Providentia

Off To New York City

I'll be spending a few days in N.Y.C. and likely won't have much time for writing while I'm there.   If you notice a certain New York flavour to some of my upcoming posts, you'll know why.  To tide you nice people over, here are a few blog links that might interest you.

• The ever-fascinating Neuroskeptic blog has a new post up on social anxiety disorder, or is it "social phobia"?
• Karen Franklin at In The News provides up with her new disturbing new series on confidentiality in forensic evaluations.
• Scicurious weighs in on how environmental enrichment can make you sexy, at least if you're a rat..
• How was the most famous bet in the history of brain sciences won and lost?  Christian Jarrett of Brain Myths has the details.
• Disturbed by the recent Times cover picture?  What is the proper time that a child should stop breastfeeding?  Eric Michael Johnson of the Primate Diaries weighs in with his own observations.
• Ferris Jabr of Brainwaves has just launched a new series: titled Know Your NeuronsL The Discovery and Naming of the Neuron.  Here is the first installment.  
• The ever-reliable Vaughn Bell of Mind Hacks has a new post describing an important new article in Nature about the dangers of unreplicated studies in psychology.
• Should therapists be using tough love with their patients? A new post in the Wall Street Journal makes a good case for it.
• How are children affected by their parents' financial instability?  According to this Huffington Post article, the damage is just starting to be recognized.
• Can a patient be charged for not taking medication that might endanger other people?  Here is a news story from USA Today that should raise quite a few questions.
• Will we ever see an end to ex-gay therapy and its advocates?  A new ThinkProgress post finds NARTH's objections to ex-gay therapy restrictions rather easy to refute.
• While we try to understand what people suffering from severe depression, how often do we get to hear about it from the first-person perspective?  Natasha Tracy of Bipolar Burble gives us a gripping account of her own experiences.

Until later.

 

 

In Praise of Pain

Human beings have always had a love/hate relationship with pain.

While pain and suffering have always been viewed as something all humans had to endure (including Biblical stories such as  childbirth pain being due to the sin of Eve or Job being afflicted with suffering to test his faith), the idea that bearing pain stoically was a sure sign of virtuous living was rarely far behind.  The very word “stoic” stemmed from a philosophical school that viewed pain and suffering as essential to being truly human. In St. Paul's First Letter to the Colossians, he wrote that: "I fill up that which is behind the afflictions of Christ in my flesh".     Virtually every organized religion has regarded pain as a necessary evil.   At the same time, herbal remedies for dealing with pain are as old as medicine itself.   While physicians and other healers often viewed pain as being an important sign of disease and that masking it with medication  interfered with treatment, they were also quick to dispense whatever pain-relieving agents that they had at their disposal to patients in agony.   That usually included the familiar standby, papaver somniferum (a.k.a., the opium poppy), which was cultivated for its analgesic properties as far back as neolithic times in most of Eurasia.

Even with the advent of anesthesia in the 19^th century, new  innovations including morphine, chloroform, and nitrous oxide were greeted with mixed feelings, especially among religious leaders who viewed such innovations as somehow being a subversion of God’s plan.  Queen Victoria’s very public decision to use chloroform to ensure a painless delivery of one of her children in 1853 was greeted with alarm at first although it also helped spread the word that anesthesia was safe and effective.  Despite religious qualms, the era of painless dentistry and surgery had begun.

By the dawn of the 20^th century, anesthesia was already widely used in surgery.  While pessimistic philosophers such as Arthur Schopenhauer stressed the inescapable nature of pain in their own writings,  improvements in medicine, including the wide availability of powerful analgesics,  made pain relief universally available (at least to those who could afford it).   Even familiar remedies such as morphine seemed to be superseded by better and stronger alternatives, including heroin which was available in numerous locations without a prescription.

