Opioids: Analgesia, Euphoria, Dysphoria, and Oblivion: Observations and a Hypothesis

Abstract

Introduction: In a previous paper, we inquired into the root causes of the two opioid crises our nation is facing, one evolved from the effects of political and psychosocial forces, one manufactured by the Centers for Disease Control and Prevention. This inquiry led us to suspect that the very different opioid consumption patterns of various groups of people were driven by very different motivations related to the opioid experience. Here we explore four potential motivations or disincentives: analgesia, euphoria, dysphoria, and the search for oblivion. We particularly focus on two populations more likely to be motivated by the search for oblivion: people addicted to opioids and terminal cancer patients, and the problem of tolerance. Methods: Analytic review of the scientific literature. Results and Discussion: Essentially all patients managed in American clinics, including many patients with cancer, are motivated by a simple desire for analgesia. A search for euphoria almost certainly motivates the population of people who use mind-altering drugs, including opioids, for recreation. Dysphoria is a feeling of unpleasantness associated with a particular opioid sufficient to motivate a patient to refuse the drug. It represents a common challenge in managing patients in chronic pain. The search for oblivion appears to be the primary motivation for people with opioid addiction. It may also be a motivating factor in certain patients with terminal cancer who suffer not just pain but also agonizing existential crisis. Conclusion: A greater appreciation on the part of clinicians, scientists and policy makers of the different factors that motivate use of opioids could have major implications for how we handle different people consuming opioids. It could disabuse us of the suspicion that every patient in pain is seeking euphoria rather than analgesia and help us to understand their vanishingly small risk of drug abuse or addiction. It could lead to serious study of the mechanisms of dysphoria and the development of means to circumvent it. It could lead to improved approaches to patients with pain from terminal cancer and optimal strategies for dealing with the addiction crisis in the streets. Methods: Analytic review of the scientific literature. Results and Discussion: Essentially all patients managed in American clinics, including many patients with cancer, are motivated by a simple desire for analgesia. A search for euphoria almost certainly motivates the population of people who use mind-altering drugs, including opioids, for recreation. Dysphoria is a feeling of unpleasantness associated with a particular opioid sufficient to motivate a patient to refuse the drug. It represents a common challenge in managing patients in chronic pain. The search for oblivion appears to be the primary motivation for people with opioid addiction. It may also be a motivating factor in certain patients with terminal cancer who suffer not just pain but also agonizing existential crisis.