professor June Dahl agrees to meet midway between the University of
Wisconsin-Madison — where she’s worked since 1957 — and Waukesha
County, which is in the throes of a heroin and opioid pill crisis.
We discuss her life’s work changing how pain is treated. Then, it’s
time to cut to the chase: Is it fair to link her efforts (and those
of a handful of other national pain researchers) to the heroin
The analytical Dahl — who, at 84, is among the oldest active
Wisconsin professors — reflects, then says candidly: “It appears
that the promotion of better pain management has led to more
liberalization of the prescribing of opioids, which has led to an
increase in the availability of the drugs, which has led to some
people abusing them, and then, when they can’t get pills, to heroin
as criminals promoted it.”
And there it is. Just a few
researchers have done as much to promote pain management as Dahl and
other UW researchers. But in a complicated irony, the pain
researchers both caused pain and eliminated it.
Dahl and other researchers talk about “balance” — the point between
regulation of legal opioids (like morphine, Vicodin, methadone,
fentanyl and OxyContin) and medical access to them and where society
should fall (no one argues heroin should be legal anymore, although
it once was).
That pendulum has shifted several times throughout the last 100
years as society tussled with the allure of the poppy, which opioids
(both heroin and pills) derive from, producing a similar high. Since
2000, that balance has moved dramatically to access as prescription
opioids were prescribed increasingly to a general pain population in
Waukesha and elsewhere. And that matters because heroin use also
exploded in the past decade, and research shows that most heroin
users start with prescription opioids, usually taking them from
people with legal prescriptions.
Big Pharma helped relax doctors’ attitudes toward prescribing
opioids with an unprecedented marketing campaign, but the UW and a
few other researchers built the intellectual foundation first.
Before the late 1990s, people generally couldn’t get opioids from
family doctors; they were for surgeries and terminal cancer care,
says Dr. Michael Miller, addiction center director at Oconomowoc’s
Rogers Memorial Hospital. He’s an intellectual who has served on
many national and state boards. And to Miller, and other experts,
it’s clear how this happened.
If you complained of knee, back or other chronic
pain before the late 1990s, you left the doctor’s office with
ibuprofen. For decades, doctors, especially those in primary care,
feared opioids’ addictive nature. Now, prescriptions are easy to
get, Miller says.
“There was a big push to market this to a much
broader market — the chronic pain market,” says Miller.
And that was a very big market, he stresses —
some 76 million Americans.
researchers had role
It was on the campus of Wisconsin’s flagship
university that this effort grew.
How influential were the UW researchers in
changing doctors’ prescribing patterns? “Very,” says Miller,
emphatically. “The driving force.”
Was their influence national? He nods, then
Miller believes David Joranson and Dahl were the
most influential. He thinks they were “well-intentioned” but should
“revisit” their theories.
Dr. Michael Miller
However, the UW researchers don’t
hide their role in changing how pain is treated across the nation;
they’re proud of it. After all, the relaxation in prescribing of
legal opioids has also alleviated the pain of millions and their
efforts to make treating pain a priority for society have become so
accepted that Wisconsin Gov. Scott Walker just declared September
Pain Awareness Month, saying pain costs $100 billion in lost
A UW site praises Dahl as “catalyst for the new
pain standards in the USA.” A Joranson bio says he helped “develop
consensus about the use of opioids in chronic pain.” The group
considered pain relief “a human right,” says a glowing UW Alumni
Others see the darker side. As with yin or yang
or the creation of any new technology, the increase in prescriptions
was a double-edged sword; for all its potential, it’s widely
recognized as fueling the rise in heroin use, a cheaper drug whose
users almost always start with prescription opioids, which, after
all, come from the same poppy plant.
“Their influence was enormous,” says Andrew
Kolodny, a leading national opioid addiction expert, of the UW
researchers. “They played a central role in ushering in this
In Greek mythology, stories capture the tragedy
of unintended consequences. There’s Daedalus, brilliant inventor,
whose benevolent attempt at genetic engineering caused negative
Dahl chafes at the well-intentioned label.
