With this first in a series of posts by Siobhan Reynolds, formerly of the Pain Relief Network, Points inaugurates a guest blogging feature, showcasing voices from inside and outside of the academic and policy worlds. Reynolds founded the Pain Relief Network (PRN) in 2003 in response to her husband’s experience with chronic pain and the stigma attached to its treatment. PRN challenged government restrictions on opioid pain treatment by advocating for and representing doctors in disciplinary proceedings and criminal prosecutions. The organization was forced to close its doors in 2010, after the Supreme Court refused Reynolds’ petition for certiorari in a case that Adam Liptak explains much more succinctly than we could. Reynolds lives in New Mexico with her son Ronan and her partner, attorney Kevin P. Byers, whose legal practice carries forward PRN’s mission.
The people of the United States seem to have mostly recovered from the federal government’s propaganda campaign that accompanied the criminalization of marijuana in the 1930’s. Reefer Madness is now viewed as a hoary, ridiculous example of just how far the feds will go to demonize the benign and medically useful cannabis plant. But as concerns opioids, the vast majority of Americans, including educated people–university professors, members of the press, physicians and anti drug war activists of all stripes–still find themselves emotionally manipulated by the propaganda that was utilized to destroy the poppy’s reputation in order to justify its criminalization. The campaign continues, now cloaked in the guise of a public health and safety message that is premised on “facts” no more factual than those presented to the public by way of Reefer Madness. The only difference between the Reefer Madness campaign and the one currently smearing opioids is one of perception. Americans mostly believe the anti-scientific rhetoric that is said to support opium prohibition. And this is where the trouble lies. In this series of articles, I lay out 6 major misconceptions about opioids. In essence, whatever you believe you know about opioids–how dangerous they are, how addictive they are, and how much they destroy our society–is probably factually incorrect
“Fact” #1: Opioids are Dangerous
Opioids are thought to be toxic substances. This is not surprising; even the bottles that contain them usually carry a little sticker picturing a bomb preparing to explode. Never mind all the dark movies associating heroin with violence, and the very real connection between the international drug trade and violence. Indeed, the DEA advises people not to flush their pills down the toilet lest they pollute the ground water. The general impression, medically speaking, is that opioids cause liver and kidney damage and destroy the heart.
The Truth: Opioids are Not Dangerous.
Opioids are derived from the poppy plant. They mimic our body’s endorphins chemically. People should fear opioids no more than they fear their own blood or urine (but don’t tell the government that). Opioids are non-toxic to major organ systems and are cardio-protective. They are a wonderful anti-anxiety medication and work to prevent the development of PTSD in traumatized people far more safely even than the also much maligned benzodiazepine. Opioids cannot explode or pollute ground water. They are safe and natural medicines when used as directed. And the biggest news is, they are remarkably safe even when abused. As researchers at London’s National Addiction Centre have argued, opioid tolerance is protective against overdose.
“Fact” #2: Opioids are Addictive
Opioids are thought to be highly addictive. It is widely believed that people who are given opioids for medical procedures routinely get addicted to them, essentially having been prescribed a life of depravity and crime. People in pain are so afraid of getting addicted to opioids that they often refuse them, even following surgery or nearing death. Physicians usually go along with this charade because they don’t want to write prescriptions for opioids at all (the reasons for this will be explained in a later post). Wolfe et al identify a culture of non-treatment of pain that extends even to the pain that dying children experience at the end of their lives. Opioids are generally thought to be “bad drugs” as opposed to “good drugs” like cannabis or ibuprofen. We are conditioned to stay away from them and to use them sparingly when we are prescribed them.
The Truth: Opiates are Not Necessarily Addictive
Because opioids are chemically identical to endorphins in the body that deal with pain naturally and regulate all kinds of bodily processes, including circadian rhythm and the endocrine system, people can and do become physically dependent on opioids if they take them regularly. The length of time over which people become dependant varies. Some become dependent in 10 days or less; others have reported no withdrawal symptoms after several months and even years of regular opioid use.
The important thing to remember is that physical dependence and addiction are not the same thing. You wouldn’t say you were addicted to your insulin or your high blood pressure medication, but you also wouldn’t want to discontinue taking those drugs without consulting a physician and carefully titrating your dose. The same is true of discontinuing opioid pain medications, as the withdrawal symptoms can be dangerous depending on the state of your underlying health. Physicians skilled in helping people come off of opioids (I won’t use the term detox because opioids are not toxic in the first place) can mitigate the symptoms of withdrawal. With anti-anxiety and anti-diarrhea drugs, some strong blood pressure meds, and a little TLC, most people can come off opioids in three to four days. Most will lose a lot of sleep, and the experience will be extremely unpleasant. But withdrawal is relatively short-lived and does not result in cravings. Quite the contrary, the experience is so unpleasant that patients usually are very leery of ever becoming physically dependent again. That reality is sharply different than the Man With The Golden Arm narrative we are familiar with, in which those who have been dependent on opioids constantly crave the drug and could relapse at any point. Such a state would require the person to have been addicted to the medications, a phenomenon entirely distinct from physical dependence.
Addiction is present when a person uses a medication or substance in a compulsive manner despite the fact that such use is interfering with his or her ability to function positively. Many people who have been thought to be addicted to opioids do very well once given a maintenance dose. Shamefully, those people are typically given methadone, the dirtiest and most dangerous of the opioids (it is actually cardio-toxic to some genetically vulnerable people) and the most difficult opioid from which to withdraw. Moreover, the incidence of sudden cardiac death in both addicts and pain patients taking methadone has been noted in the medical literature for decades. Still, methadone is prescribed for both sets of patients because it is inexpensive and exposes the treating physician to less risk of sanction either by regulatory authorities or the criminal justice system; the doctor always has the “out” of saying he knew he was treating addiction– that is, if he is duly licensed with his special addiction certificate.
In and of itself, addiction need not be an insurmountable problem. If left to doctors and patients and treated as a personal problem, the condition is easily treatable. Now, because law enforcement plays such a dominant role in what is both a public and private health issue and because an entire treatment industry profits mightily from the system as its currently structured, addiction carries with it all kinds of stigma that, looked at objectively, is wholly man-made. The real dangers of addiction, of overdose and of withdrawal without medical management are all the result of the criminalization of opioids– and the silence that attends taboo subjects–and not of any property inherent in the drug itself. [Siobhan Reynolds’ next post will discuss opiates in the drug war, and the pain management movement.– ed.]
1. “[D]ose is tailored to each patient, doses are repeated at regular intervals so that the pain is prevented from returning, and there is no arbitrary upper limit….The dose of morphine may range from 2.5 mg 4-hourly to 2500 mg 4-hourly…and there are anecdotal reports of much higher doses. This dose range of a thousand-fold or more to achieve the same end-point is remarkable and is not seen in any other area of therapeutics. Dose is titrated against effect, either until control of pain is achieved or limiting side-effects develop.” Oxford Textbook of Palliative Medicine(Doyle, et al. eds 1993), § 4.2.3 (Opioid Analagesic Therapy), at 169.