Opiophobia and opiophilia: the war continues

When there is a discussion around the topic of opioids (natural, semisynthetic, or synthetic), it is difficult to reach a consensus. The people contrary to its use are supporters of opiophobia and defend that substances that cause psychological changes along with drowsiness, lethargy, coma, discomfort reduction, pleasure, excitement, vigor, vitality, mental confusion, increased aggression, reduction of fatigue, delusion, and altered behavior due to physical dependence and/or psychic dependence, among others, can represent a risk for the individuals taking it as well as for the society of which they’re part. Thus, the restrictions on the use of opioid analgesics are exaggerated, impairing the possibilities of pain control and promoting unnecessary suffering.

The people favorable to the use of such medication are supporters of what is called opiophilia. They are not very restrictive regarding its use and defend that the alternative to it, feeling pain, and the suffering that stems from it can be higher than the possible deleterious effects caused by opioids. They exaggerate the analgesic properties of opioid medication and minimize its adverse effects, inadvertently exposing its users to risks. Opioids, far from being a panacea, constitute a class of the most effective and often used medication for pain relief. However, that does not apply to all types of pain. The best analgesic responses are obtained when the pain is classified as acute, with nociceptive predominance and/or in cancer patients. The worst analgesic responses from opioids come from its use in the treatment of chronic, neuropathic and/or dysfunctional pain. The analgesic responses are related to the several types of pain already described, but also to the variations arising from the genetic polymorphism of opioid receptors.

The prejudice from several social spheres, such as the commercial, religious, political, police, medical, paramedical, and lay, have progressively permeated the scientific and technical precepts. The outcome was a radicalization of opiophilic and opiophobic positionings, which culminated with the progressive abandonment of rationality.

There have been, in some communities, times when the predominance of opiophobia gave way to opiophilia, and vice-versa.¹

The History of Opium: A Brief Review

In the Middle East, over six millennia ago, the Sumerians already used opium as an analgesic and sleep inducing medication.

There are also records from ancient Greece, from about 4 thousand years ago, of its recreational use in addition to the medicinal use. In Homer’s work, The Odyssey, Helen offers Telemachus a juice or filtered solution that would be capable of relieving his pain and making him forget unpleasant memories.

During the Middle Ages, the medicinal use of poppy juice became particularly popular in the Arab world and the East. India soon became the biggest producer and exporter of poppy latex. During the 17th and 18th centuries, the source of profit of the East Indian Companies, especially for its English branch, migrated from the previously successful commerce of tea and silk, to opium. China was molded by the British and their representatives to become, in the early 1800s, the primary consumer market.²

Opium dens proliferated across China and housed a tremendous and growing number of users. This dependent users were easy prey for merchants and were happy to buy the then valuable English product, opium.

It did not take long for the Tau Kuan emperor to become aware of the massive loss of Chinese riches due to the commerce of Indian opium by the Englishman. A Chinese imperial decree forbidding the import of opium due to its harmful effects, mainly because its users would sell all of their belongings just to buy the drug, which back then was even more valuable than gold.

The British Empire retaliated by declaring war against China. After an initial defeat at the Canton Port, England triumphed. In addition to receiving around 6 million Patacas, the British gained ruling over the Honk Kong Island. The territory was officially occupied on November 26, 1842 and remained under British ruling almost until the end of the second millennium A.D.

After being defeated, the Chinese Empire also had to, shortly after signing the treaty, declare new regulations that encouraged an increase in poppy plantations. Little over six years, the poppy production in China surpassed the Indian.

Opium dens slowly replaced opium for tobacco. In 1850, in China, despite the slow reduction of new users, over 15 million inhabitants were chronic opium users.