As the dangers associated with opiate addiction became better understood, an inevitable backlash set in.  Many commercially available analgesics were eventually banned under international narcotics laws.  Prohibition became a dominant movement in the United States while, in other countries, medical doctors, theologians,  and social critics viewed the addictive properties of many popular narcotics with increasing alarm. This alarm was spurred by the thousands of wounded veterans of World War I, many of whom were left addicted to the pain medication that had been prescribed to them.   This public alarm led to attempts at reconceptualizing how pain should be treated.  Rather than viewing pain as something to be eliminated by any means possible,  wasn't it possible that resisting pain was actually a virtue and that giving into pain by demanding medical relief was actually a form of cowardice? 

By 1935, French writer and journalist, Julien Teppe, became the leading force in what had already been named the "dolorism" movement.  Taken from the Latin word for pain, dolorism basically exalted the value of pain, both medically and philosophically.  The two books that Teppe wrote, Apologie pour l'anormal (a.k.a. the "Dolorist manifesto") in 1935 and Dictature de la douleur in 1937 justified dolorism as a reaction against what Teppe called the "tyranny of the fit".  He viewed pain as  a way of learning about onself (essentially arguing that "I am suffering, therefore I am").  He also wrote that, "Pain, of all the psychological states, is the one which takes over the entire being, both the flesh and the spirit, with the greatest urgency and force.  It is a disposition which sweeps away, blots out, and annihilates all the rest."   Through pain, humans learn about compassion for other human beings and inability to understand suffering was the root cause for hostility and intolerance.  Not only did Teppe argue for a better understanding of pain, he also suggested that students in all programs be required to visit hospitals and sanatoriums as part of their education. 

While not an original concept (existentialist philosophers such  as Karl Jaspers and Martin Heidegger had made  similar arguments years before), Teppe's movement quickly took root.   Along with his influential books, Teppe also launched the Revue Doloriste, an episodic journal that was meant to be the standard for the entire dolorist movement.   On its first publication in 1946, the French conservative paper, Le Figaro, a tongue-in-cheek endorsement to the new journal and to dolorism in general:  "No school ever chose its hour better than this one.  Every French citizen is an unknowing Dolorist.  And [then-premier] Monsieur Gouin, perhaps, is one".   While never the financial success that Teppe had hoped, the first issue sold 5,000 copies and eventually included original essays from such prominent writers as Andre Gide and Colette.

That dolorism became a hotly debated subject before and after World War II is perhaps not surprising given the political and economic struggle to rebuild Europe.   Theologians continued to advocate pain as a necessary evil while neurologists and physiologists weighed in on the medical aspects of pain.  Teppe's chief opponent was prominent surgeon, Rene Leriche.  Having gained his experience in treating pain associated with battlefield injuries in World War I,  Leriche's book La Chirugie de la douler (the Surgery of Pain) quickly became a classic in treating "pain disorders" after its publication in 1937.  As a militant humanist as well as a surgeon, Leriche avidly fought any attempt to glorify pain and argued against the idea that pain could be beneficial or useful in any way.    Ironically, Leriche actively spoke against the use of pain medications such as morphine and argued that surgical approaches were the ideal method for pain relief. 

Another prominent dolorism opponent, prominent neuropsychiatrist Jean L'hermitte, argued that "the first duty of medicine is to heal when it can, to relieve often, and to comfort always.  As a result, a physician's role is not only to relieve moral suffering often but also, insofar as it is possible, to alleviate pain and its repercussions on the different organs."    As an important example of pain's importance, L'hermitte described cases of syringomelia in which patients with interrupted sensory nerve fibres injure themselves due to their inability to feel pain.  He also saw analgesics such as morphine as being effective in preventing suicides among chronic pain sufferers. 

Still, the spectre of addiction to pain medication was ever present.  Even L'hermitte was quick to argue that some physicians gave out morphine "too freely" and that it should only be prescribd by physicians who were certain that their patients were genuinely suffering.  He advocated that morphine only be administered through injection and at the doctor's discretion.   While he denounced dolorism as a dangerous trend, he still advocated an extremely conservative approach to pain treatment which often meant that patients were expected to "suffer in silence" rather than admit that they were unable to bear their chronic pain "maturely".  Many religious hospitals, though recognizing the need to deal with pain, often stressed the virtue of endurance and advised doctors and nurses to train patients to resist pain rather than to plead for better analgesics.   As formal treatment shifted towards specialized hospital wards to deal with chronic pain patients, pain clinics have become an integral part of most tertiary care hospitals.

