WRITING about the opioid epidemic in our community is less a pleasure than a sorrowful duty.

My earlier four articles (Chronicle, July 26, August 2, 9, 16) on the opioid crisis focused on the United States.

There, the etiology of America's opioid epidemic was the erosion of economic and social status of workers over several decades. The resultant diminution of dignity and hope created the vulnerability into which opportunistic pharmaceutical companies fostered an opioid-medication-based solution to the problem of psychologically loss-induced pain that lead to the crisis.

Too often, medical personnel complied. There, as here, people died — 64,000 in 2016 alone, more than the number of Americans killed in the Vietnam, Iraq and Afghanistan conflicts.


My fear that it was heading here as conditions ripened appears sadly to be coming true. The news announces the widespread use of Fentanyl and deaths from opioid and opiate use in our country and our community.

As opioids all act to suppress respiration, deaths from opioids is a measure of extent of usage, not necessarily of an overdose. An undetermined percentage of users, otherwise unsupervised and unmonitored, will die from these drugs.

That people are dying from Fentanyl or morphine tells us that many more are misusing them. The higher the number of users, the greater the number of deaths.

To be clear, prescription opioids are highly useful medications. Left with the choice of one medication to have on a deserted island, I'd choose morphine. The World Health Organisation lists morphine as an essential medicine to any health system, among those considered effective and safe.

So where do things go wrong? These drugs are addictive, given the right social and economic circumstances.

The story of its over-prescription in the US, encouraged by Purdue Pharmaceuticals, is now well known. For the here and now, an ounce of prevention is worth a pound of cure.
No one seriously disputes their use in instances of acute pain, of a broken limb, of a severe burn or in myocardial infarction (heart attack). Especially that last where morphine is anxiolytic, pain-relieving and helps the faltering cardiac muscle work.

The problem of potential abuse and its attendant risks — including death — occurs with use in chronic pain. Currently, US pain specialists, perhaps regarding the epidemic there, recommend opioids for acute pain only and with low doses.

For chronic pain they recommend other medications, including non-steroid anti-inflammatory meds or aspirin.

Fentanyl, highly potent, is controversial. Its usefulness in surgery is easily persuasive, but its use in chronic pain is not. That said, there are exceptions to nearly every rule and pain is a complex symptom, not to be casually corralled under one rubric.

The key to safe use in those rare cases of intractable pain, unresponsive to available meds, is low doses and careful monitoring, including availability of Naloxone which can reverse respiratory failure due to opioids.

Chronic pain requires a broad approach, and the range of such methods from yoga to mindfulness, massage, physical rehabilitation and diet. For medication as an accessory, without creating further damage, muscle relaxants, anti-inflammatory meds, anti-depressants, and medical cannabis are useful and effective.

With our new government there is a recognition of the place of cannabis in the medical pharmacopeia. It is long overdue and potentially life-saving in the face of current opioid misuse.

While adverse side-effects are a factor in all medications, the risk of death from cannabis approaches zero.

Moreover the studies show that deaths from opioids in US states that legalised medical cannabis were reduced by 25 per cent. Patients whose pain programme included cannabis as medication were less likely to use opioids, hence less likely to die.

As we start our new year, optimism can take root in our acceptance of the once unthinkable.

Gays, once scorned and necessarily closeted, can now openly marry; we're rethinking end-of-life choices; and the anti-establishment weed of the 1960s is moving away from the "Reefer Madness" nonsense of the 1930s to the doctor's office, where its pain relief may save lives.

Jay Kuten is an American-trained forensic psychiatrist who emigrated to New Zealand for the fly fishing. He spent 40 years comforting the afflicted and intends to spend the rest afflicting the comfortable.