There is the alarming rise in the number of chronic pain patients who have become addicted to opioids. And the explosion, in recent years, of opioid prescriptions by health care providers now under government pressure to curtail their prescribing.
This pressure has driven many opioid addicts to the illicit drug market to avoid the pains of withdrawal. There, according to the Centers for Disease Control and Prevention (CDC), they often find opioid heroin cheaper and sometimes more readily available despite a 50‐year “War on Drugs.” Thus they become heroin addicts.
Media hysteria begets calls to action. Politicians and the administrative state devise new laws to control this “evil plague.” As a surgeon who regularly prescribes painkillers for patients suffering from postoperative pain or painful conditions, I see a painful cognitive dissonance.
Begin with US policy towards heroin. Originally developed in the 1870s, diacetyl‐morphine was marketed under the brand name Heroin, by the Bayer pharmaceutical company. Despite pleas by the Surgeon General and the American Medical Association to keep it legal, Heroin was banned in the US in 1924 because political leaders believed it the drug corrupted an individual’s moral character.
Meanwhile, dilaudid, 3 to 4 times more potent than morphine, is legal and is routinely administered for pain both as an oral and an injectable agent. Fentanyl, or Duragesic, is legal, too, although it is more than 50 times the potency of morphine.
There is even greater cognitive dissonance with methadone, the powerful opioid approved for use in the US in 1947 and commonly used in this country to treat addiction to heroin and other opioids.
Chronic users of opioids develop a tolerance, requiring ever‐increasing doses to achieve the desired effect. A low, oral dose of methadone binds with enough of a person’s opioid receptors to prevent withdrawal symptoms yet not produce the euphoric effects.
The idea behind “methadone maintenance” programs is to transfer the addiction from heroin or another opioid. Because they do not experience the euphoria and “escape” of their chosen opioid, methadone addicts can resume a normal, productive—even conventional—life. Some can be tapered off from methadone and “detoxified.” But many remain on methadone, sometimes for their entire lives.
To put things in proper perspective, chronic alcohol use is much more dangerous. Chronic use can cause cirrhosis of the liver, cardiomyopathy (heart failure from damaged heart muscle), encephalopathy and dementia, chronic pancreatic inflammation, and has been linked to cancer of the stomach and the esophagus. In addition, one can overdose on alcohol as well—which may cause a person to stop breathing, become hypoxic, and die.
And here’s where the cognitive dissonance comes in: it is perfectly acceptable and permissible—even public policy—to allow people to be chronically addicted to the opioid methadone. The side‐effects of prolonged use are considered serious yet tolerable. But it is unacceptable and counter to public policy for a person to be chronically addicted to any other opioid, even if that person self‐doses to prevent withdrawal while avoiding the “high” in order to lead a peaceful and productive life.
The concept of “harm reduction” as an approach to substance abuse has gained increased acceptance by health care practitioners as well public health and government authorities. Harm reduction approaches chemical dependency in a non‐judgmental and realistic way, leaving drug prohibition in place.