Pills tumbling from bottle into open hand

Opioids: A Brief History

This is the story of how opioids became a problem in every community in America, including yours. And it is the story of how opioid addiction has overwhelmed and devastated some communities, maybe yours.

If you were practicing medicine in the 1990s, you already know some of this story. Maybe you remember when, in 1996, the American Pain Society coined the term, “Pain: The Fifth Vital Sign,” and urged doctors to ask all patients during every visit how much pain they were experiencing. Maybe you remember when OxyContin first came out—also in 1996—and maybe you listened to Purdue’s drug reps insisting that because it was a slow release drug, it didn’t have the peaks and troughs of immediate-release oxycodone and therefore wasn’t addictive. Maybe you remember hearing a speaker, sometime in that decade, saying it was okay to prescribe opioids liberally for chronic pain because in the presence of actual pain, the opioids don’t produce euphoria, and thus are unlikely to lead to addiction. I remember all these things.

Nobody wants to go back to the days before palliative care was developed 40 years ago. From the 1930s through the 1970s, opioids were rarely used medically in the U.S., even for cancer pain. That is because patent medicines containing them had exploded in popularity, addicting millions, from 1860 to 1914, at which point the Harrison Narcotic Tax Act was passed, limiting their use to medical prescriptions. But during the next decade, police starting arresting doctors for prescribing them to addicts, so doctors became leery of using them at all. Cancer patients enduring their last months of life bore the painful cost.

Humans have grown poppies, the source of opium, at least as early as 3000 BC when the people of Sumer grew it, naming it the “joy plant.” The ancient civilizations of Assyria, Egypt, Greece, Rome, India and Arabia all produced and traded opium. Its abilities to numb pain and induce sleep have been well known for millennia, as well as its potential to addict or poison the user.

Opium comes from slicing and draining the goo that comes from the poppy’s pod. But could opium be further refined to molecules that emphasizes its positive qualities and de-emphasizes its negative ones? That hunt began 200 years ago. In the early 1800s a German scientist isolated morphine, naming it after Morpheus, the Greek god of sleep and dreams. It induces sleep more readily than opium and is a more potent painkiller. In 1898, in an ill-fated attempt to find a non-addictive opioid, Bayer Laboratory developed heroin. Heroin pills were marketed by Bayer to cure coughs, diarrhea and menstrual cramps. Other molecules initially thought to be the solution to the problem of addiction include oxycodone (1917), hydrocodone (1920), methadone (1937) and tramadol (1977).

The quest for a non-addictive derivative of opium may be doomed from the start. The problem seems to be intrinsic to the way opioids work on the mu-opioid receptors found throughout our nervous systems. When we experience pleasure, or are in need of natural analgesia, our brain produces endorphins that plug into these receptors. But the connection is weak and fleeting. When the morphine molecule is introduced, however, it grabs that receptor in a vice grip, creating a far more intense euphoria. Does everyone exposed to this molecule become an addict? No, but a few people seem to be genetically predisposed to developing intense drug-seeking behaviors after even a single dose. And many others will be hooked if the opioid exposure continues.

What is the risk of misuse (continuing to use past the point of pain relief) or abuse (continuing to use despite harm)? After five days of continued opioid use, the risk of converting to a substance use disorder rises. And the risk keeps increasing, spiking higher after 30, and then plateauing at 90 days of use. After receiving an initial prescription for an opioid, if patients get a refill authorized, one in seven of them will be on opioids a year later. Of all Americans taking opioids, approximately one in four misuses, and one in 10 abuses.

U.S. opioid prescriptions doubled to 200 million from 1998 to 2012. Because there are so many opioids being prescribed, this adds up to a massive number of eventually-addicted people. In 2015, two million Americans were abusing prescription opioids, and 600,000 were abusing heroin.

Yes, heroin. When I was a teenager in the 1970s, heroin was only associated with inner city drug dens and street gangs. But heroin has moved to the suburbs.

There’s a direct link from prescription opioid use to heroin use. Four out of five heroin users began with a prescription. Heroin is becoming purer and cheaper, and deaths are spiking. There were 13,000 deaths in the U.S. due to heroin in 2015, a 20 percent jump from the year earlier. Heroin is smuggled in from Asia (white powder), Columbia, Pakistan and Afghanistan (brown powder), as well as Mexico (black tar). Reading Dreamland: The True Tale of America’s Opiate Epidemic was eye opening. It describes a new kind of drug cartel, one largely without guns and street crime. Small amounts of high quality, black tar heroin produced in the tiny Mexican state of Nayarit are carried by family members—usually young sugar-cane farmers—to suburban communities in a dozen U.S. states. There each pusher develops a clientele by passing out cards with his phone number, and then he responds to calls by driving a nondescript car to meet upper- or middle-class addicts in public parking lots. He carries a dozen tiny balloons in his cheek, each with a tenth of an ounce of heroin. If police stop him, he swallows the balloons. If he is deported, another young family member takes his place within the week. And so the supply continues unchecked, and families and communities are destroyed.

