Dreamland (14 page)

The Queen honored Saunders with damehood.

Dame Cicely and Twycross worked hard to change minds, though this took longer in the United States, where decades of opiate demonization made doctors wary. Twycross once said that exiting a plane in New York City, he “could smell the fear of addiction in America.”

In 1972, a British company called Napp Pharmaceuticals developed a controlled-release formula, known as Continus, that the company first put to use with an asthma medicine. One day Twycross suggested to some Napp reps that their company might use Continus to develop a timed-release morphine pill. Napp eventually did so, and this proved important to this story. It offered doctors a new tool for treating pain in dying patients. Napp, also, is owned by Purdue, the laxative manufacturer that Arthur Sackler and his brothers had purchased in the 1950s.

Meanwhile, a Swedish cancer physician named Jan Stjernsward was put in a position to change pain treatment worldwide. Stjernsward was made chief of the cancer program for the World Health Organization in Geneva in 1980. He’d spent time years before in a Kenyan hospital, where he witnessed acres of cancer patients dying in agony. The third world lacked the resources to treat cancer. With morphine, Stjernsward felt, patients could at least spend their last days pain-free. But doctors refused to use it, fearing addiction.

Now, as WHO’s new cancer chief, Stjernsward remembered Kenya. He set about establishing norms for treating dying cancer patients with opiates, primarily morphine. Ten-milligram morphine pills cost a penny apiece. This would allow, Stjernsward believed, the same care the world over to people who were leaving life as to those who were entering it.

He met Vittorio Ventafridda, who ran a foundation in Milan that was the first in Italy to provide pain treatment to terminally ill patients. Lunching with Stjernsward one day in the cafeteria of WHO’s Geneva headquarters, Ventafridda wrote out on a napkin simple principles for treating dying patients with opiates. It was a ladder of treatment. Increasingly powerful drugs, including opiates combined with nonopiates, should be used if pain did not subside. This was a radical idea at the time.

Stjernsward later gathered most of the world’s few experts in pain treatment—sixteen in all—in a medieval castle in Milan to shape a world health policy, and brought that napkin with him.

The ladder that Ventafridda outlined at lunch that day enshrined the idea that opiates should be used to deal with terminally ill patients on whom nonopiates did not work. This was a humane approach, particularly in countries where few had access to cancer treatment. WHO published a book in more than twenty languages laying out simple pain treatment steps, which came to be known as the WHO Ladder. Within it, morphine was deemed “an essential drug” in cancer pain relief.

WHO went further. It claimed freedom from pain as a universal human right. The Ladder was accompanied by a concept relevant to our story that moved public and medical opinion. It was this: If a patient said he was in pain, doctors should believe him and prescribe accordingly. This attitude grew from a patients’ rights movement that sprung in part from the Nuremberg Trials, where Nazi doctors were found to be experimenters who disregarded patients’ autonomy, and later from the 1960s counterculture that suspected the motives of all established institutions, medicine included.

With the WHO Ladder, doctors’ concern over the use of opium-derived drugs began to ease. They were, after all, remarkably effective at knocking down pain, which was now a human right. Worldwide morphine consumption began to climb, rising thirtyfold between 1980 and 2011.

But a strange thing happened. Use didn’t rise in the developing world, which might reasonably be viewed as the region in most acute pain. Instead, the wealthiest countries, with 20 percent of the world’s population, came to consume almost all—more than 90 percent—of the world’s morphine. This was due to prejudice against opiates and regulations on their use in poor countries, on which the WHO Ladder apparently had little effect. An opiophobia ruled these countries, and still does, as patients are allowed to die in grotesque agony rather than be provided the relief that opium-based painkillers offer. India, a major opium producer, has minute per capita consumption of morphine (0.12 milligrams per capita a year in 2011), due mostly to a government bureaucracy that taxes the drug heavily.

