"Pain" as Albert Schweitzer once said, "is a more
terrible lord of mankind than even death itself." Prolonged pain
destroys the quality of life. It can erode the will to live, at times
driving people to suicide. The physical effects are equally profound.
Severe, persistent pain can impair sleep and appetite, thereby producing
fatigue and reducing the availability of nutrients to organs. It may
thus impede recovery from illness or injury and, in weakened or elderly
patients, may make the difference between life and death.
Sadly, there are some kinds of pain that existing treatments cannot
ease. That care givers can do little in these cases is terribly
distressing for everyone involved but is certainly understandable. What
seems less understandable is that many people suffer not because their
discomfort is untreatable but because physicians are often reluctant to
prescribe morphine. Morphine is the safest, most effective analgesic
(painkiller) known for constant, severe pain, but it is also addictive
for some people. Consequently, it is typically meted out sparingly, if
it is given at all.
Indeed, concern over addiction has led many nations in Europe and
elsewhere to outlaw virtually any uses of morphine and related
substances, including their medical applications. Even where morphine is
a legal medical therapy, as it is in Great Britain and the U.S., many
care givers, afraid of turning patients into addicts, deliver amounts
that are too small or spaced too widely to control pain.
Yet the fact is that when patients take morphine to combat pain, it is
rare to see addiction-which is characterized by a psychological craving
for a substance and, when the substance is suddenly removed, by the
development of withdrawal symptoms (for example, sweating, aches and
nausea). Addiction seems to arise only in some fraction of morphine
users who take the drug for its psychological effects, such as its
ability to produce euphoria and relieve tension.
Furthermore, patients who take morphine for pain do not develop the
rapid physical tolerance to the drug that is often a sign of addiction.
Many people who are prone to addiction quickly require markedly
escalating doses to achieve a desired change of mood, but patients who
take the drug to control pain do not need sharply rising doses for
relief. They may develop some tolerance initially, but their required
dose usually rises gradually and then stabilizes.
I do not suggest that morphine be prescribed indiscriminately. I do urge
lawmakers, law-enforcement agencies and health-care workers to
distinguish between the addict who craves morphine for its mood-altering
properties and the psychologically healthy patient who takes the drug
only to relieve pain.
Morphine is a constituent of opium, which has been a medical therapy for
longer than 2,000 years, since at least ancient Roman times. Opium is
made by extracting a milky juice from the unripe capsule, or seedpod, of
the poppy Papaver somniferum (grown abundantly in many Middle Eastern
countries) and then drying the exudate to form a gum. This gum-the
opium-can be eaten as is or added to a beverage.
By the 16th century opium was being carried by traders to Europe and the
Orient. At about that time an opium-containing mixture called laudanum
became a popular remedy in Europe for virtually all ailments. Later,
smoking opium and tobacco together became yet another popular way to
obtain the drug's benefits.
Soon after the turn of the 19th century, a young German pharmacist named
Friedrich W. A. Serttimer isolated morphine from opium and identified it
as opium's major active ingredient. Morphine's production was followed
in 1832 by the isolation of yet another opiate, or opium derivative:
In the mid-19th century the introduction of the hypodermic needle made
it possible to administer large amounts of drugs by injection. The
standard approach to morphine therapy for ongoing pain (left) calls for
injections pro re nata (PRN), or "as needed.' In practice this
means injections are given only in response to pain; also, if the pain
returns before four to six hours have passed the patient often has to
wait for help. By the time the next injection is delivered, the pain may
be so severe that quite a large dose is needed, leading to mental
clouding and other side effects, such as nausea. A more enlightened
approach (right) seeks the actual prevention of pain and thus helps ease
the fear of recurring agony. The morphine is given orally (in a dose
tailored to the patient's needs) every four hours or even more
frequently if a shorter schedule prevents pain more effectively. Because
the doses are frequent, they typically can be relatively low, which
reduces the incidence of side effects.
Improved technology, which enabled a drug's effects to be felt quickly,
led in many regions of the world to the ready prescription of injected
morphine for severe pain. At the same time, more and more people began
taking morphine for its emotional effects, and the number of addicts
Eventually a search began for drugs that had morphine's analgesic
properties but were not habit-forming. This quest resulted in the
production of heroin, a synthetic compound similar in activity to
morphine but soon found, disappointingly, to be quite as addictive.
