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The Pain Relief Scandal

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“Opium has been recently made from white poppies, cultivated for the purpose, in Vermont, New Hampshire, and Connecticut…. comparatively large quantities are regularly sent East from California and Arizona, where its cultivation is becoming an important branch of industry, ten acres of poppies being said to yield, in Arizona, twelve hundred pounds of opium.”

–Massachusetts Government Health Report, 1871

By the mid-1800s, as many people know, opium could be legally purchased in the United States as laudanum, patent medicines, and various elixirs. Less well known is the fact that opium was a godsend during the bloody years of the Civil War. Maimed and disabled soldiers found relief in morphine, the potent alkaloid of opium named after Morpheus, the Greek god of dreams. Used against constant, intractable pain, opium and its derivatives were among the most humane medical drugs ever discovered. How could a physician withhold them?

Today, after countless drug wars have merged into a single, inflexible federal stance on “drugs,” morphine and its derivatives remain so stigmatized, so entangled in drug wars and global narco-politics, that the danger of losing sight of their humanitarian applications looms larger than ever.

At least half of all cancer patients seen in routine practice report inadequate pain relief, according to the American College of Physicians. For cancer patients in pain, adequate relief is quite literally a flip of the coin.

A September 10 New York Times report by Donald G. McNeil Jr. highlights studies by the World Health Organization which amply document the ongoing scandal in pain management. At least 6 million cancer and AIDS patients currently receive no appropriate pain treatment of any kind. In addition, WHO estimates that four out of five patients dying of cancer are also suffering severe pain. The numbers of untreated patients suffering intractable, unrelieved pain from nerve damage, burns, gunshots, sickle cell anemia, and a host of other medical conditions can only be guessed at.

Figures gathered by a different U.N. agency, the International Narcotics Control Board, make clear that “citizens of rich nations suffer less.” To put it starkly, the use of morphine per person in the United States is 17,000 times higher than per person usage in Sierra Leone. Doctors in Africa paint a grim picture of patients hanging themselves or throwing themselves in front of trucks as an alternative to life without pain relief. The U.S., Canada, Britain, France, Germany, and Australia together account for roughly 80 per cent of the world’s medicinal morphine use. Other countries, particularly the poor and undeveloped nations, scramble for what’s left.

The ironies fly thick and fast: In many cases, pain relief is the one thing doctors can offer their patients, and the one thing they withhold. Studies show that 70 per cent of patients present with painful conditions. Typically, non-addicted patients take morphine therapeutically for pain at doses in the 5 to 10 mg. range. But experienced morphine addicts regularly take several hundred milligrams a day—a huge difference.

As for concerns about addiction, recent evidence for the heritability of opiate addiction looks strong. “Harvard did some really superb studies using a huge cohort of military recruits in the U.S. Army,” according to Mary Jeanne Kreek, a specialist in opiate addiction at Rockefeller University in New York. “Heroin addiction has even a larger heritable component than any of the other addictions, so that up to 54% of heroin addictions seem to be on a genetic basis or a heritable basis.”

Opium, the main ingredient, is in abundant supply worldwide, and is relatively cheap to grow. The problem, as David E. Joranson of the University of Wisconsin’s Pain and Policy Studies Group told the Times, is the “intense fear of addiction, which is often misunderstood. Pain relief hasn’t been given as much attention as the war on drugs has.”

Moreover, generations of doctors have been taught in medical school that morphine must be used sparingly, with great caution, even if this “opium phobia” results in agony for patients, including infants. (Morphine is safe and effective for use in premature babies.)

The problem is not a new one. Ten years ago, a report by the American Academy of Pain Medicine laid the blame squarely on doctors, who were routinely underutilizing opiate derivatives for pain relief. Not much has changed. It is no secret that the move to HMOs has compounded the problem, as effective pain relief often gives way to the need to move patients out of beds as quickly as possible.

In 2001, the American College of Physicians called for more extensive pain-management education in the nation’s medical schools, noting that doctors are not learning enough about how to treat pain, or about how to talk to patients ABOUT pain, despite what Scott Fishman of the Division of Pain Medicine at the University of California, Davis, calls a “revolution” in the development of new pain medications.

We also need to recognize the problem of under prescribing morphine and other
addictive painkillers for children in hospital settings. If we continue to stringently prohibit the use and sale of opiates, then we had better remember to make one important exception: Pain abatement in medical applications “There’s a certain amount of hysteria about narcotics among doctors,” maintains one researcher. Patients suffering from serious pain cannot get adequate and sustained relief in many cases, because doctors and nurses remain reluctant to provide it.

This, rather than flashy cocaine seizures at the border, represents the lasting outcome of drug wars.

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