HowardHughesPseudoaddict.pdf

V OLUME 7, I SSUE 6

JULY/AUGUST 2007

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Howard Hughes and

Pseudoaddiction

A PPM Communications, Inc. publication

www.ppmjournal.com

Howard

A retrospective case report of this

remarkable individual’s 30-year

survival by self-medicating his

intractable pain with codeine, anti-

inflammatories, muscle relaxants,

and stimulants—not as a drug-

seeker, but as a “relief-seeker.”

W ith the emergence of opioid treatment of intractable

pain (defined here as incurable, severe, and constant),

there is great interest in the long-term survival of pa-

tients who require such treatment. At this time, there are no pub-

lished reports of opioid-treated, intractable pain patients who

have survived over a decade.

Because of a combination of fame and wealth, the revisiting

of the Hughes case was made possible due to the volume of de-

tailed public records available. Underneath the glamour, glitz,

sex, money and politics that surround the saga of Howard Hugh-

es, there is a serious and tutorial medical story from which all

concerned parties can benefit. Hughes lived 30 years while tak-

ing high dosages of codeine in an average daily dosage between

20 and 45 grains a day. He survived a plane crash in 1946, de-

veloped intractable pain, and died 30 years later in 1976 due to

specific anti-inflammatory agents that, over time, produced kid-

ney failure. 1-3

This author was contacted in 1978 by the U.S. Drug Enforce-

ment Agency to be a consultant on Hughes. I was given copies

of Hughes’ autopsy report, post-mortem toxicology analysis,

birth certificate, death certificate, a 1958 memo written by Hugh-

es involving medication acquisition, and a daily log of medica-

tion administration kept by his aides and dated October 31, 1971

through July 1, 1973. These materials were presented in a pub-

lic trial and are not confidential documents. 3 This log, covering

his habits and behavior in detail, was in the 25th and 26th year

after his plane crash and continuous consumption of opioids. It

is very revealing as to how he treated his pain and continued to

function.

In September 1978, this author compiled a written report for

the U.S. Government based on the aforementioned documents.

In addition, this author appeared as an expert witness in the

Ogden, Utah Federal trial, U.S. versus Thain (Hughes’ physi-

cian in the last years of his life) 3 and was able to interview two of

Hughes’ now-deceased, personal physicians about Hughes’ med-

ical history and treatment.

It is cogent to point out that in 1978, this author was fully vest-

Practical PAIN MANAGEMENT, July/August 2007

Hughes

P SEUDOADDICTION

by Forest Tennant, MD, DrPH

ed in addiction research and treatment

and had only begun to research and treat

intractable pain patients with opioids.

Consequently, the resulting 1978 analysis

of this matter, including terminology and

biologic concepts, were archaic given the

monumental, historic, and scientific

breakthroughs in the understanding of

addiction and pain that have occurred

since 1977.

Due to the great interest in the long-

term survival of pain patients treated

with opioids, a re-analysis and report of

Hughes at this time is most informative

and instructive for physicians and pa-

tients. This re-analysis incorporates

many of the current terms, concepts, and

scientific advances that have emerged in

the past 30 years. To provide perspective

on how pain management has matured

since that time, some relevant terms are

shown in Table 1.

T ABLE 1. S OME PAIN TREATMENT CHANGES IN TERMINOLOGY

AND CONCEPTS DURING THE PAST 30 YEARS

1977

2007

Addict

An addict was anyone who

took a prescription drug in

dosage above the usual

frequency or for an

extended duration

An individual who compulsively

uses a substance for non-pain

purposes

Psuedoaddiction

Term not used

Syndrome in which an individual

who seeks drugs for pain relief

since their pain is out of control

Intractable

Term not used

Incurable, severe, constant pain

Breakthrough

Pain

Term not used

A flare of pain above the usual

baseline pain level

Short & Long-

acting Opioids

Terms not used

Usual treatment for severe

intractable or persistent pain is a

long-acting opioid plus a short-

acting one for breakthrough pain

Precipitating Cause of Pain and

Initiation of Opioid Treatment

Born in 1905, Hughes was a world-recog-

nized, pioneering entrepreneur engaged

in diverse businesses that included chem-

icals, plastics, moving pictures, entertain-

ment, and aircraft design and develop-

ment. In 1946, at the age of 41, Hughes

solo-tested an experimental reconnais-

sance plane known as the XF-11. Shortly

after take-off from the Santa Monica, Cal-

ifornia airport he crashed. He miracu-

lously survived the crash and was imme-

diately hospitalized at Good Samaritan

Pain

Characterization

Essentially none

Common classes include neuro-

pathic, myofacial, and reflex

sympathetic dystrophy

Effect of Renal

Failure on Drug

Serum Levels

Little understanding

Poor renal clearance may greatly

raise serum levels of therapeutic

drugs

Morphine

Equivalency

Unheard of

Pain potency of all opioids are

equated to the effect of 1mg of

morphine

Practical PAIN MANAGEMENT, July/August 2007

Howard Hughes and Pseudoaddiction

taken at autopsy. His physician in the last

years of his life, Dr. Wilbur Thain, de-

scribed his skin as “extremely sensitive to

touch” and any cutting of his finger or toe

nails “hurt like hell.”

