Pharmaceutical companies did not cause the painkiller addiction crisis in a vacuum, but took advantage of a well-intentioned desire amongst doctors for a “Holy Grail” of pain treatment: a pill that could end suffering simply and free of addictive side effects. American patients wanted painkillers because they were in pain, and their doctors wanted to prescribe painkillers because they felt it was their moral obligation to help those who had suffered for so long. Prior to what Sam Quinones deems a “revolution” on attitudes toward pain that unfolded over the 20th century, morphine was highly stigmatized; doctors who prescribed painkillers were regarded as “virtual outlaws.” Thus, when researchers published documents claiming that very few patients fell into addiction from being treated with narcotics, many well-intentioned doctors leapt at the opportunity to finally be able to help patients suffering with chronic or acute pain. In reality, however, pain is multifaceted and difficult to treat—no single pill can cure it. Ultimately, posits Quinones, America’s pain revolution failed because it rested on the false premise that pain can be treated with a single, uncomplicated solution.
America’s search for the “Holy Grail” began, in earnest, in 1928, when the Committee on Problems of Drug Dependence (CPDD) brought together researchers to find a nonaddictive painkiller to replace the addictive, stigmatized drugs (such as heroin and cocaine) that had previously been overprescribed and were now rejected by respectable doctors. The idea of a “Holy Grail” drug was so appealing because it was simple and effective: it provided patients with instantaneous relief, came without the negative side effect of addiction, and was efficient for doctors—nonaddictive pills didn’t require time and energy in the form of constant monitoring and countless follow-up appointments, for example. This search for a “Holy Grail” drug to treat pain informed future drug researchers and inspired “a cadre of revolutionaries seeking a better way to treat pain in America.” Thus, what Quinones refers to as a “revolution,” was born.
Attitudes toward pain changed significantly in the 1970s, and pain relief began to be seen as a “right.” Originally, the “right” to pain relief was limited to the chronically ill (such as cancer patients), but the notion painlessness as an unalienable right was extended to a broader range of patients. In 1980, Swedish cancer physician Jan Stjernsward was named chief of the cancer program for World Health Organization (WHO). Stjernsward had experience working with dying cancer patients in Kenya and had witnessed firsthand the relief that morphine granted these patients in their final days. Stjernsward met Vittorio Ventafridda, whose clinic treated cancer patients in Milan. Ventafridda showed him a set of principles he referred to as a “ladder of treatment” for pain patients. The ladder proposed that “increasingly powerful drugs, including opiates” should be used on dying patients “if pain did not subside.” Such a notion was previously unheard of. Stjernsward endorsed the “ladder of treatment,” and the WHO published a book that promoted this new, narcotic-heavy approach to pain management.
Another critical moment in the pain revolution was the advent of palliative care, which cancer doctors Dr. Russell Portenoy and his mentor Kathleen Foley “helped midwife.” Palliative care, or “treating the pain and stress of the seriously ill,” first developed in the 1970s out of the philosophies of hospice nurse Cecily Saunders who believed “that death should be dignified.” Saunders believed that dying patients were entitled to pain relief in their last days. Over the following decades, the philosophies of palliative care were applied to more medical disciplines, such as the treatment of chronic pain, and the notion that all patients were entitled to painlessness took hold across the medical community. Though well-intentioned, this new idea that patients were entitled to pain relief led to the extreme (and often dishonest) normalization of opiate painkillers. Like the WHO’s ladder of treatment, palliative care was founded on the well-intentioned idea that death should be dignified. Portenoy saw his philosophy as “guided by the moral issues of patient autonomy and respect of cultural and individual differences.” Portenoy believed in the power of pain relief: “I believe in drugs,” he stated. “I think pharmaceuticals are a great gift to humankind.” In 1986, Portenoy and Foley published a paper in Pain medical journal. The paper would “bec[o]me a declaration of independence for the vanguard of pain specialists interested in using opiates for chronic pain.” It posited that addiction and abuse of narcotics was rare.
One critical source of Kathy Foley and Russell Portenoy’s belief in the non-addictive nature of narcotics came from a letter to the editor published in the New England Journal of Medicine in 1980, known familiarly as “Porter and Jick.” Curious about whether patients treated with narcotics tended to become addicts, Dr. Herschel Jick, of Boston University, consulted what is known today as the Boston Collaborative Drug Surveillance Program, a database that keeps track of the effects of drugs on patients. Jick’s findings revealed that of nearly 12,000 patients treated with narcotics, only four would become addicts. These findings were problematic because the non-addicts were studied while they were in the hospital, and thus largely unable to develop abusive relationships to the drugs, as they were administered to them in a controlled environment. To his credit, Jick never intended for his study, titled “Addiction Rare in Patients Treated with Narcotics,” to become as widely read as it would go on to be. Still, the study informed many doctors and gave them a false confidence in the opiate drugs they were prescribing with greater frequency to their patients.
Pharmaceutical companies like Purdue seized on studies like Jick’s and took advantage of the well-intentioned zeal of pain researchers like Portenoy and Foley to assuage the fears of doctors who for so many years had been warned on the dangers of narcotics. Purdue funded pain researchers, who in turn began to see Purdue “as an innovator and ally.” Purdue inflated its findings to propose that the drugs they patented and pushed on medical professionals—OxyContin, most notably—were safe, effective treatments for pain. Former Purdue sales manager William Gergely revealed that Purdue salespeople were instructed to claim that OxyContin was “’virtually’ non-addicting,” when this was not at all the case. The 20th century’s shift in attitude toward pain management and the minimization of narcotics’ addictive potential allowed Purdue to capitalize on the medical community’s long-fought struggle to find the perfect solution for pain relief. Thus, America’s pain revolution came to be centered around the false premise of a cure-all, nonaddictive “Holy Grail” and narcotics became normalized among doctor and patients alike.