“It implies we were wrong,” she says.
Others strongly disagree.
Dahl says opioid and heroin deaths are a small
percentage of the population, and the media largely ignore the
broader crisis of undertreated pain (including in cancer patients).
Prescription opioids killed over 16,000 Americans in overdoses one
recent year, and heroin thousands fewer (alcohol kills some 88,000 a
But drug overdose deaths are now the leading
form of U.S. injury death, and three of four involve opioid pain
relievers, the government says. U.S. Attorney General Eric Holder
called heroin an “urgent and growing public health crisis” this
spring, saying heroin deaths are up 45 percent, and tying them to
opioid pill abuse. Nationwide, opioid prescriptions rose tenfold in
five years after OxyContin’s 1995 release (southern states have
highest rates; we’re 31st).
Peter Jackson, whose daughter Emily, 18, died
after taking OxyContin, is incensed by the revelation in the media
several years ago that the UW’s Pain & Policy Study Group — which
Joranson founded — took several million dollars from drug companies
— including Purdue Pharma, OxyContin’s maker — to help fund research
arguing for less regulation in the past decade.
Joranson, now retired, who did not return
requests for comment, founded the UW group in 1996, a year after
Purdue introduced the powerful new pill that resulted 11 years later
in criminal convictions against three executives for misrepresenting
its addictive properties.
Dahl has never been part of the UW pain and
policy group. She worked closely with it though and coauthored
important research on the topic with Joranson. Dahl took drug
company grants because there’s a “deficit” of money for pain
She won’t take them now but insists, “I was
never told what to say.”
Joranson’s group, which hasn’t taken drug
company money for four years and is run by a new leader, is doubling
down on its mission.
They want global impact.
“Our advocacy for balance implies that the
medical community must pay attention to deaths related to opioid
use,” insists David Cleary, the group’s current director. “Patients
and physicians alike need to have correct information about how to
use these medicines properly. We believe strongly, however, that
broad restrictions on access are not the most effective way to
achieve that goal.”
He explains the group’s “role is to ensure
access to controlled substances, where it is deemed medically
appropriate. ... In many cases achieving balance has required the
removal of regulatory restrictions that were barriers to opioids for
Cleary says the group’s budget was $9 million
from 1999 through 2012, and $1.7 million of that came from
unrestricted grants from pharmaceutical companies. The rest came
largely from grants from foundations as well-known as the American
Cancer Society and Princess Di Fund. One of the foundations, though,
was the Robert Wood Johnson Foundation, started by a Johnson &
Johnson heir. A Johnson & Johnson subsidiary grows poppies for
American prescription drugs in Tasmania.
Asked about that, Cleary says he is not aware of
any links between that subsidiary and the foundation, which he calls
the “largest philanthropy devoted to public health.” There is no
direct taxpayer support of the UW Pain Group, he says.
Cleary, a cancer physician, has “seen up close
the devastating consequences of uncontrolled pain during serious
illness. When opioids are used as prescribed and appropriately
monitored, they are indispensable to patients who need them.”
As to the heroin link, he adds: “It is clearly
important for the whole community to contribute to ensure a balanced
situation. This includes physicians, patients, pharmacists,
regulators, politicians and pharmaceutical companies. A scale that
has tilted too far in either direction is not balanced.”
The problem with the current balancing act is
that people who weren’t prescribed take prescription opioids from
people who were (and sometimes those people switch to the cheaper
and even easier to obtain heroin), and the definition of “serious”
is debated — today it might be someone’s knee or migraines, not just
severe cancer pain.
Jackson wants the group to “take steps to end
deaths and addiction and publicly support the growing tide against
the use of opioids for chronic non-cancer pain.” Otherwise, he
insists, “the university must close them down.
“Here we are years down the road, with all of
the evidence of the fallout, and they are still holding onto their
old mission,” he says, sounding fatigued.
“I want no diversion, and certainly not of this
magnitude,” Dahl stresses. Diversion means pills used improperly.
