The Opioid Crisis

As I’m sure almost everybody has heard, we are in the midst of a rapidly escalating opioid crisis in Canada and America right now. It seems we are often hearing stories on the news about dramatic increases in overdoses and death from opioids; especially ones containing small amounts of the strong synthetic version called fentanyl. In people under 50, drug overdoses are now the leading cause of death in the US. Two thirds of those deaths are opioid related. This has been strongly and steadily increasing over the last decade or two….as has the number of prescriptions written. Opioids come in many forms from opium to morphine, heroin to codeine, laudanum (which in the old apothecary days was a tincture of opium), OxyContin, Percocet, Vicodin, etc.

Opioids have a long and fascinating history and are strongly rooted in herbal medicine traditions around the globe. They all come, initially, from the poppy – “the opium poppy” – but many other garden variety poppies have some of the similar compounds, albeit in smaller amounts. It is collected by scoring the unripe fruit (the green bulby part at the top of the stem just after the last of the flower petals falls off) with a very sharp blade in the morning. A white latex will ooze out from the injured site on the plant. It is left there to dry and turn black over a day or so. This black tarry substance is then scraped off of the plant, and this is opium in its crudest form. Inside this green bulb, or fruit, are the poppy seeds. Even poppy seeds contain some of the opioid compounds, albeit in very small and inconsistent amounts depending on where they were grown and which type of poppy they come from. Poppy seed milk has been used in countries all over the world for centuries as a sleep aid. Papaver Somniferum is the Latin name for poppy and you can tell from the second name, Somniferum, that is causes sleepiness or somnolence. Its name basically means the sleep inducing poppy. Remember Dorothy falling asleep in the field of poppies in the Wizard of Oz? This was a strong opium metaphor. Morphine is actually named after Morpheus, the Greek god of dreams.

Understanding all of this helps us understand where opioids have power as a medicine and danger as an addictive substance. For the trauma of surgery or other traumatic injury pain they are indispensable. They take your mind away from the pain. They don’t just take away physical pain, either – they help you forget your other deeper emotional pains. Opioids induce a dream-like or sleep-inducing state. And this is where people are getting into trouble. They are drawn to the escape it can provide on many levels of their lives. Of course, it can slow your system down so much that your lungs forget to breathe. They basically fall asleep, if the dose is too high and the tolerance is low. This slowing down of the breathing, body and mind is also what slows down the muscles of the bowels and lungs which helps us understand why it was historically used as a cough suppressant and anti-diarrheal treatment.

These compounds are still largely some of the best options we have in medicine for controlling severe pain. Morphine was made from opium back in the early 1800’s and was a blessing during surgery and recovering from surgery especially during wars. Unfortunately, as early as the Civil War in America and the Opium Wars between China and Great Britain, thousands of soldiers were already becoming addicts.

Opium was the drug that allowed Great Britain and later France to finally force China to open its historically closed borders to the British, and ultimately the world, for free trade and travel. Processing plants in India, run by the British for sale in China, arguably had enough product and money flowing through them at one point to pay for huge sections of London. A great read about this time is Amitav Gosh’s Sea of Poppies.

China had seen some opium trickling in on the Silk Road for many centuries, where it was largely used only as a medicine and rarely as an addictive drug as it was scarce, expensive and historically mostly only became an addiction issue for the wealthier classes. Once Great Britain, France, and others like the Dutch started to industrialize extraction and production techniques it became cheap and widely available and they utilized this to tap the huge Chinese market. China then had big problems with opium addiction and suddenly found itself having to deal with millions of addicts. To combat addiction, they used some tactics I don’t approve of, like imprisonment and execution. But they also used many other approaches involving community education about addiction, discouraging guilt about addiction, herbal “detoxification” medicines, Buddhist meditative techniques for managing anxiety and withdrawal, acupuncture, and ultimately trying to give recovering addicts meaningful jobs. These approaches helped heal millions of opium addicts. We need to be looking more to some of these strategies. I am working now on a future Harrington’s detoxification formula to really help the system handle withdrawal from drugs and alcohol based on some of the best herbs used historically. I am obviously looking deeply at China and India’s herbal medicine traditions.

Meanwhile in America, opium dens – started up by Chinese railway workers – were arguably almost as prevalent as saloons in the Wild West days of the cowboys. Strangely, this is an image we don’t see much in movies about this period. I guess people lying on a bed with a pipe for hours or days isn’t quite as exciting as what people get up to in saloon on alcohol, tobacco and gambling….

Heroin was developed by a German drug manufacturer in the later 1800s and marketed to doctors and the public as a non-addictive, safe alternative and treatment for morphine addicts. Obviously, this didn’t turn out to be the case as we know today heroin is highly addictive. It is a shame we don’t always learn from history, as this is a very similar story to what we are hearing today about the settlements that Perdu Pharma is paying the Canadian and American governments for over-marketing the safety and lack of addiction potential of OxyContin.