Although today's physicians are no longer expected to allow patients to "suffer for their own good", the old dolorist arguments have never completely faded away.  The reluctance to prescribe pain medications due to addiction risks, however legitimate, often masks an expectation that patients overcome pain on their own rather than rely on chemical aids.  That there is an obvious economic component to this argument (medication costs money, after all) makes it all the more appealing to rein in rising health care costs.   Many of the moral dilemmas and problems raised by Julien Teppe and his supporters have yet to be resolved and the stringent regulations that physicians often face in prescribing medication means that pain management remains one of the most contentious issues facing medicine today. 

And that is unlikely to change any time soon. 

 

 

 

Suicide and the New DSM

The revision process for the new version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) has generated fierce controversy in many circles.  One of the main complaints  raised is the lack of transparency in the process by which new diagnostic concepts are generated.  In a recent editorial in  Crisis: the Journal of Crisis Intervention and Suicide Prevention, Editor-in-Chief Diego De Leo discussed his own  concerns relating to proposed DSM-V changes relating to suicidal behaviour.  While self-harm is already included in the DSM-IV-TR as a symptom of various mood and personality disorders, the proposed changes involve creating several new diagnoses including "suicidal ideation and behavior" and "non-suicidal self-injury".  A related diagnosis which had been considered for inclusion, "prolonged grief disorder", has been shelved although "bereavement-related disorder" has been proposed in its place. 

While the way in which suicide is perceived by mental health professionals has changed extensively over time and across cultures, the current trend towards medicalization of suicide seems virtually complete with the new DSM.   In his editorial, Professor De Leo argued that directly assigning a psychiatric diagnosis to suicidal behaviour represents a step backwards from current multi-disciplinary approaches to dealing with suicide. Making suicidal behaviour a DSM-V diagnosis also means shutting out non-mental health professionals who are considered unqualified to make DSM diagnoses which could complicate prevention and treatment.  He also points out that slogans such as "Suicide is Everybody's Business"  which have been embraced by international suicide prevention organizations would argue against making suicide exclusively a mental health issue.   

In countries such as China and India, suicide is far less likely to be linked to psychiatric conditions than in Western countries.   In cases of suicide among the elderly, psychological autopsy studies have shown relatively low incidence of psychiatric illness.   Although suicidologists Ron Maris and Mort Silverman successfully argued fifteen years ago that "...suicide is, by definition, not a disease, but a death that is caused by a self-inflicted intentional action or behavior", the new DSM-V diagnosis process would automatically make suicide a mental disorder regardless of the actual motivation involved.  While any countries have decriminalized suicide, redefining it as a mental disorder would have far-reaching implications into laws regarding the mandatory reporting of suicide attempts and how they are treated by health professionals. 

A more profound change being considered in the new DSM is the proposed classification of "non-suicidal self-injury" (NSSI) which would distinguish between deliberate suicide attempts and engaging in self-harm behaviour without intending to commit suicide.   Previous versions of the DSM already include non-suicidal self-harm as a sign of Borderline Personality Disorder, which DeLeo's editorial criticises for being too broad a diagnostic label.  De Leo also argues that the proposed NSSI category might well be a cure worse than the disease. 

There can be many reasons for attempting suicide and differing degrees of suicide intent.  Placing "suicidal ideation behaviour" and NSSI into the DSM would limit treatment and diagnosis for suicide attempters by making suicide intention into a "yes/no" dichotomy which often fails to reflect the true extent of the underlying motivation involved.  Could the question of whether a self-harm action was intentionally suicidal or non-suicidal even be answered properly?  In many cases, the suicide attempter may not even be certain whether the attempt was deliberate or not (as I've observed myself in many cases).   In one study described by DeLeo, an Australian community study showed that almost 50 per cent of self-harmers reporting having suicidal ideation, far more than same-age counterparts who did not self-injure, even when the self-harm attempts were not driven by a desire to die.  Other studies of self-harmers showed that only a small percentage actually sought medical help for self-harm attempts (self-cutters were even less likely to seek help) despite being at a signficantly higher risk of death than other suicide attempters.  