As Hughes aged, he developed degen-

erative arthritis in several joints that ag-

gravated his pain. After his fractured left

hip was pinned in 1973, he did not walk

again and developed a contracture of the

left leg. His hip fracture and contracted

leg may also have contributed to his pain.

Dr. Thain offered Hughes a walker, wheel-

chair, and even a cute physical therapist

to help him walk again. Hughes replied

humorously to the latter, “No Wilbur, I’m

too old for that.” Thain considered, and

rightly so, that Hughes’ resistance to walk-

ing after his hip fracture was “the begin-

ning of the end.” Modern day pain spe-

cialists ask and demand physical activity

and movement from intractable pain pa-

tients if they are to escape a bed or couch-

bound state. In this regard, Dr. Thain ap-

peared to be a physician well ahead of his

time.

Hughes suffered several neuropathies

and had allodynia which presents as se-

vere pain to the touch. He would possibly

today be given the diagnosis of Reflex

Sympathetic Dystrophy or Chronic Re-

gional Pain Syndrome. At times, his pain

was reported to be so severe that a simple

touch or the touching of bedclothes pro-

duced pain. His renowned refusal to

brush his teeth, cut his toe and finger

nails, or wear shoes may have been relat-

ed to the fact that these actions may have

caused increased pain. 5,6 His multiple fa-

cial fractures probably produced a neu-

ropathy of his jaws and face. At this time,

it is not possible to correlate his pain and

its treatment to any impact on his

renowned, lifelong eccentricity and ob-

sessive-compulsive traits or to his failure

to brush teeth, cut nails, or exercise. 5,6

T ABLE 2 . I NJURIES SUSTAINED BY H UGHES IN 1946 PLANE

CRASH THAT LIKELY PRODUCED INTRACTABLE PAIN

Third degree burn of abdomen and chest wall

Fractures of chin, jaw, left knee, and left elbow

Multiple burns of left ear, left chest, left abdominal wall, little finger left hand,

left buttocks

Third degree burns in some areas. One large burn extended from his left

shoulder to left hip

Displacement of 6th cervical vertebrae onto the body of the 7th

Fracture through lateral articular facets of 5, 6, 7th cervical vertebrae

Fractures of ribs 1, 2, 3, and 4 on right. Fractures of 1, 2, 3, 4, 5, 6, 7, 8, and

9 on left

Fracture of left clavicle

Hemorrhage into left chest cavity with displacement of heart into right chest

Hemorrhage into mediastinum

Blood loss requiring transfusions

Hospital in downtown Los Angeles. His

injuries were numerous and included

multiple fractures and third degree burns

(see Table 2). He required three chest

drainings, since he recurrently bled into

his left chest cavity. Four skin grafts were

required to close a large third degree burn

extending from his shoulder to hip. He

remained at Good Samaritan Hospital for

about 5 weeks between July 7 and August

11, 1946. Hughes was given morphine

while hospitalized and was discharged on

codeine. A detailed list of Hughes’ in-

juries are listed in Table 2 to emphasize

that essentially no one can survive these

injuries without developing intractable

pain.

Modern day pain treatment specifical-

ly and clearly recognizes that neck and fa-

cial fractures are associated with in-

tractable pain. Third degree burn scars

are known to cause pain in peripheral

nerves. Pain that radiates from a central

nerve injury into the face, arms, legs, or

chest wall is now referred to as neuropath-

ic pain. This term was not used during the

life of Hughes. Details of his injuries are

given here to eliminate any misconcep-

tions and refute some public reports that

he didn’t have pain that required ongo-

ing medication.

days or weeks. A headache is a good ex-

ample. Chronic pain is an intermittent or

constant pain that persists beyond about

90 days. Millions of people suffer from

mild or moderate chronic pain due to

such causes as arthritis, lumbar sprain,

bunions, or carpal tunnel.

The severe form of chronic pain is more

and more being referred to as “intractable

pain.” This form of chronic pain is re-

served for those severe chronic pain pa-

tients whose pain is severe, incapacitating,

constant, incurable, and interferes with

biologic functions including sleep, eating,

ambulation, and social interaction. Un-

dertreatment results in reclusivity and a

home or bed-bound state. Intractable

pain patients have a persistent or baseline

pain with flares or breakthrough episodes

above their baseline pain. Injuries such as

those sustained by Hughes in his 1946

plane crash inevitably produce chronic

pain and likely cause intractable pain. Sci-

entific studies now show it is usually pos-

sible to separate intractable pain from or-

dinary chronic pain in that intractable

cases present demonstrable biologic

changes in heart rate, blood pressure, and

adrenal hormone production. Analysis of

Hughes’ medical and pain history clearly

shows that today he would be character-

ized as an IP patient.