Codeine, which is widely marketed as the “safest” and least addictive of the opioids, has long been used to treat not only pain but also coughs and diarrhea. Although it is safer, it is far from safe. Historically, many a child has fallen asleep and never woken up after being given too much cough syrup containing codeine. Many addicts have also overdosed on the codeine in cough syrups. Even though some MDs were giving Oxy to people with sprained ankles and bruised ribs (which is ridiculous), most people who are prescribed opioids don’t become addicts. They use it appropriately and stop appropriately or don’t even continue after the first couple of doses because they can’t stand how it makes them feel. It does make you kind of groggy, sleepy and checked out…which people who like to maintain control do not typically enjoy at all. Opioids can also lead to nausea, vomiting and constipation, which aren’t fun side effects for most people. 

Sadly, this is how we lost some of our most noted famous contemporaries from Jim Morrison, to John Belushi, Janis Joplin, Jimmy Hendrix and most recently Prince – who was staunchly against drugs and alcohol for most of his life, before a supposed prescription pain pill contaminated with fentanyl is what may have ended his life.

Understanding pain and mental health better are both critical pieces of managing this crisis. Though a great deal of research has been done, we still often seem to be in the dark with both of these subjects. We have a long way to go to understand them better. One recent study on pain found that when people were giving the exact same painful stimulus, a safe measurable level of shock, and asked to grade that pain on a scale of 1 to 100 the answers ranged from about 3 to 97, with everything in-between. People perceive pain so differently based on past experiences and genetics. We understand some of these but not others. Some studies suggest that early childhood pain can sensitize us, as some research shows that little boys who had been circumcised often experience pain more acutely than uncircumcised boys or little girls. Others suggest that women’s tolerance to pain may be higher than men’s as they bear the pain of childbirth. Of course, healthcare is rarely black and white. Some circumcised little boys may end up with very high pain tolerances and many women may have a low pain threshold. We cant seem to measure or predict pain very well in individuals, yet I still use a scale of 1 to 10 in my clinic on a daily basis, as this is one of the best tools I have. Opioids are not very good at managing chronic physical pain either, as our bodies learn to tolerate them, and subsequently higher and higher doses are needed to achieve the same pain relieving effects.

Looking to addiction, we also have to understand emotional pain and the need to want to escape from your life for a while. This, aside from chronic pain, is what tends to rope people into addiction. And the same problem of tolerance exists, so higher and higher doses are needed to continue pursuing escape, sadly often leading to the ultimate escape: Death.  Cutting people off prescriptions isn’t the answer, as this dependence both physically and mentally is what drives many people to pursuing illegal forms like heroin which are more and more often laced with fentanyl. Up to 80% of heroin addicts today started with a prescription for an opioid based pill, were subsequently cut off by their MDs, and have turned to more dangerous options. Instead of treating drug addiction as illegal and something to be guilt-ridden about, we need to tackle it as a physical and mental health issue. Increasing guilt and risk of prison won’t do much to improve a patient’s outcome for mental health issues like anxiety, depression or PTSD. We already have too much stigma in our culture about mental health. We need to approach it more healthily and positively. Patients with mental health issues and chronic pain often do really well with techniques like mindfulness or meditative training, cognitive behavioural therapy, yoga, exercise – especially cardio, as it releases some of the body’s natural endorphins – group therapy, and exploring spiritual pursuits. Eating a healthy diet is also a critical piece of this puzzle, as is the pursuit of a meaningful and connected life. As a result I work with patients to encourage them to find meaningful jobs, volunteer work and community connection. As naturopathic doctors looking at the whole person, we look at treating addiction with all of these tools and more. My colleagues and I are constantly combing modern research and historical techniques, looking for effective tools for managing this complex problem. I look forward to a day where the healthcare professions will hopefully work more and more together in a holistic or integrative medicine approach.

There are other pain relieving herbal medicines, besides the poppy, worthy of more attention and research. Combining some of the best known ones, and looking for alternatives to the problems that opioids (as well as ibuprofen and acetaminophen) have caused, is what drove me to create Harrington’s No. 5. This is my best stab at a fast, effective, affordable natural pain medicine alternative…for now. I am open to modifying it in the future if I learn about better ingredients. One of the herbs I wanted to introduce people to is rarely seen in the west but has historically been used in Chinese medicine. It is called Corydalis Yanhusuo. It has long been used traditionally, and in modern Chinese research has been shown to have up to 10 % of the pain relieving effects of opium without the dangerous narcotic side effects. Other herbs some may have heard of like Frankincense, have a long history in global herbal medical traditions as a great pain reliever. Our No. 5 is not the answer to the opioid crisis, of course, but I hope it can be a safe piece of the puzzle to help people manage pain. Interestingly, the growing interest in the legalization of marijuana is playing a role as an important herbal medicine. Again, it is far from perfect but in states where is has been legalized early data is suggesting that people may be using it instead of illegal opioids for managing physical and mental pain, which seems to be resulting in potentially dramatic decreases in the deaths from opioid overdoses in those states. Though imperfect, it is essentially impossible to smoke a lethal dose of marijuana. That said, it could make you reduce your inhibitions enough to take a risk like impaired driving which could end lives. In the end, there are no magic bullets for managing pain – but a comprehensive and individualized approach can help immensely and safely.