Chapter 10: Pain Management and Opioids: Today and in Historical Perspective

Chapter 10: Pain Management and Opioids: Today and in Historical Perspective

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Description

In this chapter, Dr. Hill explains that American culture does not easily distinguish between the abuse and legitimate use of opioid drugs. He summarizes points he made in an interview he gave for the television program, 60 Minutes related to a controversial colleague in pain management, Dr. William Hurwitz. Dr. Hill explains that misunderstandings about the nature of what addiction effect physicians, pharmacists, law enforcement agents, media and, of course, patients. To set context for this discussion, Dr. Hill sketches the history of drug regulations and the study of pain, going back to the Civil War (and the understanding of phantom pain), describing pain and pain control mechanisms (e.g. the ‘gate theory’) in vivid terms. He tells several stories about patients grappling with pain (at times to the point of suicide attempts), and the treatments he explored to ease their suffering.

Identifier

HillCS_02_20120217_C010

Publication Date

2-17-2012

City

Houston, Texas

Topics Covered

The Interview Subject's Story - Overview; Cultural/Social Influences; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; Critical Perspectives; Overview; Definitions, Explanations, Translations

Transcript

Tacey Ann Rosolowski, PhD:

Maybe could you outline—since we’ve gotten to that issue, really kind of in our face right now about the cultural and social barriers against these drugs. What are some of the larger problems, the ones that come from outside of the hospital or clinic setting, that have prevented adequate pain management, the greasy watermelon stuff?

C. Stratton Hill, MD:

Well, My Word Against Theirs deals with that. We were lucky to have a young lady who had worked for one of the TV stations here, so she was able to get clips of a narcotic raid. So one of the things that— And I got one of the anchors from the TV—she got one of the anchors from one of the TV stations. He’s dead now, but he narrates it. She’s the one that would say, “Say the word, say the word, say the word,” and so one of the things that I say and probably the most—well, I don’t know what the most is, but one of the major problems is we don’t distinguish between the abuse of these drugs and the legitimate use. You hear guys on television now still perpetuating all of this confusion between someone who—particularly here, when you’ve got this Whitney Houston. It’s like “They ought to put those doctors in jail that gave her this medication.” And so that’s what I’ve been preaching all this time, and My Word Against Theirs—I mean—the 60 Minutes is about this Dr. William Hurwitz. That’s what this is all about. And at the end of that 60 Minutes thing, they have a guy who was a patient of Hurwitz, who was able to get him under control, and then when they pulled his license, the guy had been trying to get a doctor for years and years and years, and he couldn’t. He finally got one, and he says, “I finally get a doctor and what do they do? They take his license away from him.” He said, “I don’t want to commit suicide, but I’m at my rope’s end,” or something like that, and he did commit suicide.

Tacey Ann Rosolowski, PhD:

And this was because Dr. Hurwitz was willing to prescribe the medication.

C. Stratton Hill, MD:

Right, he was. I got involved with him long before. That was in 1996. I first got involved with him in 1991. He had prescribed— And he got into it with the usual non-information about how to treat pain from his medical school. He got his license taken away from him by the Consumer Regulation Board or whatever it is in Washington, DC. He practiced in that area. In this tape, they’re interviewing the people from the Virginia Medical Board because he then moved his practice over into Virginia and practiced in that Washington area and the Virginia board took the license away from him and also of the pharmacist who filled the prescriptions. And his first encounter was a patient who had bilateral aseptic necrosis of both hips, and he was about 30 years old. He needed hip replacements, but nobody wanted to do hip replacements on him because they considered him to be too young. They didn’t know how long these hip replacements were going to last at the time, and so they wouldn’t do them on patients like that. So Hurwitz gave him enough medication to control the pain, but he used a drug that is a combination of oxycodone, which is the narcotic that’s in OxyContin that got such a bad name later on. He combined that with acetaminophen or Tylenol, and in the old days, people didn’t realize that—they’d say, “Well, take two of those,” and there would be 5 mg of oxycodone in that pill along with, say, 325 mg of acetaminophen. And then they’d say, “Take two of them.” Well, that gave them 10 mg of oxycodone and then whatever, 650 mg. Then they’d say, “Well, you still got pain, take another one.” What he did, he continued to up that dose, and he got toxicity from the acetaminophen, not the narcotic. See, what people don’t realize, narcotics are the safest drugs that we have in terms of organ toxicity. They don’t have any organ toxicity. It doesn’t do anything to the brain. It doesn’t do anything to the heart, the liver, the kidneys, but where you get into trouble is the amount of acetaminophen that’s in the combination drugs. So he produced a chemical hepatitis in this guy, and they had to take him off of that. Then they finally got somebody to operate on him, and the guy got off of all drugs. They had another patient who was in the Foreign Service, and he had a pain problem. Hurwitz would send him these drugs all over the world, and so he got into trouble with that. That’s how he got into trouble the first time, and then the second time was when he was writing for the medication in northern Virginia. This one pharmacist was filling it all, and you’ll see all that in the—and that’s what this is all about is the cultural part of what’s gone down on this.

