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10 Articles in Volume 7, Issue #6
Clinical Bioethics: Pain and Psychopathology in Military Wounded
Diabetic Neuropathy Study
Electromedicine: Use of TENS In Pain Management
Howard Hughes and Pseudoaddiction
Imaging: Osteoporosis Testing: DEXA Method
Interventional Therapy: Occipital Nerve Stimulation for Treatment of Migraine
Laser Therapy: Infrared Photo Energy May Reduce Neuropathic Pain
Pharmacotherapy: Pharmacologic Management of Opioid-Induced Adverse Effects
Prolotherapy: Prolotherapy For Knee Pain
Viewpoint: The OxyContin

Howard Hughes and Pseudoaddiction

Howard HughesWith the emergence of opioid treatment of intractable pain (defined here as incurable, severe, and constant), there is great interest in the long-term survival of patients who require such treatment. At this time, there are no published reports of opioid-treated, intractable pain patients who have survived over a decade.

Because of a combination of fame and wealth, the revisiting of the Hughes case was made possible due to the volume of detailed public records available. Underneath the glamour, glitz, sex, money and politics that surround the saga of Howard Hughes, there is a serious and tutorial medical story from which all concerned parties can benefit. Hughes lived 30 years while taking high dosages of codeine in an average daily dosage between 20 and 45 grains a day. He survived a plane crash in 1946, developed intractable pain, and died 30 years later in 1976 due to specific anti-inflammatory agents that, over time, produced kidney failure.1-3

This author was contacted in 1978 by the U.S. Drug Enforcement Agency to be a consultant on Hughes. I was given copies of Hughes’ autopsy report, post-mortem toxicology analysis, birth certificate, death certificate, a 1958 memo written by Hughes involving medication acquisition, and a daily log of medication administration kept by his aides and dated October 31, 1971 through July 1, 1973. These materials were presented in a public trial and are not confidential documents.3 This log, covering his habits and behavior in detail, was in the 25th and 26th year after his plane crash and continuous consumption of opioids. It is very revealing as to how he treated his pain and continued to function.

In September 1978, this author compiled a written report for the U.S. Government based on the aforementioned documents. In addition, this author appeared as an expert witness in the Ogden, Utah, Federal trial, U.S. vs. Thain (Hughes’ physician in the last years of his life)3 and was able to interview two of Hughes’ now-deceased, personal physicians about Hughes’ medical history and treatment.

It is cogent to point out that in 1978, this author was fully vested in addiction research and treatment and had only begun to research and treat intractable pain patients with opioids. Consequently, the resulting 1978 analysis of this matter, including terminology and biologic concepts, were archaic given the monumental, historic, and scientific breakthroughs in the understanding of addiction and pain that have occurred since 1977.

Due to the great interest in the long-term survival of pain patients treated with opioids, a re-analysis and report of Hughes at this time is most informative and instructive for physicians and patients. This re-analysis incorporates many of the current terms, concepts, and scientific advances that have emerged in the past 30 years. To provide perspective on how pain management has matured since that time, some relevant terms are shown in Table 1.

Table 1. Some Pain Treatment Changes in Terminology and Concepts During the Past 30 Years

 

1977

2007

Addict

An addict was anyone who took a prescription drug in dosage above the usual frequency or for an extended duration

An individual who compulsively uses a substance for non-pain purposes

Psuedoaddiction

Term not used

Syndrome in which an individual who seeks drugs for pain relief since their pain is out of control

Intractable

Term not used

Incurable, severe, constant pain

Breakthrough Pain

Term not used

A flare of pain above the usual baseline pain level

Short and Long-acting Opioids

Term not used

Usual treatment for severe intractable or persistent pain is a long-acting opioid plus a short-acting one for breakthrough pain

Pain Characterization

Essentially none

Common classes include neuropathic, myofacial, and reflex sympathetic dystrophy

Effect of Renal Failure on Drug Serum Levels

Little understanding

Poor renal clearance may greatly raise serum levels of therapeutic drugs

Morphine Equivalency

Unheard of

Pain potency of all opioids are equated to the effect of 1 mg of morphine

Precipitating Cause of Pain and Initiation of Opioid Treatment
Born in 1905, Hughes was a world-recognized, pioneering entrepreneur engaged in diverse businesses that included chemicals, plastics, moving pictures, entertainment, and aircraft design and development. In 1946, at the age of 41, Hughes solo-tested an experimental reconnaissance plane known as the XF-11. Shortly after take-off from the Santa Monica, California, airport, he crashed. He miraculously survived the crash and was immediately hospitalized at Good Samaritan Hospital in downtown Los Angeles. His injuries were numerous and included multiple fractures and third-degree burns (see Table 2). He required three chest drainings, since he recurrently bled into his left chest cavity. Four skin grafts were required to close a large third-degree burn extending from his shoulder to hip. He remained at Good Samaritan Hospital for about 5 weeks between July 7 and August 11, 1946. Hughes was given morphine while hospitalized and was discharged on codeine. A detailed list of Hughes’ injuries are listed in Table 2 to emphasize that essentially no one can survive these injuries without developing intractable pain.