Hughes’ pain, according to his physi-

cians, was constant and centered around

his neck, shoulders, back, and into his

arms. In the 1946 plane crash, he suffered

fractures of some cervical neck facets. Col-

lapsed vertebrae were noted on x-rays

Pseudoaddiction or Addiction?

After Hughes’ death and the revelation

that he had taken high dosages of codeine

and diazepam (Valium ® ) for many years,

he was mistakenly labeled an addict by all

concerned parties—including this author.

In addition, he was assumed to abuse his

medications since reports indicated he

became over-sedated with resulting pres-

sure (bed) sores, falls, reclusivity, and ob-

sessive-compulsive traits such as over-

washing. To compound this belief, a

memo was written by Hughes in 1958

Characterization of Hughes’ Pain

Today’s pain terminology, as confusing

and deficient as it may be, helps provide

a framework to understand Hughes and

all other pain patients. Acute pain is one

of sudden onset and that resolves within

Practical PAIN MANAGEMENT, July/August 2007

Howard Hughes and Pseudoaddiction

which gave detailed instructions to his

aides on how to obtain controlled drugs.

This memo was initially believed to be a

surreptitious attempt to obtain drugs for

purposes of abuse, but later information

revealed that it was simply to obtain med-

ications legitimately prescribed by his

physicians. His major physician at this

time was Dr. Vern Mason, an accom-

plished internist who cared for Hughes’

pain in the early years after the plane

crash, and prescribed codeine. His physi-

cians instructed him on how to inject

codeine.

Today, Hughes’ drug seeking would be

termed pseudoaddiction, not addiction.

There is now a standard set of terms

adopted by all major professional pain

treatment organizations and the Ameri-

can Society of Addiction Medicine. New

terms and definitions propagated by the

National Federation of Medical Boards

are critical to the understanding of Hugh-

es’ pain and medical catastrophe, and so

they are given here:

Addiction. Addiction is a primary,

chronic, neurobiologic disease with ge-

netic, psychosocial, and environmental

factors influencing its development and

manifestations. It is characterized by be-

haviors that include the following: im-

paired control over drug use, craving,

compulsive use, and continued use de-

spite harm.

Pseudoaddiction. The syndrome re-

sults from the misinterpretation of relief

seeking behaviors as though they are

drug-seeking behaviors commonly seen

with addiction. The relief seeking behav-

iors resolve upon institution of effective

analgesic therapy.

Tolerance. Tolerance is a physiologic

state resulting from regular use of a drug

in which an increased dosage is needed

to produce a specific effect, or a reduced

effect is observed with a constant dose

over time. Tolerance may or may not be

evident during opioid treatment. Physical

dependence and tolerance are normal

physiological consequences of extended

opioid therapy for pain and are not the

same as addiction.

Chronic Pain. Chronic pain is a state

in which pain persists beyond the usual

course of an acute disease of healing of

an injury, or that may or may not be as-

sociated with an acute or chronic patho-

logic process that causes continuous or in-

termittent pain over months or years.

Physical Dependence. Physical de-

F IGURE 1. This x-ray taken at autopsy shows 5 needles imbedded in Hughes’ arms. Just as dia-

betics did in those days, Hughes had to self-inject codeine intramuscularly with outmoded glass

syringes that had detachable needles which frequently came loose under the skin. When this x-

ray was first observed, an erroneous conclusion was made that it indicated addiction and abuse

of codeine rather than pseudoaddiction. Hughes’ best pain relief was by injecting codeine, but

codeine was probably not nearly potent enough to fully relieve Hughes’ pain.

pendence is a state of adaptation that is

manifested by drug class-specific signs

and symptoms that can be produced by

abrupt cessation, rapid dose reduction,

decreasing blood level of the drug, and/or

administration of an antagonist. Physical

dependence, by itself, does not equate

with addiction.

There is a no more profound example

of misinterpretation relative to addiction

versus pseudoaddiction than the finding

of 5 imbedded needles seen on Hughes’

arm x-rays taken at autopsy (see Figure 1).

After seeing these x-rays, the immediate

—and mistaken—conclusion by this au-

thor and others was that the embedded

needles must represent addiction and

abuse of drugs. Later understanding of

the effectiveness of oral versus injectable

opioid compounds reveals the true pic-

ture. Hughes self-injected pure codeine

phosphate and also took oral compound-

ed codeine (i.e. codeine with phenacetin,

aspirin, etc.). In later years Hughes’

physicians confirmed that his major pain

relief was by injectable codeine. It is now

clear that codeine would not be potent

enough or last long enough in the body

to provide much pain relief for Hughes.

For example, codeine’s effective pain re-

Practical PAIN MANAGEMENT, July/August 2007

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