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June 2 - June 7, 2021
Pain actually happens in the brain, and the brain—being quite good at what it does—largely uses the pain experience to alert us to damage in particular parts of our bodies.
“Pain is always subjective . . . Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. There is usually no way to distinguish their experience from that due to tissue damage if we take the subjective report. If they regard their experience as pain, and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain.”
Although my experience of the things in the world is subjective, those things are intersubjectively available, which is just a fancy way of saying that other people can confirm my experience. Our very ability to act and cooperate depends on the fact that others can confirm one’s experience of the world.
What is essential to pain is not that it is caused by tissue damage, but that it is an unpleasant experience. And so if I’m having that experience, even in the absence of any verifiable tissue damage, I’m in pain. Neither you nor my doctor can check that I’m reporting my pain “correctly,” because that’s just not the kind of thing pain is.
Humans go through life desperately trying to avoid pain, or to recover from pain, and the institution most directly responsible for addressing our pain is that of medicine. Doctors have as an explicit goal to relieve suffering, and our physical pains cause much of the suffering that drives the practice of medicine. So we go to doctors and ask them to relieve our pain, making our pain an object of medical concern.
The very basic tension that lies behind so many of the ethical challenges facing pain medicine today is the fact that physicians are scientifically trained to find a biological cause of ill health and to use objective tools for evaluating medical problems. But since pain is essentially subjective, it will at least sometimes elude biological explanation, and no advancement in technology will solve this problem for us.
Pain, in other words, is a symptom, like nausea or dizziness; it is not an objective measure, like temperature. And that is the basic problem of pain medicine.
Sure, I can make my own judgments more and less consistent, but no amount of reflecting on the pain scale will tell the physician how bad my pain is objectively.
Finally, we can add one more element of pain that makes judgment and comparison hard, which is that we can become accustomed to pain.
So the experience of severe pain can help us to contextualize other pains in our lives, but the experience of living with pain can also change how we experience it.
We cannot turn an essentially private, subjective experience into an objective phenomenon. Pain medicine is thus tasked with a profoundly difficult job.
Sometimes patients who can be genuinely helped by them are also patients who want them. And sometimes patients who want them lie about “needing” them. The whole lesson of the subjectivity of pain is that a physician can never know for sure which kind of patient is standing in front of her.
What makes something an opioid is its molecular relationship either to the opium poppy plant or to the human body’s “opioid system.”
The most straightforward way to do this was simply to isolate the active components—what are called “alkaloids”—which include morphine, codeine, and thebaine. These alkaloids can then be further processed, however (for example, following a fairly simple recipe can turn extracted morphine into heroin). All of these drugs are “opiates,” which just means that they are derived (in some way) from the opium poppy. What makes opiates so powerful, however, is not the plant that they come from but, rather, the role they play in the brain.
Opiates owe both their pain-relieving and their euphoric effects to their chemical function in the human body: both morphine and heroin fit into certain chemical receptors which, when activated, send signals to the brain that block pain sensation and induce a general sense of calm.
These synthetic compounds were then called “opioids” to distinguish them from the natural “opiate” compounds and included many of the common pain medications of today, such as oxycodone, hydrocodone, fentanyl, and methadone.
What holds this category together, then, is not the source but the molecular structure of the compound and the resulting effect it has on the human brain.
Endorphins, which are part of the body’s natural opioid system, are released in response to pain. Part of one’s natural ability to function after a major injury, in fact, is due to the body’s powerful endorphin response.
Importantly for our purposes, it both blocks bad signals (pain) and produces good ones (euphoria). And that makes drugs that act on this system particularly desirable, as both pain relief and euphoria are valuable states worth pursuing.
The complexity of opioids is not exhausted by these first two prongs though—the opioid system does more than just block pain and induce pleasure. Importantly, and tragically, it also sedates various bodily systems.
system. As more and more of the drug enters a user’s body, she takes fewer and fewer breaths, reducing the amount of oxygen that gets to the brain. And eventually, if the dose is high enough, she simply doesn’t breathe again. The respiratory system shuts down, oxygen stops flowing to the brain, and the brain dies.
In short, what doctors learn is that some patients have an incentive to lie about their pain, and there’s no way to ensure that they’re telling the truth. But the same drugs that relieve pain and induce pleasure can kill you, and if the doctor were to hand out prescriptions without care, she would almost certainly be responsible for some number of deaths.
The analgesic, or pain-relieving, effects of opioids were unparalleled, and so abandoning them altogether didn’t seem like an option.
By eliminating medical use of opioids, and driving its use underground, society turned addiction and opioid use into something to be spurned and reviled. Addiction became a criminal problem rather than a medical one, its victims worthy of scorn rather than sympathy.
In short, opioids continued to be our most powerful pain medication, and the advancement of medicine meant an ever-increasing population of patients with genuine, severe pain.
Worries about addiction seemed perversely puritanical in the context of a terminal disease; what, after all, is the benefit of avoiding addiction risk when one is dying?
