Before opioids, God created opiates, naturally-occurring pain-relieving substances that were derived from the opium poppy plant. Sun drying produces poppy latex which contains morphine, thebaine, and codeine. In addition to their pain-relieving properties, opiates also produce a euphoria, a high, which often led to overuse and addiction.
Unfortunately, opiates also suppress breathing, and overdoses frequently resulted in death. Due to these risks for addiction and death, the U.S. government stepped in and passed the Harrison Narcotics Tax Act of 1914 which outlawed opiates, legally referred to as “Narcotics”. The old Harrison Act later morphed into the modern Controlled Substances Act or CSA, first passed in 1970. Opiate sale or distribution is considered a crime unless prescribed by a physician “for a legitimate medical purpose in the usual course of medical practice”.
Legitimate purposes included treating cancer and terminal painful diseases. Other legitimate purposes included heart attacks, pulmonary edema, sickle cell crises, battlefield wounds, acute fractures, and the like. Opiates were rarely used to treat long-term non-cancer pain due to valid concerns about addiction and dependence.
Physicians who failed to document a legitimate medical purpose or diagnosis were often arrested and prosecuted for drug trafficking, the crime for violating the CSA.
The synthetic opiates are known as opioids although this term is now used to describe both opiates and opioids collectively. The first synthetic opioid was made from morphine in 1874 in a London lab. It was further refined to produce what is known as Heroin, a compound twice as powerful, and infinitely more deadly. The drug rapidly produced both euphoria and cravings which led to a user pattern of dependence, addiction, overdose and death. Heroin quickly became the Frankenstein of opioids, a creation gone so wrong that it has become little more than a curse that has left a wake of death, destruction and human misery that continues to this day.
The next two synthetics were created in German labs in the 1930s: Demerol and methadone. Methadone’s chief advantage was to produce far less craving. It has been used extensively in addiction treatment. Demerol proved an effective analgesic due to its quicker onset of action. By 1975, 60% of physicians prescribed it for acute pain while 22% prescribed it for long-term conditions.
Fentanyl was invented by Paul Jannsen in 1960. At 100 times the strength of morphine, it became a powerful medicinal agent used in surgical anesthesia. It made the World Health Organization’s “Essential Medicines List”. Unfortunately, due to its potency, it was also associated with greater risk for accidental fatal overdose.
The Reckitt & Colman Corporation sought to develop a synthetic opioid that retained the advantage of pain control “while shedding the undesirable side effects” of other opioids. In 1969, they succeeded in creating buprenorphine in the lab, a kinder, gentler opioid that many consider the safest ever made. One version, Suboxone, is used clinically throughout the U.S. and Europe for safer outpatient treatment of addiction with many advantages over methadone.
Another version, Butrans, is also widely used for the treatment of chronic non-cancer pain. Buprenorphine, although still dangerous if improperly used, has less potential for overdose death, respiratory suppression, cravings, withdrawal, and hyperalgesia. I have many patients who were able to ultimately taper off all opioids once they rotated to Butrans.
The two greatest drawbacks remain cost and education. Most physicians do not know enough about Butrans to select it. Opiophobia has created a public fear and stigma against all opioids. And Butrans is often not covered by insurance.
If the government subsidized buprenorphine in all of its forms so patients could afford it, millions could rotate off more dangerous opioids, and many lives could be saved-all without an increase in suffering-and all without involuntary tapers.
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