Relieving Pain and Fighting Addiction: We Have to Come to Grips With the Challenge
"If God made anything better, he kept it for himself."-- William Burroughs in Junky
The phenomena of pain still befuddles modern science. Ever since Hippocrates hypothesized it resulted from an imbalance of the vital fluids, physician debated on the cause and classification of pain. Descartes revolutionized the field with his theory that pain resulted from inputs that traveled down nerve cells and notify the brain of unpleasant phenomena. But what pain is and how to treat it remains a field in need of a revolution.
At it's most basic, a painful sensation is a sharp notification of noxious stimuli to be avoided – whether that be a hot stove, a stinging nettle or a brutal ex-wife. All animals seem to share this ability to detect pain and avoid it. In evolutionary terms, Richard Dawkins asked why the sensation of pain existed when perhaps a simple alternative like a mental 'red flag' might serve the same purpose. He decided that pain was made so painful because it needed to stand out from all the other competing drives of the body like hunger or sex. People congenitally insensitive to pain have a shorter life expectancy. The intense reflexive nature of pain allows an organism to save itself. Fitness might then be defined as the balance of pains.
The many types of pain currently measured in the laboratory speak to their evolutionary usefulness. The obvious types such as thermal, chemical, electrical and mechanical pain result from detection of the harmful stimuli by the nociceptors of the body and the signal then transmitted along the peripheral nerve fibers to brain. The category of neuropathic pain results from damage done directly to the nerves and nervous system. It ranges from bumping your funny bone to the brutal pain of cancer, late term AIDS and the mysterious phantom limb syndrome first noted by William James and Walt Whitman that can cause amputees to record pain in their missing limb. Idiopathic pain, a particularly troubling mystery, is defined pain as persisting after the apparent healing of an injury. To delineate between chronic and acute pain, an arbitrary timeline says that it's defined as chronic pain once the pain lasted from 3 months to a year after it began.
One of the most vexing aspects of pain management for doctors and drug warriors is that no independent tests exists to measure pain. The self-report of a patient is still the doctors most trusted method of assessing pain. While more nuanced questionnaires have been developed since the 60s, they only expand on the old question: On a scale of 1 to 10, how much does it hurt? With pain causing half of all ER visits and a third of family physician cases, it's astonishing that pain management is not required for medical school and according to experts like Will Rowe of the American Pain Foundation, it's not even on the radar of most medical schools.
Pill to needle pipeline
Last week, the CDC released a report showing that the rate of heroin overdose deaths in America quadrupled between 2002 and 2013. In a press briefing, CDC director Thomas Friedman said that rising use of medical opioids "primed" Americans for heroin addiction and called for "an all-of-society response," including a reduction in prescriptions and better law enforcement. Likewise, in its 2015 assessment of the threat from heroin, the DEA reported, "Increased demand for, and use of, heroin is being driven by both increasing availability of heroin in the US market and by some controlled prescription drug (CPD) abusers using heroin."
This led to the term 'epidemic' being thrown around often in the media, but scholars like Caulkins et al of Carnegie Mellon see these cycles of addiction as oscillations that extend through American history. Cocaine and heroin peaked in the Roaring 20s and then use dropped low for half a century until the experimentations of the late '60s began another resurgence that eventually faded. The constant cycling of popularity of various drugs in American society seems to swing around strange attractors that bedevil any simple explanations.
The DEA's responded to the 'opiate epidemic' with their usual hammers: strict prescribing guidelines, undercover investigations, more stringent bookkeeping and closure of the infamous pill mills, usually doctor's office in a strip mall that after a short interview, issues opiate prescriptions easily filled at the pharmacy conveniently owned and operated next door. The DEA increased the onerousness of using these pharmaceutical to treat pain with requirements of more urine tests and extra appointments. Thus, when these various controls caused the supply of pharmaceutical opioids to drop, the demand did not. For the the pain patients and the moderately addicted, an especially low street price for heroin beckoned them across the alley from the pharmacist into the black market. One study found 81% of recent heroin addicts started with prescription painkillers but many contradictory studies exist and the mechanisms of entry into opiate addiction is highly debated.
An example of this commonly told story is close to home. My roommate's mother, Mary Kay Villaverde reports how her doctor prescribed fentanyl patches. She was not told that the active ingredient diffusing across her skin is an opiate painkiller ranked as roughly 100 times more potent than morphine and 50 times stronger than pharmaceutical grade heroin. The high is less euphoric, the lung depression more severe but the higher potency of fentanyl causes it be used in lacing weak heroin and when added too liberally, causes a rash of overdoses when a batch hits the street.