The eventual yielding to the pain movement’s demands in the context of cancer led to a kind of tripartite division of pain: there was cancer and end-of-life pain; chronic, noncancer pain; and acute pain (from injury, trauma, surgery, etc.).
Purdue had patented MS Contin, which was an extended-release formulation of morphine (“Contin” here, and with OxyContin, is short for “continuous” release).
So MS Contin replaced immediate-release morphine with a version that slowly dissolved, releasing its opioid payload over many hours.
OxyContin was not so different from MS Contin; although oxycodone is more powerful than morphine (one milligram of oxycodone is equivalent to about one and a half milligrams of morphine), the drugs were both extended-release opioid painkillers,
In the case of OxyContin, Purdue’s label included the following peculiar claim: “Delayed absorption as provided by OxyContin tablets, is believed to reduce the abuse liability of a drug.” The reasoning in support of such an idea appears to have been something like the following: addiction is a result of the brain being trained to pursue a certain habit; and habits are reinforced as a result of how immediate and intense the reward from some activity is, and how regularly one engages in the activity. OxyContin, it was suggested, produces fewer and less intense “highs” by slowly releasing the
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The problem? Purdue offered no empirical evidence to support this claim. No data, no studies, no reason at all to think it was true.
first, the pain-relieving effects rarely lasted twelve hours, so patients would actually need to take the medication much sooner, or else supplement with immediate-release opioids; and second, those looking for more serious pain relief, or a more intense high, could easily circumvent the extended-release technology by crushing the pills and snorting the powder or even mixing with liquid and injecting it.
Indeed, the challenge of pain medicine is precisely that pain is a symptom rather than a sign. That is, measurement cannot be taken with an objective tool of medicine, such as a thermometer or sphygmomanometer (blood pressure monitor).
Pain as the fifth vital sign was a phenomenally successful movement, which Purdue was happy to both benefit from and help disseminate in its training.
While the need for a less-addictive opioid drove sales of Heroin at the turn of the twentieth century, the same need—combined this time with a self-aware, passionate pain advocacy movement and an unprecedented marketing campaign—drove sales of OxyContin at the turn of the twenty-first.
In short, just as had been the case a century before, the result of widespread, uncareful prescribing of opioids, combined with a message that they are safer than they in fact are, led to a rapidly growing epidemic of addiction, overdose, and death.
In short order, death from drug overdose—driven by the sharp increase in opioid overdose deaths—became the nation’s leading cause of accidental death, displacing automotive accidents.
When pain patients, or those who were already addicted to opioids, couldn’t get access to the drugs they needed, they found someone who would help out, even if that person was a criminal. And so we might expect a decrease in opioid prescribing to correlate with an increase in black market opioid use. And indeed, there is some indication that precisely this has occurred.
Making matters worse, today, heroin is much cheaper than illicit prescription opioids, so those willing to go to the black market to get their drugs are incentivized to switch to heroin.
Heroin is now regularly contaminated with illicit fentanyl, which, recall, is fifty to one hundred times more powerful than morphine, and it is increasingly even laced with carfentanil, which is used as a tranquilizer for elephants and is 10,000 times more powerful than morphine.
If medicine swings too far toward fear of opioids, we risk undertreating severe pain, and if doctors continue to be too comfortable prescribing opioids, we risk continuing to flood the country with dangerous medications. And if we fail to get clear on how to address this problem, we may well bounce erratically back and forth, without any real direction, undertreating pain and overusing opioids simultaneously.
“epistemic injustice” is the experience of not having one’s testimony taken seriously due to being part of a particular group.
Whether intentionally and consciously or not, when someone fails to take the claims of another person seriously because she’s a woman or a person of color or a member of any other marginalized group, this silencing is an insidious form of disrespect.
Unlike broken bones, complaints such as back pain, neck pain, or abdominal pain may well be present without any obvious (to the clinician) reason. These are the complaints that bring the subjectivity of pain to the fore.
A 2012 analysis of published data showed just how serious the disparities are: not only are black patients 34 percent less likely than white patients to be prescribed opioids for those “nondefinitive” conditions, but they are also 14 percent less likely to be prescribed opioids for traumatic and surgical pain.
in fact, a full 25 percent of resident physicians reported believing that blacks’ skin is thicker than whites’. Even more distressing, physicians and medical students who reported more false beliefs about biological differences between the races systematically rated black patients as experiencing less pain than white patients and recommended less aggressive pain treatment.
The disparity in opioid therapy even extends to children. In a 2015 study of pain management for children with appendicitis, black children with moderate pain were less likely than white children with the same level of pain to receive any pain treatment. And among all of those with severe pain, white children were more than twice as likely as black children to receive opioids.
Hispanic patients are also systematically prescribed fewer opioids than non-Hispanic whites, and there is significant data to suggest that women are less likely to have their pain aggressively treated.
White men are best positioned to have their pain taken seriously, which raises serious concerns about both the pain treatment of minority patients as well as the respect they are given by clinicians.
