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Misdiagnosing the Opioid Crisis

Ronald W. Dworkin

Some people are impatient before I give them anesthesia in the operating room. They want the drugs, especially the potent narcotic fentanyl, because they want to feel, in their own words, “wonderful,” “amazing,” or “without a care in the world.” A few of those headed for general anesthesia ask me to delay giving them the final knock-out dose so they can enjoy the good feeling a little longer.

This experience conflicts with what I was taught in medical school about opioids, which is that these drugs produce a feeling of euphoria in people with pain but cause a feeling of unease in the absence of pain. Thirty years of anesthesia practice have taught me that people need only experience anxiety—not necessarily pain—for opioids to make them feel better.

The problem for society, of course, is that everyone feels anxiety at some point, which means everyone might at some point in life seek and enjoy these drugs. Not for nothing do they call it the nervous system. Indeed, anxiety springs from life’s most fundamental contradiction: Each of us desires lasting happiness, yet each of us knows that lasting happiness is impossible. The resultant anxiety varies in intensity in any given person and on any given day, but for at least 2,000 years human beings have been stupefying themselves with alcohol or drugs to escape some version of this contradiction. The current opioid crisis and its remedies need to be understood against this very long-standing phenomenon.

True, within the context of the past 50 years, today’s opioid crisis does seem different, if only in the rate of overdose deaths. The heroin epidemic of the 1960s and 1970s caused 1.5 overdose deaths per 100,000; the “crack” epidemic of the 1980s resulted in two overdose deaths per 100,000; the current opioid crisis produces 10-20 deaths per 100,000.1 Yet applying a mere five-decade time frame obscures the fact that human beings have been stupefying themselves for many centuries.

Christopher Caldwell’s April 2017 essay in First Things exemplifies this narrow perspective. Caldwell argues that society has grown lax over the past half-century in enforcing the moral and social taboo against aggressive opioid use—for example, by “renouncing our allegiance to anything that forbids or commands.” He means, of course, mainly religion. However, 19th-century America, which was animated by a strong religious ethos, also had a serious opioid addiction problem. One in every 200 Americans was addicted to opioids by the end of that century.

While Caldwell does mention the 19th century’s addiction problem, he attributes it to “zealous doctors” who over-prescribed opioids to middle-class women, as well as to a one-off event, the Civil War, that led many wounded soldiers into drugs. But opioids were available without prescription during the 19th century; laudanum was one of the most popular over-the-counter forms, and its use often had little to do with doctors. Opioid abuse was also a problem in Great Britain, where there was no 19th-century civil war.

Doctors often get blamed for today’s opioid crisis, too. Dr. Tom Frieden said it as plainly as possible while serving as Director of the Centers for Disease Control (CDC): “This is a doctor-caused epidemic.” There is some truth here, as reportedly 80 percent of heroin users begin with prescription opioids, and doctors, for their part, have been prescribing opioids more aggressively over the past few decades. In the form of Vicodin, opioids are now the most popular prescription drug in the United States.

But there are good reasons for the change in prescription patterns. Pain was woefully undertreated in the past. In my own specialty of anesthesiology, for example, mild to moderate post-operative pain was typically ignored for much of the 20th century. Many anesthesiologists wrongly thought that if they aggressively treated post-operative pain with narcotics they risked turning their patients into addicts. In obstetrics, although the epidural technique for analgesia during childbirth was invented in 1942, well into the 1960s only 10 percent of American women received epidurals. Doctors, predominantly male, saw labor pain as simply a natural part of life.

In general medicine also, doctors wrongly discounted pain that lacked a visible origin. They called it “functional pain” and consigned it to a sub-category of mental illness. Later research showed that functional pain had a real physiological basis—for example, a misfiring of nerves—although it was undetectable by microscope.

Finally, many doctors in the 20th century wrongly adhered to the old Cartesian paradigm that separated mind from brain, with pain a hard-wired brain experience that supposedly occurred independent of people’s psychology. Anyone who has experienced pain knows that this rigid division is wrong, and that, for example, unhappiness exacerbates pain.

Caldwell correctly notes that opioids were taboo for many 20th-century doctors, which kept opioid prescriptions down. But if the taboo was rooted in error and bad science, why should anyone pine for its return?

2015 TAI essay by Hudson Institute fellows David Murray and John Walters blames much of today’s opioid crisis on the recent increase in heroin production. Like the other time-sensitive explanations, their argument carries some truth and may help to explain the three-fold increase in heroin-related overdose deaths in the past decade. Then again, heroin was responsible for only a third of all opioid overdose deaths in 2016, so increased heroin production can account for only part of what is going on.