Unfortunately, in the mechanisms of heroin addiction on the street, reports of an overdose cause that product to be specifically sought out as more potent than the weak smack always floating around. The DEA reported busting a lab in 2006 producing counterfeit “OC-80” tablets supposedly containing 80 milligrams of oxycodone but actually producing pills with 1.5 mg of fentanyl hydrochloride. It appears common that Mary Kay, or MK as she's known to her many friends, wasn't told about the abuse potential of her trans dermal medicine.
After MK noticed that one patch didn't work as well as it used to. Her doctor recommended applying more. As the pain from her condition faded, she noticed strange flu-like symptoms as she stopped using the patches as much. Her daughter Kathryn wanted to help and went online to look up about the patches. She found forums endlessly repeating the same story: patients using them to treat acute pain and then winding up physically dependent, not informed by their doctors about the addictive potential and then taken by fierce surprise when they tried to stop taking their medicine. Suburban users who never thought the word addicted might ever apply to them ended up pouring their stories out on the forums looking for honest information and some relief.
Reducing the harm
"Heroin is the perfect drug for anyone who has been damaged by lack of self-esteem or traumatized by historical upheaval. It is a drug of battlefields, concentration camps, cancer wards, prisons and ghettos. It is the drug of the resigned and the dissolute, the surely dying and the victims unwilling or unable to fight back."
- Terrence McKenna in 'Food of the Gods'
But according to data from the Substance Abuse and Mental Health Service Administration, 75% of people misusing prescription painkillers do not get them from a doctor. They come from friends, from relatives and from dealers. A thorough study from the Cochrane Institute looking specifically at clinical studies of pain patients without a history of drug abuse find less than one percent become addicted. In fact, the greatest predictor of opioid misuse is the consumption of illegal drugs within the previous year. A Vice article states the case well: “Opioid addiction usually begins in the same place that all other addictions start: in the childhoods, traumas, mental illnesses, and genes of those affected.” As advocates like Ethan Nadelmann of the Drug Policy Alliance often mention, one of the most important things to remember about drugs is that the vast majority of users do not go onto abusive behavior. Like alcohol, the worst psychoactive drug in the opinion of anyone paying attention, many people use drugs on the weekends and in their downtime with only a moderate and quite acceptable level of negatives.
For the vast majority of citizens, they're not liable to opiate addiction. As Burroughs reported in his groundbreaking sociological work of scholarship disguised as the early drug novel Junky,
It takes at least three months’ shooting twice a day to get any habit at all. And you don’t really know what junk sickness is until you have had several habits. It took me almost six months to get my first habit, and then the withdrawal symptoms were mild. I think it no exaggeration to say it takes about a year and several hundred injections to make an addict.
The questions, of course, could be asked: Why did you ever try narcotics? Why did you continue using it long enough to become an addict? You become a narcotics addict because you do not have strong motivations in the other direction. Junk wins by default. I tried it as a matter of curiosity. I drifted along taking shots when I could score. I ended up hooked. Most addicts I have talked to report a similar experience. They did not start using drugs for any reason they can remember. They just drifted along until they got hooked. If you have never been addicted, you can have no clear idea what it means to need junk with the addict’s special need. You don’t decide to be an addict. One morning you wake up sick and you’re an addict.
However, for a small minority, there's a distinctly different reaction. Perhaps the most common phrase I've heard from those hardest out on the street is that the first shot of heroin felt like the first hug they ever experienced. According to Dr. Gabor Mate of Vancouver's notorious Downtown East Side, the stories of those most addicted to opiates have childhoods of abuse so profound that the true tales would outstretch the most horrible of imaginations. That kind of early childhood abuse and neglect seems to leaves an indelible imprint on the developing brain. It downgrades the number of receptors for endorphins, your body's natural morphine-like molecules responsible not only for pain but also underlying aspects of human connection, the molecules that function as the reward a brain gives to someone when gazing at their child or seeing a loved one, a shot of natural heroin used by evolution to foster connection. With a permanently lowered level of endorphin receptors, it seems that someone might be as unable to register a facial movement as a smile as a colorblind person is to see a light colored green. That first hit of opioids might finally reach a level that matches the “normal” experience of a brain not brutalized in infancy.