Previous versions of the DSM have shown a tendency to inflate the number of people diagnosed as new diagnostic labels are introduced.  The inclusion of suicide attempts as a diagnostic criterion of borderline personality disorder despite limited evidence to support the link led to an increased stigmatization of suicide attempters.  Will assigning a diagnosis of NSSI lead to further stigmatization that might prevent suicide attempts and self-harmers from seeking help until it is too late?  This is an especially troubling question given the alarming rise in suicide attempts among adolescents (lifetime incidence of self-injury among adolescents can be as high as 14% according to some estimates).  

In concluding his editorial, Professor De Leo points out that there is still too much that isn't known about suicide to justify the potential risks involved with the two proposed suicide diagnoses.  Since suicide is often a complex process that can be shaped by a range of internal and external factors, including cultural, legal, and economic aspects, directly placing "suicidal ideation and behavior" and "non-suicidal self-injury" in the new DSM may well do more harm than good.  In his own concluding words, "As a researcher, a clinician, and a caring human being, I believe we are not ready. Not yet."

For the abstract.

Is There a Fentanyl Epidemic?

When Paul Janssen first synthesized the narcotic analgesic known as fentanyl in 1959, he intended the powerful mu-opioid agonist to be a radical new treatment for treating acute pain in cancer patients.  Far more powerful than morphine, fentanyl was first marketed as an intravenous anesthetic under the brand name, Sublimaze, by his company (now part of the Johnson and Johnson corporation).   As a fast-acting analgesic agent which passed out of the system rapidly, fentanyl quickly inspired a variety of analogues including sufentanil, alfentanil, and lofentanil.   The 1990s ushered in a new generation of fentanyl derivatives designed to improve quality of life in palliative care patients.  Along with the familiar intravenous form, fentanyl doses could also be delivered in the form of transdermal patches, lollipops (sold under the brand name of Actiq) and buccal tablets (Fentora).    As the most widely used synthetic opioid in clinical settings, demand has far exceeded available supply and there is currently a fentanyl shortage as a result.    Despite adverse side effects including nausea, diarrhea, breathing problems and, in rare cases, aphasia, fentanyl is still regarded as being safer than morphine despite concerns over potential withdrawal effects.

Far more worrying is fentanyl's growing appeal as a street drug.  Much like morphine, heroin, and other opioids, fentanyl works by binding to the body's opiate receptors and driving up dopamine levels which can lead to feelings of euphoria and relaxation.  While the "high" produced by fentanyl is less intense than heroin, its far greater potency makes it more dangerous, especially given the risk of respiratory distress and fatal overdoses.  Since the mid-1970s, transdermal fentanyl patches have been available on the black market under street names such as "Apache", "China girl", "China white", "murder", and "Tango and Cash".   Despite attempts by drug manufacturers to adapt fentanyl patches to make removing the drug content more difficult, fentanyl abusers can still get a high through smoking, snorting, injecting, and even eating the patches directly.   The number of fentanyl deaths has risen sharply over the past twenty years although available statistics largely focus on cases in the United States.    Studies of fentanyl-related overdoses show that victims are typically female, white non-hispanic, and older than the usual overdose demographic.   Even the Actiq lollipops are becoming increasingly available on the black market (where they are commonly known as "percopops").   Though most prescription pain medications have become popular as street drugs, fentanyl is rapidly becoming a drug of choice given its extreme potency.  Some dealers are even mixing it with heroin which has led to a rash of overdose deaths across the United States (and elsewhere).   Much of the fentanyl sold on the black market comes from Mexico but black market labs manufacturing fentanyl and counterfeit oxycontin tablets have also been found in the United States and Canada.   The high potency and extended duration of some fentanyl compounds make its manufacture extremely profitable for street use. 

