Geographical Insights Into Pain Management

I’m a geographer, not an expert in palliative care. For those who may not have heard of palliative care the term refers to a type of care provided to patients who suffer from terminal illness, long-term illness, or incurable conditions and the associated pain.

The pain I describe is not simple, immediate, and temporary pain associated with a cut, broken bone, or closing fingers in a car door. I am talking real pain, the 9-10 scale pain suffers have 24 hours a day, 7 days per week. Yes, pain like this does exist.

My dad has cancer and has survived cancer for about 1o years. Part of his throat, tongue, and nearby tissue have been excised to remove cancer cells. All of the lymph nodes from below his right ear to his right scapula have been removed. He underwent a serious number of radiation sessions early in his treatment. The radiation sessions fused his lower teeth to his mandible and destroyed his tear glands and salivary glands. Chemotherapy treatments didn’t seem to create any long-term health issues.

The radiation also complicated recovery from a broken neck. A bicycle accident, which ultimately led to discovery of cancer, broke his C5 and C7 vertebrae. While convalescing from his bike injury, a physical therapist noted odd lumps in his shoulder and back. Following her recommendation, he went for tests and the cancer was discovered. Working through the University of Kansas medical center, dad went through extremely aggressive radiation and chemotherapy treatments. The radiation blasted the cancer into remission but left behind spinal stenosis as well as the other concerns.

Spinal stenosis is a narrowing of the spinal column, a constricting of the channel used by the spinal cord. Minerals build-up, like calcium deposits, similar to bone spurs people frequently get. Except the bone spurs grow on the inside of vertebrae and put pressure on spinal nerves, creating unceasing pain.

Had the spinal stenosis occurred lower in his back, surgery might have been an option. If he had not had his cervical bones fused by radiation, surgery might have been an option. Surgery is not completely out of the question; the probability of permanent paralysis or death is greatly increased, though.

And, he has lost the ability to swallow. Of all the movements our bodes accomplish over a given day, having a bowel movement and swallowing are two muscular contractions we probably don’t give much thought to. Unless we can’t have either. Being constipated can become extremely comfortable, feeling like we are walking around with a broomstick shoved up our backsides. Emergency rooms can help people poop.

Think about how often you swallow. An article in the Journal of Dental Research [first page] suggests the average number of swallows per day ranges 1,200 – 2,400. Emergency rooms cannot help you swallow if you have lost the mechanical ability to swallow. He has a brand-new gastric feeding tube to help him overcome the inability to swallow and to ingest calories. A person cannot effectively take in enough calories to maintain body weight without the ability to swallow. Swallowing not only diverts food into our stomach but also away from our lungs. Aspirating food will eventually lead to pneumonia.

Palliative care is being used to help manage dad’s pain. He has invested in some new bedroom furniture, a new chair for the living room, and some new boxes of liquid protein for meals. But, in spite of all the above dad works on his motorhome, his Jeep, and takes his dog Buster to the dog park, and visits his daughter and grandchildren.

He recently spent some time in the Emergency Room for pain. Later, the pain became exponentially worse and he was moved to ICU for a while. In communicating with my mom during his stay in the hospital she mentioned he was given Dilaudid for pain management since the Morphine really was not working. According to the Wikipedia entry for Hydromorphone, Dilaudid is about 6-8x’s more potent as morphine.

Teaching World Geography exposes me to a lot of topics which is why I like teaching. Teaching is not only about the communication of information but also about the learning and gleaning of information which can be passed along. I speak on the Opium Wars fought between Great Britain and China in the mid-1800s, the movement of opium between India and China, and the use of opium in popular society in Britain and the United States.

Diluadid is a derivative of morphine which itself is derived from opium. Today, many substances are the focus of international law enforcement organizations (LEO). Opium, cannabis, and ephedrine  capture the scrutiny of international LEOs. Opium and ephedrine are both classed as “medicines” which gives them special legal rights and protection. Cannabis is termed a “drug” which allows for no special legal protection.

