Annals of Medicine: Where is the Pain?


We are losing the war on drugs. We have been fighting it for 50 years and the problem is worse than ever. Last year, more Americans died of drug overdoses in a single year (72,000) than died in all of the 20 years of the Vietnam War (58,000 total). Americans represent 4 percent of the world’s population and consume 80 percent of the world’s prescription opioids.  

I am on the front lines of this war and deal with the casualties on a daily basis. So I was intrigued to attend the Charlottesville Festival of The Book this month and listen to a voice from the other front in this war, Mexico. 

Don Winslow is a novelist who lives on the U.S. southern border and has written a deeply researched trilogy of novels detailing the cost of the U.S. war on drugs to the Mexican people. It is estimated that over 200,000 Mexicans have been killed in the past decade in the violent trade of smuggling drugs to supply America’s drug habit.  Winslow came to the Charlottesville festival to discuss his work and shared some of his thoughts on the opioid epidemic.  

Winslow’s most profound observation was that if opioids are painkillers, where is the pain? What has changed in our society that we need so many painkillers?

His answer was that we have retreated from face-to-face social interaction, like the very discussion group we were having with him, in favor of online communication and social media.

Perhaps. But actual physical pain in America is increasing. 

Ironically much of this increase in chronic pain may in fact be caused by the opioid epidemic. First, opioids are not very effective in chronic pain; they require ever increasing doses, and any decrease in dose results in the original pain returning with a perceived greater intensity. Second, opioids can decrease pain tolerance, a phenomenon known as opioid-induced hyperalgesia (OIH).  This OIH is most strikingly revealed in injection drug user’s paradoxical dread and near intolerance of medical IV sticks.  

So what should be done? I guess we could spend less time online and more time face-to-face interacting with people. The curmudgeon in me doesn’t like this idea. More practically we could increase the federal funding for addiction treatment from the $2 billion a year we currently spend to levels approaching the $35 billion a year we spend to treat HIV/AIDS.  Drugs now kill more Americans per year than die from HIV.  More Americans die from drugs each year than are killed in car crashes and gun violence (both suicide and homicide) combined. We have a public health emergency and we need to approach it with a sense of urgency.   

But Don Winslow was onto something that is practical and can be done by each of us. Get out into the community.  Attend events like the Festival of the Book and participate. The Festival is a Charlottesville treasure. Hundreds of authors descend on Charlottesville for four days of mostly free gatherings and deep discussions. It is wonderful and stimulating. It is our community at its best.  I highly recommend it. 

Oh and for the pain? Read two books and call me in the morning. 


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