometimes are simply a reflection of unrelieved pain or other problems unrelated to addiction. Therefore, good clinical judgment must be used in determining whether the pattern of behaviors signals the presence of addiction or reflects a different issue.

Behaviors suggestive of addiction may include: inability to take medications according to an agreed upon schedule, taking multiple doses together, frequent reports of lost or stolen prescriptions, doctor shopping, isolation from family and friends and/or use of non-prescribed psychoactive drugs in addition to prescribed medications. Other behaviors which may raise concern are the use of analgesic medications for other than analgesic effects, such as sedation, an increase in energy, a decrease in anxiety, or intoxication; non-compliance with recommended non-opioid treatments or evaluations; insistence on rapid-onset formulations/routes of administration; or reports of no relief whatsoever by any non-opioid treatments.

Adverse consequences of addictive use of medications may include persistent sedation or intoxication due to overuse; increasing functional impairment and other medical complications; psychological manifestations such as irritability, apathy, anxiety or depression; or adverse legal, economic or social consequences. Common and expected side effects of the medications, such as constipation or sedation due to use of prescribed doses, are not viewed as adverse consequences in this context. It should be emphasized that no single event is diagnostic of addictive disorder. Rather, the diagnosis is made in response to a pattern of behavior that usually becomes obvious over time.

Pseudoaddiction is a term which has been used to describe patient behaviors that may occur when pain is undertreated. Patients with unrelieved pain may become focused on obtaining medications, may “clock watch,” and may otherwise seem inappropriately “drug seeking.” Even such behaviors as illicit drug use and deception can occur in the patient’s efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.

Physical dependence on and tolerance to prescribed drugs do not constitute sufficient evidence of psychoactive substance use disorder or addiction. They are normal responses that often occur with the persistent use of certain medications. Physical dependence may develop with chronic use of many classes of medications. These include beta blockers, alpha-2 adrenergic agents, corticosteroids, antidepressants and other medications that are not associated with addictive disorders.

How important are definitions?

Few things are more important. We interact with the world through language. Words cause emotional reactions, compose our thoughts, represent us to others. Would you want to be introduced to a group of strangers as an “addict” or as a “pain patient”?

Let’s look at the decision to replace “addiction” with “dependence” in the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). This thick volume is the official dictionary and guide for defining mental disorders, including addictive behaviors. (Change in the DSM can contribute to profound social and legal change––as when, after a series of redefinitions, homosexuality was finally removed from the list of disorders in 1987.) An editorial in the American Journal of Psychiatry (2006) discusses this decision to use “dependence” not only to describe physical dependence, but also for addiction, as differentiated in the document quoted above.

All of the authors of this editorial are involved in the next revision of the DSM (DSM-V), and one has been part of the revisions since the 1980’s. They favor changing back to a distinction between “addiction” and “dependence,” and describe how the decision was made to merge both into “dependence”:

Those who favored the term “dependence” felt that this was a more neutral term that could easily apply to all drugs, including alcohol and nicotine. The committee members argued that the word “addiction” was a pejorative term that would add to the stigmatization of people with substance use disorders. A vote was taken at one of the last meetings of the committee, and the word “dependence” won over “addiction” by a single vote.

It was a victory for Political Correctness!

The authors criticize the widening of the term because of the negative effect on pain patients:

This [redefinition] has resulted in confusion among clinicians regarding the difference between “dependence” in a DSM sense, which is really “addiction,” and “dependence” as a normal physiological adaptation to repeated dosing of a medication. The result is that clinicians who see evidence of tolerance and withdrawal symptoms assume that this means addiction, and patients requiring additional pain medication are made to suffer. Similarly, pain patients in need of opiate medications may forgo proper treatment because of the fear of dependence, which is self-limiting by equating it with addiction.

A Canadian article (2006) describes the reluctance of many physicians to prescribe opioids for pain, and why they are reluctant:

In a recent national survey, 35% of Canadian family physicians reported that they would never prescribe opioids for moderate-to-severe chronic pain, and 37% identified addiction as a major barrier to prescribing opioids. This attitude leads to undertreatment and unnecessary suffering.

This is over one-third of Canada’s doctors who will never “prescribe opioids for moderate-to-severe chronic pain” no matter what. We cannot know how many would do the ethical thing and refer such patients to someone more experienced in treating pain, and how many just leave the patients to their own devices. If 35% would never prescribe opioids, some additional percentage would fall into the “rarely” category, which also results in undertreatment of pain.

Why does medical opinion on a fictional TV show matter?