Drug Route Map

Common drug routes for opiates and non-opiates (Wikipedia).

I use the term “special” to discriminate between the legal economy of opium and ephedrine and the illicit economy of cannabis. The United States, for example, purchases opium from Turkey and India for medicinal purposes. Ephedrine is legally manufactured in many countries but has been increasingly controlled due to use in the illicit manufacture of methamphetamines. Possession, growth, or manufacturing of cannabis is likely to get your butt through in prison, however.

Opium as a source of medical treatment has been part of humanity for 3,000 years or longer (DEA Museum, PBS/Frontline). Upon investigation of cannabis, I discovered a similar historical timeline – even coincident geography! The earliest cannabis cultivation occurred in South-central Asia, essentially in the region encompassing modern-day Afghanistan, Pakistan, and India (PsychologyToday, Narcanon).

You can probably see where I am going:

“Why is opium acceptable as a medicinal use today, and cannabis is not?”

The pursuit of cannabis legalization has divided many states. Not only has cannabis legalization divided states but has also divided Several U.S. states have initiated efforts to decriminalize cannabis in flagrant disregard of federal statutes. Most of us are familiar with California and legislative efforts to bring “medical marijuana” into the treatment battery for suffers of chronic disease and pain or the treatment of the side effects associated with other medical treatments. I was not aware of the some of the other supporters, like Nebraska, Mississippi, Maine, and Ohio. I am surprised by the absence of Washington; I figured Washingtonians were more progressive.


Both opium and cannabis share a rich history of use as medicines, tinctures, and for achieving religious or spiritual enlightenment or simply used for pleasure and enjoyment. Great Britain essentially pushed opium onto the Chinese masses in order to undermine the Manchu government in pursuit of favorable trade deals and silver.

Why the extremely divergent paths for two natural plants?

The answer is probably not as complicated as I am going to make it but I am going to make an educated guess. Opium has pretty limited use. Poppy seeds are used for cooking. Poppyseed oil is used in cooking and in food products. Opium is used to derived medication, analgesics for the most part. Opium does not pose a threat to any other industry. Houses cannot be made from opium, nor newspapers, nor clothes, and opium is not a good substitute for iron ore, coal, and from what I discern, is completely inappropriate for use in a smartphone.

Cannabis is different. Cannabis grows like a weed. Cannabis is woody, like vines and bushes. Cannabis has bark which is just as rich in cellulose as other woody growths, like trees. Cannabis is known by two other common names, at least, “marijuana” and “hemp.” Now, hemp is important to the my answer. Hemp bark has about the same cellulose content as other fiber-producing plants, about 58%-74% cellulose. The main stem does not have this cellulose content but the bark does. Hemp was an important source of fiber in clothing and fabric products in the late 19th century and early in the 20th century. Hemp has lots of competition from actors beyond medicine.

The publishing magnate William Randolph Hearst was interested in paper and was friends with Andrew Mellon. Andrew Mellon was the world’s wealthiest man and also the U.S. Secretary of the Treasury. Mellon was friends with and heavily invested monetarily with the du Pont family. The du Pont family is famous for a significant number of contributions to U.S. industry and one such contribution was the invention of nylon. Hemp and nylon would be natural competitors. Both are fibers used in textiles. As the conspiracy theory goes the small cabal of men organized efforts to demonize cannabis among U.S. society. Hand-in-hand with these efforts were other national temperance efforts to outlaw alcohol. In fact, any and all “addictive” drugs were to be outlawed or placed under government control. Even opium was placed inside this wide-cast net. Over the decades, many illegal substances would gain their freedom (alcohol) or would be classified as “controlled substance” and would require certain government licenses or permission to be allowed use or access. Cannabis has really never made the cut.

The United States Congress appears to be the entity to blame. Environmentalists and U.S. Congresspeople rail against Brazil for decimating the Amazonian rainforest and the loss of potential medicines from indigenous plants yet Congress remains constipated against medical research into cannabis. A recent story in the Toronto Star highlights a California study conducted with Multiple Sclerosis patients.