Despite controversy over prescribing long-term opioid medications for chronic non-cancer pain, the increasing popularity of these medications has made their availability as street drugs a fact of life.  National surveys of drug use have shown that nearly 12 million Americans 12 years old or over (4.8% of the population), have reported non-medical use of prescription pain relievers.   ER visits relating to non-medical opioid use have skyrocketed over the past decade and the death rate due to overdose is at an all-time high. While most of those deaths have been linked to more popular opioid pain relievers such as oxycodone (i.e., Oxycontin or Percocet) and hydrocodone combinations (i.e., Vicodin), fentanyl deaths are becoming increasingly more common.    As high-profile cases involving accidental fentanyl deaths have demonstrated, that trend is likely to continue. 

 

 

Opiate Crackdown Planned in State of Washington

The rising financial costs involved in treating chronic pain has led to increasing confrontation between pain patients and government agencies attempting to crack down on abuse of pain medication.  With an estimated 116 million Americans suffering from pain problems as well as the billions of dollars spent each year due to lost productivity and medication costs relating to chronic pain, calls for tightened prescriptions on pain relievers such as Oxycontin, Vicodin, Methadone, and other opiates have faced stiff opposition.   Since the 1990s, physicians have been accused of overprescribing pain medications which now account for more than ten percent of all written prescriptions.   Due to lingering public suspicion concerning use of opiates for treating chronic non-cancer pain, many state medical boards have invoked disciplinary authority to discourage the prescribing of opiates for non-cancer pain due to concerns about efficacy, toxicity, and addiction.

As a reaction to a rash of high-profile cases involving pain prescription overdoses as well as the increased availability of pain medications being made available as street drugs,  Washington's State Legislature has ordered the Department of Health to crack down on prescribing practices.  Beginning in January of this year, physicians who prescribe opiates for chronic, non-cancer, pain will be required to maintain health histories for all patients requesting pain medication.  These histories will need to include information on patient psychiatric conditions, history of addictions, "risk of significant adverse events" (such as potential injuries), and "the effect of pain on physical and psychological function".    Consultation with pain specialists when prescription exceed set thresholds are also mandatory under the new legislation.   The most important aspect of the new legislation involves the creation of a computerized central database which, beginning in January 2012, will be used to identify patients who are "prescription-shopping" pain medications at multiple clinics.

While physicians acknowledge the need for monitoring pain prescriptions, concerns have been raised about the intensified record-keeping required as well as the possiblity of increased liability in the event of patient overdoses.   Both the Washington State Medical Association and the Washington Academy of Family Physicians have formally protested the "increased administrative burdens" of the new legislation.  Patient groups have also expressed concern over the possibility that increased vigilance regarding over-prescribing pain medications may lead to pain patients being undertreated for legitimate pain conditions.   They are also concerned that family physicians may avoid taking on chronic pain patients to eliminate the administrative headaches involved.  While physicians will be able to use the proposed central database to identify drug-seekers among their patients,  critics have questioned the potential value of the database in preventing overdoses and whether chronic pain patients with severe pain will be unfairly flagged as "drug seekers".

As the demand for  better pain treatment grows across the United States,  policies such as the one planned in Washington state will likely become more common.  Whether the "baby is thrown out with the bathwater" as many critics argue remains to be seen. 

For more information

How Do People Stay Healthy?

Which psychological variables have a positive impact on health during middle age?  A research study published in a recent issue of GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry examined data collected from 393 middle-aged participants (aged 35–45 at T1 and 45–55 at T2) as part of the National Survey of Midlife Development in the United States (MIDUS) to investigate the associations between health, optimism, positive affect, social support, and a cumulative burden score. Results show a positive association of the protective factors and a predictive value of positive emotions on health over time. The burden score showed no unique association with health. Overall, the predictors explained 17% of the variance of physical health and 33% of the variance of mental health. These findings emphasize the importance of investigating protective pathways.

For the abstract.

Caring for the Elderly

A paper published in a recent issue of GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry presents the EUROFAMCARE study findings, examining a typology of care situations for family carers of older people, and the interplay of carers with social and health services. Despite the complexity of family caregiving situations across Europe, the study results determined the existence of seven “caregiving situations,” varying on a range of critical indicators.  These indicators include: degree of impairment experienced by the care recipient, the extent of the burden placed on the caregiver, and the underlying support network.  The study also describes the availability and use of different support services for carers and care receivers, and carers’ preferences for the characteristics of support services. These findings have relevance for policy initiatives in Europe, where limited resources need to be more equitably distributed and services should be targeted to caregiving situations reflecting the greatest need, and organized to reflect the preferences of family carers.