The Asian migration to the U.S. Pacific Coast brought Chinese cultural elements that included the habit of smoking opium. The Chinese became to the U.S. What the English had been to the Chinese Empire half a century before. The first reaction by the U.S. was to pass an act on the taxation of opium and morphine use in 1890.²

At the end of the 19th century and beginning of the 20th, opium use was linked to Chinese immigrants and the American government initiated a deprecatory campaign against the Chinese that was highly segregationist and suggested that American should keep their distance from the lying mischievous Asians. Several texts and lyrics described the Chinese as people with reproachable habits who could stain the pure soul of the American people.

The same imperial acumen that led China to defy the forces of the British Crown in the mid-19th century later inspired several nations to, by means of public and private bodies, draft programs aiming to inhibit production, sale, and consumption of the substances, making them licit or illicit, forbidden or available under stricter regulations. Measures were progressively implemented worldwide, restraining the use and commerce of opium and, later on, morphine, its substitute.

The world consumption of illicit drugs is continuously increasing, despite the regulations. In the United States, there is also a rise in the use of licit opioids. Such problem is linked to the excessive prescription of these drugs. Over the past years, elective surgeries have been postponed due to an insufficient number of hospital beds in intensive care units, usually occupied by patients undergoing treatment for complications from opioid abuse. In addition to the overcrowding of intensive care units by the ones who survive, a high number of deaths caused by opioid abuse has been detected and, consequently, reported by the country’s centers for disease control and prevention. The legal and illegal opioids have been and still are the cause for an average of 150 death per day in the U.S., according to data presented by the White House. In 2016, its combined economic impact between healthcare, work, and legal costs was estimated to be around US$ 92 billion in the U.S.

Measures to curb the excessive increase of opioid prescriptions have been implemented in the country since the first decade of this millennium. A recent call for action to reduce abuse and overdoses on prescribed opioids was jointly made by the White House Office of National Drug Control Policy, the Drug Enforcement Administration, and the U.S. Food and Drug Administration.

In Brazil, we have seen a significant increase only in the use of illicit drugs, not licit ones. There is still undertreatment of pain here, and opioids are underused (with restricted prescription). ⁶,⁷

The low consumption of licit analgesics in Brazil has a multi-factor origin, which includes lay and medical culture filled with opiophobic prejudice, bureaucratic barriers to its prescription, low per capita income, and the relatively high costs of such medications, aggravated by average taxes of over 30%.

In the past years, also in Brazil, elective surgeries have been postponed due to a lack of hospital beds in intensive care, occupied by patients with multiple trauma. Most of them are car accident victims, many other victims of motorcycle and domestic accidents.

Proposed Solutions

In the United States, measures and solutions were adopted to prevent the abuse of prescription drugs, especially opioids. A strategy of the U.S. Administration for the control of opioids was deployed, including actions in four fronts for reducing prescription: education,⁸,⁹ sale and prescription monitoring, and judicial, legal, and police support.

The purpose of the educational pillar is to raise awareness among lay people and health professionals to the risks of prescription drug abuse. The monitoring will be perfected with programs for monitoring prescription, which will identify prescribers and of potential duplicates of prescriptions. Other programs will be created to improve sale control. Tools for law enforcement will be developed, production of medication reduced, abusive, duplicate, and triplicate prescriptions retained, and prescription drug traffic contained.

The American measures already implemented have already shown early results, many of which are worthy of celebration, such as the reduction in deaths in some states. On the other hand, some are worthy of reprimand and disapproval, such as the joint defense by several institutions in the area of suppressing the use of pain as a fifth vital sign.¹⁰

The strategy of recognizing pain, known to be a symptom, as a vital sign represents the active search of those who needlessly suffer in silence. There has been a new awakening in the medical community in favor of opioid-free anesthetics in American educational centers on Anesthesiology but, despite the efforts, with few adepts.

The November 2017 White House decision to sponsor scientific works on opioids aiming at mitigating overprescription will influence doctors worldwide and may cause a bias in countries where this is not a public health issue, especially those where there is an insufficient treatment of pain.

The recognition of pain as a fifth vital sign should be maintained and more widely adopted by health institutions. Opioid-free anesthesia techniques deserve to be developed but are still indicated for exception cases.

