What Would a Genuine Drug War Look Like?

An essay on biomedicine and the body politic.

Millions of addicts in America want effective treatment, and cannot get it. Funds for research and treatment are still scarce, compared to money for interdiction and law enforcement. What would happen if we took the billions spent on interdiction and let it flow into addiction research and treatment? What would happen if we gave people truthful, accurate information about drugs, and trusted them to make intelligent decisions more often than stupid ones? Can it end up any worse that the present state of affairs?

Susan Sontag’s warnings about the danger of disease as metaphor still ring true. In modern American society, heart disease, cancer, AIDS, alcoholism, and cigarette addiction account for millions of deaths. They are all disease entities with strong psychological and behavioral components—complicated, multicellular, multi-organ disorders. But they have all been associated, at one time or another, with negative personality traits and moral flaws. The less we know about the mechanics of a human disorder, the more likely we are to view its external symptoms as signs of laziness, or neuralgia of the spirit, or as a form of damage caused by specific kinds of thoughts and emotions. Without a doubt, all kinds of flaws are sometimes expressed in the behavior of people who have these disorders. Yet none of these flaws can be considered the root cause of the diseases.

The genuine drug war is being fought in the arena of biomedicine. Addiction is being added to the roster of physical disorders once thought to be symptoms of insanity, but which are now seen to be physiological disease entities with mental components. The real crisis is the indisputable fact that there exists today an appalling shortage of funds for biomedical research. The cause of the dilemma is a fundamental misunderstanding among politicians and the public about how diseases can be understood and conquered. Research into the viral mechanisms of the common cold may ultimately yield more insights into AIDS then all of the directed research now underway. In biomedicine, there is no guarantee that goals can be reached through the front door, by a systematic assault akin to an engineering project. We cannot, for example, hope to cure addiction, or even the common cold, by means of the same methods we used to put a man on the moon.

There are, however, certain things we can do immediately, if we are serious about drug abuse. To begin with, we can attend to the staggering number of drug-related deaths, injuries, and hospitalizations caused by the abuse of prescription medications. The government itself has proven the case for this contention in numerous reports issued by the National Institute on Drug Abuse and other official bodies. According to the U.S. Department of Health and Human Services, older Americans account for more than half of all deaths from drug reactions, leading one to suspect that the majority of drug fatalities in this country stem from accidentally fatal overdoses by heavily medicated senior citizens. Our national fixation on illegal drugs has blinded us to the verifiable facts about prescription drug abuse.

We also need to recognize the problem of underprescribing morphine and other addictive painkillers for children and adults in hospital settings. One of the great scandals to come out of the drug war is the growing understanding that potent painkillers are not being offered in sufficient amounts to patients suffering intractable and agonizing pain.

“There’s a certain amount of hysteria about narcotics among doctors,” maintains one researcher.

At least half of all cancer patients seen in routine practice report inadequate pain relief, according to the American College of Physicians. For cancer patients in pain, adequate relief is quite literally a flip of the coin.

A September 10 New York Times report highlights studies by the World Health Organization which amply document the ongoing scandal in pain management. At least 6 million cancer and AIDS patients currently receive no appropriate pain treatment of any kind. In addition, WHO estimates that four out of five patients dying of cancer are also suffering severe pain. The numbers of untreated patients suffering intractable, unrelieved pain from nerve damage, burns, gunshots, sickle cell anemia, and a host of other medical conditions can only be guessed at. Typically, non-addicted patients take morphine therapeutically for pain at doses in the 5 to 10 mg. range. But experienced morphine addicts regularly take several hundred milligrams a day—a huge difference. In many cases, pain relief is the one thing doctors can offer their patients, and the one thing they withhold

These outcomes, rather than flashy cocaine seizures at the border, represent the lasting fruits of the drug war.

Photo Credit: www.foreignpolicyjournal.com

The Morphine Scandal

Patients in Pain Due to "Opium Phobia"

“Opium has been recently made from white poppies, cultivated for the purpose, in Vermont, New Hampshire, and Connecticut.... comparatively large quantities are regularly sent East from California and Arizona, where its cultivation is becoming an important branch of industry, ten acres of poppies being said to yield, in Arizona, twelve hundred pounds of opium.”

