Monday, September 10, 2007

Japanese Slowly Shedding Their Misgivings About the Use of Painkilling Drugs - New York Times

September 10, 2007

Japanese Slowly Shedding Their Misgivings About the Use of Painkilling Drugs

OKAYAMA, Japan — If any nation ought to lead the world in the consumption of painkillers, it is Japan.

Its population is aging, and cancer is the leading cause of death.

It has universal health insurance, and few restrictions on prescription narcotics.

And it is a heavily medicated society; it consumes half the world's Tamiflu, the anti-flu drug.

Yet, on charts detailing the per capita consumption of narcotic painkillers throughout the world — routinely topped by the world's richest countries — Japan is down in the neighborhood of Bulgaria and South Africa. It consumes one-twelfth as much per capita as the United States.

The leading reason for that, said Dr. Fumikazu Takeda, a retired neurosurgeon who leads the fight for better pain control, is patients' fear.

Until recently, morphine was used only in hospitals, and near the end.

"People hate morphine because they think, 'As soon as the doctor injected morphine, my father died,' " Dr. Takeda said.

Also, until recently medical schools taught that narcotics should be used only briefly at low doses.

And some national sense of "gaman" — that suffering in silence is a virtue — persists even in hedonistic modern Japan.

"Long ago, a samurai who complained about pain was considered a very weak samurai," he said. Young people have other ideas, but with life expectancies over 80, the typical cancer patient is from another generation.

"Patients in their 70s and 80s who lived through World War II feel guilty to have survived the war," said Atsuko Uchinuno, vice president of the Japanese Society for Palliative Medicine. "I had one patient who told me, 'I need some pain, because I feel bad about the people who died.' "

Some experts scoff at that but admit that the reluctance exists.

"Saying we don't take morphine because of gaman in today's Japan is a stereotype like geishas and Mount Fuji," said Hajime Mizuno, who writes about medical issues. "The biggest reason is that doctors think morphine is evil because it causes addiction, and ordinary people do, too."

But those attitudes are changing. In 1980, Japan was using only 1 percent of the morphine it uses now. And last year, Parliament adopted a new national cancer plan.

Historically, governments feared opium because they saw it devastate China. After World War II, China had 40 million addicts, including the last empress. Mao cracked down ruthlessly, burning crops and executing dealers; by 1960, addiction was virtually gone.

Disdain for pain control is also a byproduct of Japan's medical system.

In May 2006, a member of the Parliament disclosed that he had cancer and said the system was so shamefully disorganized that it left thousands of "cancer refugees" roaming the archipelago looking for care.

Care is typically led by a surgeon who oversees chemotherapy and radiation as adjuncts and focuses less on drug management, including pain control, experts said.

And, until recently, patients were not even given their diagnoses. In a scene from a decade-old documentary well known here, a surgeon shows a family their mother's excised breast on a steel tray to point out the tumor; but she was not even told she had cancer.

Now disclosure is normal, and there is a government campaign urging patients to request pain relief. "Tell Us About Your Pain!" posters decorate hospital walls.

Drug enforcement agencies are struggling to adjust to the new reality.

Dr. Junichi Ikegaki, chief of palliative care at Hyogo Cancer Center, gave an example. His wife runs an outpatient clinic, and 100 OxyContin tablets disappeared from her narcotics cabinet.

In low-crime Japan, the theft of even 100 pills was such big news that television crews showed up with the police.

One narcotics officer criticized Dr. Ikegaki's wife, he said, because the cabinet was not bolted to the wall.

But the officer's partner, saying the country used too few painkillers, took her aside and asked her to prescribe more.

"Hon-ne and tatamae?" Dr. Ikegaki asked, using a Japanese expression for the difference between one's public facade and one's real feelings. "One was a suppressor and the other was a promoter."

Murakami Takahisa, director of drug compliance at the national Health Ministry in Tokyo, chuckled at the story.

His office is decorated with posters warning teenagers about the dangers of Ecstasy, but he is not worried about a crime wave, he said. Heroin use, for example, is negligible. His department sponsors symposiums encouraging doctors to prescribe more painkillers.

"In situations like this," he said, "narcotics officers have to change."

Kumi Takagi, 40, was initially reluctant to take morphine. Her breast cancer has spread to her spine and pelvis, and she has endured surgery, chemotherapy and radiation.

Touching her shoulder blades and lower back, she parsed her pain: "Up here, it was a stinging pain. But down here, it felt like the bones were grinding against each other, as if they were sticking and then breaking free. I wanted to slam my back against a wall."

She resisted until she found herself unable to get out of a chair without help. "Its image in Japan is that you will get hallucinations, or will have difficulties in your daily life," she said. "I was afraid I wouldn't be able to do my work or make my son's lunch."

She now takes morphine every 12 hours and carries a "rescue dose" for the sudden, severe pain called breakthrough pain.

"It's not all gone," she said, "but it's mild, and I can bear it. And I can sleep. Honestly — I wish I'd started it before."

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