For the abstract

New Report States that More Than 116 Million U.S. Adults Live With Chronic Pain

According to a new report released by the Institute of Medicine (IOM),  an estimated 116 million American adults deal with chronic pain  -  more than all patients directly affected by cancer, heart disease, and diabetes combined.  Medical treatment and lost productivity related to chronic pain costs more 635 billion U.S. dollars each year. 

The report, titled Relieving Pain in America: a Blueprint for Transforming Prevention, Care, Education, and Research,  presents the results of an IOM study committee investigating chronic pain.   Acting under the mandate of the U.S. Department of Health and Human Services (HHS), the Committee on Advancing Pain Research, Care, and Education was chaired by Philip A. Pizzo of Stanford University and Noreen M. Clark of the University of Michigan.    In addition to presenting the committee's findings, the report also provides specific recommendations and calls on HHS to implement a plan to:

• heighten awareness about pain and its health consequences
• emphasize the prevention of pain
• improve pain assessment and management in the delivery of health care and financing programs of the federal government
• use public health communication strategies to inform patients on how to manage their own pain, and
• address disparities in the experience of pain among subgroups of Americans

The committee identifies a series of current shortcomings identified in pain treatment including the lack of innovation in the development of new pain medications despite 10% of all written prescriptions being for the treatment of pain.   As well, primary care physicians are often the main providers of medical treatment despite their limited formal training in pain management.  There are only 3500 pain specialists nationwide and many Americans have no access to comprehensive pain centres.   To compound the problem,  insurance plans are more likely to pay for invasive surgeries than for physical rehabilitation or psychological counseling which can be more effective in dealing with chronic pain.   As a result, "perverse incentives"  are established in which costly medical treatments are favoured over less invasive methods which are more cost-effective.  

Chronic pain specialists routinely report dealing with patients who have endured years, and at times decades, of chronic pain which has been inadequately treated.   Since many surgeons have limited training in dealing with post-operative pain, they often prescribe narcotic medication without addressing the underlying causes of pain.   Related issues such as depression, sleep disorders, and cognitive impairments associated with pain are also poorly understood by many medical specialists. 

The report concludes by stating that "pain is a major driver for visits to physicians and other healthcare providers, a major reason for taking medications, a major cause of disability, and a key factor in quality of life and productivity.  Given the burden of pain in human lives, dollars, and social consequences, relieving pain should be a national priority."

For more information.

For the report (pdf)

"Suicide Kit" Linked to Oregon Suicide

When Jake Klonoski got no response from his younger brother's bedroom as he called him to dinner, he had no idea what he would find when he picked the bedroom lock to investigate.  29-year old Nick Klonoski had apparently taken his own life using a "suicide kit" that he had ordered by mail from a company in California.    The kit basically consisted of Derek Humphrey's book Final Exit, as well as plastic tubing and a plastic bag with a collar to be fitted around the neck.    The company providing the kit, the Gladd Group, charged Klonoski $60.00 U.S. for the kit and advertise their products online and by mail order.  They reportedly sold more than 1,700 kits last year alone grossing approximately $100,000.00 U.S.  

Klonoski, a University of Michigan graduate and the son of U.S. District Court Judge Ann Aiken, had been suffering from chronic fatigue syndrome and depression for years.  According to family members, he had been reading Final Exit on the day of his suicide.  A store receipt found in his room by police indicated that he had rented a large tank of helium from a party goods store near his home which he  had apparently used to asphyxiate himself.    Following Klonoski's suicide, police raided the home of the 91-year old California woman behind the Gladd Group as part of their investigation.  Sharlotte Hydorn defended the sale of the kits and stressed that she was not responsible for how they were used and that they were only meant for people in pain.   Since current legislation is ambiguous concerning the legal definition for "assisting" suicide, the only charge that Hydorn is facing at this time is mail fraud.

