Long Term Chronic Pain Management: the Realities of Heroin

Long Term Chronic Pain Management: the Realities of Heroin. 

Few medical conditions have been handled as poorly as long term chronic pain. For starters, we often fail to clearly define pain, or it’s causes, or how to treat it. We all know pain is unpleasant. Depending on the level, the pain may become insufferable. Pain always hurts—no hurting, no pain. Pain can be physical in origin or mental in origin. Either way the result is unpleasant. There are regions in the brain which originate the sensations of pleasure, and regions in the brain which originate the sensations of pain. The ‘feeling’ about pain is one thing, the perception of it is another. 

Physical pain mostly originates when body cells are damaged, and these cells release chemicals which stimulate pain nerve endings, thus sending messages to the brain. Different areas of the body have different concentrations of pain nerve endings. The brain itself has no pain nerve endings. So our brain can’t hurt, although the membrane around the brain has pain nerve endings and brain swelling can activate them. A patient can be fully awake as electrodes stimulate different areas of the brain and this helps identify which brain regions do what, but no matter what part of the brain is stimulated the person never feels pain in the brain itself. 

Ok, so what activates the pleasure and pain centers of the brain? Physical pain can be caused by damage to body cells as mentioned. These damage cells release chemicals which activate the sensory pain receptors. Then it gets a bit tricky. There are two pathways of physical pain to the brain. One pathway ends in the cerebral cortex and tells us the nature of the pain, the level of the pain, where the pain is coming from (at least sometimes, unless it is referred pain which will be explained later on). This is called the perception of pain and is fairly uniform from person to person. For example, the temperature at which everyone labels the temperature painful is fairly uniform. What differs is how different people feel about the same perception of pain. There is a wide range in how different people react to the same perception of pain. The second pathway of physical pain to the brain goes to subcortical levels of the brain and determines how we feel about the pain. Some people, to the same degree of pain, will scream bloody murder, and others react much less forcefully. 

Physical pain is a valuable sensation in that it tells us we need do something to correct what is damaging our body cells. Morphine/heroin both reduce pain via the same receptors in the brain and  both block the receptors that generate how we feel about pain, that second pathway to the brain. This is why these drugs are useful. We tell the doctor about pain, the doctor gives us some morphine, and the next day will ask us how we feel. We will reply that the pain is still there but it doesn’t ‘bother’ us as much.  A drug that blocks the perception of pain would be useless in a medical situation. Doctors need to know if the pain is still there. It is necessary to understand that the body can produce it’s own endogenous opiates, and these endogenous opiates act on the same receptors as morphine and heroin (the body converts heroin to morphine). So morphine/heroin are not ‘unnatural’ compounds to our body. 

For many decades the government/politicians misrepresented morphine/heroin as extremely dangerous drugs, and drugs which, once used, we could become automatically very addicted to, and could even kill us. Of all the major recreational drugs of abuse, heroin is the least toxic to the body. For decades, patients in hospitals were only allowed certain levels of morphine to relieve pain because otherwise, it was claimed, patients would become hopelessly addicted to morphine/heroin after release from the hospital. 

At this point it is necessary to understand that there is physical and emotional pain. If we become emotionally upset, the same subcortical centers which determine how we feel about pain, become activated. Once again our feelings to, in this case emotional pain, produce unpleasant feelings about our emotional situation. If we are admitted to the hospital because of physical pain, and the condition causing the physical pain is medically corrected, then we no longer feel any need to take morphine/heroin. These drugs alleviate how we feel about pain, and if the physical pain is gone, the need for morphine is gone too. It has only been recently when hospital patients, with reluctant permission from the government, are permitted to press a button whenever they need more relief via morphine from pain. 

If morphine/heroine only relieved physical pain the government would never have distorted the information given to the public about these drugs. The catch is that these drugs also relieve emotional pain. That is to say, if there are things going on in our lives which create unpleasant emotional feelings and we take heroin/morphine, the unpleasant feelings won’t go away BUT they won’t BOTHER us as much. At first this sounds like a wonderful drug to take if we are emotionally and hopelessly dealing with a life situation which is emotionally unpleasant for us day after day. THE PROBLEM IS, heroin/morphine will not of course correct our life situation which is causing the emotional distress. These drugs don’t cure anything, physical or emotional in nature. 

