Forget marijuana. What we really need is more morphine, more doctors who
understand it 97 and less meddling by authorities.

THE MORPHINE MYTH

By Stephan Herrera

MARIJUANA HAS BEEN making headlines ever since California and Arizona
vot ers legalized it for medical use a few months ago, but the drug that
deserves the ink is morphine. "The real issue is why more patients
aren't getting the morphine they need for their pain," says Dr. Kathleen
Foley, cochief of the pain program at Memorial SloanKettering Cancer
Center in New York.

Unlike marijuana, morphine has plenty of scientific research to support
its medical use. Few drugs work better and with fewer side effects than
morph ine on the chronic pain of cancer, AIDS and myriad serious medical
conditions . Yet there are too many patients who need it who are not
getting it97to t he point that some end up asking doctors to help them
commit suicide. Even t he Viennabased International Narcotics Control
Board, which oversees narcot ics quotas and distribution worldwide, has
called on governments to lighten u p their restrictions. The U.S. is far
from the best place to get morphine when you need it. In the U.K. the
number of morphine prescriptions per capita is nearly twice that of the
U.S. In Denmark it's almost four times as high.

Why are doctors here so inhibited? Two reasons. One is that they have
bee n trained since their medical school days to believe that morphine
is dangerous97very addictive and prone to cause death by respiratory
depres sion. The other is that they have the Drug Enforcement
Administration looking o ver their shoulders. Chemically, morphine is a
near cousin to heroin. Fearful that morphine could be diverted for
illicit use and mindful of its percei ved hazards, the DEA and state
authorities keep a close eye on which doctors prescribe morphine and for
what purpose. "Sometimes I have been questione d by pharmacists about
the amount of morphine I prescribe," says Foley. "And I know that I have
raised the DEA's interest in what's going on over here [at
SloanKettering]."

The DEA agents audit pharmacies, visit doctors and conduct undercover
investigations. They ferret out doctors with drug addiction problems of
t heir own. Many doctors steer clear of morphine just to be on the safe
side. According to a 1992 University of Wisconsin Pain & Policy Study
Group rep ort, almost half of 300 doctors surveyed underestimated the
relief that pain treatment such as morphine provides to cancer patients.
"The [authorities] say that all they care about is stopping the
diversion of morphine," says Dr. Richard Payne of the M.D. Anderson
Cancer Center in Houston. "But they don't understand the chilling effect
that a phone call from the DEA or a letter [from the state medical
board] can create."

Patients are sometimes ambivalent about morphine, too. Elaine Heifetz, a
65yearold New Yorker, suffers from a cyst of the spinal cord, which
cau ses persistent and burning pain. For years she shunned narcotics,
fearing the y would take over her life. "Try telling an employer or your
family that yo u're using a narcotic," she says. Now retired from the
State Department after a career in diplomacy, she has been using
oxycodone, a cousin of morphine, for the last six months. "Opiates gave
me my life back," she says.

Is a painracked patient likely to become an addict? No, said Dr. Dwight
Moulin of the University of Western Ontario in an article in the Lancet
l ast year. Morphine, he says, does not produce euphoria in patients
with pain, so no craving for anything beyond pain relief ever develops.
Foley says that in her 30 years as a doctor she has seen only a few
cases of morphine addiction among patients with chronic pain.

Moulin's study confirmed what others have been saying for a while. A
stud y 20 years ago by Drs. Jose Medina and Seymour Diamond of the
Diamond Headache Clinic in Chicago found that only 2 of 2,369 patients
exhibited signs of psychological dependence as a result of receiving
morphine and other drugs.

These studies define addiction fairly narrowly: Only patients who remain
dependent on a drug 97 meaning they crave it after being taken off it 97
are classified as addicted. But that's not how many doctors in this
country s ee addiction. Doctors believe that a patient who exhibits
tolerance and any withdrawal symptoms is addicted. Some patients taking
morphine do in fact develop tolerance (meaning they need a higher dose
to achieve the same effect) and withdrawal symptoms (like nausea,
vomiting and the shakes). But is either of these a reason to make
desperately ill people suffer? You ca n develop tolerance to cortisone,
withdrawal problems from caffeine. Morphine's withdrawal symptoms
vanish in 12 hours. They are minor compared with thos e from heroin and
alcohol.

What about severe constipation, a common side effect of morphine? It's a
small price to pay if you have disabling pain. The problem can be
combatt ed to some degree with overthecounter laxatives.

The other reason for avoiding morphine 97 fear that its medical use will
lead to its diversion for recreational use 97 is bogus too. Another
Universit y of Wisconsin study notes that an increase in morphine
prescriptions in Wisco nsin from 1976 to 1992 did not create a
corresponding increase in supply of th e drug to the street.

In fact, morphine is not a drug of choice among drug addicts. In a study
of emergency room visits related to drug use nationwide in 1993, less
than 2 % resulted from the use of prescription drugs like morphine.
Facts on morphine: Opium sources Prescription medicine: India (about
80%) Contraband: Afghanistan, Burma, Thailand Leading U.S. morphine
producers: Roxane Laboratories, Inc. (Columbus, Ohio) Purdue Frederick
Co. (Norwalk, Conn.)

Dosage range: From 10 mg to 5,000 mg per day

U.S. prescriptions: 1.9 million

Consumption per million residents (kg)

Denmark 75
U.K. 39
U.S. 21
Germany 8

Sources: U.S. Drug Enforcement Administration; IMS America Ltd.; Dr.
Kath leen Foley, Memorial SloanKettering Cancer Center; International
Narcotics Control Board.

May 19, 1997 Issue A9 Forbes Inc. 1997