Obstacles to Pain Treatment Through the Use of Narcotic Analgesia apparently what my word processor (clarisworks) encodes as a "tab" your system or lynx or something takes as an excuse to majorly fuck up and send me to all sorts of help pages and idicates all sorts of comands like list and edit and search and anyway because of this i had to submit with new paragraphs indicated by a bunch of spaces on the same line as the previous paragraph
Pain, especially severe pain can be considered the single greatest detriment to a patientOs quality of life. Even minor pain experienced over an extended period of time can negatively affect oneOs cognitive, affective and biological functioning (Melzack, 1973). Chronic, severe pain can take away the suffererOs will to live. Appetite and sleep patterns often suffer, affecting the patientOs health. Functions of the immune system can be impaired, which slows recovery, and in severely ill patients can make the difference between life and death (Melzack, 1990).
There are many methods of pain control available to the medical profession today, the most effective of these are the narcotics. The term narcotic is often inappropriately used to refer to all currently illegal psychoactive drugs. For our purposes however, the term will refer only to opium, its derivatives, and related synthetic compounds; including but not limited to: morphine, heroin, codeine, paracodeine, percodan, percoset, demerol and dilaudid.
The medical, ritual, and recreational use of narcotics has a long history. Opium was cultivated and used in Sumeria around 4000 BCE. It has had a prominent place in the pharmacopia of most old world civilizations for at least two thousand years. For all of its history narcotics have been, for the most part, freely available to anyone who wished to acquire them. The extensive restriction and regulation of the production, transport and distribution of narcotics is a very recent trend. The first law restricting the availability of narcotics in the U.S. was enacted in 1887. It outlawed importation and possession of opium by chinese persons (Lusane 1991). Narcotics remained legal for white Americans until the enactment of the Harrison Narcotics Act of 1914 (Ibid.). Over the course of this century the degree of restriction, regulation and criminalization of narcotics (as well as most other psychoactive compounds) has reached a level widely regarded as excessive.
The analgesic (pain killing) effects of narcotics result from their chemical similarities to endorphines, natural substances in the nervous system which tend to decrease the frequency and strength of nerve firings from pain transmitting pathways. After an extended exposure to narcotics the body no longer responds normally to endorphines. Simply put, the narcotic user needs narcotics to maintain a stable nervous system. The result is addiction. Addiction is a frequently misused term. In popular culture, one often hears of chocolate addicts, sex addicts, reefer addicts, TV addicts etc. To use the term in such ways belittles the seriousness of the condition. Addiction is a biological phenomenon which occurs on a molecular level in the addictOs cells (Herz et al. 1992). The withdrawal of narcotics causes physiological and affective distress until the addictOs body is able to return to normal functioning. Other effects of narcotics are drowsiness and lethargy (hypnosis), constipation, loss of
loss of sexual drive, aversive response to alcohol, a decrease of anxiety, muscle tone and motor activity and euphoria (Ausubel 1958) Despite the unmatched efficacy of narcotics in treating most types of pain, they are grossly underused worldwide (Zenz, 1993, James 1993), due chiefly to three interrelated factors: regulatory practices, fear of, and ignorance about the risk of addiction, and a societal prejudice against euphoria producing agents other than alcohol. The production, transportation and distribution of narcotics is regulated to varying degrees in most of the developed and developing world through the policies of individual nations and internationally through the United NationsO International Narcotics Control Board. There is a wide range of restrictions from country to country; in Belgium, the Netherlands and the U.K. for example, narcotics are prescribed no differently from any other medication (Zenz, 1993). In Italy, by contrast, a number of forms must be signed by both doctor and
patient in the presence of a government official each time a morphine prescription is given. To further complicate the process each prescription is only valid for an eight day supply and new forms must be filled out each time the prescription is renewed (Garattini, 1993). The need for some degree of narcotics regulation is clear. Free access to narcotics in the past led to extremely high addiction rates. It is estimated that in 1900 there were 250,000 addicts in the U.S., nearly 1 out of every 400 citizens (Lusane,1991). In societies such as ours where narcotics are criminalized (and thus expensive) and treatment is scarce, such as ours, addiction has been correlated to a higher probability of engaging in criminal behavior, chiefly theft and robbery (Ibid.). Even in the absence of increased criminal behavior narcotics abuse is a drain on the addictOs quality of life and should be fought against. The question that must be asked is what is the effect of strict regulation practices on the incidence