The problem of chronic non-cancer pain (from now on I’ll just call it “chronic pain”) is immense. All medical professionals see chronic pain patients, although the burden of addressing this problem is generally on the shoulders of primary care doctors. Pain specialists cannot possibly see all of the nearly 50 million Americans who suffer either daily or intermittently from chronic pain. So what can we do if we are not writing opioid prescriptions?

As I’ve written before, nine months ago, there are many good options for helping people with chronic pain. Briefly, they include: daily exercise, adequate sleep, psychological support, non-opiate medications and physical therapy. But all of these treatments take time—time to explain them to the patient, and lots of elapsed time before they take good effect. And if the patient has taken opioids in the past, you can double the amount of time it will take to explain why you think opioids are not currently a good idea.

The more you know about the dangers of opioids, the easier it is to choose to use other treatments for chronic pain. We want to help our patients. But it also helps to know that opioids are no more effective for chronic pain than the other treatments I listed. In a review of meta-analyses on the subject, published in the British Journal of Pharmacology, the authors conclude, “even though sponsors and authors have likely identified the optimal scenarios for improvement of the (randomized controlled trials’) participants during the last two decades, there is no evidence to support the sole or preferential use of opioids.”

As if addiction or misuse isn’t enough to worry about, it looks like opioids actually enhance the very pain they are supposed to relieve. This phenomenon is called “opioid induced hyperalgesia” and is distinct from the process of tolerance. Although its exact mechanism isn’t understood, and it may not happen in all users, it has been demonstrated in studies of methadone users, post-op patients and normal volunteers. By giving opioids, we may be making pain worse.

If at all possible, we want to relieve pain. But as followers of Jesus, we also know pain is often used by God to get people’s attention. That is, to point people to Himself. Caring for patients means just that—caring. We have compassion for our patients’ suffering, regardless of whether their own choices were the cause. And pain can be the pathway to maturity. As Timothy and Kathy Keller write, “there is seldom real growth without life’s difficulties, its blows and wounds. People who have led completely charmed lives are often superficial and unable to sympathize with others, and usually have an unrealistically high estimation of their own endurance, patience, and strength."

Christians aren’t the only ones who know this. I previously mentioned Dreamland: The True Tale of America’s Opiate Epidemic, which is a masterful piece of investigative reporting by Sam Quinones. I have no inkling whether Mr. Quinones is a man of faith, but in his book characterized by straightforward facts, he took a rare detour for wise reflections on the underlying reason addicts stay addicted:

“In heroin addicts, I had seen the debasement that comes from the loss of free will and enslavement to what amounts to an idea: permanent pleasure, numbness, and the avoidance of pain. But man’s decay has always begun as soon as he has it all, and is free of friction, pain, and the deprivation that temper his behavior.”

Stemming the flood of current opioid users will not be a simple process because it didn’t have a simple beginning. Clinicians, pharmaceutical companies, accrediting organizations, Mexican drug cartels and public expectations have all played a part. But those of us who care for patients need to be part of the solution, however tiny that contribution may be.

It’s time to take a hard look at our own prescribing habits of opioids for patients with chronic pain. At the very least, we must strive to “do no harm.”

Related Resources
Treating the New Chronic Pain Patient by Amy Givler, MD
Christian Doctor’s Digest - November 2017

Amy Givler, MD

About Amy Givler, MD

Amy Givler is a family physician in Monroe, Louisiana. She and her husband Don met in 1980 at a CMDA student event her first year of medical school, and they have both been active members of CMDA ever since. Amy graduated from Wellesley College and Georgetown University School of Medicine, and she then completed her family medicine residency at the same indigent-care hospital where she now works part time. She also works at an urgent-care clinic and is the medical director for a Shots for Tots clinic. Amy loves to write and has written many articles and one book, Hope in the Face of Cancer: A Survival Guide for the Journey You Did Not Choose. She and Don have a heart for missions, and hope to do more short-term trips now that their three children have launched from the nest.