Current medical “best practices” and principles regarding the differentiation of addiction from dependence have been slow to reach doctors and other medical professionals, let alone the public. Of course doctors should not be getting their medical information and attitudes from television, but television has a strong influence on viewers who know little about the topic presented–that’s all of us who are not medically trained. A person who believes that taking opioids results in addiction is far less likely to push for adequate pain treatment for him/herself, or family, and may even reject it if offered. If friends, relatives, and employers of pain patients share the confusion about addiction, they will exercise social pressure or threaten loss of employment. So the attitudes promoted by a popular TV show––in the US, House was the most-watched scripted program on TV during the 2007–08 television season––can have profound effects on the health care people receive.

When House stops taking the vicodin, he suffers headaches, sleeplessness, nausea, inability to concentrate, and irritability. All are symptoms of physical dependence, as in the definition paper cited above. That these same symptoms are felt by addicts is beside the point: addicts and chronic pain patients both are physically dependent, and both will suffer similar withdrawal symptoms as a result. For the pain sufferer, the symptoms of increased pain are added.

As a pain patient, I have experienced withdrawal from methadone. It is hell. It gave me much more compassion for addicts. Yet, in trying to get off methadone “cold turkey” when my doctors claimed they could not assist me, I went through seven days and nights of absolutely no sleep, intense physical and mental suffering from the withdrawal, and increased pain. There’s the pain you were medicating, and in addition the cessation of methadone makes all your bones ache, worse than any flu. And all this time the methadone was on the shelf. Untouched. Not typical addict behavior. On the eighth day with no sleep I realized that there had been no lessening of my symptoms, and that I could not endure it another 24 hours, so with distaste and reluctance I began taking the methadone again. I resolved then that I needed to find different doctors, who would help me through this, and subsequently did so with complete success. (I wrote about this in an earlier post.)

In my case the pain being treated had changed (improved, by a nerve block) during my time on opioids; the increased pain I had during withdrawal was nothing like that which House suffered from his leg. He showed great fortitude and self-control, but while dramatic it was medically pointless. The man has pain so bad he cannot function if it is not controlled; if nothing else works other than opioids, then that’s what he needs to use. Current medical thought recognizes this; the writers of the show do not.

Some of the behaviors relative to pain medication shown by House are reprehensible, such as stealing medication and forging prescriptions. This seems like classic drug addict behavior. But see the paragraph above on Pseudoaddiction, including the statement “Even such behaviors as illicit drug use and deception can occur in the patient’s efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.” In fact, much of House’s often-criticized behavior has to be considered in light of the fact that even the vicodin never adequately relieves his leg pain. Irritability, mental and physical restlessness, combativeness, and harsh remarks can be the signs of unrelieved physical pain.

pain behavior chart.jpg

Chart from “Pain Assessment in Older Adults” (2006). The source references mentioned at the bottom of the chart are : 8. The management of persistent pain in older persons. American Geriatric Society (AGS) panel on persistent pain in older persons. J Am Geriatr Soc. 2002;50:S205-S224; and 9. Ferrell BA, Chodosh J. Pain management. In: Hazzard WR, Blass JP, Halter JB, et al. Principles of Geriatric Medicine and Gerontology. 5th ed. New York: McGraw-Hill Inc; 2003:303-321.

We have been told that even before his leg injury, House wasn’t a sunny sociable person. But he’s gotten worse since then, and in the show the doctors around House nearly always blame his pills––his addiction–not his pain.

Addicts and pain patients, differences and similarities

I intended to include some data here about the low actual rate of addiction (not dependency) in pain patients as a result of taking pain meds. I remember reading figures that ranged from 5% to 10%. When I did a quick search for substantiation I found that many of the research articles online are only available for a fee. The rates I did see varied so much, I must assume that the studies are not all using the same standards. Different researchers have different definitions of addiction vs. dependence; there is also an overlap of characteristics or symptoms between addicts and those who are physically dependent. If I had had no legal access to relief when I was in extremis after seven days of no methadone, I probably would have lied or stolen, if necessary to end the withdrawal. Nothing violent; I would have gotten myself somehow to the emergency room instead. But if turned away there, who knows?

This is the sort of mental and physical suffering that confronts the organism with a stark choice: solve this, or die. (If you are too debilitated to protect yourself or find food, you will die, as far as the primitive part of our brain is concerned.) Once physical dependency has been established, both addicts and pain patients are motivated to get their drugs, driven more powerfully than anyone can imagine who has not experienced it. The distinctions between addict and dependent patient must be made on criteria other than the evidence of physical dependence, since this is the same for both.

The chart below presents some criteria that seem to square with my experience and reading, although the source does not give scholarly or research citations for it.

Chart,addict-patient.jpg

[The last item under Addicts should read “The life of an addict is a continuous downward spiral.”]

Individual responses to potentially addictive drugs vary. Not everyone who tries heroin becomes addicted. Different responses are based on biological and psychological factors we are only beginning to glimpse: everything’s neurological in the end, I suppose, but increasingly it appears that experience (from conditions in utero to nutrition, upbringing, and exercise) can cause physical changes in the brain and nervous system, and therefore in thinking, emotion, and behavior [see note 1]. Even the physical brain, where our sense of “I” resides, is changeable throughout our lives: adapting, adding complexity, growing (or shrinking) based on what happens to us. The activity of our genes themselves can be enhanced, reduced, suppressed entirely, depending on outside conditions from before birth to the day we die.

