Opiate painkillers are extensively used in pain therapy.
These molecules form two large categories: narcotic opiates (morphine, codeine etc.) and opiates with no narcotic effect, the so-called synthetic opiates (tramadol etc.).
Since exhaustive evidence proved that the undesired effects of “physical dependence“, “tolerance” and “addiction” typical of morphine are extremely low when there is pain, the use of morphine has also been stretched to pain that is incorrectly called non-malignant, pain that is not caused by cancer (ie. the extremely frequent and common back ache).
Regulations enforced till last year on the use of morphine and narcotic opiates were very strict. Failure to comply with them caused many judicial and criminal problems especially to pharmacists, as pointed out by Paola Minghetti and Pietro Balocco on the 4th Day for Updates on Pain, November 2001.
One year ago, under the auspices of the then Minister of Health Umberto Veronesi, new regulations in regards to prescriptions and the transport of narcotic opiate painkillers became law, conforming with European regulations.
These variations simplified prescription procedures to a great extent and, though the high pecuniary penalties were left unaltered, the criminal aspect was removed. According to some opinion leaders, this was supposed to cause an immediate and evident increase in prescriptions for morphine, to the benefit of many patients, especially terminal ones. Pain therapy was surrounded by the triumphal atmosphere of a social conquest, as if nothing or very little had been done in Italy till this moment to treat and assist those twenty million people suffering from chronic pain of various origin and nature.
For example a well known daily’s headlines were “The Senate’s yes to the liberalization (sic!) of morphine”, as if doctors could freely prescribe morphine under these new regulations! The headlines were also ambiguous: “Pain therapy becomes law”, or emphatic: “Pain’s epoch-making defeat”. Someone even suggested proclaiming the Minister of Health a “national hero”.
Now, a year later, we note that the expected increase in prescriptions for morphine did not take place or is trifling. Why did the results fall short of the triumphant expectations? If we accept the theory that morphine intake must be considered the only and absolute indicator of efficient medical assistance and progress of pain therapy in a country, and if we consider that Italy is last but two in this list and that our country did not alter this low rate of consumption even after the new law was implemented, then millions of disappointed and worried Italians could rightly ask themselves what awaits them and the pain that could affect them one day.
There seems to be every reason to despair. I would instead like to see these people encouraged and reassured. The syllogism “morphine consumption means progress in pain therapy” is not acceptable. Apart the fact that morphine is not the only pain treatment, statistically speaking it is incorrect to compare and create lists based only on the consumption of morphine in various countries without specifying the method of administration adopted. Let me make myself clear. Morphine can be administered in many ways (oral, sublingual, parenteral, spinal, epidural) which, despite producing the same results, call for extremely different dosages (and hence global consumption). Subsequently if, for example, one country adopts oral administration while another chooses the spinal one, the consumption rate of morphine in the first will be much higher than in the second, though the number of patients treated is the same.
But this does not mean that in the first country Pain Therapy as such is resorted to more often and is more developed. Just simpler regulations concerning prescriptions and the decriminalization of a crime have not convinced doctors to administer more morphine to patients. No result will be achieved without a specific program to spread scientific and clinical culture, that is, the consumption of morphine in Italy will always be behind. It is true that morphine is an excellent painkiller but it has its limits and contraindications and it does not always work (in pain caused by cancer morphine fails to act or stops being active in 30% of cases). It is also essential that doctors be updated even on new methods of administering long term opiates and they should study the opioid “rotating” method, a technique that follows the principles of molecular dynamics of drugs. In fact every opiate acts on a special type or subtype of receptor.
But after a period the specific receptor “gets used” to the drug and begins to lose its painkilling effect. Then, following a specific method of administration, the doctor should change the opiate, that is he should rotate drugs. Lastly, moved by the respect due to colleagues and also that due to patients and citizens, I would like to suggest that false and distorted information of the sort , for example, that simpler regulations concerning the use of morphine are the greatest conquest in pain treatment in recent years and that Italian universities have so far been unheedful of problems centreing on research and information on pain should not be spread. Let us remember that the University of Milan was the first in the world, exactly twenty years ago, to add to the prospectus of its Faculty of Medicine the course on Physiopathology and Pain Therapy, which later became compulsory in every university. I agree that all this can widen certain stores of popularity in politics but it is almost always objectionable to lie to the sick.
(traslation by Interpres)

MARIO TIENGO
Professore Emerito di Terapia del dolore
Università Statale di Milano