The Brazilian Society for the Study of Pain (Sbed), chapter of the International Association for the Study of Pain (Iasp) in a project entitled “Brazil with no pain”, proposed: the creation and compulsory deployment of a Commission for the Control and Treatment of Pain in all private and public hospitals, clinics, and Immediate Care Units (UPAs); creation and compulsory deployment of a Unit for Treatment of Acute Pain in all hospitals with up to 100 beds, within three years from the approval of the new regulation; creation and compulsory deployment of a Unit for Treatment of Chronic Pain in all hospitals with up to 100 beds, within three years from the approval of the new regulation; creation of the National Pain Combat Day (August 29).

Sbed also defends the government support to the scientific investigation and teaching of pain, by means of clinical, experimental, psychosocial, social-cultural, and behavioral studies and postgraduate programs (lato sensu) in all University Hospitals in the country.

After the new regulation comes into effect, Sbed and the “Brazil with no pain” campaign will promote training on the treatment and control of acute and chronic pain to the staff of public and private hospitals, UPAs, and other services of primary and secondary care.

Conclusions

The strategy for the proper control of pain includes the deployment of programs of community education and training of health professionals, such as doctors, nurses, pharmacists, administrators, among others. It also provides for the availability of medicaments, adequate prescription, distribution, and administration of drugs and the creation of health policies that emphasize the need for pain relief.

The inadequate pain treatment in Brazil and the crisis related to the abuse of opioid prescription in the United States are distinct public health problems, that require equally separate solutions.

The acknowledgment of these differences should not induce the risks of future abuse, probably even as a result of our incentive to the study and use of pain treatment, to be overlooked.

Hospital commissions for pain control can, based on hard scientific evidence, interfere and curb abuse cases, at the same time they reduce undertreatment and promote the improvement of pain control, thus reducing the suffering associated with it. The “Brazil with no pain” program, supported by Sbed can be the answer for us to reach proper pain treatment without the risk of drug abuse.

References

• ¹
  Webster F, Bremner S, Oosenbrug E, Durant S, McCartney CJ, Katz J. From opiophobia to overprescribing: a critical scoping review of medical education training for chronic pain. Pain Medicine, 2017;18(8):1467-75.
• ²
  Simões EC, Lima CHH, Oliveira Jr JO. Ópio e seus derivados: histórico e significados psicossociais. In: Oliveira Jr JO (ed). Opiáceos – O estado d’arte. 2001;(2):13-29.
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  Beswick A, Piccininni C. The cost of pain. University of Western Ontario Medical Journal, 2018;87(1): 71-2.
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  Dasgupta N, Beletsky L, Ciccarone D. Opioid Crisis: No Easy Fix to Its Social and Economic Determinants. American journal of public health, 2018:108(2):182-6.
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  National Academies of Sciences, Engineering, and Medicine. 2017. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Washington, DC: The National Academies Press. Page 70. doi: https://doi.org/10.17226/24781
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  Fabro, P. R. (2017). Avaliação do uso de analgésicos no tratamento da dor operatória em diferentes especialidades cirúrgicas no ambiente hospitalar. Pós-Graduação em Ciência da Saúde.
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  Silva LM, Silva AS, Andrade EWOF, Azevedo AP, Costa FWS, Azevedo MKP. A avaliação do recém-nascido realizada pela equipe de enfermagem. Rev Uningá Review. 2018;33(1):1-11.
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  Currie J, Schnell M. (2018). Addressing the Opioid Epidemic: Is There a Role for Physician Education?. American Journal of Health Economics, Forthcoming.
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  Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States. Jama, 2016;315(15):1624-45.
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  Levy N, Sturgess J, Mills P. (2018). “Pain as the fifth vital sign” and dependence on the “numerical pain scale” is being abandoned in the US: Why?.

Publication Dates

• Publication in this collection
  May 2018

History

• Received
  24 Apr 2018
• Accepted
  24 Apr 2018