In 1985, members of the International Association for the Study of Pain met in Buenos Aires. While there, the pain specialists visited a hospital where a neurosurgeon told them that opiates were allowed only for those undergoing surgery. He was forced every year to perform a thousand cordotomies for those with chronic pain—severing the pain and temperature nerves in a patient’s spine.

“It was appalling. That was more than all the cordotomies done annually in the U.S. and Europe,” said Dr. John Loeser, who was on the tour from his multidisciplinary pain clinic at the University of Washington.

Experiences like these seared doctors who were interested in pain management. Also on tour that year was Dr. Kathleen Foley, from New York’s Memorial Sloan Kettering Cancer Center. Foley began her career in the 1970s, during the last years of the opiate dark ages, when doctors used these drugs under only the most controlled circumstances.

By the 1980s, Foley, a devout Catholic, had become a voice for these dying cancer patients, and an advocate for treating their pain with opiates. In 1981, she transformed pain treatment for cancer patients at Sloan Kettering, bringing together researchers to study pain and clinicians to provide pain treatment—the first pain group of its kind.

As time went on, Foley, however, took her advocacy of opiate treatment a step further. Opiates should not be confined to just cancer or postsurgical patients, she believed. They should also be used, she argued, to treat patients with pain that did not grow from a disease, injury, or surgery: pain that was chronic but equally life mangling—bad lower backs, knee pain, and others.

As I followed my story, I came to realize that this idea, alighting on the realities of American medicine and medical marketing of the 1980s and 1990s, eventually connected to why, years later, men from a small town in Mexico could sell so much heroin in parts of the country that had never seen it before.

In 1984, a young doctor came to Sloan Kettering for a fellowship under Foley. Russell Portenoy had grown up in Yonkers and developed an interest in biology as a child. A dapper and articulate man, Portenoy attended Cornell University, then medical school at the University of Maryland. He did a neurology residency at Albert Einstein College of Medicine.

Portenoy worked among Sloan Kettering cancer patients for almost two years. During the 1980s and 1990s, he and Foley helped midwife a new specialty in American medicine. Palliative care—treating the pain and stress of the seriously ill—grew from a variety of influences: the hospice movement of Cicely Saunders and the idea, then surprisingly uncommon in medicine, that death should be dignified. Palliative care involved far more than just drugs. It included psychological, spiritual, and family counseling. The new discipline gave Russell Portenoy “the talking points I needed to mold my work life,” he once wrote. As an emerging discipline, palliative care appealed to a bright young doctor interested in staking out his own ideas. Comforting the seriously ill and dying touched on the altruistic reasons why anyone would enter medical school in the first place.

What’s more, it challenged him. Just knowing a symptom didn’t mean he understood the patient. Portenoy wrote later that he found himself forced to study the profound psychosocial and spiritual impact of advanced illness. He was forced to learn, for example, how to tell a family of a loved one’s life-threatening illness. Palliative care, he came to believe, was guided by moral issues of patient autonomy and respect for cultural and individual differences. Decisions were made with the input of the patient and family. This was very different from how medicine had treated serious illness and pain. Watching people struggle with pain, and talking to families who faced the loss of a loved one, gave Portenoy a touch of idealism, a bit of the crusader pushing up against conventional wisdom.

In fact, the 1980s were good years for a young doctor with pain as his focus doing battle with conventional wisdom. Researchers had come to new understandings of how pain happened in the brain. The work of Cicely Saunders in England was dissolving the old bugaboos about the prohibition on using opiates in the United States. Medical advances were extending the lives of cancer patients in some cases from months to years. These treatments were themselves painful, and thus many more patients required attention for their pain.

In 1984, Purdue Frederick produced one solution. It released MS Contin, a timed-release morphine pill—the product of that conversation Robert Twycross had with the Napp Pharmaceuticals reps in England years before. MS Contin was intended for cancer and postoperative patients.