She says education is the answer because doctors “prescribe
carelessly,” don’t reassess patients and give out too many pills
(other experts agree).
Dahl was born in Hudson to a telephone operator
mother and railroad father. She obtained a Ph.D. in chemistry, and
followed her chemistry professor husband to Madison in the 1950s,
eventually becoming a tenured pharmacology professor.
cancer treatment to drug of abuse
The 1980s were pivotal in the pain management
movement, which initially focused on terminal cancer patients, who
sometimes couldn’t get opioids. A member of the state’s Controlled
Substance Board, Dahl met Joranson, a staffer.
A turning point came when Congress rejected an
attempt to legalize heroin to treat cancer patients in 1984. A
journal article says up to 80,000 cancer patients were suffering and
26 countries, notably England, allowed medically administered
Dahl and Joranson opposed legalizing heroin (“a
more controversial form of morphine,” she says) but agreed terminal
cancer pain was undertreated. “When people get to the point of death
from cancer, their pain is so severe that only opioids relieve it,”
Joranson was moved, recounted UW Alumni
magazine, by travels overseas to “cancer hospitals where ... doctors
walk past suffering patients, and those in the worst agony are
placed in what’s called a ‘screaming room.’” Dahl saw patients in
India with head and neck cancer, agony visible because of distorted
heads. “There was no oral morphine in all of India,” she says.
New York doctor Russ Portenoy’s 1986 study on
using opioids to treat noncancer patients was influential to Dahl
and many others. Portenoy recently told national media he’s had a
change of heart and was wrong about opioids’ addiction risk being
Portenoy now focuses on serious pain patients
and didn’t want to be quoted. “He’s sort of the guru of this,”
His study of 38 patients was the “scientific
launching pad,” wrote Barry Meier in the book “Painkiller.” In it,
Portenoy concluded “opioid maintenance therapy” can be safe and
Dahl called global and national experts to a
Racine conference. The Wisconsin Cancer Pain Initiative was born;
other states’ initiatives followed. The group distributed thousands
of pamphlets on cancer pain.
Rogers Memorial Hospital
in Oconomowoc is the fourth largest
behavioral health center in the country. It
is where most Waukesha County addicts go for
Eventually, the movement
broadened. At an early 1990s meeting of state pain initiatives,
people asked: Why stop there? Shouldn’t other pain sufferers be
helped? More groups formed.
OxyContin was released in 1995, with a time
release whose marketers claimed made it almost non-addictive;
Kolodny thinks the addiction rate is around 25 percent. Joranson,
who has a master’s degree in social work, started the pain group at
UW the following year. Dahl, who coauthored research with Joranson,
decided they “needed a stick.”
Dahl (with Robert Wood Johnson funding) began
encouraging the Joint Commission, which accredits most American
hospitals and doctors’ offices, to adopt new pain assessment
Miller chaired a board that rejected them,
concerned that patients’ expectations would become unrealistic. Two
years later, they were in place anyway. If you’ve seen the smiley
and frown faces, you’ve experienced them.
Dahl stressed they don’t mention opioids. Others
think the standards were very important because they created a
nationwide mandate that doctors prioritize pain treatment.
“Now screening for pain had to be done in every
primary care setting,” says Kolodny. And once OxyContin came out,
there was a new way to do it.
Meanwhile, Joranson’s group attacked
regulations; the pain movement was systematically dismantling
regulatory barriers to prescribing opioids. In one example, Joranson
spurred the Federation of State Medical Boards to issue a policy
that doctors could be sanctioned for undertreating pain, says
Medicare began linking funding to patient
satisfaction surveys, giving incentive for doctors to prescribe
If pain researchers’ work was kindling, though,
Purdue’s billions were lighter fluid. “Guess who was speaking (at
their conferences)?” Dahl asks. “Me.” She feels “possibly used.”
As she leaves, Dahl tosses out a D.H. Lawrence
quote: “A little morphine in all the air. It would be wonderfully
refreshing for everyone.”
Coming Thursday: A marketing
campaign promises wonders of opioids