--Massachusetts Government Health Report, 1871

By the mid-1800s, as many people know, opium could be legally purchased in the United States as laudanum, patent medicines, and various elixirs. Less well known is the fact that opium was a godsend during the bloody years of the Civil War. Maimed and disabled soldiers found relief in morphine, the potent alkaloid of opium named after Morpheus, the Greek god of dreams. Used against constant, intractable pain, opium and its derivatives were among the most humane medical drugs ever discovered. How could a physician withhold them?

Today, after countless drug wars have merged into a single, inflexible federal stance on “drugs,” morphine and its derivatives remain so stigmatized, so entangled in drug wars and global narco-politics, that the danger of losing sight of their humanitarian applications looms larger than ever.

At least half of all cancer patients seen in routine practice report inadequate pain relief, according to the American College of Physicians. For cancer patients in pain, adequate relief is quite literally a flip of the coin.

A September 10 New York Times report by Donald G. McNeil Jr. highlights studies by the World Health Organization which amply document the ongoing scandal in pain management. At least 6 million cancer and AIDS patients currently receive no appropriate pain treatment of any kind. In addition, WHO estimates that four out of five patients dying of cancer are also suffering severe pain. The numbers of untreated patients suffering intractable, unrelieved pain from nerve damage, burns, gunshots, sickle cell anemia, and a host of other medical conditions can only be guessed at.

Figures gathered by a different U.N. agency, the International Narcotics Control Board, make clear that “citizens of rich nations suffer less.” To put it starkly, the use of morphine per person in the United States is 17,000 times higher than per person usage in Sierra Leone. Doctors in Africa paint a grim picture of patients hanging themselves or throwing themselves in front of trucks as an alternative to life without pain relief. The U.S., Canada, Britain, France, Germany, and Australia together account for roughly 80 per cent of the world’s medicinal morphine use. Other countries, particularly the poor and undeveloped nations, scramble for what’s left.

The ironies fly thick and fast: In many cases, pain relief is the one thing doctors can offer their patients, and the one thing they withhold. Studies show that 70 per cent of patients present with painful conditions. Typically, non-addicted patients take morphine therapeutically for pain at doses in the 5 to 10 mg. range. But experienced morphine addicts regularly take several hundred milligrams a day—a huge difference.

As for concerns about addiction, recent evidence for the heritability of opiate addiction looks strong. “Harvard did some really superb studies using a huge cohort of military recruits in the U.S. Army,” according to Mary Jeanne Kreek, a specialist in opiate addiction at Rockefeller University in New York. “Heroin addiction has even a larger heritable component than any of the other addictions, so that up to 54% of heroin addictions seem to be on a genetic basis or a heritable basis.”

Opium, the main ingredient, is in abundant supply worldwide, and is relatively cheap to grow. The problem, as David E. Joranson of the University of Wisconsin’s Pain and Policy Studies Group told the Times, is the “intense fear of addiction, which is often misunderstood. Pain relief hasn’t been given as much attention as the war on drugs has.”

Moreover, generations of doctors have been taught in medical school that morphine must be used sparingly, with great caution, even if this “opium phobia” results in agony for patients, including infants. (Morphine is safe and effective for use in premature babies.)

The problem is not a new one. Ten years ago, a report by the American Academy of Pain Medicine laid the blame squarely on doctors, who were routinely underutilizing opiate derivatives for pain relief. Not much has changed. It is no secret that the move to HMOs has compounded the problem, as effective pain relief often gives way to the need to move patients out of beds as quickly as possible.

In 2001, the American College of Physicians called for more extensive pain-management education in the nation’s medical schools, noting that doctors are not learning enough about how to treat pain, or about how to talk to patients ABOUT pain, despite what Scott Fishman of the Division of Pain Medicine at the University of California, Davis, calls a “revolution” in the development of new pain medications.

We also need to recognize the problem of under prescribing morphine and other
addictive painkillers for children in hospital settings. If we continue to stringently prohibit the use and sale of opiates, then we had better remember to make one important exception: Pain abatement in medical applications “There’s a certain amount of hysteria about narcotics among doctors,” maintains one researcher. Patients suffering from serious pain cannot get adequate and sustained relief in many cases, because doctors and nurses remain reluctant to provide it.

This, rather than flashy cocaine seizures at the border, represents the lasting outcome of drug wars.

Email this •