One unhappy result has been the infamous opioid crisis. Opioids, as surely everyone knows by now, are painkillers that act in much the same way as heroin and come from the same addictive source: opiates. For a long time, they were mostly used sparingly, primarily for short-term relief after surgery or in the treatment of cancer. But in the late 1990s, pharmaceutical companies began pushing them as a long-term solution to pain. A promotional video made by Purdue Pharma, the maker of the opioid OxyContin, featured a physician who specializes in pain treatment looking straight into the camera and claiming with evident sincerity that opioids were perfectly safe and hardly ever addictive. “We doctors were wrong in thinking that opioids can’t be used long term. They can be and they should be,” he added.
The reality was rather different. People across America were becoming rapidly addicted and often dying. Between 1999 and 2014, by one estimate, a quarter of a million Americans died from opioid overdoses. Opioid abuse remains for the most part a peculiarly American problem. The United States has 4 percent of the world’s population but consumes 80 percent of its opioids. About two million Americans are thought to be opioid addicts. Another ten million or so are users. The cost to the economy has been put at over $500 billion a year in lost earnings, medical treatments, and criminal proceedings. Opioid use has become such big business that we have now reached the surreal situation that pharmaceutical companies are producing drugs to alleviate the side effects of opioid overuse. Having helped to create millions of addicts, the industry is now profiting from medications designed to make their addiction a little more comfortable. So far the crisis doesn’t seem to be going away. Every year opioids (both legal and illegal) claim forty-five thousand or so American lives, far more than are killed in car crashes.
The one positive to come out of the experience is that opioid fatalities have led to a rise in organ donations. In 2000, according to The Washington Post, fewer than 150 organ donors were opioid addicts; today the number is over 3,500.
* * *
—
In the absence of pharmaceutical perfection, Irene Tracey focuses on what she calls “free analgesia”—understanding how people can manage their pain through cognitive-behavioral therapies and exercise.
“It’s been really interesting to me,” she says, “how useful neuroimaging has been to persuade people to engage with the brain to recognize that it does seem to have a big role in making pain bearable. You can achieve a lot with that alone.”
One of the great advantages with pain management is that we are marvelously suggestible, which is of course why the well-known placebo effect works. The concept of the placebo effect has been around for a very long time. In the modern medical sense of something given for psychological benefit, it is first recorded in a British medical text as far back as 1811, but the word “placebo” itself has existed in English since the Middle Ages. For most of its history, it meant a flatterer or sycophant. (Chaucer used it in that sense in The Canterbury Tales.) It comes from a Latin term meaning “to please.”
Nobody knows quite why placebos work, but they do. In one experiment, people who had just had a wisdom tooth extracted had their faces massaged with an ultrasound device and overwhelmingly reported feeling better. What was interesting was that the treatment worked as well with the machine turned off as on. Other studies have shown that people given a colored tablet with corners will report feeling better than when given a plain white tablet. Red pills are deemed more fast acting than white pills. Green and blue pills have a more soothing effect. Patrick Wall, in his book on pain, reported how one doctor got good results from handing his patients pills held in a forceps, explaining that they were too potent to be held by bare fingers. Extraordinarily, placebos are even effective when people know they are placebos. Ted Kaptchuk of the Harvard Medical School gave people suffering from irritable bowel syndrome sugar pills and told them that that’s all they were. Even so, 59 percent of those tested reported relief of symptoms.
The one problem with placebos is that while they are often effective for matters over which our mind has some control, they can’t help with problems that lie below the conscious level. Placebos don’t shrink tumors or banish plaque from narrowed arteries. But then, come to that, neither do more aggressive painkillers, and placebos at least have never sent anyone to an early grave.
20 WHEN THINGS GO WRONG: DISEASES
I came to typhoid fever—read the symptoms—discovered that I had typhoid fever, must have had it for months without knowing it—wondered what else I had got; turned up St. Vitus’s Dance—found, as I expected, that I had that too,—began to get interested in my case, and determined to sift it to the bottom, and so started alphabetically—read up ague, and learnt that I was sickening for it, and that the acute stage would commence in about another fortnight. Bright’s disease, I was relieved to find, I had only in a modified form, and, so far as that was concerned, I might live for years.
—JEROME K. JEROME ON READING A MEDICAL TEXTBOOK
I
IN THE AUTUMN of 1948, people in the small city of Akureyri, on the north coast of Iceland, began to come down with an illness that was at first taken to be poliomyelitis, but then proved not to be. Between October 1948 and April 1949, almost five hundred people, out of a population of ninety-six hundred, grew ill. The symptoms were wondrously diverse—muscle aches, headaches, nervousness, restlessness, depression, constipation, disturbed sleep, loss of memory, and generally being out of sorts but in a pretty serious way. The illness didn’t kill anyone, but it did make nearly every victim feel wretched, sometimes for months. The cause of the outbreak was a mystery. All tests for pathogens came back negative. The disease was so peculiarly specific to the vicinity that it became known as the Akureyri disease.
For about a year, nothing more happened. Then outbreaks began to occur in other, curiously distant places—in Louisville, Kentucky; in Seward, Alaska; in Pittsfield and Williamstown, Massachusetts; in a little farming community in the far north of England called Dalston. Altogether through the 1950s ten outbreaks were recorded in the United States and three in Europe. The symptoms everywhere were broadly similar but often with local peculiarities. People in some places said they felt unusually depressed or sleepy or had very specific muscle tenderness. As the disease proliferated, it attracted other names: post-viral syndrome, atypical poliomyelitis, and epidemic neuromyasthenia, by which it is most commonly known now. Why outbreaks didn’t radiate outward to neighboring communities but rather leaped across great geographical expanses was just one of many puzzling aspects of the disease.*1
All the outbreaks attracted little more than local attention, but in 1970, after several years of quiescence, the epidemic reappeared at Lackland Air Force Base in Texas, and now at last medical investigators began to look at it closely—though not, it must be said, much more productively. The Lackland outbreak made 221 people sick, most for about a week but some for up to a year. Sometimes just one person in a department came down with it; sometimes nearly everyone did. Most victims recovered completely, but a few experienced relapses weeks or months later. As usual nothing about the outbreak fit into a logical pattern, and all tests for bacterial or viral agents came back negative. Many of the victims were children too small to be suggestible, ruling out hysteria—the most common explanation for otherwise unexplained mass outbreaks. The epidemic lasted for a little over two months, then ceased (apart from the relapses) and has never returned. A report in The Journal of the American Medical Association concluded that the victims had been suffering from a “subtle but nevertheless primarily organic illness whose effects may include exacerbation of underlying psychogenic illness.” Which is another way of saying, “We have no idea.”