Suicide kits are readily available and instructions for their use can be found online through blogs and YouTube videos.   Alan Berman, executive director of the American Association for Suicidology, calls mailing the kits immoral and equivalent to "basically handing someone a gun" without checking on their history or whether they are a minor.    The Final Exit Network has more than 3,000 members nationwide and maintains that any mentally competent adult has the right to commit suicide.   While the network has faced legal battles in the past in states with assisted suicide legislation,  they also have the assistance of civil rights groups defending the network's publication of suicide manuals and "exit guides" to help family members conceal evidence that a suicide has occurred.    The actual number of suicides using helium hoods remains unknown at this time although suicide rights advocates insist that they number in the hundreds.

Oregon legislators are considering new legislation based on the Klonoski case which would make it a criminal offense to "sell or transfer any substance or object to another person" knowing that it would be used for suicide.  The proposed legislation has received unanimous approval by the Oregon Senate and state legislators are seeking to tighten the bill's language to make prosecution easier.

While assisted suicide has been controversial since Jack Kevorkian made it a mainstream topic in the 1990s, the sale of helium hoods and similar "suicide kits" has led to a rekindling of the assisted suicide debate across the U.S.    Ironically, Oregon was one of the first U.S. states to pass physician-assisted suicide legislation although assisted suicide is restricted to terminally ill patients only.   The legal process of physician-assisted suicide also requires multiple doctor consultations and a possible psychological assessment before the suicide is allowed to proceed.    In 2010 alone, there have been 65 physician-assisted suicides in Oregon.

For more information.

The Chloroform Man

All Horace Wells ever wanted was to relieve the pain of his dental patients.   He probably should have quite while he was ahead.

Born in 1815, he attended schools in Hampshire and Massachusetts before deciding to become a dentist.  Since there were no formal dental schools at the time, Wells received his training by serving an apprenticeship with several practicing dentists in Boston.  After a brief period as a traveling dentist, he established a permanent practice in Hartford, Connecticut in 1836.   By 1838, Wells was a well-known dentist in the community and had even made a name for himself among other dentists with his An Essay on Teeth, Comprising a Brief Description of Their Formation, Disease, and Proper Treatment.   Although his practice was successful, Wells was frequently distressed by the pain that his patients experienced.  Early nineteenth-century dentistry was frequently agonizing for patients since there was no reliable method of anesthesia available.   Due to the medical risks involved, opium (and, later morphine) could not be safely administered for tooth extraction and alcohol had its own drawbacks.  Looking into other methods,  Wells stumbled onto a possible solution while attending a very unusual lecture.   

When nitrous oxide was first discovered by Joseph Priestley in 1772, its properties weren't immediately obvious.  First named "nitrous air" by Priestley, the colourless, non-flammable gas had a sweet odour and taste.   In his later research, Humphrey Davy discovered that the gas had anesthetic properties (ironically enough, he had a wisdom tooth removed and found that nitrous oxide relieved the pain).  Although Davy commented on nitrous oxide's potential role in surgery in a 1799 book, nothing really came of it at first.   Still, the euphoric feeling experienced after inhaling nitrous oxide quickly earned it the nickname of "laughing gas".  For the next few decades, nitrous oxide was popular for the recreational high it brought and "laughing gas" parties became popular, first with British aristocrats and gradually spreading to both sides of the Atlantic.    According to the 1839 flier advertising a typical party, "The gas will be administered only to gentlemen of the first respectability. The object is to make the entertainent in every respect a genteel affair" (although you have to wonder how "genteel" the guests became after too much nitrous oxide intoxication).  More serious lecturers even provided nitrous oxide cannisters in lecture halls so the audience could sample its effects themselves. 

