Pain Management and the Normalization of Narcotics Theme Analysis

Pharmaceutical companies did not cause the painkiller addiction crisis in a vacuum, but took advantage of a well-intentioned desire amongst doctors for a “Holy Grail” of pain treatment: a pill that could end suffering simply and free of addictive side effects. American patients wanted painkillers because they were in pain, and their doctors wanted to prescribe painkillers because they felt it was their moral obligation to help those who had suffered for so long. Prior to what Sam Quinones deems a “revolution” on attitudes toward pain that unfolded over the 20th century, morphine was highly stigmatized; doctors who prescribed painkillers were regarded as “virtual outlaws.” Thus, when researchers published documents claiming that very few patients fell into addiction from being treated with narcotics, many well-intentioned doctors leapt at the opportunity to finally be able to help patients suffering with chronic or acute pain. In reality, however, pain is multifaceted and difficult to treat—no single pill can cure it. Ultimately, posits Quinones, America’s pain revolution failed because it rested on the false premise that pain can be treated with a single, uncomplicated solution.

America’s search for the “Holy Grail” began, in earnest, in 1928, when the Committee on Problems of Drug Dependence (CPDD) brought together researchers to find a nonaddictive painkiller to replace the addictive, stigmatized drugs (such as heroin and cocaine) that had previously been overprescribed and were now rejected by respectable doctors. The idea of a “Holy Grail” drug was so appealing because it was simple and effective: it provided patients with instantaneous relief, came without the negative side effect of addiction, and was efficient for doctors—nonaddictive pills didn’t require time and energy in the form of constant monitoring and countless follow-up appointments, for example. This search for a “Holy Grail” drug to treat pain informed future drug researchers and inspired “a cadre of revolutionaries seeking a better way to treat pain in America.” Thus, what Quinones refers to as a “revolution,” was born.

Attitudes toward pain changed significantly in the 1970s, and pain relief began to be seen as a “right.” Originally, the “right” to pain relief was limited to the chronically ill (such as cancer patients), but the notion painlessness as an unalienable right was extended to a broader range of patients. In 1980, Swedish cancer physician Jan Stjernsward was named chief of the cancer program for World Health Organization (WHO). Stjernsward had experience working with dying cancer patients in Kenya and had witnessed firsthand the relief that morphine granted these patients in their final days. Stjernsward met Vittorio Ventafridda, whose clinic treated cancer patients in Milan. Ventafridda showed him a set of principles he referred to as a “ladder of treatment” for pain patients. The ladder proposed that “increasingly powerful drugs, including opiates” should be used on dying patients “if pain did not subside.” Such a notion was previously unheard of. Stjernsward endorsed the “ladder of treatment,” and the WHO published a book that promoted this new, narcotic-heavy approach to pain management.

Another critical moment in the pain revolution was the advent of palliative care, which cancer doctors Dr. Russell Portenoy and his mentor Kathleen Foley “helped midwife.” Palliative care, or “treating the pain and stress of the seriously ill,” first developed in the 1970s out of the philosophies of hospice nurse Cecily Saunders who believed “that death should be dignified.” Saunders believed that dying patients were entitled to pain relief in their last days. Over the following decades, the philosophies of palliative care were applied to more medical disciplines, such as the treatment of chronic pain, and the notion that all patients were entitled to painlessness took hold across the medical community. Though well-intentioned, this new idea that patients were entitled to pain relief led to the extreme (and often dishonest) normalization of opiate painkillers. Like the WHO’s ladder of treatment, palliative care was founded on the well-intentioned idea that death should be dignified. Portenoy saw his philosophy as “guided by the moral issues of patient autonomy and respect of cultural and individual differences.” Portenoy believed in the power of pain relief: “I believe in drugs,” he stated. “I think pharmaceuticals are a great gift to humankind.” In 1986, Portenoy and Foley published a paper in Pain medical journal. The paper would “bec[o]me a declaration of independence for the vanguard of pain specialists interested in using opiates for chronic pain.” It posited that addiction and abuse of narcotics was rare.

One critical source of Kathy Foley and Russell Portenoy’s belief in the non-addictive nature of narcotics came from a letter to the editor published in the New England Journal of Medicine in 1980, known familiarly as “Porter and Jick.” Curious about whether patients treated with narcotics tended to become addicts, Dr. Herschel Jick, of Boston University, consulted what is known today as the Boston Collaborative Drug Surveillance Program, a database that keeps track of the effects of drugs on patients. Jick’s findings revealed that of nearly 12,000 patients treated with narcotics, only four would become addicts. These findings were problematic because the non-addicts were studied while they were in the hospital, and thus largely unable to develop abusive relationships to the drugs, as they were administered to them in a controlled environment. To his credit, Jick never intended for his study, titled “Addiction Rare in Patients Treated with Narcotics,” to become as widely read as it would go on to be. Still, the study informed many doctors and gave them a false confidence in the opiate drugs they were prescribing with greater frequency to their patients.

Pharmaceutical companies like Purdue seized on studies like Jick’s and took advantage of the well-intentioned zeal of pain researchers like Portenoy and Foley to assuage the fears of doctors who for so many years had been warned on the dangers of narcotics. Purdue funded pain researchers, who in turn began to see Purdue “as an innovator and ally.” Purdue inflated its findings to propose that the drugs they patented and pushed on medical professionals—OxyContin, most notably—were safe, effective treatments for pain. Former Purdue sales manager William Gergely revealed that Purdue salespeople were instructed to claim that OxyContin was “’virtually’ non-addicting,” when this was not at all the case. The 20th century’s shift in attitude toward pain management and the minimization of narcotics’ addictive potential allowed Purdue to capitalize on the medical community’s long-fought struggle to find the perfect solution for pain relief. Thus, America’s pain revolution came to be centered around the false premise of a cure-all, nonaddictive “Holy Grail” and narcotics became normalized among doctor and patients alike.