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Pain Management and the Normalization of Narcotics Quotes in Dreamland
Like no other particle on earth, the morphine molecule seemed to possess heaven and hell. It allowed for modern surgery, saving and improving too many lives to count. It stunted and ended too many lives to count with addiction and overdose. Discussing it, you could invoke some of humankind’s greatest cultural creations and deepest questions: Faust, Dr. Jekyll and Mr. Hyde, discussions of the fundamental nature of man and human behavior, of free will and slavery, of God and evolution. Studying the molecule you naturally wandered into questions like, Can mankind achieve happiness without pain? Would that happiness even be worth it? Can we have it all?
In heroin addicts, I have seen the debasement that comes from the loss of free will and enslavement to what amounts to an idea: permanent pleasure, numbness, and the avoidance of pain. But man’s decay has always begun as soon as he has it all, and is free of friction, pain, and the deprivation that temper his behavior.
Novocain, invented in 1905, avoided the need for addictive cocaine in dentistry. Why not a morphine substitute? Such a drug could cleanse doctors’ image as clueless dealers of dangerous drugs that they’d earned by widely prescribing heroin in the early 1900s. Academics, meanwhile, hoped for a new era of modern scientific research applied to medicinal drugs. Law enforcement hoped a nonaddictive pain reliever would lessen the fallout from its attempts to rid the country of opium. Researchers called this drug the Holy Grail and the search for it would take the rest of the century and beyond.
The new discipline gave Russell Portenoy “the talking points I needed to mold my work life,” he once wrote. As an emerging discipline, palliative care appealed to the bright young doctor interested in staking out his own ideas. Comforting the seriously ill and dying touched on the altruistic reasons why anyone would enter medical school in the first place. […] Watching people struggle with pain, and talking to families who faced the loss of a loved one, gave Portenoy a touch of idealism, a bit of the crusader pushing up against conventional wisdom.
But “there is a philosophy among many patients—‘I’m entitled to be free of pain,” said Loeser. “People are entitled to health care. Health care should be a human right. Pain management must be a part of health care. But they are not entitled to pain relief. The physician may not be capable of providing them with pain relief. Some problems are not readily solvable. […] You’re not entitled to pain relief any more than you’re entitled to happiness.”
The new pain movement pushed past these doubts. It acquired a quasi-religious fervor among people seared by the nontreatment of pain of years past. A pendulum began to swing. The cruelty of earlier times discredited those who might question the emerging doctrine of opiates for chronic pain. Pain specialists working toward a new day felt gratitude to pharmaceutical companies for developing the drugs and devices that made possible the humane treatment of pain.
“We can get away from these silly elixirs and cocktails into tablets that people take once or twice a day, and we’re into a revolutionary field of pain management…It was the drug-delivery service that changed, not the drug, and with that the whole mentality, ‘Well now that we have this drug, we can treat pain.’ Really extraordinary.”
Some Purdue reps—particularly in southern Ohio, eastern Kentucky, and other areas first afflicted with rampant Oxy addiction—were reported to have made as much as a hundred thousand dollars in bonuses in one quarter during these years. Those were unlike any bonuses ever paid in the U.S. pharmaceutical industry. […] Whatever the case, the bonuses to Purdue salespeople in these regions had little relation to those paid at most U.S. drug companies. They bore instead a striking similarity to the kinds of profits made in the drug underworld.
Many of these methods—premiums, trips, giveaways—were time-tested strategies that grew from the revolution Arthur Sackler began and were refined over time by many pharmaceutical companies. Only this time, the pill being marketed contained a large whack of a drug virtually identical to heroin.
In Portsmouth, it began with what came to be called pill mills, a business model invented in town, but growing from the aggressive nationwide prescribing of opiates, particularly OxyContin. A pill mill was a pain-management clinic, staffed by a doctor with little more than a prescription pad. A pill mill became a virtual ATM for dope as the doctor issued prescriptions to hundreds of people a day.
As the pain revolution was taking hold across the country, however, Procter and his physician progeny showed a beat-down region a brand-new business model. Before long some of the first locally owned businesses in years opened in Portsmouth, known to folks in town as the “pain managements.”
“It was not only okay, but it was our holy mission, to cure the world of its pain by waking people up to the fact that opiates were safe. All those rumors of addiction were misguided. The solution was a poppy plant. It was there all along. The only reason we didn’t use it was stigma and prejudice.”
“Nobody thinks those things are of value. Talk therapy is reimbursed at fifteen dollars an hour,” Cahana said. “But for me to stick a needle in you I can get eight hundred to five thousand dollars. The system values things that aren’t only not helpful but sometimes hurtful to patients. Science has shown things to have worked and the insurance companies won’t pay for them.”
Katz admired Portenoy, who, he said, had spent a career searching for better ways to relieve his patients’ real and considerable pain. Portenoy had helped make pain a topic of research. Moreover, Portenoy was always clear that pain treatment needed balance and time; doctors needed to be selective in the patients who received this treatment. But “people want simple solutions,” Katz said. “People didn’t want to hear that and the commercial interests didn’t want to emphasize that.”
We wound up dangerously separate from each other—whether in poverty or in affluence. Kids no longer play in the street. Parks are underused. Dreamland lies buried beneath a strip mall. Why then do we wonder that heroin is everywhere? In our isolation, heroin thrives; that’s its natural habitat.
