The surge in demand for painkillers is astonishing. How much importance do modern patients place on addictive pain-relieving drugs?
When something hurts you, you’re just looking for something to break it, ‘says 53-year-old Robert dryly. He was a sales specialist for years, but has been retired since 2003, when he was first struck by bouts of repetitive, excruciating abdominal pain, the nature of which remains unexplained. Another specialist, after longer hesitation, prescribed to the suffering patient tablets with slowly released morphine into the body. At this point, Robert has joined a growing number of British patients who are given the strongest opioid drug available to relieve the pain associated with chronic (implicitly non-fatal) ailments.
Robert’s daily dose of morphine increased gradually to a whopping 3000 mg (3 g) – enough to kill most people who would have been given it without preparation. Robert experienced other side effects. After consecutive doses of morphine, this very intelligent, speaking a pretty language, sober man began to experience a rapidly decaying mature personality. – Morphine increases lethargy – he recalls – but at the same time a person becomes more and more irritable, shaky and prone to abuse. Robert resorted to Viagra’s help several times, not wanting to give up his sex life despite his serious ailments – and when he gave up his daily dose of morphine once or twice, not wanting to mix up potent drugs unnecessarily, the classic elements of the withdrawal syndrome appeared in the blink of an eye. “Everyone saw drug addicts on TV,” recalls Robert. – Unnatural, slow movements, trembling hands and jaws, confluence of sweating, agitation. Exactly the same thing happened to me.
Robert is not alone: ten years ago in Britain one million prescriptions for strong opiates were written in a year; today that number is over four million. More and more English bathroom cabinets are filled with painkillers so powerful that one of them, OxyContin (a slow-release synthetic oxycodone), is known in the US as “heroin for hooligans.”
All opiates, from codeine to diamorphine, more commonly known as heroin, act on the central nervous system in much the same way: they reduce agitation and anxiety, but create a delightful feeling of happiness and security; they also reduce pain. It is their lack of pain relief potential, however, that makes them so popular in Hollywood, where many ambitious film and television professionals prefer to “relax” by taking a few tiny dark blue OxyContin tablets than traditional martinis. Doctors in Britain are very concerned. They are, of course, pleased that the medical industry has taken seriously chronic pain, long neglected by pharmacists and internists. They fear, however, that the generous prescribing of drugs available today is resulting in an uncontrolled increase in the amount of addictive pharmaceuticals made available to the public. The first available statistics show that there is something to worry about. According to NHS data, compiled by Dr. Cathy Stannard, author of Opiates for the Treatment of Chronic Pain, the number of opioid prescriptions issued in the UK increased from 1999 million to 2008 million from 1,8 to 6,2. The research we commissioned for this article supports this conclusion: the number of prescriptions for the most potent opioid preparations (morphine, oxycodone, phenanthyl, and buprenorphine) increased from a million to over four during this time.
In late February, the British Pain Association issued a new recommendation on prescribing opiates to patients. Compared to previous recommendations, the current document, co-authored and edited by Dr. Stannard, is much more restrained in wording; the ambition is to recognize both the advantages and disadvantages of broad access to strong painkillers.
How do specialists explain the fourfold increase in the number of prescriptions? The most innocent reason is that drugs like OxyContin are relatively new to the market. Large pharmaceutical companies are constantly working on expanding the range of methods of administering a given agent – from traditional tablets and injections to quickly absorbing lozenges, lollipops (!) And transdermal patches – so they come out of the skin to properly advertise completely new products. Many physicians may also readily use opiates after years of experience with non-steroidal anti-inflammatory drugs, which in excess can lead to gastric mucosa bleeding and other potentially life-threatening problems. However, the thesis that the increase in the sale of opioids is caused by a change in the attitude of doctors to the phenomenon of permanent or long-lasting (chronic) pain is the most pessimistic.
