Image source: Figureworm Creative
An American drama about how the painkiller OxyContin triggered the opioid crisis, "The Addiction Dose," is becoming popular. It's a popular popular story: it's a core story about how the Sackler family, who realized the American Dream, led a powerful pharmaceutical company, Purdue Pharmaceuticals, and, in collusion with the health care system and government, caused mass drug abuse, addiction, and a series of related social crises among ordinary Americans over the decades.
However, behind the popular popular public stories, there is often the "dark side of the moon": in order to exacerbate the dramatic conflict, several of the main "victims" in the play, including a doctor, are portrayed as innocently addicted to prescription medication, which reinforces Purdue Pharmaceutical's heinous crime. In fact, according to the 2015 annual report of the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), nearly 80 percent of opioid addicts did not initially get a prescription for pain to get exposure to opioids, but illegally from family or friends. Most of these young people are for entertainment purposes, and opioids can produce large amounts of dopamine in the brain.
The shows only the image of "20% of prescription addicts", which certainly does not wash away purdue pharmaceuticals' knowledge that OxyContin has caused addiction but frequently denies and extinguishes the evils for the sake of huge commercial benefits, but for chronic pain patients who still need opioids for pain management, the public fear caused by linking painkillers to the image of addicts is likely to make them unable to obtain drugs. For people with symptoms who don't seek diagnosis and treatment, worry and shame can make them avoid medical treatment and endure pain, which can be a very bad choice for their health and even their lives. The suicide rate among unintermediated patients with chronic pain is quite high: 9 percent of the 123,000 suicides in the United States between 2003 and 2014 experienced chronic pain. (Annals of Internal Medicine, October 2018) This is precisely the biggest concern of authoritative medical experts about the opioid crisis, and people will return to the dark ages of suffering because of fear.
According to the "China Pain Disease Development Report (2020)", there are more than 300 million chronic pain patients in China and are growing rapidly at a rate of 10 million to 20 million people per year, but at present, only a few hospitals in first-tier cities have opened separate pain specialties.
The distance between us and pain, like our distance from evil, is worth thinking about and re-understanding.
At the macro level, human beings recognize that pain is not a stigma, pain is not only related to the body, but also related to the mind, and should be treated, behind which is the germination and manifestation of individuality, which means that modernity is not easy to come. We should not only learn that pain is a disease, but also that it is a systemic disease with complex connections to social problems, and as Kai Bowen, a Harvard medical anthropologist, puts it, the "local scene" of power is the social source of human psycheal suffering, and its "somatization" causes chronic pain that is physically incurable. Therefore, to address the chronic pain of individuals on a large scale, it is also necessary to pay attention to the inequalities suffered by individuals and seek corresponding ways of social change.
Microscopically, experts in the field of pain have replaced "pain control" with "pain management," which means that for pain patients, it is no longer their goal to endure or eliminate pain, but instead to learn how to live with pain and regain control of their lives. One of the most critical methods is to take the initiative to receive more correct and complete pain education, and sports and interpersonal support are equally important.
Fear of the masses:
"Addiction" caused by "pain relief"
Public fear of painkillers is triggered by the opioid abuse crisis. This is a crisis that has lasted in the United States for more than two decades and has not yet ended. In 2017, then-US President Trump made a speech emphasizing the scourge of opioid abuse in the United States and declaring a national public health emergency. But a few years later, according to statistics, between April 2020 and April 2021, the number of drug overdose deaths in the United States still exceeded 100,000, most of which died from opioids.
The history of painkillers and addictions once intertwined with each other. Throughout the 19th century, opiates were the standard therapy for the treatment of acute pain and recurrent pain caused by injuries, such as headaches or toothaches. In the late 19th and early 20th centuries, the invention of syringe injections and cough drugs heroin led young Americans to discover that pressing painkillers into powders or injections could provide unparalleled dopamine pleasure, recreational abuse and addiction, and even overdose deaths. The outbreak of the number of "addicts" on the streets was of great concern to the medical community, which led to the harrison Narcotic Act in 1914. Since then, opioids have been regulated for a long time.
Pandora's box was temporarily closed. But after the 1970s, the medical community began to pay more attention to hospice care, and opioids became the ultimate comfort for terminally ill patients and were recognized by WHO. Later, the American Pain Association launched the "Pain as a Fifth Vital Sign" campaign to advocate for people to value chronic pain. In 1995, OxyContin developed and produced by Purdue Pharmaceuticals was officially listed with the approval of the US Food and Drug Administration (FDA). It has been hailed as a medical breakthrough: OxyContin is the first extended-release formulation of oxycodone, which is said to be effective for up to 12 hours, and is expected to treat chronic pain.
