THE CASE FOR MORPHINE

IF NOTHING IS BETTER FOR PAIN THAN NARCOTICS,
WHY DON'T MORE DOCTORS PRESCRIBE THEM?



Doug Ventura will never forget that fall day in 1981. He and two other police officers from Montgomery County, Maryland, were trying to arrest a man strung out on angel dust when the suspect started kicking Ventura in the side and face, again and again and again. It took four operations for doctors to repair Ventura's fractured spine. But the pain never really went away. It was as if someone had forgotten to turn off a switch somewhere deep inside his body.

The only painkiller strong enough to relieve his suffering was morphine, a narcotic that is, like heroin, derived from opium. But Ventura's doctors were reluctant to give him an open prescription for fear he would become addicted. Forced to retire, Ventura spent much of the next 10 years confined to a hospital bed in his living room. Sometimes in his despair his thoughts turned to suicide.

Then in 1990 a new doctor suggested a radical solution: Ventura should go back on morphine and stay on it. Drug companies had developed a timed-release formula that had proved helpful in other cases. The treatment allowed Ventura to abandon his hospital bed and, for the first time, lift his infant son. The downside was that he was chemically dependent on morphine; the upside was that he was no longer in pain. "I had a lot of trepidation about taking narcotics," says the ex-cop, now 46. "But until I was put on sustained-release morphine, I had no life."

Look behind today's headlines about physician-assisted suicide and the right to die, and you'll find that what people are really talking about is the management of pain. Or rather, the mis-management of pain. For the more neurologists learn about pain--what it is and how it is experienced--the more they are convinced that the key to pain relief is already at hand. Most kinds of severe pain, these scientists say, could be treated safely and effectively if doctors would only make more liberal use of narcotic drugs, particularly morphine.

Narcotics. The word conjures up images of dope peddlers, undercover cops and mandatory prison terms. No matter that morphine is more effective than most prescription-strength painkillers. No matter that the vast majority of patients today can take the drug without becoming addicted. Quite a few doctors, a large number of their patients and much of the health-care establishment want no part of it. Even specialists in the treatment of pain who prescribe narcotics on a regular basis refer to the drugs as "opiate medications," as if calling them by a different name would counter their shady reputation.

No one is advocating the use of narcotics to treat a stubbed toe. These powerful drugs are indicated only for the most severe, disabling pain. But research conducted over the past 20 years into the mechanisms by which the body experiences grievous pain suggests that certain narcotic drugs are so well suited to relieving suffering that it seems callous, maybe even negligent, not to use them.

Consider what happens inside your body when it is subjected to intense pain. Say, for example, you're on your way to work when a runaway car jumps the curb and crushes your left leg. First, your mangled limb lets loose a flood of chemicals, called prostaglandins, that trigger swelling and activate the nerves that stretch from leg to spine. As soon as the nerve signals reach the spinal column, another group of nerves takes over and passes the message on to the brain. It is only after the brain gets in on the act that you can "feel" your own pain.

Scientists have long known that morphine blunts that chain of pain reactions by preventing the spinal nerves from signaling the brain. But what they didn't know until the late 1980s is that these nerves are more than just glorified gatekeepers. They actually "remember" the body's past travails, causing permanent changes that are recorded in their molecular structure. "Think of the spinal cord as a voice- mail system," says neurobiologist Allan Basbaum of the University of California, San Francisco. "A message comes in and leaves something behind." The longer the injury persists, the more sensitive the spinal nerves become to painful stimuli--and the more intensely they signal the brain that something is wrong.

When Basbaum and his colleagues stumbled on this mailbox effect, they quickly realized that it could revolutionize surgery. In the past, most patients were put to sleep with a general anesthetic, which dulls the brain's memory of what has happened but does nothing to stop the spinal nerves from reacting. In the early 1990s, Basbaum's team showed that the spinal cord triggers a cascade of chemical and electrical signals during an operation. Once the brain comes out of its anesthesia-induced fog, it translates all this electrochemical activity into sheer agony.

Physicians have since learned how to short-circuit that chain reaction. By numbing the surgical site with a separate injection of a local anesthetic, they can prevent many of the pain signals from ever reaching the spinal cord. Then, by administering small amounts of morphine to the spinal cord once the operation is over, they can significantly reduce any pain that occurs after the local anesthetic wears off.

Basbaum's work proved that morphine not only relieves pain but prevents it from occurring in the first place. Building on his insights, other researchers determined that morphine and pre-emptive anesthesia given to patients undergoing abdominal surgery reduced their pain so effectively that they left the hospital, on average, more than a day ahead of schedule.

But doctors were not entirely comfortable putting these ideas into practice. There is an ingrained prejudice within the medical community against using narcotics--even when they are indicated. Everybody seems to be concerned about possibly turning thousands of sober, law-abiding patient into morphine addicts.

That's nonsense, says Robert Raffa, a pharmacology professor at Temple University in Philadelphia. "Clearly there is potential for abuse," he admits. "But the idea that your mom will go into a hospital, be exposed to morphine and automatically become an addict is just plain wrong."

Unquestionably, people who take a narcotic for a long period will become physically dependent on the drug. But researchers have learned that dependence is not the same biological phenomenon as addiction. Most patients don't become addicts that easily, perhaps because they lack the addictive body chemistry, perhaps because they take the drugs in a social setting different from that of illicit users.

"When addicts use drugs, they become less functional, more isolated, and they move away from the mainstream," says Dr. Richard Patt of the M.D. Anderson Cancer Center of Houston. "When pain patients use drugs, they become more functional, much less isolated, and they move toward the mainstream." And when they no longer need the drugs, Patt says, they have, almost without exception, no difficulty gradually eliminating their intake.

That doesn't mean a doctor can prescribe narcotics with impunity. For one thing, this can be hazardous to one's career. Medical-review boards in some states, notably Tennessee, West Virginia and New York, are notorious for singling out physicians who prescribe a lot of narcotics and yanking their licenses. "I tend to underprescribe instead of using stronger drugs that could really help my patients," a West Virginia doctor admits. "I can't afford to lose my ability to support my family."

A physician who nearly did lose her license is Dr. Katherine Hoover, formerly of Key West, Florida. In December 1993, Hoover got into trouble with Florida authorities because she had treated the chronic pain of seven of her 15,000 patients with narcotics. A pain specialist testified at her 1995 hearing that she was practicing within accepted guidelines. But the review board censured her anyway-- a decision that was reversed on appeal. Says Hoover, who now practices in West Virginia: "There is a belief that anyone who prescribes narcotics is a bad doctor."

In no field of medicine is the controversy more intense than in the treatment of children. Dr. Kathleen Foley, head of the pain service at Memorial Sloan-Kettering in New York City, remembers an adolescent who was terminally ill. "The father didn't want his son on morphine because he was afraid the boy would become an addict," Foley recalls. In his grief over the imminent loss of his son, it seems, the father failed to see the absurdity of worrying about long-term addiction in a child who is dying in pain.

Of course, narcotics are not the answer for everything. Nor should doctors prescribe any medications, opiate or otherwise, just to placate their patients. But studies have shown that when physicians take their patients' suffering seriously--and do all they can to relieve it--the patients respond by getting better faster and staying better longer. Asked why they want to die, most people who seek physician-assisted suicide respond that it's because they can no longer stand the pain. But when their pain is relieved, most would-be suicides suddenly find they are a lot more interested in living.

BY CHRISTINE GORMAN
TIME Magazine APRIL 28, 1997 VOL. 149 NO. 17
TIME Online






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