Tacey Ann Rosolowski, PhD:

So one of those cultural elements is the myth that narcotics are very easy to abuse, and they’re thought of only as drugs of abuse, not drugs of treatment.

C. Stratton Hill, MD:

It’s a misunderstanding about what addiction is. The World Health Organization took that word out of their lexicon in about 1960 or 1950, maybe. It’s either a physiological dependency or psychological dependency.

Tacey Ann Rosolowski, PhD:

So they don’t use the word addiction.

C. Stratton Hill, MD:

No. Physiological dependence occurs in everybody who takes these drugs chronically because the cells adapt to the presence of this drug in the system. When you take them away, there’s a physiological response, so-called withdrawal response, or abstinence response, cold turkey and stuff like that, and you have the physiological reaction by your body. All you’ve got to do to avoid that is just to taper them off of the drug, and so physiological dependency is no problem. Psychological dependence is when you have a compulsion or a craving, or both, to take the medication or take the drug or take anything when you know full well it’s going to cause you harm. That’s the so-called addiction. The complexity of what goes into that entity is not well understood. We think that— Our society thinks that if you take this drug, you will ineluctably be drawn into addiction and fall over the cliff into a depraved antisocial behavior, and you have no control over that, that in spite of all that you can do, that’s what’s going to happen if you take that, and it happens 100 percent of the time. That’s crazy. Most people who take these drugs do not get euphoria. They get dysphoria. They don’t like it. They don’t like the way it makes them feel, and so the vast majority of people who take the drug do not become psychologically dependent on the drugs. Now, physicians have—are somewhat responsible for some of this because they don’t—these drugs have more than just euphoric or mind altering properties. They relax people. They’re anti-anxiety drugs, and so you can have anxiety, and that relieves that. Your pain goes away, but you still have anxiety, so you say, “Well, I still need this drug,” so you get the narcotic. It’s up to the doctor at that point to say, “Wait just a minute. If you’ve got anxiety, tell me how you feel. What is it that’s bothering you? Your pain has gone away, so what’s the problem?” “Well, I just get all jittery. I get nervous and so forth.” “Well, okay, fine. Let’s give you something else for that. Let’s give you an appropriate drug.” You get some people who take cough medicine that’s got hydrocodone in there. You’ll say, “How long you been taking this cough medicine?” “I’ve been taking it two years.” “Two years? Have you got a cough?” “Well, yeah.” They’re not going to tell you they don’t have a cough because they’re afraid you’ll cut them off, but nobody has stopped to ask them. They just refill it, refill it, and refill it. Then you have to look at the history of drugs. Before the Food and Drug Act, which came into being in 1906—and all that did was to say that you had to say what was in drugs. You could put anything you wanted to in there, but you just had to say what it was. One of the things that they had was they had rectal suppositories that contained opiate, and of course, people got dependent on opium, and they would take rectal suppositories forever. And so when they said you’ve got to take that out of there, they didn’t like that. See, you didn’t get the Harrison Narcotic Act until 1913, so how we got control of drugs is a very fascinating story, and that’s what David Musto researched in his book. He tells about that. It all came about after the Spanish-American War and the turn of the 20th century, right about 1898 or whenever that war was. And we got— From Spain, we got the Philippines. We got Puerto Rico. I think that’s supposedly the least costly war in terms of men killed. I think there was like 350 or something like that total, and then we got all that property. When we got the Philippines, there was an Episcopal bishop. His name was [Charles] Brent, and he was sent to be the Episcopal bishop of the Philippines, and the governor of the Philippines was William Howard Taft. When they got there, one of the things that they realized was that Spain was giving out opium to the Chinese that lived in the Philippines, so that meant that the government was in the opium business. Well, that didn’t go over too well with this bishop, so he goes to Taft and says, “Hey, we’ve got to do something about this. We don’t want to be in the drug business.” Before that, you could bring anything you wanted to into the United States. You could put it into medication. There was no control at all. So Taft then said, “Well, if we’re going to do this”— Well, of course, they were held up from doing anything until the insurgency got over because the Filipinos thought we were just going to get rid of the Spanish and give them the Philippines, and we didn’t do that. So there was about 10 years of insurgency in there. After all that was over, then they decided that we’re going to go in there and set up things and find out all about this opium. Taft said, “Well, you’re going to have to go see the British because they run India, and that’s where all the opium comes from that goes into China.” That’s where the Opium Wars all came from. Then that means it’s in the Department of State. So he did all that, and the British said, “You must be joking. That is the main cash source for India is selling opium. You think we’re going to stop that? You’re crazy.” And he wanted him to regulate. He says, “Well, we’ve got to regulate this all over the world.” Then they said, “Well, wait a minute. You don’t regulate that in the United States. You’re coming to us and saying we’ve got to regulate things?” Then by that time William Howard Taft was president, so he was pushing to get this done. That’s when it started all this business with The Hague and the World Councils, and they decided to set up treaties. It’s a long, complicated story, but it never worked. However, we did get drug controls in the United States. The Harrison Narcotic Act was passed in 1913 and then even in that— I had a student one time. He was researching all of this. He was a law student. They had a combination program—they still do over at the School of Public Health—where you can get a Master’s in Public Health and a law degree at the same time. He researched all of the congressional records of the arguments during that time. A lot of the senators were saying “Hey, wait a minute. We don’t want to stop the legitimate use of these drugs. We’ve got to be careful about this,” and so forth.