Various other opioids (chemicals with activity similar to that of opium)
were then introduced, including methadone and meperidine (Demerol). Like
the opiates, many of the opioids relieve pain, induce changes in mood
and, unfortunately, are addictive to some extent.
Inevitably, the rising abuse of narcotics (by which I mean opiates and
opioids) and of other mood-altering drugs spurred countries throughout
the world to adopt anti-drug regulations. At the same time, the extremely
cautious administration of narcotics for pain became commonplace.
Today morphine therapy for pain is generally restricted to two groups of
patients. It is prescribed over relatively short periods for
hospitalized individuals who have discomfort caused by surgical
incisions, and it is given over potentially longer periods to ameliorate
the pain suffered by burn victims or people who have incurable cancer.
In many hospitals the standard prescription order says "PRN"
(pro re nata, or "as needed"). This order essentially means
that the drug is given orally after pain returns. Typically, it is
delivered by injection into a muscle or under the skirt.
The result of the PRN approach is often a confrontation between the
patient and the care giver, who expects morphine analgesia to last for
four to six hours. The patient, whose pain has returned earlier than
expected, is in agony and pleads to have the next injection. The
health-care worker, fearful of causing addiction, refuses to comply.
When the pain is finally treated, it may be so severe that a large dose
has to be given, which increases the likelihood of side effects, such as
mental clouding and nausea. Particularly when a patient has a terminal
Illness, the issue of addiction is meaningless, and delaying relief is
There is another, more humane way to treat pain, one that is slowly
gaining acceptance. In this approach doses are given regularly,
according to a schedule that has been actually tailored to prevent
recurrence of the individual's pain. Thus, pain is controlled
continuously; a patient does not wait for discomfort to return before
receiving the next dose.
This enlightened, preventive approach evolved from pioneering work first
undertaken some 20 years ago by Cicely M. Saunders, an English physician
who established the first modern center devoted to caring for people who
are dying of cancer or other dis. eases: St. Christopher's Hospice in
London. Saunders urged physicians caring for terminally ill Patents to
face reality and palliate-to relieve Pain, nausea and other discomforts
instead of making futile attempts to cure disease. The final days or
weeks of a person's life, she believed, should be a time of peace and
comfort, spent as pleasurably as possible in the company of family and
To achieve this aim, Saunders prescribed the Brompton mixture, a version
of a liquid analgesic that had been used for advanced cancer by several
London hospitals, including the Brompton Chest Hospital, since the late
19th century. The mixture (made of morphine, cocaine, chloroform water,
alcohol and flavoring syrup) had been eclipsed by injectable morphine,
but Saunders realized that an orally delivered compound would allow many
patients to spend a number of their last days at home; a visiting nurse
would simply monitor them, making sure their pain was controlled.
Morphine has since been found to be the only important ingredient in the
Brompton mixture, and so today patients who are treated with the
preventive approach to pain take morphine alone, either as a tablet or
mixed into a beverage. An initial dose of 10 milligrams is typically
given and repeated every four hours. Then, over the course of perhaps
several days or weeks, the dose and timing are adjusted until a
maintenance regimen is established that controls pain around the clock
without producing mental clouding and other side effects.
For patients who have cancer, an approach emphasizing pain prevention is
particularly wise. Pain and the fear of pain are perhaps their greatest
source of suffering. In the early stages of the disease, some 80 percent
of people have pain resulting from the cancer itself or from the
procedures designed to arrest its spread. By the time the cancer has
reached its final stages, about 70 percent of people report pain, which
tends to be intense and persistent.
About 80 to 90 percent of cancer patients treated with the preventive
approach obtain satisfactory relief, reporting that their discomfort is
consistently bearable or, more frequently, gone. Roughly half of the
remainder obtain relief with the addition of other therapies. This
success rate is remarkable in view of the destructiveness of cancer and
the severity of the pain associated with it.
Treatments continue to improve. There are now special capsules that
release morphine slowly and so need to be taken only a few times a day.
