By Jerrold Winter
When the seed capsule of the poppy is pierced, a milky fluid oozes from it which, when dried, is opium. Though it held an honored place in Greek, Roman and Arabic medicine for millennia, it was not until early in the 19th century that a German chemist isolated a substance from opium to which he gave the name morphine. William Osler, an eminent American physician, called it “God’s own medicine.”
Beginning in the 1980s, there was increasing recognition that many Americans were living and dying in pain. The remedy provided was increased prescription of morphine and morphine-like drugs such as oxycodone and hydrocodone. There is no doubt that the overall burden of pain was reduced.
But the sword of opiates is double-edged. In 2014, prescription opiates and heroin were implicated in more than 28,000 deaths. In response to what has been called an epidemic, ever more stringent restrictions on access to opiates have been implemented.
Death is an unequivocal endpoint. More subtle is the phenomenon of physical dependence. When our brains are exposed to opiates, adaptive changes take place such that, when the drug is stopped abruptly, a constellation of effects occurs; this is the withdrawal or abstinence syndrome. Each of us, without exception, will become physically dependent if exposed to an opiate in sufficient dose for a sufficient time.
A definition of addiction is harder to reach. Neuroscientists call it a brain disease. Others think it is simply a choice or moral failing. I prefer to say that addiction is a behavioral state of compulsive and uncontrollable drug craving and seeking. The majority of those treated for chronic pain will not become physically dependent. More important, even in those who develop dependence, only a tiny fraction will become addicted.
The late Irwin Paige, a distinguished cardiologist, suffered a heart attack at age 66. Reflecting on his treatment, he thought that every cardiologist would benefit from experiencing a mild heart attack. In a similar vein, I rather wish that every prescribing physician, politician and rule-maker would experience for a time a degree of pain; sciatica would serve nicely. After nights without sleep, inability to walk more than a few steps at a time, and interference with simple daily functions, we would allow the use of a modest dose of an opiate. The pain and the relief provided would, I believe, forever change the attitude of those who would write our rules.
The roots of addiction are multiple and often intertwined: adolescent risk-taking, poverty and homelessness are among them. The potential remedies are equally complex, but one thing is certain: No addict will be saved by inflicting pain upon another.
Jerrold Winter, Ph.D., is professor of pharmacology and toxicology in the School of Medicine and Biomedical Sciences of the University at Buffalo.