of narcotic addiction? A convenient index of narcotics abuse is the annual number of deaths caused by narcotics in a country. In 1990, Belgium and the Netherlands, the European nations with the least restrictions of narcotics prescriptions had the least number of deaths due to narcotics. Greece, one of the most restrictive countries had no fewer deaths than the U.K. despite its strict regulations. Italy had four times the number of drug deaths as the U.K. despite its strict regulations. In France between 1986 and 1990, medical use of morphine increased 650% while drug deaths increased only 89%. Over the same period of time in Greece, medical use of morphine did not increase at all while drug deaths increased 136%. Between 1975 and 1980, SwedenOs use of morphine for medical purposes increased 1700% while illicit drug use remained stable (Ibid.). Medical morphine consumption in Japan increased 2500% between 1979 and 1991 with no corresponding increase in diversion of narcotics to illicit trafficker
s (Garattini, 1993). Across the board there is no correlation between the degree of regulation of and the number of deaths from narcotics, suggesting little or no correlation between medical use of narcotics and their illicit use.(Zenz, 1993). One effect that strict regulation tends to be correlated with is a lower number of prescriptions written nationally. Three of EuropeOs most restrictive countries; Greece, Italy and Spain, had the lowest average number of defined daily doses (DDD) of morphine per million inhabitants between 1986 and 1990; 39, 91 and 168 respectively (Zenz, 1993). That these rates are insufficient is clear given that in Italy alone there were an average of 2600 cancer deaths per million inhabitants annually (Garattini, 1993) and that 70% of terminal cancers are associated with severe pain (Melzack, 1990) which can be relieved by narcotics in 75-90% of patients (James, 1993). Moreover, in Germany where roughly 85% of doctors do not prescribe narcotics, 17.5% reported prescriptio
n regulations as the reason why they didnOt. Lighter restrictions however, do not necessarily correspond to a higher medical use of narcotics. From 1986 to 1990, Portugal, a very restrictive country, consumed nearly 50% more DDDOs of morphine per million than Belgium. The highest per capita rate of consumption in Europe is in Denmark which is given a restrictiveness rating of 1 on a scale of 0-4 (ie. Belgium to Italy) with 3048 DDDOs per million inhabitants. It is clear that strict regulation of narcotics is not very effective in controlling narcotic addiction and that it leads to their being underused for legitimate, medically necessary purposes. The practice also has several other negative effects on patients. First and foremost, it puts the patient in the degrading and dehumanizing position of needing to repeatedly ask for relief from pain (Hill, 1987), which should be regarded as a basic human right. It encourages the physician who is asked to write a prescription for narcotics to view the
the patient with immediate suspicion. To a doctor in such a position the patientOs desire for relief from pain may resemble a desire for relief from withdrawal, joy at the loss of pain may resemble euphoria (Ibid.). On the rare occasion that a patient does become addicted, some state laws require that they be registered with regulatory agencies as addicts (NIDA, Cooper et al, 1992). When narcotics are prescribed at all, regulations often dictate the amount and dosage that can be prescribed or give OguidelinesO, deviations from which can arouse government and peer suspicion and investigation. The sufficiency of morphine dosages can vary greatly between individuals. The dosage for analgesia of severe pain in one patient may be fatal to another or even the same patient when the pain is less severe. Patients with a prior history of either licit or illicit narcotic use often require a higher dosage for effective analgesia (Melzack, 1990). Decisions which are best left to individual physicians are bein
g made by politicians with little or no medical knowledge. A third effect of strict regulatory practices is that many private corporations, fearful of incurring the severe penalties even minor mistakes in handling narcotics can bring, charge high prices for their goods and services or simply refuse to deal in narcotics, allowing the businesses still doing so to raise their prices further do to market scarcity(INCB, 1989). The least controversial of the medical uses for narcotics is in treatment of cancer pain, partly because of the pain caused by both the disease and the treatment, and due to a OtheyOre going to die anywayO attitude, placing addiction below pain but above death on the spectrum of quality of life. Adequate pain-relief is afforded in 20-50% of cancer patients in the U.S. and Europe making it the best treated type of severe pain (Melzack 1990, James 1993). The acute pain suffered by postoperative patients and burn victims are the types of pain next most likely to be adequately
treated with narcotics. The dosages generally given are insufficient in 30% of postoperative patients, mostly older patients whose pain tends to be more severe and last longer. This is usually not taken into account and these are the people suffering the most in these situations. Thirty-three percent of burn victims report having extremely severe or severe pain (4 or 5 on a 0 - 5 point scale) when at rest. These figures rise to 53% during the excruciating but necessary debridement procedures where open burn wounds are scrubbed (Melzack, 1990). It is in the treatment of non-terminal chronic pain that the use of narcotics is most controversial and consequently, the least used. The medication cannot be withdrawn after a definite period of time as in the case of acute pain and the situation lacks the Osafety netO that the cancer patientOs impending death provides against addiction. It is the hesitancy of the medical community to use narcotics to treat this type of pain that best illustrates the prevail