Also available are electronically controlled, portable pumps that
deliver a steady infusion of medication under the skin.
Enough evidence has now been collected to demonstrate that the
traditional, PRN approach, based as it is on the fear of addiction makes
little sense. Study after study of patients whose pain is most often
treated with narcotics-namely, cancer patients, burn victims and those
hospitalized for surgery-has shown that the patients who develop rapid
and marked tolerance to, and dependence on, the narcotics are usually
those who already have a history of psychological disturbance or
Studies of patients who received narcotics while they were hospitalized
have also uncovered little evidence of addiction. In an extensive study
Jane B. Porter and Hershel Jick of the Boston University Medical Center
followed up on 11,882 patients who were given narcotics to relieve pain
stemming from various medical problems; none of the subjects had a
history of drug dependence. The team found that only four of the
patients subsequently abused drugs, and in only one case was the abuse
Equally persuasive are the results of a survey of more than 10,000 burn
victims. These individuals, who were studied by Samuel W. Perry of New
York Hospital and George Heidrich of the University of Wisconsin at
Madisom underwent debridement, an extremely painful procedure in which
the dead tissue is removed from burned skin. Most of the patients
received injections of narcotics for weeks or even months. Yet not a
single case of later addiction could be attributed to the narcotics
given for pain relief during the hospital stay. Although 22 patients
abused drugs after they were discharged, all of them had a history of
Further evidence that narcotic drugs can be administered for pain
without causing addiction comes from studies of "patient-controlled
analgesia" in surgical patients and those hospitalized for burns.
in such studies patients push a button on an electronically controlled
pump at the bedside to give themselves small doses of morphine (through
an intravenous tube). When these devices were introduced, there was
considerable fear that patients would abuse the drug. Instead it soon
became clear that patients maintain their doses at a reasonable level
and decrease them when their pain diminishes.
Studies that explore how morphine produces analgesia are helping to
explain why patients who take the drug solely to relieve pain are
unlikely to develop rapid tolerance and become addicted. On the basis of
such studies, my former student Frances V. Abbott and I proposed in 1981
that morphine probably has an effect on two distinct pain-signaling
systems in the central nervous system and that one of these-which gives
rise to the kind of pain typically treated with morphine-does not
develop much tolerance to the drug.
In view of the complexity of the neural mechanisms of pain, it is not
surprising that morphine's ability to produce analgesia has been found
to vary greatly from person to person. An important message emerging
from studies of such variation is that the need for a high dose is not
necessarily a sign of addiction.
In one such study involving cancer patients, Robert Kaiko, now at the
Purdue Frederick Company in Norwalk, Conn., and Ws colleagues at the
Memorial Sloan-Kettering Cancer Center found that to achieve a given
level of analgesia, less morphine was needed by older patients than by
younger patients, and less was needed by blacks than by whites.
Similarly, patients with dull pain needed less morphine than did those
with sharp pain, and patients with stomach pain needed less morphine
than did patients with pain in the chest or arm.
Society's failure to distinguish between the emotionally impaired addict
and the psychologically healthy pain sufferer has affected every segment
of the population. Perhaps the most distressing example is unnecessary
pain in children Many health-care workers undertreat pain in youngsters,
not only because of fear of addiction but also because of the mistaken
belief that young children do not feel pain as intensely as adults. In a
classic study, Joann M. Eland and Jane E. Anderson of the University of
Iowa found in 1977 that more than half of the children from four to
eight years old who underwent major surgery-including limb amputation,
excision of a cancerous neck mass and heart repair-were given no
medication for relief of their postoperative pain; the remainder
received inadequate doses. When 18 of the children were matched with
adults who underwent similar procedures, the children as a group were
found to have been given a total of 24 doses of analgesic drugs, whereas
the adults were given a total of 671 doses.
The elderly also pay the penalty of ignorance. In a study of
postsurgical pain my colleagues and I found that surgical wards contain
two basic populations: a young and middle-aged group that recovers
quickly and an older group whose pain remains severe and lingers for
many days beyond the normal three- to four-day recovery period. Despite
the persistent, high level of pain in these older patients (presumably
because of complications that arise after surgery) and despite the
longer recovery period, they do not receive larger doses or a higher
daily amount of medication. About 30 Percent of the patients on a
surgical ward at any time fall into this older category; they thus
represent a substantial number of people who suffer needlessly high
levels of pain.