Oxycodone, a semi-synthetic opioid component that is chemically close to heroin, is twice as potent as morphine. This powerful potency once made doctors so frightened of its addiction that they were only willing to apply it to acute cancer pain and hospice treatment. While OxyContin is slow to release its effects, its risk of abuse is considered to be much lower than other opioids, so it is approved for chronic pain.
"The delayed absorption mechanism provided by OxyContin tablets is believed to reduce the risk of substance abuse." The FDA approved Purdue Pharmaceuticals to use this line in the label of the bottle, and a similar statement never appeared in previous descriptions of similar narcotic controlled drugs. The "endorsement" from the official indicates that AuschContin will be smooth sailing after its listing. As a "blockbuster" drug, OxyContin reportedly brought about $35 billion in revenue to Purdue Pharmaceuticals.
However, OxyContin opened the dark floodgates of the opioid crisis: by the end of the 1990s, a large number of addictions and abuses had already emerged. The crisis first emerged in appalachia. The area, which includes northern Georgia, northern Alabama, and northern Mississippi, is a traditional Coal and Forestry District in the United States with a large number of workers engaged in heavy manual labor.
The Appalachian region is the first stop for Purdue Pharmaceutical to enter after receiving the "endorsement" of the FDA. Purdue bought prescription files from chain pharmacies and insurance companies, obtained information on which towns and cities doctors prescribed the most painkillers, and looked for communities with severe levels of poverty, lack of education and opportunities, and the Appalachian region, which was nearly depleted of resources and had a large number of patients suffering from long-term work injuries. Once the goal was set, Purdue's medical representatives would visit these village doctors attentively and persuade them to prescribe more OxyContin, such as Dr. Fenix in The Addictive Dose. Samuel Finnix) experienced that they would offer doctors free dinner parties, as well as countless small benefits not mentioned in the show: thanksgiving turkeys, and even filling the tank with oil.
With its high potency, high satisfaction, and cheap short-term prescriptions, these village doctors began to believe they were helping to relieve the pain of poor people. Unfortunately, "miracle effects" come with drug resistance, from drug dependence to addiction. Later government investigation documents revealed this mechanism of addiction: the efficacy of OxyContin could not be maintained for 12 hours, and even patients who took the drug according to the doctor's instructions had to reduce the interval between taking the drugs, otherwise they would suffer huge fluctuations in pain sensations, indirectly increasing the dose and increasing the risk of addiction. Purdue invented the term "pseudo-addiction" to deal with it, that is, the disease was not cured so that patients still needed the drug, and Homeopath introduced a larger dose version of the pill: from 10mg, 20mg to 80mg, 160mg.
Such abuses spread in appalachian regions. Beth Macy, author of "Addiction: Dealers, Doctors, and the Drug Company that Addicted America," the original "Addiction Dose," wrote that the first town cop she interviewed said he could easily spot orange and green stains on the shirts of townspeople walking down the street. Orange is the color of the 40 mg release layer of OxyContin, and green is the color of the 80 mg release layer. These drug abusers hold the drug in their mouths to soften the release layer (reminiscent of the trick of the squid game in the Squid Game) and then rub the softened relief layer on their shirts. This way, they can get the pleasure that the whole drug can provide at once faster. These abusers also learned to grind Oxycontin into powder and suck it — the same way they used heroin.
OxyContin became "country heroin". And people really recognize that this development has become a crisis, coming from a skyrocketing crime rate. In calm towns with fairly low crime rates, people began to loot, destroy public facilities, and even murder. Addicts broke into houses with Oxycontin bottles and even went so far as to kill their owners.
Addiction to prescription opioid analgesics like OxyContin can easily escalate to a more devastating opioid addiction, such as heroin addiction. According to a 2014 paper published in jama Psychiatry, the Journal of Psychiatry, the American Medical Association, 75 percent of people who received heroin withdrawal began by abusing painkillers. The paper also points out that the important reason for people to switch from prescription opioids to heroin is not because the latter provides a more intense pleasure experience, but because it is more readily available than prescription opioids. The mix of the two also makes death more likely to occur.
This is almost exactly the portrayal of the tragic career of Betsy, a young miner in the town in "Addiction Dose": her addiction to OxyContin led her to sell OxyContin for smoking, and in the absence, she began to smoke heroin, fell into various crimes in exchange for drugs, and eventually died of an overdose. In reality, drug dealers from Mexico took over the "Oshcontin Zone" with inferior, lethal black tar heroin, and rural whites became the new group of addicts — as well documented in the american journalist Sam Quinones' documentary book Dream Addiction: The Truth About the Opioid Epidemic in the United States.