This makes up one more of the modern medical paradoxes stemming from racism and arrogant drug warriors feeding misinformation to lazy doctors. If your brain's slightly deficient in serotonin, take a Prozac to boost the levels. If it needs a little more dopamine for energy, college students and business suits are welcome to Adderall (dextroamphetamine) but Middle America is prosecuted for methamphetamine (Desoxyn), the quite similar dopamine agonist. The first endogenous cannabinoid ever discovered, anadamide, has never seen a clinical trial in humans while the later found oleamide, another cannabinoid somehow related to sleep and found in the human brain, can be ordered on Amazon.
But the paradox is most vicious when it comes to endorphins. I maintain that for every “junky” on the street, there's a doctor or nurse with an opiate predilection that they manage to keep under wraps because of the nature of their position, even though both groups apparently need a boost to their own endorphin level. The most obvious example of this continuing phenomena is the famously important and ingenious Dr. William Stewart Halsted, a founder of Johns Hopkins, an early champion of aseptic surgery and a lifelong morphine addiction (see “The Knick”, the excellent series on a fictional NYC hospital at a dawn of modern medicine led by a character loosely based on the pioneering and ingenious Halsted).
As with all drug use, most does not cause harm. The silent majority of people deciding their own dosing and doing a decent job of it – even with the opiates. From doctors in the wards to people on the streets, many just need a little boost to their own endorphins to balance them out to get through the day. As Johann Hari laid out in his excellent Chasing the Scream, when looking at the heroin assisted therapy work in Switzerland, where people are given unlimited amounts of pure heroin, almost all the users gradually titrate their use until after an average of ten years, they stop using the drug altogether. A small minority continue to use for life but it enables them to lead functional lives and most importantly, if you care more about human lives than the impossibility of a drug free world, there's not been even one overdose from this program.
None of this to deny that true addiction doesn't exist – especially in the terrible programs in the United States setting up people in situations designed for failure - and that scenes exist far worse than any Requiem for a Dream could ever honestly portray. Despite the media furors that may or may not be based on the facts on the ground, the rate of opiate addiction in the United States has held steady between 1 to 2 people per one thousand citizens for the last century since Bayer introduced the morphine syringe in the Sears catalog.
The Evil Elephant in the Room
The problem greater than domestic addicts getting too much is the rest of the world's patients getting too little. In this country, there's an extreme under serving of pain with doctors afraid to give adequate doses and uninformed of their options. Even more hauntingly, the entire continent of Africa is almost completely void of pharmaceutical opioids because of international fears that “those people” will be diverting the drugs onto the black market.
As the New York Times lays out the gory charges,
The World Health Organization estimates that 4.8 million people a year with moderate to severe cancer pain receive no appropriate treatment. Nor do another 1.4 million with late-stage AIDS. For other causes of lingering pain — burns, car accidents, gunshots, diabetic nerve damage, sickle-cell disease and so on — it issues no estimates but believes that millions go untreated.
Figures gathered by the International Narcotics Control Board, a United Nations agency, make it clear: citizens of rich nations suffer less. Six countries — the United States, Canada, France, Germany, Britain and Australia — consume 79 percent of the world’s morphine, according to a 2005 estimate. The poor and middle-income countries where 80 percent of the world’s people live consumed only about 6 percent.
At pain conferences, doctors from Africa describe patients whose pain is so bad that they have chosen other remedies: hanging themselves or throwing themselves in front of trucks.
A helpful data mine of graphs in US News charts the trends, including the vital fact that abuse of prescription pharmaceuticals far outpaces heroin with one in 20 Americans reporting non-medical use in the last year. The deaths from pain medications total more than heroin and cocaine combined.
“Enough painkillers were prescribed by American doctors during one month in 2010 to medicate every American around the clock for an entire month.” But even at 240.9 million scripts for painkillers in 2012, that's only a 33% increase over the previous decade.
Factors playing in to this growth cannot be traced to simple answers like lazy pernicious doctors or patients brainwashed by pharmaceutical advertising into requesting certain medications. It's also the result of advocates for chronic pain patients who feel underserved, politicians confronted by dying teenagers, drug warriors trying to stamp out a pernicious habit they see as soul sucking. Though these shoals, doctors must swim in waters of messy data and messier people, trying to find the sweet spot for treating pain.
If the world were sane and medicine honest, the overwhelming data showing synthetic cannabinoids effective against every type of pain measured would be pursued. But that's an essay for another day. Labs around the world are hunting for the next molecule that might ease human pain, pharmaceutical companies are hoping to find the next blockbuster but in the meantime, our schizophrenic treatment of pain leaves us awash in painkillers while the rest of the planet suffers.