How should society regard people with chronic pain?

When a starving person steals bread, we do not say that he should have simply endured his hunger, or that he is “addicted” to food. Believe me, the situation of a person in great pain, or even moderate chronic pain, is also desperate and unbearable, and the organism will get relief.

The compassionate and socially responsible action is to meet these needs in an appropriate way. Can we assist this starving person in earning money so as to feed himself or herself? If not, most of us agree that the helpless, the elderly, the people so injured by life as to be unemployable, should receive aid rather than be allowed to starve or freeze to death. The pain patient deserves the same action: the question to be asked is: How can the pain best be alleviated? There may be surgical options, transfer to a different job, physical therapy, use of TENS units and the like, as appropriate. Meditation, mild exercise, and cognitive training may offer some relief too. But the response to pain must not be limited to only non-drug approaches.

The patient is the final judge of what works, and how much pain is too much, and the patient should not be silenced with threats and accusations of addiction.

A question that needs to be asked about drug addiction is Why? Why do so many of our fellow citizens seek out heroin, cocaine, methamphetamine, illegal prescription drugs, too much alcohol? What is their pain? Not physical, perhaps, but certainly psychological or spiritual: despair, lack of meaning in life, lack of true positive connexion to other human beings and to the natural world. Until we approach drug addiction in this way we will never understand how to reduce its occurrence. Neither after-the-fact tactics (punishment, ostracism, rehab), nor prevention (education and interdiction) have worked very well. But asking Why? about addiction would reveal aspects of our society that are senseless and cruel to many, but pleasant and profitable for a few. Danger, ssssshh!

We have been so cowed and brainwashed by the continually failing War on Drugs and our native streak of puritanism that we even permit medical professionals to deny adequate pain relief to terminal cancer patients. Is it really because they “might get addicted” in the weeks before they die? Or is it the imposition of society’s fears and prejudices upon the most helpless among us? Clearly, we have made little progress in reducing the numbers of illegal drug users over the past forty years––but law-abiding people who go to doctors, they can be denied and controlled.

And so, apparently, can Dr. Gregory House, who is pitched to us as the independent thinker extraordinaire, smart and brave, ready to track truth to its lair and drag it out into the daylight. I wish his writers would let him do exactly that on the issue of pain and addiction.

1. Further reading on the “plasticity” of the brain (an unsystematic quick gathering)

  • Scientists map maturation of the human brain (2003), a short overview
  • Brain changes significantly after age 18 (2006), “The brain of an 18-year-old college freshman is still far from resembling the brain of someone in their mid-twenties. When do we reach adulthood? It might be much later than we traditionally think.”
  • Research finding persistent physical and functional changes in human brains caused by smoking, chemotherapy,
  • Empirical research on structural brain changes affecting social cognitive development after childhood (2007);
  • Various environmental factors can cause “epigenetic changes…reversible heritable changes in the functioning of a gene can occur without any alterations to the DNA sequence. These changes may be induced spontaneously, in response to environmental factors…” and be associated with development of schizophrenia and other psychiatric disorders or the quality of an individual’s performance as a parent
  • Childhood lead exposure can predict criminality(2008), even after controlling for factors such as socioeconomic status of the family; “Lead can interfere with the brain by impairing synapse formation and disrupting neurotransmitters, such as dopamine and serotonin. It also appears to permanently alter brain structure.”





Timeline and map of Mumbai terrorist attacks

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Anyone who is looking for a concise orderly picture of the multiple terrorist attacks in Mumbai, and timeline of the attacks and response, cannot do better than the UK Guardian’s page by their guy Paddy Allen.

Events have gone on now for 3 days, starting before midnight on the 26th, and the timeline covers all three days (click on “Next” to view successive parts of the timeline, and on the camera symbols on the map to see some still photos). The Guardian also many articles providing good coverage and analysis.

This is the sort of information presentation which television news could do, but never seems to bother with. They have the computer graphics and know-how, they have our visual attention, but they squander our time showing us repeats of a few dramatic scenes or unidentifiable scenes straight from local news channels. For run-of-the-mill stories we have to watch file footage of pills running through a counter while the presenter talks about health care problems, Big Pharma, or the latest drug recall; our eyes could be better occupied watching informational graphics to fill in other aspects of the story. Most of us can take in information a lot faster than a tv anchor talks, so we are left twiddling our mental thumbs. Print media does a much better job with information graphics (and always gives more background and information than tv) but of course cannot compete with the web for timeliness or interactivity. No wonder people turn away from tv news, to web news sites.