In Salt Lake City, a doctor named Lynn Webster had been studying new techniques for acute pain at Holy Cross Hospital. One day in 1989, a woman named Dorothy had surgery on her lung. During surgery Webster inserted in Dorothy’s back an epidural catheter with an injection of pain medicine. Through the catheter Webster gave her small, continuous doses of opiate anesthetics. Epidurals had been used in labor and delivery, but new research showed epidurals could be used for other things. They could, Webster reasoned, allow him to gain more localized pain control with less medication than the typical intravenous or muscular injections.

In fact, Dorothy left surgery awake and coherent, unlike typical post-op patients, who were prostrate and completely sedated. Word spread through the hospital. She asked for coffee, stood up, and raised her arms—to the shock of hospital staff. “Nobody’s done this before at the hospital. All these doctors and nurses are standing in the doorways,” remembered Marsha Stanton, a nurse who worked with Webster at the time. “She drinks her coffee and she’s fine. She’s not nauseated, which usually they are.”

Webster, and then others, energized by new possibilities, began treating more patients with this kind of pain control.

To Russell Portenoy, these were revolutionary times. It was cruel not to give pain-relieving opiate drugs to dying cancer patients or those emerging from surgery. Soon this was no longer a controversial opinion in America. Terminal patients no longer had to die in agony. The pendulum was swinging toward more humane pain treatment.

It thrilled him, Portenoy said later, to be able to relieve the crippling pain he saw in patients. He viewed pain management as “a white-hat” profession, made possible by pharmaceutical companies’ innovations. Their powerful new pain relievers seemed far less addictive because through their timed-release formulas they eased relief out to the patient over many hours.

Now, to the patient crushed by pain, “the pain-management specialist who knows what he or she is doing can go in there and find a way to offer something that—it doesn’t provide comfort, it provides hope,” he said later. “I believe in drugs. I think pharmaceuticals are a great gift to humankind.”

Pain and the Pro Wrestler

Seattle, Washington

John Bonica was born in Sicily, grew up in Brooklyn, and began lifting weights at age eleven. In college in Long Island and New York, he was a star collegiate wrestler. He earned his way through college and medical school as a pro wrestler. This career continued after he joined the U.S. Army before World War II. When a higher-up told him that pro wrestling was unbecoming of an officer, he donned a mask to hide his identity and became the Masked Marvel, touring with carnivals and wrestling as many as twenty people in a day. He met his future wife, Emma, at a pro wrestling match.

Pro wrestling also proved important to his future work. It partly disabled Bonica and bequeathed him lifelong chronic pain from torn hip joints, shoulder injuries, multiple rib fractures, and excruciating cauliflower ears “like two baseballs” that required plastic surgery.

“Working 15 to 18 hours a day,” he told
People
magazine in 1977, kept the pain at bay.

Watching his wife go through searing pain in childbirth in 1943 set Bonica on his career as an anesthesiologist. He trained hundreds of anesthesiologists in the U.S. Army Medical Corps. After the war, he became chief anesthesiologist at Tacoma General Hospital and wrote a classic textbook,
The Management of Pain
.

Bonica opened America’s first pain clinic when he was appointed chief of anesthesia at the University of Washington School of Medicine in 1960. Pain could only be salved, Bonica believed, when many disciplines within medicine, and beyond, were applied. The clinic pioneered an approach to pain that had patients see as many as fourteen specialists, who would then work out a therapy that a patient would be asked to follow in his daily life. Bonica’s multidisciplinary approach was complicated and required a lot of the patient, but was often effective.

Bonica retired in 1977. His successors, Drs. Bill Fordyce and John Loeser, expanded the Center for Pain Relief at the UW medical school. The clinic used occupational and physical therapists, psychologists, social workers, and others to treat pain. Patients spent three weeks in the clinic and left with medical and life strategies for controlling pain, such as exercise and diet—a bio-psycho-social approach, in the term Loeser coined.

“We were trying to teach [patients] that they were the ones who controlled whether they were well or not well,” Loeser said. “The patient has to do the work. Chronic pain is more than something going wrong inside the person’s body. It always has social and psychological factors playing a role. Physicians have traditionally ignored such things.”