But we must recognize that "addiction" is not the original sin of painkillers. Admittedly, Purdue Pharmaceuticals' repeated concealment of OxyContin's addiction and abuse problems is indeed extremely heinous, but the rate of addiction in patients with chronic pain for a long time is not as sensational as in the story. In 2016, Nora D. Volkow, director of the National Institute on Drug Abuse, noted in his paper that when patients get a proper diagnosis, the rate of addiction to long-term opioids to treat chronic pain is less than 8 percent. For advanced patients and some people with chronic pain, opioids may be their only source of pain relief. As a result, authoritative medical experts, such as Sean Mackey, a pain expert at Stanford University, are more worried that people, out of fear, are dominated by "Counterfactual thinking", no longer see pain as a "real problem" that needs to be treated, and go back to the era when suffering is taken for granted, which undoubtedly throws up to 100 million chronic pain patients in the United States into darkness.
From body to mind:
Pain, as a systemic disease
What is pain?
Pain is a disease recognized by WHO. The World Health Organization has included pain in the International Classification of Diseases (ICD) and divided acute and chronic pain into acute and chronic pain within three months of the course of the disease. The International Society of Pain currently defines pain as: "Pain is an unpleasant feeling and emotional experience associated with actual or potential tissue damage, or an experience similar to this.".
In fact, being able to recognize that suffering is not only related to the body, but also to the mind, is the hard-won crystallization of the progress of human civilization. In the past history of mankind, both East and West, the expression of pain and shame has been highly correlated. In the West, suffering is considered a religious crucifixion; in the East, forbearance is considered a noble virtue, and Guan Yu's story of "scraping bones to heal wounds" has always been praised.
Until modern times, people still have a high degree of skepticism and disdain for patients who cannot find specific physical lesions, but claim to be in excruciating pain: in an extreme case, in 1862, an American soldier was crushed in a railroad accident, and after amputating a small part of his limb, he still claimed to have strong pain, and under the anxiety and suspicion of not being able to find the lesion, the famous surgeons at that time amputated his leg one after another - all the way to the buttocks, and finally claimed that the patient was pretending to be ill because he was eager for opium treatment.
It was not until the advent of modernity, which focused on individuality and individual experience, that people began to think that pain was an individual experience, and that alleviating suffering for the individual was a moral act. In particular, in the 1960s, nurse Cicelli Sanders vigorously promoted late hospice therapy in the UK and established an exemplary hospice facility to help patients through their last difficult days with a variety of means including powerful analgesics ("a mixture of heroin, morphine, and gin").
Clinically, people are becoming more aware that pain is a complex problem, not only physical and mental, but also closely related to quality of life and social systems, and the concept of "pain management" centered on the individual patient has begun to emerge. Chronic pain, in which no specific lesion can be found, is the most complex manifestation of this complex problem. Reading Harvard Medical Anthropologist Arthur Kleinman(sometimes translated as "Kai Bowen"), based on more than two decades of clinical experience, the story of pain: suffering, healing, and the human condition helps us understand this question.
Kebbervin agreed with the American community's view of chronic pain at that time: that chronic pain was a major public health problem and increasingly became a common cause of disability. But in his 1989 book, he predicted that medicine is "dangerous" for treating chronic pain: the pharmaceutical industry makes addictive narcotic analgesics and produces compounds with serious side effects; doctors overuse expensive and risky tests on patients and perform unnecessary and seriously injurious surgeries. He believes that this can only make patients feel antagonistic and indignant about medicine, and frustrated and frustrated.
In Kebvin's view, somatization is the main mechanism of action of chronic pain. The reason why doctors find it difficult to find the lesion is that chronic pain is more from the pain in the psychomotive, the pain projected into the body. To understand this, it is necessary to have a comprehensive understanding of the patient's own case, as well as his situation and the social relations in which he finds himself.
Kebwen illustrates this in detail with his clinical case: He interviewed a Dr. Shuye who had a long history of abdominal pain, and through detailed conversational interviews, learned that the deep causes of the patient's suffering were the decline of class and the pressure of being a minority. From this, Kebwen leads to what he understands to be the deeper mechanism of chronic pain: the vulnerable in society who are under greater stress and lack of support systems have to endure a vicious circle of injustice and inability to change bad situations, and can only do nothing about it. "These local scenes create or deepen feelings of hopelessness and generalize that feeling, expanding from specific problems to whole lives, creating pain, depression, and despair." Kebberman writes, "Chronic pain symptoms that would otherwise be caused by biological injury or disease are exacerbated and prolonged by these unfortunate vicious cycles." ”
Therefore, he believes that to cure chronic pain, it is important to study it as a way of life. For "for some people with chronic diseases, pain and suffering have a greater bearing on life— especially with the darkness and fear of life, and thus negate aspects of life —than with the disease itself." Doctors need to listen to and find the pain of life behind the pain of the patient, and change this pessimistic interpretation of the continuous cycle of meaning in life.