In a recent Wall Street Journal editorial, drug-policy adviser Kevin Sabet and former Congressman Patrick Kennedy also analyze the opioid addiction phenomenon within a narrow time frame. They pin the blame on marijuana’s recent legalization in several states, supplementing their charge with the statistic that 70 percent of today’s illicit drug users started with marijuana, not prescription opioids. But this statistic is misleading. Plenty of young people try pot. Indeed, the average age of a marijuana initiate in the United States is 18. Yet the vast majority of teenagers who try pot do not go on to opioids. For those who do, the events may be unrelated. That a 45-year old man with a bad back falls into a prescription opioid habit has nothing to do with the fact that he puffed on a joint 30 years before.

All of these explanations for the opioid crisis come with a solution. But because the explanations are either inadequate or just wrong, so are the solutions. A better solution demands a better explanation. To get it we need to ponder some long-standing trends in Western society.

My specialty, anesthesiology, has exhibited a clear trend since its inception in the mid-19th century. It has divided and sub-divided the targets of anesthesia, including pain, awareness, amnesia, and consciousness, such that putting patients to sleep with anesthetic gas alone has been replaced with using specific agents to dull select feelings and experiences. For example, to block a patient’s memory formation and awareness I use the drug Versed. To induce loss of consciousness I use Propofol. To lessen incisional pain I use opioids. To lessen deep tissue pain I sometimes use Ketamine. To lessen post-operative pain I use Toradol.

What happened in anesthesiology is a microcosm of what happened in society at large. Two centuries ago (and long before that) people used alcohol the way doctors used anesthetic gas. Alcohol numbed people to life’s problems, non-specifically, almost by scattershot. When people felt discord between their lives and their consciences—in other words, between how they lived and how they thought they should be living—they drank. Neither the cause of their discord nor the quality of their misery mattered. All that mattered was that, for one reason or another, people across the centuries have been plagued by some inner voice telling them that their lives were wrong in some way. Because they could not silence life, they silenced their consciences by dulling consciousness generally, using the only or easiest thing available to them: alcohol.

Over the next two centuries, pharmaceutical entrepreneurs eyed the various unpleasant feelings that prodded people to stupefy themselves with drink, then divided them into different categories (for example, anxiety, depression, insomnia, or pain), and then, as in anesthesiology, targeted them with specific agents. Alcohol ceased to be the only solution. Laudanum was an early addition to the apothecary. Codeine was another popular opiate.

Today, we have multiple classes of psychoactive and pain relief drugs, as well as multiple subclasses and subtypes within those subclasses, all targeting a particular form of mental distress. For example, to treat insomnia, one Valium-like drug gets people off to sleep immediately, another kicks in after four hours to forestall an early morning wake-up, while a third’s claim to fame is protecting REM sleep. Over 60 different benzodiazepines now exist. In pain therapy, naturally occurring opiates, semi-synthetic opioids, and synthetic opioids exist alongside non-opioid pain relievers. Even the synthetic opioid fentanyl has more than 1,000 subtypes, including Alfentanil, which is intense but short-acting, and therefore useful in ear, nose, and throat cases, and Sufentanil, the most powerful opioid of all.

It was not advancing science alone that made this targeting possible. Drug companies spotted needs both in my specialty and in society at large, and invested in efforts to create new drugs to address them. That made them money and enabled better medicine. Curiously, in the case of the opioid crisis, this event has generated odd-bedfellow critics. Leftists regularly accuse capitalism of causing evil, but some conservatives have also joined in with criticism of the pharmaceutical industry for creating abusable substances. But this is absurd: All that capitalism has done in this case, as with most others, is identify a market and serve it to mutual benefit, which is what it is supposed to do. Consumers drive capitalism, and silencing inner discord is what consumers wanted—only they wanted something better than the big gun, alcohol. They wanted drugs that would safely and precisely treat their shade of inner turmoil.

The safety issue is important. Before the 20th century, people in a non-sober condition were able to accomplish much. Not all people with inner discord went to work outright drunk, but many were calmly intoxicated, at least from the residual effects of drinking the night before. Millions of men climbed up Manhattan skyscrapers, stayed there a while, put in rivets, and went down again; or they laid down rails in the middle of the desert, surrounded by rattlesnakes and scorpions, and lived apart from society for months; or they went into battle as soldiers to kill or be killed. They submitted against their reason, sometimes even against their will, and for many of them, some degree of intoxication made all this possible by stifling their consciences within. Meanwhile, their intoxication risked their own safety and the safety of others. Many industrial accidents happened.