The pain suffered by burn victims is known to be agonizing, and yet it
too, tends to be poorly controlled. Manon Choiniare of the burn Center
at the Hotel Dieu in Montreal and I found that even in the best burn
facilities-those with highly capable, compassionate physicians, nurses,
physiotherapists and others-pain levels are high. Our study of 30
consecutive patients who underwent debridement and physiotherapy
(exercise to prevent loss of joint flexibility) classified the severity
of pain on the basis of the Pain questionnaire I developed with
Torgerson. We discovered that during treatment in the first two weeks,
23 Percent had severe ("horrible") pain, and 30 percent had
extremely severe ("excruciating") pain. Even when the Patients
were at rest, 13 percent of them reported having severe pain, and
another 20 percent said they had extremely severe pain. These data, by
the way, were obtained from patients who were already medicated
according to standard textbook recommendations (that is, the drug order
For many patients who are hospitalized for surgery or burns or who have
terminal cancer, the prescription is clear: a preventive approach to
pain should be instituted to maximize the effectiveness of narcotics
therapy. What, though, should be done for people who suffer from
debilitating chronic pain but who do not have a fatal illness? These
people have traditionally been excluded from long term therapy with
narcotics, again for fear they would become addicts.
Consider the case of a 26-year-old athlete who sustained a major spinal
injury that caused him to suffer from excruciating pain in the back and
legs. The pain rendered him unable to work, and he became a burden to
himself, his family and society, which pays his medical bills. His
physician discovered that small doses of morphine taken orally each day
(the way cancer patients receive them) obliterated the pain. With the
help of the medication, the young man resumed working and made plans to
marry his childhood sweetheart, who was accepting of his injury.
One day, however, the physician was accused by his regional medical
association of prescribing narcotics for a purpose unapproved by the
association and of turning the patient into an addict. Fearful of losing
his medical license, the physician stopped prescribing the drug. (Where
morphine administration is allowed by law, physicians can technically
prescribe it at will, but they are in fact restricted by the regulations
of medical societies, which control licensing.)
Of course, the young man's pain returned. In desperation, he turned to
other physicians and was rebuffed. He then sank rapidly into depression
and again became mired in helplessness and hopelessness.
It was once unthinkable to give narcotics indefinitely to patients who
were not terminally ill. Yet studies designed to examine addiction
specifically in such patients are beginning to show that for them, as
for the standard candidates for narcotics therapy, these drugs can be
helpful without producing addiction.
In one recent study Russell K. Portenoy and Kathleen M. Foley of
SloanKettering maintained 38 patients on narcotics for severe, chronic
non-cancer pain; half of the patients received opioids for four or more
years, and six of these were treated for more than seven years. About 60
percent of the 38 patients reported that their pain was eliminated or at
least reduced to a tolerable level. The therapy became problematic in
only two patients, both of whom had a history of drug abuse.
With cautious optimism, Portenoy and Foley suggest that morphine might
be a reasonable treatment for chronic pain in many patients who are not
terminally ill. They point out the problems that may accompany narcotics
maintenance therapy, and they provide careful guidelines for monitoring
patients. Studies such as theirs are doing something in medicine that is
akin in aeronautics to breaking the sound barrier. They represent a
breakthrough to a reasoned, unbiased examination of the effectiveness of
narcotics in patients who have rarely been considered for such therapy.
Among the critics of long-term narcotics therapy for such patients are
physicians and others who fear that people will simply be given a
prescription for a drug and will never receive the advantages of a
multidisciplinary approach to the care of pain. Yet both approaches are
compatible; in fact, they complement each other.
For the future, many more well-controlled studies are needed to provide
data on the long-term effects of narcotics on chronic non-cancer pain. At
the same time, medical and government agencies must provide the
authorization and funds for such studies to take place. The goal is
nothing short of rescuing people whose lives are now being ruined by
by Ronald Melzack; Scientific American; 262(2);