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7 Articles in Volume 5, Issue #1
Diagnosing and Managing Interstitial Cystitis
Intractable Pain Centers’ Treatment Approach
Musculo-Skeletal Diagnostic Ultrasound Imaging
Pain Management Pitfalls
Selection Criteria for Intrathecal Opioid Therapy: A Re-examination of the "Science"
‘High Dosage’ Opioid Management
‘Opiophobia’ Past and Present

‘Opiophobia’ Past and Present

The one drug class that has the optimum profile to manage severe, unremitting, intractable pain—opioids—is often shunned due to social stigma, lack of dosing guidelines, misunderstanding of side-effects (addiction, respiratory depression), and a pervasive fear of unwarranted regulatory persecution.
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The word “pain” is derived from the Greek word “poin” which means “penalty” and the Latin word “poena,” for “punishment.”1 Indeed, the ancient Greeks believed that pain was a punishment from the gods.2 Today, we know better than our ancestors yet — despite great strides in understanding the mechanisms of pain — some pain patients continue to suffer with inadequate pain relief. Due to the intense regulation of controlled substances, the government at both the federal and state level has caused an extreme chilling effect on physicians’ willingness to prescribe certain powerful medications that would help these patients. No doctor wants to lose his medical license — his livelihood — over writing a prescription that another doctor could just as easily write. As a result, patients who need these medicines suffer needlessly.

The most egregious and widespread aspect of this problem is the flat out refusal of many doctors to prescribe opiate painkillers, the most effective analgesics known for both chronic and acute pain.3 This fear of prescribing opiate painkillers is known as “opiophobia” in reformist circles.4 Either doctors refuse to prescribe opiates at all, or they prescribe far too little — never enough to properly alleviate the pain. This phenomenon of opiophobia is widespread in America, and it results in patients with moderate to severe intractable5 pain being unable to obtain the necessary medication to live a tolerable life.6

Take, for example, the case of A.M.7 He was hit by a drunk driver, went straight through his windshield, and was left with severe head and back injuries. These injuries resulted in relentless chronic pain. A.M. went to nearly twenty different doctors, none of whom were willing to give him adequate pain medication. Instead, as is typical, they gave him anti-depressants and anti-inflammatories. Nobody was willing to properly treat A. M.’s pain, and he became suicidal. Fortunately, A. M. found another doctor who was willing to prescribe the medications required for him to function without the debilitating pain and helped get his life back from being completely bed-ridden. That same doctor subsequently came under investigation for his use of opiates to treat his patients’ pain. Eventually, the doctor will have to make a choice, and A. M. will be the one who suffers.

While the government’s “War on Drugs” is perceived as necessary for our society to function, the regulation of prescription medicine to avoid addiction and diversion must be balanced with pain patients’ ability to obtain the medication they need. These competing interests are currently — and have been for a considerable time — unbalanced and inequitable to those unfortunate patients suffering from intractable pain.

Historical Perspective

Opiates8 are natural or synthetic derivatives of opium, the juice of the seed pods of the opium poppy, Papaver somniferum.9 The major alkaloids contained in opium are morphine, codeine, and thebaine.10 Morphine is the strongest of the three, and the most important pharmacologically.11 In 1803, the German pharmacist Friedrich Wilhelm Sertürner isolated morphine from opium.12 Morphine was commonly used in hospitals from that point on, as it is much stronger than raw opium and capable of being measured precisely.13 With the isolation of morphine, many new opiates were derived from it.14

Up until opium became America’s first illegal drug with the passage of the Harrison Act in 1914,15 it had enjoyed widespread use ever since it became popular on these shores in the mid to late 1800’s.16 The earliest known reference to opium in America was in 1781,17 and Benjamin Franklin was known to use opium regularly.18 Up to the mid nineteenth-century, opium and its derivatives were considered extremely valuable medicines and were liberally used as such.19 Despite those medicinal qualities, opium would eventually become associated with crime, immorality, inescapable addiction, and end up feared and prohibited,20 as is the case still to this day.

Around 1848, in the midst of the California gold rush, many thousands of Chinese immigrated to America in search of a better life.21 Much work was available on the West Coast, thus a vast majority of the Chinese immigrants ended up there working in the mines and on the railroads.22 The Chinese instantly became the poor laborers, and racism towards them began almost immediately due to their appearance, language, and habits.23 One such habit brought with them from China was smoking opium and, before long, opium became inextricably associated with the Chinese.24 Rumors of Chinese men snatching white women and dragging them to hidden opium dens, where they would become addicted and enslaved, were quite common.25 As smoking opium was not popular with whites at the time, anti-Chinese laws were passed to ban smoking opium.26 As opium use became more restricted, those whose longtime tradition of smoking opium suddenly became illegal were classified as criminals if they did not cease.27-28 Increasingly thereafter, the smoking of opium became associated with crime, and this gave credibility to those who had been arguing against opium on moral grounds.

In the 1870s, the English Protestant churches and America joined together to campaign for temperance and against opium.29 Through a relentless crusade, the anti-opium movement was able to get a series of laws passed, each making opium more and more restricted. With each step closer to total prohibition, opium use was driven further and further into the black market. In 1914, Congress passed the Harrison Act.30 While the purpose of the Act was to “prohibit recreational use of opiates yet allow doctors to prescribe them in ‘good faith’ as part of a legitimate medical practice,”31 the overall effect was the near prohibition of all medical use of opiates, since opiate-prescribing doctors were frequently charged with violating the Harrison Act.32

Over the years, opiates only became more stigmatized. The medical establishment had come to the conclusion that the risks of opiate use far outweighed their clinical benefits.33 Early on, opium, morphine, and heroin “were the tools of Bolsheviks and trade unionists.”34 Later, they became tools used by the communists to poison our children’s minds.35 While these stereotypes may not have been grounded in reality, they have had their effect; opiates are not the über-analgesic of times past, but rather the atomic bomb of pain relief — admittedly effective, but to be avoided at all costs. Those costs, unfortunately, are not in proportion to the actual dangers of opiate therapy.

Impediments to Opioid Use

The history of opiate regulation in America has resulted in these drugs being severely underutilized in today’s pain management armentarium. There are three main reasons why doctors in America are hesitant to prescribe opiates:

Last updated on: January 5, 2012