The new drugs, including anti-anxiety agents, antidepressants, and opioids, calm people’s inner discord more selectively. They cause fewer symptoms of intoxication and make the users of such drugs safer to be around—not completely safe, but safer.

One other long-standing trend in Western society feeds today’s opioid crisis. From ancient Greece to the present day, writers have generally agreed that pleasure is good and pain is bad. From east to west there are religious traditions encouraging self-denial, but by and large in the West, from Epicurus to John Stuart Mill, the strategy has been to parse both pleasure and pain, and to argue that just as some pleasures are better than others, some pains are worse than others.

But the subjectivity of pleasure and pain has always dogged the effort to finely distinguish degrees among them. Over the past two centuries, as industry targeted people’s bad feelings with drugs, the West gradually surrendered on this other point, and agreed that each person has his or her own private experience of pleasure and pain. This new view penetrated medicine. Doctors were no longer granted the authority to tell people how they should be feeling based on some supposedly objective assessment of their bodies. Just as Adam Smith said in his time, it became a matter of professional consensus that no objective standard exists by which to judge.

Against this historical backdrop, the controversies surrounding today’s opioid crisis come into better focus. Some people blame drug companies such as Purdue, the maker of OxyContin, for creating and aggressively marketing new opioids. But, as already suggested, it makes little sense to blame capitalism for responding to consumer demand, even if we could perhaps agree that the marketing has sometimes been a bit too aggressive. Consumers resent a one-size-fits-all mood-modifying drug like alcohol as much as they resent a one-size-fits-all car. They want substances tailored to their particular forms of inner discord, whether anxiety, depression, or pain. The drug companies have simply responded to that demand.

Some people still insist on blaming doctors for over-prescribing opioids. But how can a doctor question another person’s subjective pain experience? When I doubt a patient’s pain complaint in the recovery room—for example, when the patient has a tiny surgical incision but wails nonetheless—the patient looks at me as if to say, “I am the person who feels and not you. You cannot know or judge what I feel.” The patient is right. Inevitably, I give in to my patient and prescribe more narcotic. Millions of other doctors give in to their patients for the same reason, causing an increase in opioid prescriptions and, reasonably enough, cases of addiction.

Some people bemoan the fact that unhappy people have turned to opioids for pleasure, not for pain relief. With a touch of contempt they note the positive correlation between bad economic conditions and the opioid abuse rate (and the Trump vote) and imagine huge crowds of malingerers with nothing better to do than to get high. But deep down, what bothers these almost invariably upper-class critics is not that unhappy people in Trump country use drugs; it’s that they use the wrong drugs. If people feel lousy because they have lost their jobs and can’t support their families or measure up to what is expected of them, then they should be on an antidepressant, not an opioid. If they can’t sleep because of their unhappiness, then they should be on an anti-anxiety agent, not an opioid.

Embedded in this criticism is an admission that opioid addicts hardly differ from other people who want to hide from their own active minds the unwanted aspects of their lives. How opioids work confirms this point. Opioids work not by eliminating pain but by detaching people from their pain, causing them to grow indifferent to it. Other psychoactive drugs work similarly. The life circumstances that cause unhappiness may persist, but for those taking antidepressants, anti-anxiety drugs, and especially alcohol, the feeling of unhappiness becomes vaguely distant. Users care about it less, or even imagine that the unhappiness belongs to someone else. Whether it is opioids, alcohol, antidepressants, or anti-anxiety agents, what bothers sober people does not bother drugged people.

If we add up the 60 million or so Americans who use a sleep aid at night, the 30 million Americans on antidepressants, the 15 million Americans on anti-anxiety drugs, the 16 million Americans who regularly abuse alcohol, and the 65 million Americans who admit to binge drinking at least once a month, the 2.1 million Americans with an opioid abuse disorder represent just a small fraction of Americans who regularly stupefy themselves to escape some ugliness or senselessness they perceive in their lives.2 About half the country self-intoxicates. The opioid addict’s error is sometimes little more than taking the wrong drug for a life condition that includes anxiety and unhappiness but not pain.