Tacey Ann Rosolowski, PhD:

They foresaw the problem back then.

C. Stratton Hill, MD:

Well, that’s right, that this would be a problem. The Harrison Narcotic Act, nobody paid much attention to that, and so it was just a can of worms. The Public Health Service ran some addiction clinics where people who declared that they were drug addicts could come and get that from the US Public Health Service. They didn’t close that down until the late ‘30s.

Tacey Ann Rosolowski, PhD:

Interesting, so all those things contributing—

C. Stratton Hill, MD:

All of this stuff has contributed, and if you go back and look in the literature, before the discovery of ether, the American Medical Association was coming up with a behavioral program where if you’ve got to have surgery, just expect to be held down to have the surgery. And so this guy, anthropologist, deals with that some in here.

Tacey Ann Rosolowski, PhD:

I was going to ask you about the flip side, when you and others at MD Anderson were collaborating to set up the pain clinic and beginning to do some real treatment, because there’s the cultural image of the drugs that you were using. But what about the theories of pain? What was the understanding about how pain worked in the body at the time?

C. Stratton Hill, MD:

Well people were getting—I mean—physicians were seeing more of neuropathic pain. They knew that people who had usually motor vehicle accidents or trauma where if they got those old washing machines that had the roller to dry—

Tacey Ann Rosolowski, PhD:

Oh, yeah. The hand crank.