Kebvin's views are undoubtedly extremely insightful. Nearly three decades later, medical experts have found that the neglect of the psychetric pain of patients with chronic pain by frontline physicians has contributed to the indiscriminate issuance of opioid prescriptions. In 2015, two physicians, Jane C. Ballantyne and Mark D. Sullivan from the University of Washington, published an article in the New England Journal of Medicine titled "The Intensity of Chronic Pain: The Wrong Measure?" The Intensity of Chronic Pain—The Wrong Metric?) paper argues that lowering patient pain intensity scores has become a major goal for U.S. physicians today, which has directly contributed to the widespread use and rising dose of opioid painkillers. And they question that lowering a patient's pain index is not necessarily a better option for patients. "The pain intensity score is not necessarily a reflection of tissue damage or sensory intensity in patients with chronic pain." They point out that humans (such as athletes) may endure extreme pain in pursuit of important goals, but for chronic pain patients who have experienced less pain for a long time, the pain may be more unbearable, because the pain caused by persistent feelings of helplessness and hopelessness may be the root cause of pain in chronic pain patients.
In line with Kai Bowen's view, the two doctors believe that doctors should pay more attention to the pain of the patient's mind than to the pain. Taking it a step further, they explain its biological mechanisms with forward-looking neuroscience: The sensation of pain is initially associated with the brain regions of the "pain matrix" in the brain, but later to the brain regions involving emotions and rewards. Over time, the association between the intensity of pain and the perception of pain decreases, while the association with emotional and psychosocial factors increases. This explains that opioid therapy is the least likely "bad option" for chronic pain patients with pre-existing mental health and substance abuse problems. These patients, who already have mental health problems, are vulnerable to long-term opioid treatment, followed by drug abuse, and experience adverse drug effects that lead to emergency visits, hospitalizations, and deaths.
Therefore, they also point out that the most important thing in treating chronic pain is to help patients understand the source of pain, and when patients can understand pain and the pain generated by it is no longer an invincible threat, the patient's anxiety can be reduced and they can re-engage in valuable life activities. "There is nothing more convincing and therapeutic than communication between patients and clinicians," and the two physicians encourage clinicians to listen to their patients to understand their patients' experiences and give "compassion, encouragement, guidance, and hope."
But as mentioned earlier, pain as a complex systemic disease, a more effective way to treat pain is to really improve the social construct in which the individual lives, which is what Kai Bowen refers to when analyzing the chronic pain of dr. Kyopjen. In his 2008 book, The Social Roots of Pain and Disease: Depression, Neurasthenia, and Sickness in Modern China, he explains in greater detail why, in his view, the "local scene" of power is the social root of human suffering—which leads to unequal distribution of resources and the inequity of the influence of large-scale socio-political, economic, and ecological forces that put "specific groups of people under maximum social pressure." In this multi-hierarchical system of family, social network, work, and community, illness and mental suffering are largely the consequences of an individual's place in the local cultural system, especially a network of relationships.
While Kebvin argues that the involvement of psychiatry, public health, and social work has the potential to slow or even break the vicious circle of "local environments," i.e., to systematically treat individual pain, such interventions ultimately "must be accompanied by social change to be effective."
Kebwen predicts the closeness of the link between people's pain and social problems. As Nobel laureate Economist Angus Deaton and his wife Anne Case coined the term "death of despair" in an influential 2015 paper. They found that, with the exception of war and epidemic periods, the world's population has been declining for decades, and against this backdrop, the mortality rate among middle-aged white Americans has been rising sharply since 1999. White men and women of working age without college degrees are dying from suicide, drug overdose and alcohol-related liver disease so quickly that life expectancy in the U.S. population has fallen for three consecutive years. They called it a "death of despair" and attributed it to the loss of social capital caused by rising economic inequality and job instability. Deaton and Case also linked it to pain, arguing that this explains why data surveys show that middle-aged whites in the United States have had much higher pain rates than people in 30 other wealthy countries over the past three decades, and ultimately provide an explanation for so many opioid overdose deaths.
Managing Pain:
How do we get along with pain today
In fact, pain in China is not a problem of overcorrection, but a problem that is not taken seriously enough. According to the China Pain Disease Development Report (2020), there are more than 300 million chronic pain patients in China and are growing rapidly at a rate of 10 million to 20 million per year. However, most people, even doctors, do not recognize that chronic pain is a disease in itself. The development of pain medicine in China is less than twenty years.