Marijuana relieves muscle tightness, pain of multiple sclerosis” (Toronto Star, 14 May 2012)

As late as July 2011 the United States Drug Enforcement Agency (DEA) Administrator Michele Leonhart stated “ [cannabis] has no currently accepted medical use in treatment in the United States” and “lacks accepted safety for use under medical supervision.”

Interesting comments, seeing Canada appears to differ. Not only Canada but Germany, but also the United Kingdom, Spain, New Zealand, and Denmark. Each of these countries has allowed treatments based on cannabis.

“Sativex, a cannabinoid medicine for the treatment of spasticity due to multiple sclerosis and in development for cancer pain.” (GW Pharmaceuticals, 2012)

For a better researched discussion of the United States government opposition to pursuing medicinal cannabis I refer you to a recent blog written by Paul Armentano, writing in the Huffington Post.

“Change We Can Believe In? Not For Medical Marijuana Research” (HuffPost, 16 Feb 2011)

Please do not misunderstand me; I am not an advocate for smoking dope, getting high, getting stoned, losing control, or chilling in front of my LCD-TV watching Cheech & Chong’s “Things Are Tough All Over.”

What I am advocating is for a logical, scientific approach to the study of all herbs, fruits, vegetables, plants, poisons, toxins, etc. for exploration and discovery, to enhance and advance human knowledge and experience.

For our Federal Government to turn its figurative back against research is simply stupid and ignorant and flies in the face of reason.  For bureaucrats to argue against the pursuit of knowledge based on nothing, no research, or worse, bad research conducted 40-100 years ago is simply insulting and demeaning to scientists everywhere. How do these peoples even attain office? By being hired by other complete nitwits? My personal belief is bureaucrats use “feelings” and “beliefs” rooted in religion rather than science, logic, and reason. I don’t think I could ever be elected to office due to my own intransigence to dealing with anything other than science, logic, reason, and critical thinking.

“People don’t want logic, they want to “feel” like they made the right choice.”

The job of a bureaucrat is to use unbiased data, information, and research to help make good policy decisions not to make policy decisions which affect the livelihoods of perhaps millions of people. They mights as well state “you can make any kind of wheel you want as long as it isn’t round. Round objects roll; rolling things hurt people, ergo nothing that rolls should be made due to the potential for harm.”

A home-health provider could have come to my dad’s house. She (or he) would have brought a morphine pump. Both she and my dad would have engage in a morphine dance, she leading and my dad following all under the watchful guise of the Federal Government. Pay no mind morphine has the potential of being more addictive than cannabis. Nicotine has a lethal dose; a person can die from overdosing on nicotine. Dying from cannabis overdose is next to impossible.

Again, I am not advocating people going out and getting toked-up. One of my least favorite things to do is engage in conversation with someone who is  stoned, or deal with people who are stoned. My point is our civil engagement with the study of cannabis is not in proportion to the alleged societal danger or societal cost or opportunity cost.

I can make no sense of out of the fact my dad can have all of the morphine he wants, or dilaudid, at least in theory, yet our Federal Government remains stalwartly idiotic regarding research into the positive uses of cannabis.

The governmental warning (left) is ironic. Young impressionable girls are warned about the shrewd friendly stranger peddling “marihuana” which promises Murder! Insanity! Death! You might even find some in your tobacco cigarette – which, of course, is part of every day life and never mind tobacco executives lied under oath about not knowing about the long-term health effects of smoking, and why would our government allow something dangerous to be sold to us?

If a process exists for opium-derived medicines to be available for people who suffer chronic pain, then a process exists for people who want access to cannabis-derived medicines. If a process exists for medical research based on opium, or coca (heroine), or willow trees (aspirin), or artichoke (cynarin), or tobacco (nicotine, used as an insecticide), then cannabis should have the same rights and privileges any other plant from which medicinal treatments are developed. I wonder if we changed the name to “hand weed” based on the arrangement of the cannabis leaves the plant might gain some legitimacy.

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Liana Brooks

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