download“If the entire materia medica at our disposal were limited to the choice and use of only one drug, I am sure that a great many, if not the majority, of us would choose opium; and I am convinced that if we were to select, say half a dozen of the most important drugs in the Pharmacopeia, we should all place opium in the first rank.”

Macht DI. (1915) The history of opium and some its preparations and alkaloids. JAMALXIV:477–481

Disabled, chronically abandoned

(Sign held by a young woman protesting in front of a pain clinic shuttered by the DEA last week)

Often in nature, a substance is found (or some believe God has placed a substance) that has serendipitous properties in humans. One of the first instance of humans discovering this was with the milky substance found in a flower now known as the poppy. Thousands of years ago, someone (we think an Arab adventurer) for whatever reason ingested that the milky substance in the “proto” poppy plant and found it relieved his pain. For the next thousand years, through cultivation and trial and error the opium poppy was born in China. Papaver somniferum. 

Pain is a funny thing in people. It is a mechanism almost all of God’s creatures have to tell them that if they stay in their current situation bad stuff might happen to them. One of the things we are taught in medical school is how to get people to describe their pain. We tell students to get people to use a 1-10 scale with “1 being a paper cut and 10 being an elephant sitting on your chest.” Did you know there are a lot of people whose paper cuts are a 10? Once the situation has resolved, we have chemicals in our body that connect with the pain receptors (there are 4 such receptors, with mu being one) to relieve the pain and give pleasure. The opium poppy, which likely could only move back and forth and doesn’t need a lot of pleasure materials, has been bred to have 12% of its latex made up of these pleasure drugs (morphine, codeine, and to a lesser extent thebaine which was used to make hydromorphine).

Having a drug that reduces pain is lucrative. Having a drug that causes pleasure is more lucrative. In the 1800s, German scientists were able to extract pure opium from the poppies. Although available for pain relief, the larger market was in euphoria production in shops (mostly in China) using water pipe technology. Ironically, it was declared illegal in China (where the poppies were grown) but was smuggled by the British into China and sold to the opium dens to offset the imbalance of trade they found themselves in from importing tea. Only fair, I suppose.

We don’t need flowers today. Thanks to the God-given ability of humans to reverse engineer, the world produces about 700 tons of narcotics. Most of this medication makes its way to the US. We have 5% of the population and account for 99% of the hydrocodone use in the world (active ingredient in Vicodan), 83% of the hydrocodone use (active ingredient of Oxycontin), and 37% of the world supply of Fentanyl. We consume twice as much per capita as the next highest nation. Within our country, even, there is much variation with Alabamians consuming 2 1/2 times (1 1/2 prescriptions per person) as much as Hawaiians. The misuse of these drugs contributes to 17,000 deaths annually, as many as ovarian cancer but without a ribbon to raise awareness. Deaths aside, there is the problem of diversion. Many people get a prescription for 90 Vicodan, take 60, and sell 30. There are willing markets of buyers and many physicians are unaware that their sweet little elderly lady patient (who has the medicine in her urine) has a side business.

It turns out opioids have a downside. They are addictive, meaning that they cause aberrant behaviors on people unable to get access to the drugs by buying pills from the guy down the street. They cause a physical dependence. People who are suddenly denied access will suffer from physical symptoms such as nausea, vomiting, and profuse sweating. Chronic use results in tolerance, meaning that it takes an increasing dose to get the same effect. If you are going to create a market, what better product to sell?

As detailed in this New Yorker article, this problem has been a long time coming, and we in the healthcare field are complicit. Beginning in the 1980s, scholarly articles encouraging the addition of narcotics to our inadequate pain treatment regimes have been published. Some very smart people believed that treatment of chronic, non-cancer pain with opioids could work  “with relatively little risk of producing the maladaptive behaviors which define opioid abuse.” In the 1990s makers of legal narcotics (Purdue in particular) began marketing their products to physicians and patients as safe for everyday ailments such as neck and back pain. With a team of 5000 sales people, a bonus system that encouraged “market growth,” and the assistance of the Joint Commission which began requiring hospitals to evaluate and treat pain, over $1 billion worth of Purdue’s Oxycontin was sold in the US in 2000.

So, God placed this wondrous drug in the proto-poppy for what reason? If used correctly, say for the pain associated with metastatic cancer, it is truly a miracle. If used by people to mask the psychic pain of living in America and written by physicians who are just too busy to talk to their patients, it is probably not what God intended. If given by physicians to folks in exchange for sexual favors thus feeding their addiction it is almost certainly not what God intended.

Perhaps God put the proto-poppy on earth to test physicians. We can make a lot of money selling these poppy derivatives but we can also get in big trouble. The test for us is to use it correctly.