C. Stratton Hill, MD:

People would get in the wringer, and they would pull avulsive injuries from things like that and getting into machinery, industrial accidents. What happened there is you would pull the nerve away from the spinal cord, maybe not completely, but almost completely. Well, then you got a condition that was called at that time reflex sympathetic dystrophy, and that is horrible. People would get that. Now they call it complex regional pain syndrome because it’s more than just the sympathetic nervous system involved in that. People with that oftentimes committed suicide. It was just intolerable pain, and that is one reason why they said everybody— When the Civil War came along, they said that was the first time that they really had morphine, and they just invented the hypodermic syringe. That was the first time that they were able to give morphine parenterally by injection. That’s a long story, too, because those cannons, the ball did not explode. They didn’t have anything like that. If you hit somebody— If a cannonball hit you, it generally mutilated you. In other words, you hit the arm, and it would just knock the arm off, and of course, that just pulled all those nerves out there. I’ve researched that, and I’m convinced— And of course, then they said after the Civil War, everybody came home addicted. They were drug addicts. They were dope fiends. That’s what they called them. They were just in all kinds of pain, and it was neuropathic pain. They even had what they called stump hospitals. Do you have any idea what a stump hospital is?

Tacey Ann Rosolowski, PhD:

For the amputees, I assume, or no?

C. Stratton Hill, MD:

How many amputees? How many extremities?

Tacey Ann Rosolowski, PhD:

I have no idea.

C. Stratton Hill, MD:

All four—all four extremities gone. There were enough people to where they had just hospitals for those people, and they were called stump hospitals. They got perfect descriptions of neuropathic pain that these guys— And there was a guy named Weir Mitchell.

Tacey Ann Rosolowski, PhD:

Yes, Silas Weir Mitchell.

C. Stratton Hill, MD:

Yeah, and he was the first one to—and he called that causalgia. That was basically phantom pain, and he was the first one to really describe that. But see, the misconception from a medical point of view and not understanding neuropathic pain, wait a minute, you’re all healed up. You don’t have an arm or a leg, but you’re all healed. There’s nothing there that could cause you that pain. So they didn’t understand that. They didn’t understand phantom pain either. It was causalgia. You’ve got a pain in the foot you don’t have. You must be crazy. That’s another thing that I call atypical complaint. I’ve got a pain in my right foot. Where is your right foot? Well, I don’t have it. The guy’s crazy.

Tacey Ann Rosolowski, PhD:

Of course, now we understand—a neural understanding of how the brain is wired.

C. Stratton Hill, MD:

Yeah, that’s right, and not only that, then he’d say, “Where is your right foot?” “Well, it’s sticking right out front there, and I sure would like to just relax it and put it in its normal place.” They have an image that it’s in this abnormal place. There’s a guy that was a good friend of mine, Dr. Ronald Melzack. He and this guy, Pat Wall, came up with the gate theory of pain. That’s a whole other subject, but that’s the accepted theory of pain at the moment.

Tacey Ann Rosolowski, PhD:

And what does that say?

C. Stratton Hill, MD:

Well, that says basically if there is an impulse going in one pathway, that it will block another impulse from coming in there. This would be theoretically maybe the mechanism for acupuncture. Nobody knows what that is. It’s about endorphins, gate theory, things of that sort.

Tacey Ann Rosolowski, PhD:

Isn’t that also the logic behind those hot and cold rubs you put on the body? To make the body—

C. Stratton Hill, MD:

Oh, yeah, or just rubbing. See, in other words, you are stimulating—you’re sending a message up for the brain to handle, and you’re blocking these painful stimuli from getting in there. So that’s what the gate theory is, and you can have that either going up to the brain, or the brain can send messages down to block that area from coming in there. It’s sort of like if you got the freeway from here to Dallas, and Houston says, “I’m going to stop the people from getting on the freeway in Dallas,” and it’s because of something up here. That was a whole other thing that happened with this Civil War. The other part of it was infections. Boy, they got infections like crazy, and they’d have to amputate. Then when the North blockaded the South, there was an article that they think was written by Weir Mitchell in the Atlantic Monthly or Saturday Review or something. I’ve forgotten the guy’s name. But anyway, he became a stump, and so he describes—that’s why I guess they think it was written by Weir Mitchell, because he described the pain. Now, the guy may have described that to Weir Mitchell but—

Tacey Ann Rosolowski, PhD:

I think I remember reading about that, and I can’t remember if it was narrated or if it was a fictional thing by Weir Mitchell.

