Sometimes linked misunderstandings possess awful power. Such has been the occasion of our growing public opioid mess. Opioid overdoses kill tens of thousands yearly, but will undoubtedly lead to far more fatalities. A misunderstanding of how opioids – the many synthetic and “natural” products of opium and morphine – work, has now been joined with a misunderstanding of what to do with those who use them. The end result is a place where heaven lies very far away.
The First Mess
Simple explanations are often wrong. But they often prove highly alluring.
Physicians are frequently taught that drugs are magical, a spell pharmaceutical companies work actively to enlarge. So in the 1980s, a series of linked teachings came out that pushed higher and higher doses of opioids as the treatment of chronic pain.
First came the belief that opioids were underused. Pain is, has been, and will be for many the worst, most awful experience of their lives. Studies of surgery in the seventies and eighties showed a miniscule number of people addicted to opioids following surgical operations. Connected to this finding was the woolly assumption that higher doses of opioids would “fix” chronic pain syndromes. This helped lead the rise of a new, highly lucrative specialty – pain medicine. Regulators eventually noted the major rise in addiction and illegal use of synthetic opioids. They failed to note how many millions were already hooked.
What did become embedded in people’s minds is that the treatment of pain occurred either through procedures or drugs. That pain syndromes create extraordinarily complicated interactions between people’s physical, mental, social and spiritual lives was thoroughly neglected for a simpler, more profitable narrative – there are opioids receptors. Hit them with the right drugs, through pills or injections, and pain goes away.
However, work done in 2016 showed how inaccurate that vision is. Research done by Linda Watkins’ group at UC Boulder demonstrated in rodents that opioids prolong and enhance pain responses. Everything just gets worse. And the cause they found was not in the neurons – the brain cells everybody looks to when explaining pain responses. It was in the glia.
There are a lot more glia than neurons in the nervous system. Relegated to “housekeeping” functions by theorists, glia are a large part of how the CNS works. In the Boulder experiments, it turns out that inflammatory cascades involving Interleukin 1B set in motion by glia responding to opioids markedly increase pain responses. Even worse, in these animal models, opioids negatively impact cognition and mood.
An animal in great and prolonged pain due to opioids is one thing – a depressed, mentally deteriorated animal is yet more terrifying. So the CDC felt uncommonly comfortable with declaring opioids a scourge on America, with new guidelines declaring that their use should be for only brief periods. This is now helping fuel another public health crisis.
The Next Mess
There’s a problem – at last count, eleven million Americans, perhaps a couple of million more, are physically dependent on opioids. People with chronic pain syndromes who have made peace with lives having taken opioids for decades are increasingly told "you must come off." Physicians who keep handing them out “freely” get disciplined and occasionally sent to jail.
The great national opioid withdrawal is in full swing.
People have responded as expected – actively and angrily. Pulled off their opioids, people go out to the streets to find cheaper replacements. Thousands are now dying from heroin overdoses, often laced with vastly more powerful fentanyl. Others are now rushing to medical marijuana clinics, where a bewildering variety of cannabinoids will be tried. Hit or miss will be the order of business there – there’s virtually not useable data to guide pain practitioners on what to do with cannabinoids. And the vast increase in CBT treatments researchers have recommended may never be happen as the health care system goes through its next gut-wrenching “reform” (read – decreased money and benefits, especially for people on disability.)
A misreading of how pain is actually processed by the body, aided by extraordinarily profitable pharmaceutical franchises (check the history of Purdue Pharma) led to a new “paradigm” of pain treatment – chronic opioid prescriptions. Now that system is getting unwound. Millions of people with often truly horrifying pain are being pulled off these medications with poor or often nonexistent alternative treatments on offer. Tens of thousands have died. While many feel happy to be off their opioids, and work actively on physical therapy and CBT, others are writhing in pain. Frequently they turn to heroin, and die using it.
Mistakes can compound mistakes. Until there’s a national conversation on what to do with pain treatment, who will pay for it and how to make it comprehensive along physical, mental and social lines, the results are inevitable: lots of people are going to hurt. For a long, long time.