New Worlds: Painkillers

(This post is part of my Patreon-supported New Worlds series.)

Pain sucks.

And unfortunately, we have a limited number of ways of dealing with it. Willow, myrtle, and a few other plants are naturally occurring sources of salicylates like aspirin, and their use in treating pain, fever, and inflammation goes back to antiquity. (We’ll talk more about herbalism at a future date.) But many other staples of our modern medicine cabinets — ibuprofen, naproxen, and acetaminophen, aka paracetamol — are modern inventions, no more than a hundred and fifty years old and requiring fairly advanced chemistry to synthesize. Before then, we had to make do with other options.

I deliberately placed this essay after the one on alcohol because booze is a fairly universal and ancient painkiller. Ethyl alcohol depresses the central nervous system, which means it has some beneficial effects for dulling pain. But that doesn’t mean it’s terribly effective: it dulls pain rather than making it go away entirely. And of course the treatment brings some fairly significant side effects, ranging from the obvious intoxication and potential addiction to a reduction in the blood’s ability to clot — not good, if the pain in question comes from some kind of open wound.

But it’s cheap and widely available, so the stereotype of giving somebody a slug of whiskey before the doctor sets a bone or digs out a bullet has basis in reality. The process will still hurt, but the patient won’t care quite as much. (Not analgesic use, but: Mary Robinette Kowal has also pointed out that alcohol can temporarily mitigate essential tremor. The frontier doctor knocking back a drink to steady his hands? Might have been treating more than just his nerves.)

Nature offers a few other options beyond alcohol and willow bark. Cannabis has utility in treating certain kinds of pain, and although it’s long been demonized in the United States and other countries, its side effects aren’t any worse than those of alcohol. For centuries, though, the painkiller of choice — if you could get it — was opium.

Our current epidemic of opioid addiction means this has a fairly sinister reputation, and it’s not undeserved; that category of drugs is wildly addictive. But we’ve relied on opium as a painkiller, sedative, and recreational drug for thousands of years. Like pretty much any psychoactive drug, it’s also been used in religious rituals. There is, however, a very large difference between the latex of the opium poppy (obtained by scoring the immature seed pods so they leak a viscous fluid) and the kinds of drugs we use today.

Opium latex consists of about 12% morphine, and smaller quantities of codeine. It’s therefore not as powerful as morphine itself: the “morphium” extracted by Friedrich Sertürner in the early nineteenth century was six times stronger than opium, and fentanyl is a hundred times stronger than pure morphine. Opium latex also contains other chemicals like thebaine, which acts as a stimulant, partially countering the depressive effects of morphine and codeine. Its effect is therefore much more complex — and harder to measure precisely, because the strength of any natural drug is variable.

The depressive/sedative function of opium brings us around to the cousin of analgesics, anaesthetics. Local anaesthetics dull or eliminate nerve sensations in a specific area, and most of the naturally-occurring ones are either derived from coca leaves — i.e. cocaine — or are neurotoxins. General anaesthesia treats pain by putting the patient out cold. Opium was not just a painkiller but the general anaesthetic par excellence before the discovery of chloroform and ether. Mandrake also works, but the fact that most people think of it as a component of witchcraft first, a poison second, and anything else a distant third tells you how hazardous it can be.

Even now, general anaesthesia can be dangerous. There’s a reason “anaesthesiologist” is a distinct type of doctor, separate from the surgeon who’s operating on you. Too much general anaesthetic and you might stop breathing, or suffer cardiac arrest. The medical objections to Queen Victoria being sedated with small amounts of chloroform during the delivery of her eighth and ninth children were somewhat defensible; they didn’t want to lose their sovereign. (The religious objection that God meant for women to suffer the pains of childbirth win less sympathy from me. After the daughter of the Archbishop of Canterbury took chloroform for her lying-in, though, that war was pretty much lost.)

Despite the risk, anaesthesia is worth it. Imagine you’re a surgeon, and ask yourself which would you rather operate on: a patient who’s screaming and thrashing against their restraints, or one who’s lying quietly on the table while you work? Anaesthesia makes surgical treatment infinitely less traumatic for the patient — and for the doctor, too. A sedated patient allows a surgeon to concentrate and take their time to do things properly, rather than trying to perform an amputation or kidney stone lithotomy as fast as humanly possible.

All of this depends on being able to obtain the drugs in question. As I said before, many of them are developments of the nineteenth century or later; the ones that existed earlier did so in impure form, which makes calculating dosage more difficult, and often dilutes the effect. Addiction and side effects notwithstanding, opium was a gift from the gods . . . but that gift wasn’t equally distributed across the world. The opium poppy is native to the eastern Mediterranean, and although trade spread it throughout Asia and Europe, many regions had to trade for it.

Which means that opium wasn’t just a painkiller, an anaesthetic, and a recreational drug; it was also a political force. There have been not one but two wars named for it, both of which were sparked by Britain trying to balance out their trade deficits by exporting the drug from their Indian plantations to China. The Victorian stereotype of Chinese people as opium-eaters was one the Brits themselves had created — one of the countless ills of colonialism. Similarly, the opioid crisis in the United States was created by drug companies vigorously pushing for doctors to prescribe newer, more profitable narcotics — one of the countless ills of capitalism.

But drugs have never been separable from politics. We’ll see that again next week, when we turn to the contentious topic of hallucinogens.

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New Worlds: Painkillers — 8 Comments

  1. Having just undergone surgery I’m all in favor of anesthetics. There is, however, a school of thought that post-op the patient first has to recover from the anesthetics before the body can begin to heal. This is the argument put forth by proponents of acupuncture, used more often in Asia where western drugs are not in abundant supply. I’d rather sleep through the procedure.

    My brain is still having trouble though. My hip is nearly healed after 90 days. But I’m still having trouble with dyslexia which wasn’t present before though the genes are in the family.

    Surgery is always a risk but much safer today than even 10 years ago. I’d still rather sleep through it.

    • I’ve had multiple surgeries and cannot imagine being awake for them. Yes, you do have to recover from general anaesthetic, but that’s a price I’m willing to pay.

    • Trust me: It’s much worse with emergency surgery than it is for relatively planned ones. Part of this is merely the interference-with-good-preoperative-procedure produced by emergency circumstances. You know all of those directions not to eat for X hours prior to surgery, etc.? They’re not just about avoiding regurgitation — they’re also about producing a predictable, stable level of blood sugars, which makes the anesthesiologist’s job easier. So, too, does not having to fight significant traumatic pain.

      And the type of surgery matters, too. All surgery involves soft tissue, but things get Interesting when structural support tissues (like bone, cartilage, tendons, and smooth muscle) are also involved in the cutting. Sure, there aren’t any nerve endings in bones or tendons… but there are in the surrounding tissues that have to be pared away to get at the bones and tendons. (Cartilage is interesting for other reasons because it’s not fully differentiated.)

      Then, too, it’s not as much about recovering from the anesthesia as it is from general postoperative pain and wound healing, let alone any complications resulting from surgery (silly things like compressed nerves). But we’re getting into TMI territory.

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  3. No mention of laudanum, combining opium and alcohol?

    Boston’s Public Garden has a statue to the discoverer of ether’s use. That was cute.

    I didn’t know mandrake was a real plant!