Pharmacology 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 crisis?
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.
UW 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 adds: “International.”
Miller believes David Joranson and Dahl were the most influential. He thinks they were “well-intentioned” but should “revisit” their theories.
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 productivity.
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 magazine feature.
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 epidemic.”
In Greek mythology, stories capture the tragedy of unintended consequences. There’s Daedalus, brilliant inventor, whose benevolent attempt at genetic engineering caused negative consequences.
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 year).
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).
Drug company funding
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 research.
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 pain relief.”
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.
From 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 heroin.
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,” says Dahl.
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 extremely low.
Portenoy now focuses on serious pain patients and didn’t want to be quoted. “He’s sort of the guru of this,” Kolodny says.
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 humane.
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 treatment.
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 standards.
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 Kolodny.
Medicare began linking funding to patient satisfaction surveys, giving incentive for doctors to prescribe painkillers.
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.”