It was at an 1844 lecture by Professor G. Q. Colton where Wells tried laughing gas for the first time and realized that it could be useful for tooth extraction.  After seeing another audience member injuring himself and showing no pain while under the influence, Wells decided to experiment further.    He arranged a demonstration with Colton on the following day in which Wells had his own tooth extracted using nitrous oxide.  Wells was excited by the success of the experiment and later commented that, "I did not feel it so much as the prick of a pin.  A new era in tooth pulling.  It is the greatest discovery ever made".  Unfortunately, a followup demonstration that he had arranged for other Boston dentists and medical students was unsuccessful because he accidentally turned off the nitrous oxide too soon.  The patient sat up and screamed and the audience walked out after declaring Wells' discovery to be a hoax.    Despite this setback, Wells continued his experiments and successfully used nitrous oxide with his own patients.

In the meantime, other developments were happening in Europe.  The analgesic properties of chloroform and ether had long been known but it was only during the 1840s that physicians and dentists began using them for surgical operations.  After  Wells' former partner, William T.G. Morton, first used ether for tooth extraction at Massachusetts General Hospital in 1846, newspapers in Boston widely praised him for his medical discovery.  Painless surgery had suddenly became popular (Queen Victoria helped the process along in 1848 by asking for chloroform during the birth of her seventh child)  and a battle quickly developed over who should should have the credit for inventing anesthesia (the term was coined by Oliver Wendell Holmes in that same year).  Although Horace Wells tried to have his own work recognized, he faced stiff opposition from the Boston medical community (they regarded Morton as one of their own and wanted Boston to be recognized as the birthplace of anesthesia).  It was as much a matter of money as prestige since Morton also tried to patent his anesthetic which would have made him a wealthy man. 

With an aggressive campaign to have his early experiments in nitrous oxide recognized, Wells established his place in medical history after traveling to France and presenting his claim to the French Academy of Medicine.   Although Wells' pioneering work was eventually recognized, his life quickly went downhill after his successful return from France in 1847.    Since chloroform provided a safe alternative to ether, Wells began his own experiments which involved self-administering the drug in large dosages.  The toxic effects of chloroform exposure were not well understood at the time and Wells became increasingly deranged.  According to his obituary,  Wells was approached by a patient who had apparently asked him for some "vitriolic acid" to help him "pay back a loose female, who injured his dress".  He and the patient prepared a spray bottle of acid and squirted it on the woman in question.  When the patient suggested "continuing the sport" with other women, Wells refused and went home.    Unfortunately, Wells continued inhaling large doses of chloroform over the next few nights.  According to the confession that he left behind,

"I lost all consciousness before I removed the inhaler from my mouth.  How long it remained there, I do not know, but on coming out of the stupor, I was exhilarated beyond measure, exceeding any thing I had ever before experienced, and seeing the phial of acid, I seized it and rushed into the street and threw it at two females, I may have thrust it at others but I have no recollection farther than this.  The excitement did not leave me for some time after my arrest."

Wells made no attempt at defending himself and was primarily worried about what would happen to his wife and child.  Confined to a small cell in New York's notorious Tombs jail, Wells had somehow managed to smuggle in a razor and, after anaesthetizing himself with a dose of chloroform that he had poured into a handkerchief, he cut the femoral artery on his left thigh.  When his body was finally found on January 24, there was a pool of blood in the floor of the cell as well as several sheets of paper on which he had written his confession as well as a final note to his wife.  In that note, he explained his suicide on the grounds that he was fast "becoming a deranged man or I would desist from this act.  I can't live and keep my reason and, on this account, God will forgive my deed.  I can say no more".  The note also gave instructions for his burial and disposal of his personal effects.

Although Horace Wells' final letter requested that he be buried in secret, he was interred at Cedar Hill Cemetery in Hartford Connecticut.  William Morton and the Boston medical community played on the bizarre circumstances of Wells' death to reinforce Morton's claim as being the inventor of anaesthesia.  It would take many years, and vigorous lobbying by Wells' supporters, before the American Dental Association and the American Medical Association formally recognized Horace Wells as a pioneer.  Monuments to Wells have been raised in Paris and in Hartford, Connecticut.    Nitrous oxide continues to be used as an anesthetic and, ironically in Wells' case, it has been successfully used in treating certain types of addiction including alcohol withdrawal.

And yes, laughing gas parties are still around (perhaps too much so).