Dear Colleagues!  This is Asrar Qureshi’s Blog Post #725 for Pharma Veterans. Pharma Veterans welcome sharing of knowledge and wisdom by Veterans for the benefit of Community at large. Pharma Veterans Blog is published by Asrar Qureshi on WordPress, the top blog site. Please email to for publishing your contributions here.

This series of blogposts is based on multiple sources, links to some of which appear at the end.

We now look at the factors other than those associated with the pharma companies working.

Individual physicians’ approach to the concept of pain relief determines the prescribing habits. While some physicians advise patients to learn to bear a certain degree of pain, the others believe that pain relief must be provided by all means and that the patient must not suffer unnecessarily. In the US, chronic pain was mostly managed by cognitive behavioral therapy, and the insurance companies also accepted the cost. Later, they stopped accepting this expense and the practice was replaced by drug treatments.

Individual patients’ threshold for tolerating pain is another consideration by the prescribing physicians. A patient with low threshold will present her/his pain in exaggerated terms and force the physician to write not just one but more painkillers. These patients also experimented with adding other, stronger opioids like heroin, and later fentanyl and other opioid drugs. The cocktail of drugs initially aimed at providing good pain relief quickly transformed into the need for euphoria, leading to addiction.

Reasons for chronic, severe pain increased. The Institute of Medicine report includes these factors among the contributing factors leading to rise in the prevalence of chronic pain: greater expectation of pain relief; musculoskeletal disorders of the ageing populations; obesity; increased survival after injury and cancer; and increasing frequency and complexity of surgical procedures. Pharma and medical devices manufacturers sensed the opportunity and brought out novel drug delivery systems; transdermal patches, nasal sprays, oral dissolving strips, and extended-release formulations. In about a decade, chronic pain became big business.

The high incidence of NSAIDs – Non-Steroidal Anti-Inflammatory Drugs causing severe gastrointestinal damage, and the liver toxicity of paracetamol also prompted physicians to explore safer alternatives for long term use. Opioids offered to become a good alternative, particularly after claims of addiction to be rare.

Poor health, poverty, substandard living and working conditions, lack of opportunity, lack of access to healthcare are also important contributing factors.

One structural analysis focusing on ‘diseases of despair’, referring to the interconnected trends in fatal drug overdose, alcohol-related disease, and suicide, shows that the mortality in this cohort rose extraordinarily. The trend was especially pronounced among middle-aged Whites without a college degree, who were dying earlier on average than did their parents.

Another hypothesis focuses on obesity which has been steeply rising in the US and many other countries due to affluence, junk food, binge eating, eating disorders, metabolic disorders, or a combination thereof. Obesity is linked with disability, chronic pain, depression, body-negativity, and proneness to drug and substance use/abuse.

Life expectancy saw a decline in the US between 2000 and 2015, with a twenty-year difference between the least healthy and the healthiest counties. This is largely explained by socio-economic factors correlated with race, ethnicity, behavioral and metabolic risk, access to healthcare, a multidecade rise in income inequality, and economic shocks arising out of deindustrialization, and loss of social safety nets. Poverty and substance use are synergistically related and may be compounded by psychiatric disorders. The jobs available to poor, uneducated/less educated people are mostly labor intensive with increased risk of physical hazards and injuries. Imagine the laborer carrying a stack of bricks on his head and going up and down floors every day. Or people working in industrial manufacturing units facing high heat, dust, and heavy work are highly likely to resort to substance use. These are mostly daily-wage jobs; even when they work in the same unit for years, they are not given permanent employment, and they cannot risk taking days off as it leads to loss of income, or maybe job loss. They are more inclined to keep taking some substance which keeps them going. Work related injuries over time become a source of chronic pain and a history of medicines use becomes drug dependence.

An uneven approach to check substance users results in many people caught for minor charges and receive undue incarceration. In Pakistan, our entire criminal/ judicial system is based on dehumanizing people of lesser means. Police rounds up scores of people for petty crimes to show their ‘performance’. These people are either not presented to courts promptly, or when it is done and the court grants bail, they do not have means to arrange the bail. So, they stay in lockups and prisons for months because the disposal of cases is very slow for those who have no one following up with money. The family income is lost meanwhile, the poverty deepens, the social stigma is serious, and the woes are compounded. When they are finally freed, they may have big difficulty getting work because of previous conviction. The situation in the US is no different.

It has also been observed that people tend to somaticize or physicalize social disasters as pain. Subjective economic hardship due to Great East Japan Earthquake in March 2011 was associated with new onset low-back pain. It was the strongest earthquake in the recorded history of Japan with a magnitude of 9.0 on Richter scale. Similarly, work stressors after 9/11 affected many people, groups, and countries adversely. Substance use under such conditions is increased and may even become rationalized.

Our country of reference in this series is United States, and the discussion centered on opioid analgesic drugs misuse leading to opioid crisis. In the next post, which will be the last of this series, we shall see what remedial measures were taken there. I keep pointing that very little information about substance abuse is available for Pakistan. It is either UN reports, or some small-scale survey-based studies done by individual researchers. When we look at the measures, we may find some clues about us also.

To be Continued……

Disclaimer: Most pictures in these blogs are taken from Google Images and Pexels. Credit is given where known; some do not show copyright ownership. However, if a claim is lodged at any stage, we shall either mention the ownership clearly, or remove the picture with suitable regrets.

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