The fact is that only a small percentage of prescriptions are received by patients struggling with terminal cancer. Most of them go to victims that are as severe as harmless: from “back pain” to osteoarthritis. It is a complete contradiction of many years of practice: for much of the XNUMXth century, pain as a phenomenon was neglected by doctors who were reluctant to prescribe opiates even to the deeply suffering. Over the past XNUMX years, both patients and their relatives, as well as a growing number of journalists and social activists, have tried to sensitize doctors to the “problem of pain” and lead to a change in their attitude; Pharmaceutical companies turned out to be an unexpected ally with somewhat ambiguous motivations, allocating increasing amounts of money to inform the medical world about new solutions and cases in which they can be used. The results of research clearly showing that in cases where opioids are used to prevent intense pain have been helpful in this argument, cases of addiction are extremely rare. Addiction in the strict sense of the word – in other words, a situation in which a person demands more and more doses of a given substance and is not able to give up taking it in any way – most often occurs when a healthy person reaches for a given substance directed exclusively at the desire for a “euphoric effect”. A patient who suffers from an injury or severe illness may become somewhat dependent on a fixed dose of the drug, but is not addicted in the above sense – and this distinction, however hermetic, is crucial from the point of view of social medicine and therapy. addictions.
The above considerations, however, can easily be disavowed as “theory.” So what does the practice say? What is pain? Is it really the sensation the person experiencing it is complaining about? If so, why do people experience it so differently and with such different intensity? And is it really only the differences in the conduction of stimuli through the nervous system, or is it somehow culturally conditioned?
‘Explaining’ chronic pain ‘is one of the greatest teaching challenges of a modern traumatologist, and jokes like’ all of us have had a toothache ‘in no way contribute to making this phenomenon more understandable,’ Dr Stannard observes wryly. Contemporary medical sociologists, when writing about pain, take into account cultural, social, metabolic and psychological factors at the same time. Moreover, it is impossible not to try to make complex and multifactorial explanations in a situation where a common-sense assessment of the facts leads us to nothing. How to explain the fact that, according to research by the World Health Organization, chronic pain is experienced by as many as 40,8 women living in Santiago, Chile, while in the Italian city of Verona, this experience only affects 3,9%, which is nearly ten times less? Perhaps our generation is less stoic than that of our grandparents. It is not just about the importance we attach to the comfort of our lives. Dr. Stannard, like many thinkers observing the present day, draws attention to a kind of “medicalisation of life”: due to both general education and aggressive advertising campaigns, partial (often false or inaccurate in detail) knowledge about the “secrets of the human body” is much more widespread than ever before. Of course, however, attention to comfort is of great importance. “Until recently, many people would have agreed to live in a way that seems to defy their ambitions or appetites today,” says Stannard. This opinion is strongly shared by Dr Des Spence, an internist in Glasgow, who has been observing the way patients (over) use opioids for years with such apprehension that in January he decided to publish a lengthy article in a high-circulation and industry-renowned British Medical Journal. Spence believes that the surge in the number of painkillers prescribed is not in any proportion to the number of cases or the severity of the disease. Doctors are increasingly “diagnosing persistent pain hastily and too easily,” he said. According to the Scottish internist, strong painkillers are not necessarily what the patient needs most – even if he or she himself believes at some point. Their abuse has not only disastrous medical consequences; it also worsens the functioning of the recipient in the community and leads to an “inability to tolerate pain”.
For Dr. Spence, the practice of using painkillers in the United States is a negative benchmark. In doing so, he is obviously aware of the differences in both cultural traditions and organizational solutions. The British healthcare system, in line with the trends prevailing in Europe after the last war, remains highly centralized and largely subject to state control, which means that British doctors are subject to market pressure to a much lesser extent than their counterparts overseas – this, in turn, means that in the British conditions, the formula “the client is our master” can only be applied to a small extent. The National Health Service, thanks to its software, is able to monitor the contents of issued prescriptions in more detail than ever, and the market of “non-prescription drugs” is much poorer and more restrictive than in the US. Therefore, the practice known in the US as “doctor-shopping”, ie a journey from office to office, during which a patient with an appropriately affluent wallet, appropriately determined by pain or other needs, has no chance of success, can obtain an almost unlimited number of prescriptions.
