Far from the public eye, in medical institutions that
most people prefer not to think about, a quiet revolution
is taking place. With little publicity, cancer wards,
hospices and pain clinics are doling out larger doses
of prescription morphine, so much that per capita morphine
consumption has tripled since 1995, making Oregon truly
a state of tranquility.
Experts say the sharp rise represents a paradigm shift
in the treatment of pain, both in terminal illnesses
such as cancer and in chronic conditions such as back
injury.
"It doesn't surprise me," says Dr. Brett Stacey, director
of the Pain Management Center at Oregon Health Sciences
University. "There's been a huge educational effort
in recent years to say that using opioids for chronic
pain is often appropriate."
For the nation as a whole, per-capita morphine consumption
has more than doubled over the last four years--from
1,076 grams per 100,000 population in 1995 to a projected
2,636 grams this year, according to the federal Drug
Enforcement Agency.
In Oregon, the jump has been even more pronounced,
soaring from 1,463 grams four years ago to a projected
4,980 grams in 1999, making us the morphine capital
of America.
How did we get here? Researchers point to the protracted
fight over doctor-assisted suicide."Physician-assisted
suicide has elevated awareness by the medical community
that a more aggressive approach needs to be applied
in pain management," says Bob Dernedde, executive director
of the Oregon Medical Association.
Earlier this month, for example, the Oregon Board of
Medical Examiners took unprecedented disciplinary action
against Roseburg doctor Paul Bilder for under-prescribing
pain medications to patients, several of whom were dying
of cancer.
One of the oldest and most powerful drugs known to
modern medicine, morphine was first widely used during
the Civil War. Ironically, its addictive qualities were
poorly understood--doctors hoped that injecting morphine
would somehow stave off the habit-forming properties
associated with smoking or eating opium--and many soldiers
wound up addicted to the drug.
More than a century later, the specter of drug-addicted
patients still haunts American medicine. In recent years,
doctors have tended to be miserly in prescribing morphine,
fearing that their patients would get sucked into the
vortex of addiction.
Research now suggests, however, that when properly
monitored, the use of morphine to treat severe pain
is unlikely to result in addiction, says David Joranson,
director of the Pain and Policy Studies Group in Madison,
Wis.
Doctors have also worried that a generous prescription
pen would invite scrutiny from state and federal investigators
charged with combating the drug scourge. "The war on
drugs was not just fought in the streets," says Barbara
Coombs Lee of the Compassion in Dying Federation. "It
was fought at the bedside of dying patients."
Another factor in the surge of morphine use was the
passage of Oregon's Intractable Pain Act in 1995, which
set out specific guidelines for the prescription of
painkillers, freeing physicians from the anxiety that
they might be investigated.
The BME's action against Dr. Bilder shows that the
grin-and-bear-it philosophy no longer carries the official
seal of approval. "The culture has changed," says Dr.
Susan Tolle, director of the Center for Ethics in Health
Care at OHSU.
Studies demonstrate that morphine and other narcotics
are extremely effective in treating the agonizing pain
associated with terminal cancer, says Dr. Stacey of
OHSU. While there is little research showing the benefits
of morphine in the treatment of other kinds of pain,
there are no studies showing that it has negative effects,
so doctors are increasingly prescribing it in chronic
conditions and after major surgery or even childbirth.
"We used to say, 'Of course you're going to hurt the
next day,'" says Dr. Tolle. "Now we say, 'What can we
do for you?'"
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Willamette Week | originally
published September 15,
1999
