My new medical thriller STRESS FRACTURE deals with Post Traumatic Stress Disorder (PTSD). A recent article in the New England Journal of Medicine (NEJM) titled “Morphine Use after Combat Injury in Iraq and Post-Traumatic Stress Disorder” offers some interesting insights into the genesis of this poorly understood psychiatric disorder. The gist of the article is that injured soldiers who received morphine seem to have a reduced incidence of PTSD when compared to those that were not treated with this analgesic medication. The authors of the article and the author of the editorial in the same publication felt that this was due to the reduction in pain felt by the soldiers during their time of injury. This is likely true but I have a slightly different take on it. Let me explain.
PTSD is often associated with war but the truth is it can occur under many other circumstances. Things such as an abusive household relationship, severe illness, and virtually any other situation where there is prolonged and unrelenting or frequent intermittent stress of a significant nature. The victim is constantly vigilant, constantly waiting for the next shoe to drop, constantly waiting for the next wave of pain or fear or stress. This has a tendency to cause psychological damage and fatigue and will also ingrain certain pathways of response within the individual. It can be almost Pavlovian in nature.
The so-called flashbacks that occur among war veterans are examples of PTSD. Maybe a soldier who had been in Vietnam hears a helicopter overhead and all those old feelings of fear and anxiety arise. His heart rate elevates and he begins to sweat and in some sufferers a full-blown panic attack follows. The trigger, the sound of the helicopter blades, causes the response, the flashback to a very fearful time.
So it would seem that anything that blunted the initial response, that is anything that relieved the soldier’s fear at the time of the original events, would also lessen or even eliminate the later Pavlovian response to anything that reminded him of that situation. In the case of the injured soldiers, the reduction of pain after the traumatic event and during the healing phase should serve to lessen future anxiety events surrounding similar injuries or fear of similar injuries. So far so good.
But why is morphine singled out in this circumstance? It brings me back to my days in medical school. One of my professors in Birmingham at the University of Alabama was without a doubt one of the true giants of medicine. Dr. Tinsley Randolph Harrison is hands-down the greatest physician I’ve ever known and is known by physicians throughout the world. He literally wrote the book. Harrison’s Textbook of Internal Medicine is read by every medical student, intern, resident, and practicing physician in the country. In fact, virtually every one of them has a copy on the shelf. I’m looking at one of my several copies right now.
Dr. Harrison taught us many things and he had so many pearls of wisdom that he imparted to us on a daily basis that I can’t even begin to recount them all. We called them “Tinsleyisms.” One of those was his belief that you should use morphine rather than another analgesic such as Demerol when someone was having a heart attack — a myocardial infarction or MI. His belief was as usual on very firm ground and came from years of experience.
Back in those days we didn’t jump into the middle of a heart attack and try to abort it. We simply did not have the knowledge or the means. We did not have thrombolytic drugs or angioplasty balloons or cardiac stents. We simply allowed the heart attack to happen and dealt with the aftermath. All he could do was make the patient comfortable and reduce his anxiety as much as possible and then treat the complications as they arose. Hard to believe it was done that way but it was.
Dr. Harrison rightly believed that fear killed as many of these patients as anything else. We now know that to be true but at the time it was a rather novel idea. He also authored along with Dr. T. Joseph Reeves another important book in the history of cardiology. This was titled Principles and Problems of Ischemic Heart Disease. It was published in 1968 and one of my proudest possessions is a copy of this book signed by both Dr. Harrison and Dr. Reeves, who was my old chief of medicine. The point relevant to this discussion is that they closed this book with a paraphrase of Corinthians 13:13:
And now abideth pain, breathlessness, and fear, these three;
But the gravest of these is fear.
When someone is having a heart attack they almost invariably have these three: pain, breathlessness, and fear.
Dr. Harrison said that you can use any analgesic medication to relieve pain but only morphine has a profound euphoric effect so that the patient is not only pain free but fear free. Seen it a 1000 times. You give someone morphine and they absolutely do not care anymore. They’re not concerned about their heart attack attack or broken leg or whatever is going on. They are simply giddy and happy.
In a heart attack the most dangerous chemical in the body is epinephrine, also called adrenaline. This is the fight or flight chemical within the body. If a bear crashes into your bedroom you better pump up the adrenaline and get the hell out. Under those circumstances this chemical is life-saving. But in a heart attack it can cause deadly cardiac arrhythmias that can result in death and indeed this is the most common cause of death in heart attacks even today. So anything that relieves pain, lessens fear, and lowers the epinephrine levels in the body is beneficial. Morphine scores on all counts.
The same mechanism is likely operative in PTSD when this drug is used. A victim whose pain is relieved but he is still left with fearful memories and his brain completely engaged in the circumstances of his injury is still under stress. A victim whose pain is not only relieved but he is euphoric does not suffer the same level of stress and this might be critical in the later development of PTSD. I’m not sure this is true but it certainly makes sense and I would bet that Dr. Harrison, were he still with us, would say the same thing.