Tuesday July 04, 2017

Opioids, addiction and our troubled history with pain

Opioid crisis, or pain crisis?

Opioid crisis, or pain crisis? (Ben Shannon/CBC)

Listen to Full Episode 27:29

With a quick tour of his idyllic property in B.C.'s Fraser Valley, Jack paints a picture of his relationship with painkillers.

"I was on morphine when I rebuilt that" he says, pointing to an old pickup truck. "And it turned out ok, so I can't be too messed up I would say." 

"I built the shop when I was on morphine. I was on morphine when I painted it too" he says

Jack has been taking painkillers on and off for thirty years, and prescribed morphine for the last five years to help him cope with a lifetime of chronic pain.

'It just won't stop."

He grew up in Vancouver's Lower Mainland, and went into the trades right out of high school. In his early twenties, a large door fell on him in an industrial accident, practically crushing him and leaving him with a ruptured disc in his back. It was the beginning of a lifetime of pain management.

Opioid Database

(Rich Pedroncelli/Associated Press)

A motorcycle accident in his thirties only made things worse — with pain he describes as burn, similar to what you would feel if you stuck your hand into frigid water for a long time.

"It doesn't hurt at first, but then it burns. It's like a weight, it's friggin' torture. It just keeps coming and coming, it won't stop. The only thing that stops it is some sort of painkiller," he says.

A series of surgeries and experimental hormonal treatments did little to help — until Jack found a doctor who prescribed him morphine and that, he says, has allowed him to maintain a relatively normal life, and balance two jobs.

But Jack's morphine prescription might not be available much longer, as the opioid crisis currently ravaging the country continues to claim countless lives.

Officials are trying to stop the spread of opioids at their original source — in doctors offices.

As a result, the Canadian Medical Association has recommended that doctors taper dosages down for patients on long term opioid treatment. In B.C.. new standards limit a single prescription of opioids to three months.

Patients with chronic pain need to be reassessed 4 times a year, with doctors recommending lower dosages for less time, in the hopes of getting them off opioids completely -  and that has Jack worried.

"I'd said to him well it really doesn't make a lot of sense to me because if somebody's in bad pain, they come to you to get some sort of prescription, to take away the pain and then that door closes, well then they may, depending on who they are, they may go looking for it on the street," he says, adding that in his view that's where B.C.'s fentanyl crisis is rooted. 

"Wouldn't it be safer to give a safe prescription to someone who is not as in need of it than to have them trying to find some other avenue for it? It just doesn't make sense," he says. 

Pain: 'the oldest medical problem'

History would agree with Jack on the the confounding problem that is pain. Whether it creeps up suddenly, or has been chronic for decades - in whatever form pain appears it's difficult to quantify, and invisible to anyone not experiencing it.

Medical historian Marcia Meldrum said it "is the oldest medical problem and the universal physical affliction of mankind."

Our ability to control and suppress pain seems sophisticated, compared to the crude methods of the past.  

As recently as the 19th century, a shot of liquor might have been all you'd get before heading into a major surgery or amputation. And if you were living with chronic pain - there was no fix.

Friedrich Serturner

Friedrich Serturner

That changed when German pharmacist Friedrich Sertürner, who between 1803-1805, managed to isolate the active ingredient in opium poppies.

Sertürner aptly named his discovery morphine after Morpheus — the Greek god of dreams and sleep.

But according to Joanna Bourke, an English historian and author,  it was years before morphine was actually put to work realizing its full potential.

"You know people, doctors, scientists, knew about how they could alleviate pain, let's say in surgery, for decades, before it was ever used," she says.

And that reticence, in Bourke's view, is because of pain's relationship with morality and religion.

"We really can't underestimate the importance of religion in explaining that paradox - and that is that there was such a strong belief that pain was something sent by God, there was a reason for it, there was a message in it. That by us suffering pain in this world you wouldn't suffer it in the next world."

Burke, author of The Story of Pain: From Prayer to Painkillers, says one of the central premises in the relationship between pain and religion is that pain taught people to be moral, and it then followed that if pain was taken away or relieved by anaesthetics or analgesics, then society would let sin into the community.

She also adds that honour was won by living with pain.

"There's also very strong ideas about the moral value irrespective of spiritual value, the moral value of being stoic and suffering silently. And I think that actually is still with us today."

An opioid crisis...or a pain crisis?

Researchers at Tulane University are trying to find away to decouple the pain relieving qualities of opioids from their addictive properties. But keep in mind, science has been trying to do this since at least the 1920s. In fact heroin was originally created as an attempt at a less addictive form of morphine.

According to Brenda Lau, anaesthesiologist and pain specialist in Vancouver, so much onus of the conversation falls to the question of drugs, we forget that a pain crisis may be the real issue at hand.

Brenda Lau

Brenda Lau (Geoff Turner/CBC)

"In the midst of this opioid crisis a lot of emphasis both locally in B.C and nationally, even internationally, has been on addiction management.

"It's been interesting reading about the response to the opioid crisis because the first reaction is obviously around saving lives, but there hasn't been a lot of discussion yet on why people have gotten there in the first place."

She says "one of the main reasons people have access to opioids is because of undertreated pain and/or that the system only thinks about treating pain using opioids. So I feel like there hasn't really been an emphasis on addressing the root cause of the opioid crisis only at trying to fix those who are addicted or who have opioid related deaths."

"Probably one of the main reasons why a lot of physicians are actually going away from prescribing these because fewer and fewer people are prescribing. And those who are prescribing are linked to their patients indefinitely unless they are off their opioids. Because of that, often physicians don't even have a backup for them to write these prescriptions on a continuous basis. So there's a real danger when people don't get access to those prescriptions, then they go to walk-in clinics, they might go to emergency departments, then it becomes a labeling of them seeking, it just becomes a spiral of problems of being labeled as a drug addict, as a seeker."

According to a Canadian study in the Journal of Pain Research and Management, veterinarians receive better education about pain than physicians. 

Whose pain do we believe?

There are also discrepancies in terms of whose pain is believed - and that has varied considerably over history.

"In the 18th century infants were regarded as being exquisitely sensitive to pain and therefore were treated with utmost kindness and tenderness," says Joanna Bourke.

Research in the 1870s purported to show that infants don't feel pain at all — and that their screaming and crying were instinctive reactions rather than indicators of what they were sensing.

This meant that in some cases, infants would undergo dramatic surgery without anaesthetic.

Even today, Bourke says that access to pain medication is very unequal.

"There's very very good evidence today that minority groups are routinely given less analgesics, less pain relief. And there's good evidence that shows that women are sent to specialist pain clinics at relatively later stages in their suffering compared to men with exactly the same ailments."

"There's also very good evidence that the elderly are systematically under medicalized for pain - and I think that's a sad indication of some of the attitudes in our society today," says Bourke.

And to Brenda Lau, the conversation around opioids is missing a whole dimension: emotional pain.

 "Pain is not just physical, it is an emotional impact, it is a psychological and spiritual challenge. When someone is seeking pain therapy, they themselves sometimes aren't even aware that they're looking for help on multiple levels."

Meanwhile, here in Canada, 19 million prescriptions for opioids were dispensed last year. Which means that if doctors are serious about weaning people off the drugs, there are going to be a lot more stories like Jack's.