6 Comments

  1. Victoria Macki, MD on August 30, 2018 at 9:43 pm

    By way of personal observation:
    I had been a primary care FP for almost 30 years when, shortly before Christmas in 2013 I fell asleep at the wheel and woke just in time to see that I was rapidly approaching the rear end of a braking semi. I swerved and slammed on the brake, but not in time to avoid the collision, which, because I was literally standing on the brake, shattered my right tibia and fibula and resulted in an open compound fracture. I am blessed to still have a foot attached to the end of my leg.
    On release from the hospital following the surgery that saved my foot, I was given a LARGE prescription of oxycodone. I think this was because the injury LOOKED so awful. In reality, because I trashed the joint capsule and severed most of the sensory nerves, I had relatively little pain. My non-medical sister who came to pick me up asked in slack-jawed amazement, “What are they trying to do–set you up with your own little retail business?”
    I did need the pain medication for a short time. Within 3 days, however, I was down to 2 pills a day, and shortly thereafter, 1 at bedtime. That’s where it got interesting. I didn’t think that for such a short duration, and relatively low dose, I would be affected. But, oddly, after a couple weeks I realized that I NEEDED that HS pill. Or I thought I did. About once a week, I would try to get to sleep without it, and failed. After about 6 weeks (and with still over a half bottle of them) I realized that I had a degree of physical dependency on them, and it horrified me. Is this addiction? I knew I couldn’t sleep without them. I was progressing nicely in rehab, but for that one, little thing.
    I did not mention it to any of my ortho providers, but I looked at the calendar and decided that the end of February would be my last pill. It was miserable. The first night, there was NO sleep. I thought that being sleep-deprived for 36 hours (by the time the next bed-time rolled around), would be enough to send me off to a good night’s sleep. After all, it always had during residency.
    No such luck. The second night was almost as bad. Maybe 2 hours sleep out of 8 attempted. The next day was a groggy haze, but I determined to not nap or slow down, because, surely, after 60 hours and only 2 hours of sleep, I would zonk that 3rd night. Nope. Possibly 3 hours out of 8, and very fragmented. Day 4 I was practically a zombie. I don’t think I could utter a coherent sentence. My body was just screaming for that little white pill. I prayed. Actually, I HAD been praying. I knew that EVENTUALLY I would have to sleep, and after 3 bad nights, on the 4th, I slept. The spell was broken. After that, I just get up to relieve my aging bladder.
    But it was a sobering experience. I don’t think that we doctors have any real idea of the unintended consequences of the treatments (especially medications) that we so blithely prescribe, all with the noblest of intentions. We want to alleve pain and suffering. But maybe we shouldn’t. I would have, in retrospect, gladly tolerated more ankle pain to not have to go through the misery of withdrawal.
    So, do I still prescribe opiates? Yes. But less. For shorter duration. And with a LOT more counseling as to what can be expected, both pro and con.

    • Kathleen Wildrick on August 31, 2018 at 2:39 pm

      Wow. Thanks for sharing your story.

    • Amy Givler on August 31, 2018 at 4:11 pm

      Thank you, Victoria, for that powerful story. Every person is different, but some people have an extremely difficult time getting off opioids, even after a relatively brief exposure. I am so glad to hear that you were able to get off them. This is a cautionary tale. You also had a remarkable degree of insight into what was happening, and how you needed to proceed. I have cared for many otherwise reasonable, intelligent, educated, logical (etc.) people who could not even countenance the thought that their brain might be seeking the drug for a non-physical need. Our brains are powerful and mysterious and cannot always be trusted.

  2. Rita Hancock MD on September 1, 2018 at 11:26 am

    Really nice article, Amy. You probably know that I’m a pain management sub-specialist, so this is right up my alley. If I may, I’d like to go into even greater detail about how depression, anxiety, stress, and a history of abuse, abandonment, neglect, etc., can MARKEDLY increase a person’s perceived pain rating and lead him or her to unknowingly reach for narcotics for the wrong reasons. Depression and anxiety, along with stress, can absolutely aggravate underlying pain problems and lead unsuspecting patients to believe that their pain is 100% physical, when, in actuality, their pain is due to a combination of physical plus emotional factors. I.e., a person with NO emotional stressors might perceive (for example) a cut on his foot as causing a 4/10 pain, whereas a different person with many emotional stressors might feel that exact same cut as a 9/10 because he doesn’t have extra coping skills to deal with the pain after dealing with his other issues. Put another way, there are two components of pain: the physical component and the emotional/cognitive interpretation that can amplify the experience of pain. PET scans actually visually depict this. Two separate neurological pathways light up on PET scans when patients are in pain. One pathway involves the neurotransmission of pain signals to the brain from the nociceptors (pain receptors) firing in the tissues. The other brain pathway that lights up relates to the emotional context of the pain (limbic system, etc). In other words, this is why lawyers talk about “pain and suffering” like they’re two different things. There’s a difference between “pain” (the physical experience of nociceptors firing due to tissue injury) and “suffering” (the emotional context through which that pain is experienced/translated/understood). How does the emotional component feed addiction? People don’t realize it when anxiety magnifies their pain and triggers them to reach for pain pills. All they feel is pain, and that pain feels real to them, but they don’t realize that their stress is making their pain feel worse than it is. The take-home message for patients is this: before reaching for the pain meds, ask yourself, “What’s going on in my life that could be stressing me out and causing me to focus on my pain?” “What purpose could this pain attack be serving? Am I trying to avoid thinking about something else?” If there is stress, find non-narcotic ways to cope, where possible.

    • Amy Givler on September 4, 2018 at 7:18 am

      Thank you, Rita, for this excellent enhancement of my column. Living with chronic pain is difficult and enhances psychological distress, even as psychological distress enhances pain. Both sides need to be addressed simultaneously. Unfortunately, opioids make both worse. The pain threshold is lowered, and the psychological distress isn’t dealt with.

  3. Jim Small MD PhD on September 7, 2018 at 11:26 am

    This raises an interesting question for ME; I have rotator cuff reattachment surgery coming up in a month. How best to manage the pain? But narcissism aside, how will we best help patients manage THEIR postop pain with lowest risk, but also trying to avoid the issues of pain?

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