Some people worry about the crime and family break-ups associated with the opioid crisis, although they also worry about the Drug Enforcement Agency (DEA) pushing addicts toward illegal heroin by cracking down on legitimate opioid prescriptions. Yet these worries spring from the illegality of opioids in the first place. If opioids were less restricted there would be no illegal market for them, let alone criminal gangs associated with that illegal market. Nor would opioid addicts need to exhaust their family savings, rob, or murder to get money to buy drugs. They could stupefy themselves legitimately the way anxious and depressed people do now with anti-anxiety agents, antidepressants, and alcohol.

Some observers cite the high death rate from opioid abuse as a reason to restrict opioids. Yet on balance opioids are safer than alcohol. I would much rather manage the emergency anesthetic of a trauma victim “high” on opioids than the anesthetic of someone drunk, as alcohol causes far more physiological trespass. True, opioids are not harmless; they cause gastrointestinal trouble and may depress the immune system. But the major health problems associated with opioid abuse typically arise from their illegality and not from the drugs themselves—for example, AIDS, sepsis, hepatitis, and endocarditis stemming from the use of dirty needles, or overdoses that occur because of inaccurate drug doses created in street labs.

Way back in 1990 I supported the idea of government-run safe injection sites where opioid addicts could legally inject opioids while under physician supervision, thereby removing the need for addicts to steal to get drugs. I have not since changed my mind. The sites, I argued then, would also rid the streets of dirty needles while rendering the illegal drug market superfluous.3 This idea became a reality in several Canadian cities a decade ago and was introduced just this month in New York City. It works in Canada and it will work in New York. It lacks the appeal of a morally pure, revelatory sort of solution that will banish sin and restore virtue—but it does work. Similar programs should therefore be encouraged throughout the United States as at least a partial solution for today’s opioid crisis. Blaming doctors or pharmaceutical companies or capitalism is futile; bad diagnoses will always generate bad solutions.

At this point it does not matter how the great mass of today’s opioid addicts became addicts, but only that they are addicts now. The error up to now has been to push these individuals outside the stream of history and award them the status of special malefactors. People have been self-stupefying for thousands of years. As the old joke goes, man was probably a pharmacologist before he became a farmer. The main problem with opioid addicts—and one they share with other addicts like alcoholics—is that their efforts to escape life’s troubles can sometimes go too far, necessitating safe injection sites for opioid abusers, just as AA is sometimes needed for alcohol abusers.

The opioid crisis will likely fade over time. It’s not that doctors will suddenly fine-tune their prescriptions. Addictive behavior is sometimes an unavoidable risk factor when treating chronic pain with opioids. In some cases the treating physician must ask himself or herself, “What is a reasonable degree of addictive behavior in this patient, allowing the patient enough pain relief to function but not so much that the addiction itself leads to problems?” Fine-tuning with opioids is hard.

Instead, such fine-tuning may become unnecessary. In response to consumer demand, industrial capitalism will likely develop non-opioid pain relief alternatives, just as it developed opioids, antidepressants, and anti-anxiety agents in the past. The economy might also improve, reducing somewhat the number of people who seek to use drugs to hide from themselves the truth of their lives. With aggressive mental health programs, those still unhappy with their lives will be routed toward more appropriate antidepressants or anti-anxiety agents.

Yet so long as there is pain, there will be opioid addiction of one kind or another—and thus there will always be a need for safe injection sites. And yes, there will be problems with these sorts of band-aid solutions, as we know from our experiences using methadone as a substitute for heroin. Human beings will never stop comparing how they live with how they want to live or think they should be living. They will never accept their pain as a product of unavoidable circumstances, and they will never stop wishing for their pain to go away. In their misery, they will never stop craving opioids if opioids are the only drugs that work for them. In short, whether you consider them to be acting for good reasons or bad, people in pain will never stop wanting to stupefy themselves. Nor, for other reasons that lead to other drugs, will billions of other people.

1 See “Annual Causes of Death in the United States,” in Drug War Facts. See also Peter Dale Scott and Jonathan Marshall, Cocaine Politics: Drugs, Armies, and the CIA in Central America (University of California Press, 1991).
2 For the antidepressant rate see Olfson and Marcus, “National Patterns in Antidepressant Medical Treatment,” Archives of General Psychiatry, 66:8 (2009). For insomnia aids see Robin Lloyd, “Sleep Deprivation: The Great American Myth,” Live Science, March 23, 2006. One in six Americans now takes a psychiatric drug.
3 Ronald Dworkin, “Drugs and the Principle of Utility,” The Evening Sun, May 30, 1990.

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