The next concept needed to digest here relates to exactly why people take morphine/heroin for pain and the consequences for using these drugs. Recreational drug use is always about changing our mental state in ways which are desirable for a particular situation. The situation could be social event, a celebratory event, or an undesirable situation in which we feel uncomfortable or stressed about. In many cases of recreational drug use it is more about how we use the drug rather than if we ever use it at all. If taking morphine/heroin is the only way to get relief from pain——physical or emotional—it is self evident that a person is going to be reluctant to stop taking morphine/heroin. We can call this addiction but only if we understand it is not a mindless addiction. Everyone wants relief from pain. Good luck with trying to change anyone’s mind on this point. 

We often make the mistake of thinking recreational drug abuse is only bad if it is toxic and can lead to serious medical conditions. This explains why the government has, and continues to insist heroin is very toxic to the body. Ironically, huge numbers of people die from medical conditions related to alcohol and nicotine use, but these drugs are legal. We hardly know anyone, probably no one, who died from medical conditions caused by marijuana, and this drug has been the main illegal drug which had driven the ‘Drug Wars’ the last 50 or so years.  Logically this is rather weird. And obviously, morphine/heroine, which are not very toxic at all to the body, are also illegal. 

The reality is this: the use of a drug can be quite non-toxic and still be abused. Recreational drugs are taken for differing reasons. We may take a drug to reduce our inhibitions in a social setting. We may take a drug to increase the intensity of pleasure, we may take a drug because it calms us down, we may take a drug because it will keep us alert or give us more endurance for a task, and we may make take a drug to reduce our feelings about a life situation. Another reality, this one political, is that people tend to want recreational drugs that they use to be legal, and any different drugs used by others to be illegal. That is precisely why recreational drugs used by any minority tend to be illegal, and the drugs used by the majority tend to be legal. This true world-wide.  

Drug abuse should never be classified as a criminal act and treated as a problem to be solved by the police and the prison system. Drug abuse is a medical condition, and as such, should be treated as a medical problem. Right now drug abuse tends to get medical attention for the affluent, and prison terms for the non-affluent. 48% of those in American prisons are there for drug offenses. It costs 30-40 thousand dollars a year to incarcerate a person. This incarceration does nothing, in almost all cases, to solve a drug problem at all, but just virtually ensures, that when a prisoner does get released, their chances for useful employment are then far less than before they went in. That also means their chances of committing crimes or returning to drug use for  emotional relief sky rockets. So a large percentage of released prisoners will be back in jail for crimes or drug use again. There are 2, 266,800 people in American jails. So roughly 1,133,400 people are in jail for drugs. If we multiply this by the $35,000 a year cost per inmate, this comes to a really really large number. Providing medical addiction centers throughout the country would be a much more effective way to deal with drug abuse. Unfortunately, the vast number of us want these abusers punished, not treated. Unless, of course, it is a member of our own family—then suddenly it becomes a sad situation in need of medical attention. 

Heroin use has always been a favored drug for those trapped into the worst situational environments. Everyone knows many of those living in our numerous and expanding ‘ghettoes’ turn to heroin for relief from emotional pain. It is hard not to have emotional pain living in a ghetto. Thus, many drift to heroin for relief. They get relief alright, from the emotional pain, but no relief at all from the cause of the pain. The only thing changed is now they don’t care so much that they have no job, no treatment for their health problems, no satisfactory family life, no hope much for the future and so on. And of course we get really angry at them, furious that they don’t care much about anything that we care so much about. We depend on the police to stop any access of these people to heroin. But of course, and we all really know this, the heroin industry just goes underground. Gangs are formed as a means of income for young people who otherwise have no income. Unemployment rates in these ghettoes can be as high as 60-80 percent. Many young people perceive their option as one of having no income, or go sell heroin and marijuana. Many choose to sell drugs, adopt a gang as family, get arrested, and sometimes receive mandatory 10 year sentences. What they learn in jail for ten years is how to be good at some criminal activity when they get out. After all, who is eager to hire anyone who has been in jail for ten years?  Their income choices are quite narrowed. 

Clearly, the only solution for those using heroin is to find a way that will enable them to feel better about their lives. The real problem is that our society has already missed the boat to do this.  I am impressed by a Catholic nun who made the following comment: "I do not believe that just because you're opposed to abortion, that that makes you pro-life. In fact, I think in many cases, your morality is deeply lacking if all you want is a child born but not a child fed, not a child educated, not a child housed. And why would I think that you don't? Because you don't want any tax money to go there. That's not pro-life. That's pro-birth. We need a much broader conversation on what the morality of pro-life is."