In 2006, 18 academicians of the Chinese Academy of Sciences, including Han Jisheng, jointly wrote to the Central Committee calling for the establishment of a pain department in China. The following year, the Ministry of Health issued Document No. 227, which allowed eligible hospitals above the second level to apply for the addition of pain departments, and China had pain medicine. However, to this day, it is still rare for chinese hospitals to open pain departments. According to the "China Pain Disease Development Report (2020)", only a few hospitals in first-tier cities such as Beijing and Shanghai have opened separate pain departments, accounting for less than 40%.
The International Association of Pain emphasizes that unresponsive pain is widespread not because of the lack or backwardness of analgesic techniques, but because of the lack of a sound pain management system. Therefore, the "China Pain Disease Development Report (2020)" calls for the establishment of an effective pain management system, so that pain specialists can form a medical association with other departments, and through hierarchical diagnosis and treatment, sink into the community, from pain screening, diagnosis, assessment, treatment, rehabilitation and other aspects, the whole cycle of pain patients management.
In the existing international pain management system, the treatment of pain has long been not limited to the analgesic treatment of painkillers, from interventional treatment of nerve block, physical rehabilitation, pain psychology, yoga and other complementary alternative therapies to self-management.
Self-management of pain does not mean that the self learns to endure pain. Enduring pain is actually a very unhealthy option. "Sustained pain stimulation can cause central sensitization, and after central sensitization, the neuronal sensory threshold for pain stimulation decreases, increasing the intensity and duration of pain." The "China Pain Disease Development Report (2020)" wrote so. Self-management of pain does not help pain sufferers eliminate pain, but it can learn skills to manage the pain they face, help them live a more productive, social, and productive life, and regain control of their lives.
In writing the National Pain Strategy on behalf of the U.S. Department of Health and Human Services, Sean McKee, a pain expert at Stanford University mentioned earlier, emphasized that self-pain management can improve quality of life and is therefore an important component of acute and chronic pain prevention and management. The role of the healer has tended from being a physician to a facilitator, helping pain patients identify clear functional goals, such as returning to work, supervising, and helping them achieve their goals step by step. McKee sees this as an important way to help break the vicious cycle of chronic pain, and people are like toddlers who learn about their bodies and gradually adjust and control their ability to partially recover from pain.
He pointed out that pain education and health education are the key to this. By learning about pain and health, people can better understand and accept their situation, the actual pain will become much lower, and the quality of life will be greatly improved. But McKee also emphasizes that self-pain management does not mean rejecting medication altogether, but rather that it is scientific: taking medication on time, not just when you feel pain, which only brings about a "roller coaster" change in the level of medication in the body.
Exercise is also a good option to help manage pain. Studies have shown that the benefits of exercise for pain relief far outweigh other assistive treatment modalities, such as massage and stress management. Contrary to what most people recognize, "resting" without exercise tends to enhance the sensitivity pathway of pain, and exercise tends to reduce pain immediately and raise the threshold of pain that people feel.
People don't need to be stuck in specific types of exercise. Swimming is considered by many people with chronic joint pain to be quite helpful in relieving their pain, which is quite friendly to their joints. Yoga and tai chi are also considered useful by some pain sufferers. Finding the right sport for you is the most important.
But be careful not to be too hasty. For people with chronic pain, pain is easily exhausting, and the energy bandwidth that can be used for daily life is quite limited. As author Christine Miserandino proposed in order to explain how chronic diseases affect her daily life, the total amount of energy of chronic patients in a day is likely to be only 12 spoons, small tasks such as dressing will cost one spoon, and large tasks such as cooking will cost three or four spoons, so they must use their energy very carefully. So, for patients with chronic pain, overexertion means overexpending energy and even increasing their pain. Pain experts advise you not to exercise for more than two hours and not to put too much pressure on yourself, even if it is beneficial to walk the dog or take a walk.
Getting more interpersonal support is also key. Michael Clark, a psychiatrist and director of the Pain Treatment Program at Johns Hopkins Hospital, notes that about one-third to three-quarters of chronic pain patients experience moderate to major depressive disorder. The combination of pain and depression makes it easier for patients to experience the breakdown of interpersonal relationships, and even the relationship with relatives can become tense. Antidepressants are useful for these pain sufferers, but experts encourage them to be more proactive in unblocking their hearts, seeking more interpersonal support, and even starting a new relationship. A study led by McKee showed that a newly initiated, intense, passionate love relationship can even mobilize the nucleus accumbens like opioids, providing amazing analgesic effects.
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