Table 2 . Injuries Sustained by Hughes in 1946 Plane Crash that Likely Produced Intractable Pain

  • Third-degree burn of abdomen and chest wall
  • Fractures of chin, jaw, left knee, and left elbow
  • Multiple burns of left ear, left chest, left abdominal wall, little finger left hand, left buttocks
  • Third-degree burns in some areas; one large burn extended from his left shoulder to left hip
  • Displacement of 6th cervical vertebrae onto the body of the 7th
  • Fracture through lateral articular facets of 5, 6, 7th cervical vertebrae
  • Fractures of ribs 1, 2, 3, and 4 on right. Fractures of 1, 2, 3, 4, 5, 6, 7, 8, and 9 on left
  • Fracture of left clavicle
  • Hemorrhage into left chest cavity with displacement of heart into right chest’
  • Hemorrhage into mediastinum
  • Blood loss requiring transfusions

Modern day pain treatment specifically and clearly recognizes that neck and facial fractures are associated with intractable pain. Third-degree burn scars are known to cause pain in peripheral nerves. Pain that radiates from a central nerve injury into the face, arms, legs, or chest wall is now referred to as neuropathic pain. This term was not used during the life of Hughes. Details of his injuries are given here to eliminate any misconceptions and refute some public reports that he didn’t have pain that required ongoing medication.

Characterization of Hughes’ Pain
Today’s pain terminology, as confusing and deficient as it may be, helps provide a framework to understand Hughes and all other pain patients. Acute pain is one of sudden onset and that resolves within days or weeks. A headache is a good example. Chronic pain is an intermittent or constant pain that persists beyond about 90 days. Millions of people suffer from mild or moderate chronic pain due to such causes as arthritis, lumbar sprain, bunions, or carpal tunnel.

The severe form of chronic pain is more and more being referred to as “intractable pain.” This form of chronic pain is reserved for those severe chronic pain patients whose pain is severe, incapacitating, constant, incurable, and interferes with biologic functions including sleep, eating, ambulation, and social interaction. Undertreatment results in reclusivity and a home or bed-bound state. Intractable pain patients have a persistent or baseline pain with flares or breakthrough episodes above their baseline pain. Injuries such as those sustained by Hughes in his 1946 plane crash inevitably produce chronic pain and likely cause intractable pain. Scientific studies now show it is usually possible to separate intractable pain from ordinary chronic pain in that intractable cases present demonstrable biologic changes in heart rate, blood pressure, and adrenal hormone production. Analysis of Hughes’ medical and pain history clearly shows that today he would be characterized as an intractable pain patient.

Hughes’ pain, according to his physicians, was constant and centered around his neck, shoulders, back, and into his arms. In the 1946 plane crash, he suffered fractures of some cervical neck facets. Collapsed vertebrae were noted on x-rays taken at autopsy. His physician in the last years of his life, Dr. Wilbur Thain, described his skin as “extremely sensitive to touch” and any cutting of his finger or toe nails “hurt like hell.”

As Hughes aged, he developed degenerative arthritis in several joints that aggravated his pain. After his fractured left hip was pinned in 1973, he did not walk again and developed a contracture of the left leg. His hip fracture and contracted leg may also have contributed to his pain. Dr. Thain offered Hughes a walker, wheelchair, and even a cute physical therapist to help him walk again. Hughes replied humorously to the latter, “No Wilbur, I’m too old for that.” Thain considered, and rightly so, that Hughes’ resistance to walking after his hip fracture was “the beginning of the end.” Modern day pain specialists ask and demand physical activity and movement from intractable pain patients if they are to escape a bed or couch-bound state. In this regard, Dr. Thain appeared to be a physician well ahead of his time.

Hughes suffered several neuropathies and had allodynia, which presents as severe pain to the touch. He would possibly today be given the diagnosis of Reflex Sympathetic Dystrophy or Chronic Regional Pain Syndrome. At times, his pain was reported to be so severe that a simple touch or the touching of bed clothes produced pain. His renowned refusal to brush his teeth, cut his toe and finger nails, or wear shoes may have been related to the fact that these actions may have caused increased pain.5,6 His multiple facial fractures probably produced a neuropathy of his jaws and face. At this time, it is not possible to correlate his pain and its treatment to any impact on his renowned, lifelong eccentricity and obsessive-compulsive traits or to his failure to brush teeth, cut nails, or exercise.5,6

Last updated on: April 13, 2017
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