C. Stratton Hill, MD:

Yeah, I’m not sure. I’m not sure anybody knows, because it was in either— I think it was in the Atlantic Monthly. Actually, I have that someplace. He described this pain, and the description that he had was— I wish I could remember the exact quote. Something to the effect that my hand was basically dead except for the fire that was in the fingers. He couldn’t feel his— He’d been shot in the nerve up here, and he lost the sensation. He couldn’t feel the hand, but one of the descriptions of neuropathic pain is burning sensation, and he talked about that, and that was really a beautiful description of neuropathic pain.

Tacey Ann Rosolowski, PhD:

And that’s descriptions that you’ve heard from patients that you’ve worked with, too?

C. Stratton Hill, MD:

Well, not as poetic as that. I wish I could remember that. I think I’ll try to look that up just to try to remember it, but, oh, yeah, burning pain is almost pathognomonic of neuropathic pain. And then, see, you’d have other— The other part of it is we saw this in women who had mastectomies, post mastectomy syndrome, post thoracotomy syndrome. I had this one patient, a young woman, and this was just a problem that we were up against. Some of the residents from Hermann would rotate through our service, and they had one anesthesiology resident from over there with a female. I sent her to see a consult in the plastic surgery clinic because she was 28 years old and had breast cancer, had the breast removed, but they had made her a new breast with a flap and so forth. It was an absolutely beautiful job, absolutely beautiful. She had nothing in terms of deformity. Both breasts looked the same, no scars. She looked fine, but she was complaining of this terrible pain. Her surgeon, the plastic surgeon, didn’t have a clue. He didn’t have a clue, and she was just beside herself. And of course, then she had a mother-in-law who when she was complaining of this pain, she said that the mother-in-law would say, “Well, Betty had that, but she never had anything like that,” like it’s all in your head. I explained to her what it was, and I said, “Look, I think you ought to come in the hospital and let us try to get this straightened out because it’s not going to happen right overnight. It takes a while for this medicine to take effect,” because we know now that the neurotransmitters, basically the hormones that transmit the nervous impulse, have to readjust themselves, and you have to get a bigger concentration of a different one, and then it takes a while for this medicine to do that. She said, “I can’t do it. I’ve got to go home. I’ve got to take care of my son.” She lives in Fort Worth. I said okay, so she went home, and about 10 days later I get a call from a psychiatric hospital in Fort Worth that she’d made a major attempt to commit suicide. They said, “She’s okay now. Will you take her?” And I said, “Yeah, we’ll take her.” We brought her back, and we got her straightened out. I kept seeing her for—then she got—she then developed cancer in the other breast, and then she developed metastatic cancer. All of that was treated. I remember she felt this lump in her other breast, and so they said, “Okay, we need to get an ultrasound,” and they couldn’t do it for four or five days. She comes up bawling to me in my clinic and saying what’s going on, so I go down and talk to the guy in the ultrasound clinic to see if I can get in. He says, “I’ll take her tomorrow,” so he took her, and she got treated. She got treated, and she was one of the ones that I was still seeing when I left in 1996. She was 15 or 20 years after her diagnosis and so forth with all that problem. But after I explained the first time, she said, “That’s all well and good, doctor, but give me something for my pain.” And I said, “I’m telling you, we don’t have anything to give you. You need to stay here. We can give it to you in the hospital to make you better, but it’s not going to be better until—and we can actually give you this stuff intravenously. You can’t take it on the outside.”

Tacey Ann Rosolowski, PhD:

What were you giving her?

C. Stratton Hill, MD:

We were giving her an antidepressant, amitriptyline or nortriptyline, and we would put her on a PCA pump at that time. And we would give her some morphine, but we knew that that wasn’t going to do it by itself, and we could give her intravenous amitriptyline, too, in the hospital. Anyway, that’s the type of patients that we— Well, she had a terrible time getting anybody to refill her medication. She couldn’t get it refilled in Fort Worth. She had to come back, and I’d write it, and I made arrangements so I could fax a prescription or mail it up there, because we had triplicate prescriptions for that.

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Chapter 10: Pain Management and Opioids: Today and in Historical Perspective

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