Therein lies the crux of the issue. When we deprive children of good schools, good teachers, safe environments, good health care, and job opportunities from the teenage years on, we have essentially groomed excellent candidates for heroin use. They, like all young people, want to feel good about their lives. And if they can’t, heroin in always out there, offering them a chance to at least not care so much about the realities of their lives. 

During the Vietnam War, for the soldiers trapped on the front line of a war in which no one really knows who the enemy is, and no enemy soldiers are in uniform, the stress can be unbearable. So many of them turned to heroin for relief. The dangers were still there but they cared less about the dangers. According to our government, who decades ago, during the Nixon administration, banned any research money to be spent on research about any of the illegal recreational drugs—according to what the government preached, these soldiers would be hopelessly addicted to heroin. As it turned out, once these soldiers returned home, only 3% of them continued heroin use. Why would they continue? The emotional pain from being on the front line of battle was gone, and thus, so was the need for any more heroin. Those who continued to use heroin probably had home environments which were stressful and thus their heroin use continued.

Allowing politicians to dictate how recreational drug abuse is approached is a huge mistake. Politicians have used recreational drug abuse as a political tool for election. Getting tough on drug abuse has always been simplistic political issue: put these abusers in jail, the more time in jail the better. Politicians like to use the word zero tolerance. Unless of course the abuser is in their own family. Only then it is considered a tragic situation in need of medical help. 

Unfortunately for heroin abuse, it is more than medical help that is needed. To reduce heroin abuse actually requires all children to receive good health care, good schools, good teachers, safe environments, and all citizens to have opportunities to work at a job for livable wages. In Sweden, there is little heroin use for probably two reason: first, there are state funded heroin clinics available. Second, in Sweden, the government has established good schools for every child, good health care for all citizens, free college for those who can pass admission tests, workers are mandated 6 weeks vacation, and in general, all the things many Americans worry about are taken care of by government. The trade off is a high 56% tax rate in Sweden. Americans find this outrageous. Our tax rates are lower now than any time since the 70’s. On the other hand, any poll of citizen happiness indexes in countries around the world always finds Sweden among the top countries. While they don’t have as much left over after taxes, all the significant things Americans worry about are simply not there to be worried about. And thus, perhaps it is no surprise that heroin use is very low in Sweden. Happy, contented people don’t use heroin. They have no reason to. 

The American government continues to promote heroin as a very toxic drug that kills many users from overdose. They conveniently ignore the fact that it is rare for heroin to kill anyone unless they take alcohol along with heroin, in which case breathing can be inhibited and one can die from respiratory failure. When these kind of deaths occur the police will tell the media the person died from a heroin overdose, when in reality the person died from a heroin/alcohol combination intake, which can be fatal. 

To comprehend the difficulty to treat a typical heroin addict we just have to visualize a typical heroin addict from one of our urban, suburban, or rural drug war ravaged communities. It will likely be a young male, in their twenties, poorly educated, significant health problems, poor diet, unstable or nonexistent family situation, no legitimate job, unable to support a family or any fathered children, no material wealth, not high on the attractiveness scale, no pleasant personality, not the sharpest knife in the drawer intellectually, and no realistic plans for the future. For a social life they hang out, or maybe play computer games all day. They use heroin because heroin helps them not be bothered by the realities of their life. It lessens the pain of their reality. After all, they watch TV and know how other people live, and their life is nothing like that. If all you can do is preach to them about not using heroin and how dangerous a drug it is, there is little chance they will ever stop. It would be like telling a person in love with person X, that they need stop loving that person because that person is not good for them. Love is not an emotion that someone gives up because someone else tells them to. Heroin is not something a person gives up because someone tells them it is better to feel the pain of their life existence than to have that pain lessened. 

Thus, to really break the heroin habit one needs to find a way to improve that person’s actual life. In Sweden, the usual problems that exist to drive a person to heroin do not exist. With all sorts of neglect during their formative years in the areas already listed, how do we go back and erase all of this past history? Many of the kind of jobs which existed 70 years ago no longer exist. It is now past the point where they could ever be successful in college, their past employment record often includes a stint in prison, or is nonexistent, or a series of failures, and so who is going to hire the person? Abuse of heroin is often a situation where the seeds for abuse originated years past.  The reality is that the government would not spend the money to create a level playing field for them during their formative years, and so now the the government would need to create jobs for them, provide health care for them, and give them a safe environment in which to live. Then their need for using heroin would no longer exist. We, as a society, are simply not going now to foot a bill today we should have footed years ago. It is not in our culture as the good nun explained to us earlier in this treatise. No, we would rather spend $35,000 dollars a year to keep them in jail, which I guess makes them the biggest welfare queens of all by public insistence. Actually that is probably not true, the real wealthy have more tax breaks, tax shelters, tax deductions, tax deferments, bankruptcy escape from huge debts, tax havens, legal protections from jail, etc. than any other segment of society.