Spence, aware of the restrictive nature of the British pharmaceutical market, warns, however, that also in the UK, the pressure of patients to access painkillers will increase – especially in the case of the “upper middle class”, i.e. people aware of their health, keenly interested in the “comfort of life” and with sufficient resources to provide it. In his opinion, the pressure of patients to provide them with “appropriate, according to expectations care”, although psychologically understandable, lead to the creation of a system in which the patient-doctor relationship begins to dangerously resemble the standard “client-service provider” formula, and this cannot lead to anything good.
These arguments sound very reasonable – and at the same time, it is impossible to disregard dozens of reports, often from people we know personally, to whom only the possibility of using sufficiently effective painkillers restored the meaning of life, or at least – the ability to enjoy it despite experiencing an illness. “We are here to open a window to a pain-free world for patients, to show them an alternative to their condition,” declares forcefully Dr. Christopher Jenner, an analgesics consultant at one of London’s most respected clinical hospitals. – Only by treating their suffering properly, are we able to fight them – and none of us “overwhelm” the problem with an excessive amount of drugs administered without thinking. I don’t know of any clinic where a person suffering from pain would simply be told, “You’ve got your morphine here. Next!”.
Patients who have resorted to strong analgesics first speak of relief, the amazing power to remove, suspend, or suppress pain. Miriam, 39, who has been suffering from sciatica and degenerative changes in the lumbar spine for years, has been unable to control her physiological functions for several years, has been on a pension for five years, counting the days. After persuading her friends, she decided on a trial therapy with OxyContin: the doctors of the clinic dealing with pain treatment had doubts due to its general condition, but ultimately decided not to refuse her opioids.
“It was just wonderful,” Miriam recalls. – The best comparison I can think of is flipping the light switch. And my euphoria? Finally something works! After years of torment, I felt liberated. After a few months, however, she is able to distance herself from her euphoria at the time: she realizes that she has become hyperactive and aggressive, and is working together with specialists to reduce the daily dose. – I am afraid that I have become something like an addict, and I would like to deal with it – he declares.
The dilemmas that Miriam experiences have been with mankind since the Neolithic times – it was probably then that our ancestors started using the poppy straw decoction. Back then, they experienced an effect that they probably couldn’t name yet: opioids don’t make the pain go away, the way an aspirin tablet does on a toothache: rather, they let you endure it painlessly, they make it fade away. Humanity was more and more willing to use similar solutions: the Victorian era, as we know today, was marked by the eagerly and unrestrictedly sold by drugstores laudanum, under which this old-fashioned name is nothing else than a strong opium tincture. Morphine, named after the Greek god of sleep, Morpheus, was first distilled from the juice of Central Asian poppies at the beginning of the XNUMXth century, and its remarkable properties were realized almost immediately: Sir William Osler, practitioner and internist considered to be the father of modern British medicine considered it to be “a drug from God Himself.” Even today, morphine remains a kind of “benchmark”, a model that allows to determine the strength of action of subsequent specifics – and in this role it occupies a respectable place in the pharmacy museum: patients who often use drugs many times stronger than laudanum, instinctively fear drugs that in their names contain some allusion to morphine. “The fear of opiates is more widespread than it seems,” comments Dr Jenner. – The term “morphine” is frightening. It can be repeated to patients many times that oxycodone is a drug based on morphine – but as long as it does not have the prefix “morph” it does not arouse social fears, so it is desirable.
Robert, whom we mentioned at the beginning of this article, is also beginning to realize the risks of being too closely associated with the dream god. Although, he says, he never felt particularly “screwed up” on the morphine, he does not deny that he became too attached to the dispenser in which he kept the pills. During his next visit to the hospital, he opted for an opioid withdrawal program. “I still use painkillers, but much milder ones,” she reports. – Of course, I suffer. I have a choice of morphine or pain – only I realized that pain allows me to see the world more soberly.
Andrew M. Brown
Also read: My life with pain