ing social values which consider narcotics addiction a greater evil than individual suffering. What then are the effects of addiction to narcotics that they are considered so detrimental and what are the risks of a patient becoming addicted? Numerous clinical studies have shown that the risk of addiction from the medical use of narcotics is extremely small. A study of 11,882 patients treated with narcotics at Boston University Medical Center found that only four of them subsequently abused drugs. A study of 10,000 burn victims who had been treated with narcotics for weeks or months found that only 22 subsequently abused drugs, all of whom had a history of drug abuse. The vast majority of patients who become addicted to narcotics are those with a history of substance abuse or psychological problems(Melzack, 1990). This view of addiction as a psychological problem must be taken with caution however, as an American novelist and former addict of 15 years writes, OIn Persia...70% of the adult population
is addicted. So we should psychoanalyse several million Persians to find out what deep conflicts and anxieties have driven them to the use of opium?O (Burroughs, 1958). Unlike the most widely used addictive drug and the most widely used euphoric drug, nicotine and alcohol, narcotics have been found to have little or no chronic harmful effects on frequent users (Schur, 1965). Some studies have shown slight immunodeficiency and increased chromosome fragility among longtime addicts, which could suggest an increased risk of cancer (Falek et al, 1991), however, this data was obtained from a study of street addicts; any number of lifestyle factors not the least of which is the great number of toxins used to manufacture and OcutO street drugs could be confounding this data.
One of the examples of the negative effects of addiction most often given is the supposed cost to society due to crime and decreased worker productivity. Addicts are generally less physically active and they do tend to miss more work days than the general population, but then so do 18-25 year olds. The difference in annual income between the average addict and his or her estimated income were he or she not addicted is $3064 (Winick, 1977). It is not clear how this is a significant drain on society. The crime associated with addiction is in no way an inherent quality of narcotics. Two separate studies conducted in 1885 and 1889 before narcotics were criminalized in this country found that the vast majority of addicts were productive members of society. In fact, addicts with sufficient finances to maintain their habits are less likely to commit crimes in that they are less likely to do anything (Schur, 1965). As the aforementioned novelist noted, OThe addict is immune to boredom. He can look at his
shoe for hours or simply stay in bed. He needs no sexual outlet, no social contacts, no work, no diversion, no exercise, nothing but morphine.O (Burroughs, 1958). It is the criminalization of narcotics which allows street prices to become exorberantly high and forces addicts to come into contact with criminal elements; increasing the likelihood of their committing crimes. As studies of heroin maintenance programs in the Netherlands have demonstrated, making safe, pharmaceutical quality narcotics available to addicts at a fair market price can not only reduce crime but in conjunction with education and treatment, actually reduces instances of addiction (Lusane, 1991). Possibly the most insidious factor involved in the underuse of narcotics is our cultureOs irrational fear and disdain of euphoria produced by any drug other than alcohol. This attitude, like the criminalization of these drugs is a recent trend historically. Puritanical politicians and businessmen, many of whom were also proponents of
the failed experiment of prohibition, quite literally conspired in a campaign to demonize drugs and drug users and to terrify middle class Americans with tales of Oreefer mad MexicansO, and Onegro cocaine fiendsO; all of whom were invariably prone to raping white women (Ibid.). The effect of these, and subsequent campaigns, most of which were based entirely on falsehoods and exagerations are so widespread that we accept them as fact. What, though, is inherently wrong with euphoria which is, be definition, a pleasant experience. Arguments could be given that chemically induced euphoria impairs oneOs functioning outside of a euphoric state, the data is not conclusive and very little of it is gathered objectively, and why alcohol alone does not produce these effects significantly enough to outlaw it is not clear either. In any event, it is certainly absurd to say that feeling happy and content for a few hours is a greater drain on oneOs health and quality of life than severe pain.
The medical establishmentOs use of narcotic analgesia is clearly in need of change. Physicians must be educated as to the actual risks and effects of addiction. Pain must be recognized for what it is; the single greatest detriment to quality of life. Existing regulatory practices do not affect rates of abuse and serve only to hurt the suffering. Addiction is a terrible thing but it must be viewed objectively. The risk from medical use of narcotics is negligible. In the unlikely that a patient becomes addicted it is infinitely preferable to pain, and if recognized as a medical rather than criminal problem; treatable or at least safely maintainable with minimal negative effects on the individual and society.
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