What about those affluent people who are heroin addicts?  I reckon it goes back to the old saying that ‘all that glitters is not gold’. Some people who take the ‘rat race’ very serious and over-extend themselves to maintain a title, income, power, reputation, or ‘success’ find the stress too much and this too can create a lot of emotional pain. So the person takes heroin to reduce the degree to which all these other ‘false goals’ have created unpleasant pressures.  Anyone who has been around top administrators close up is well aware they are rarely any ‘tip toe through the tulips” “zippedy do da day” pictures of happiness. Enough is never enough in their lifestyle, and their whole life becomes endless compulsive behaviors, not the least of which is looking over their shoulders to see who is gaining.” Well, there is always heroin. 

It is well to remember that it is not always toxicity to the body as the only reason to refrain from using a drug. For most people, to solve their life problems they need to work through them, not take a drug which simply makes them care less about their problems. That is not a solution. 

Finally there are those who take a drug to reduce tensions in their lives, calm them down a bit.There are two problems here. All drugs have side effects and sometimes the side affects can be too dangerous to justify any good they might also do. Second, any drug which calms us down is also likely to decrease our ‘get up and go’ or the extent to which we are willing to go to be competitive. This is a charge often leveled at marijuana.  We take marijuana to mellow out, be less feisty about things, to just roll with the punches more. This gets a bit more tricky. Maybe we do need to mellow out, and maybe we need not mellow out but reach down and even give a greater effort to achieve a particular goal. There are probably two general groups of people—those who need to mellow out, and those who need to jack themselves up a bit and push harder. Using marijuana takes a good judgment call. 

This has been short, at least for how my treatises can often go, but the goal here was to provide basic perceptions which enable one to view drug abuse in the big picture. Without this big picture, any opinions on drug abuse is useless, about as good as most politicians understand drug abuse.

Some might wonder, well what drug am I on perpetually?  Actually none. However, perhaps my body is different in that my body is producing it’s own endogenous duplicates of cocaine, marijuana, LSD, and who knows what else. Smile. One thing is for sure. There are times when my body needs to step up production of endogenous opiates. Especially when around some people—the annoying type. Then maybe I would be less of a loner. Smile. 

Addendum: I avoided the issue of long term intractable pain which can make life miserable for those so afflicted. It has been 18 years since I have had a responsibility to teach the science behind drug abuse. These cases of intractable physical pain were an enigma back then and remain so today, perhaps to a lesser degree, but it is an area which I have not kept abreast. I do know that attempts are made to teach people to live with the pain. I don’t feel qualified to pass judgement on this. Is there a clear cut toxic level of morphine/heroin which can kill you? Of course there is, almost any substance needed by the body can kill you at some point including oxygen, glucose, water, and on it goes. We also need remember that while morphine/heroin can reduce how much pain ‘bothers’ us, it is not a ‘cure’ for the cause of the pain. In some cases, the opiates will not be able to reduce the feelings about the pain enough to do the trick. These are real tragedies in life and not unique to the kinds of pain talked about here. Some people have a ringing in their ears—tinnitus—which science cannot eradicate and they end up ‘learning’ to live with it. Some people are quadriplegic, and they have to ‘learn’ to live with it. Some people are born very ugly and they have to ‘learn’ to live with it. I look back at an older age and wonder how certain ugly girls could find the will to come to school everyday. Certainly morphine/heroin  would be no solution. Remember, heroin/morphine are not selective in what you care less about. People in abject poverty who become heroin addicts die, on the average, a lot earlier in life because they don’t take care of their health either. They don’t ‘give a shit’ about taking care of their health either. Intractable pain is just another life instance in which there are no magic bullets. 

Most musings I write these days are matters of opinion, not scientific fact. This musing is scientific in nature, but there are aspects of it which are still opinion and I avoided these aspects of the subject. Anyone 18 years away from a science subject need be aware of where to draw the line between fact and opinion. Am fairly confident I have done that with this topic.