Friday, January 28, 2005

As Long as You're Up, Make Us a Brompton's Cocktail 

We never thought we'd say this, but what if Rush Limbaugh was right? Painkillers Vioxx and Celebrex were recently found to to double the risk of heart disease and stroke; the alternatives, naproxen, ibuprofen and aspirin, create gastrointestinal disorders that kill some 16,500 Americans each year. Another class of painkiller -- opioids, including morphine and "hillbilly heroin" (also known as OxyContin) -- is more reliable and has fewer side effects, but is not generally available to the American public. Maria Szalavitz, writing in the current issue of New Scientist, wonders why:
Not only are they the most effective painkillers, they are also among the safest drugs on offer. Taken as directed, their most significant side effect is constipation, and possibly flu-like withdrawal symptoms if they are discontinued too abruptly. They are often billed as being irresistibly seductive and addictive, but although many patients feel sleepy or "spacey" when they first take opioids, research shows that people taking a steady, regular dose do not suffer cognitive or physical impairment . . . .

So why do these drugs have such a poor reputation? The fears about using opioids for pain relief stem largely from the dangers of recreational use. Yet even these have been overplayed. For example, while half of American soldiers in Vietnam tried heroin, only around 40 per cent of those who used it experienced any addiction, and just 1 to 3 per cent developed long-term addiction. In other words, at least 97 per cent of people in the highest-risk age group exposed to the scariest opioid under the most stressful circumstances did not become lifelong junkies.

The risk of overdose has been similarly exaggerated. For one thing, more than 80 per cent of deaths attributed to opioid overdoses are caused by taking a mixture of substances. Secondly, there is a harmless antidote that can neutralise an overdose, so when a patient starts using the drugs or needs to increase their dose, medical supervision can virtually eliminate any danger.

Despite this, the drugs continue to get a bad press. Last month, a prominent American pain specialist was convicted of 50 narcotics-related charges that could land him in jail for life. All federal prosecutors had to do was demonstrate that William Hurwitz prescribed more painkillers than the government believed was "medically necessary". They convinced the jury that this was a crime, with testimony from an expert witness who claimed that the use of high doses of opioids to treat non-life-threatening chronic pain is itself drug abuse. That testimony has since been condemned as "factually wrong" by leading pain specialists.

So why are patients allowed to take inherently risky drugs, but have a hard time getting access to those that harm only when misused? It comes down to one word: politics. Entire government bureaucracies - from the US Drug Enforcement Administration and the drug tsar to state police and prosecutors - are devoted to demonising opioids. The truth about these drugs is politically inconvenient. It undermines a basic tenet of the multibillion-dollar war on drugs: that exposure to corrupting substances inevitably causes addiction or death.

As Siobhan Reynolds, founder of the advocacy group Pain Relief Network, puts it: "Opioids are the safest pain-relief drugs on the market, but patients are going to have to fight for them if they want to be able to take them."

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