Thursday, September 23, 2010

4.(4-5) Pain? Opium Drugs?

Physician's Notebooks 4 - See Homepage

Two Chapters - Pain (& Pleasure) and Opium Drug for Recreation (For opioids, scroll down) Update 2 December 2018

Chapter 4. Pain
The following column has main topics as they appear.
Types of Pain
Medication for Pain
Pain Management 
Endorphin Pleasure
End Note:  Principles of Anti-pain Medication

Once you convince yourself a pain is harmless to your health and life, it tends to become tolerable and may even disappear. However, pains that disable one, like muscle pains of the waist and thigh, as I have much, can be worrisome and limiting. And a pain that excites your fear of deadly diagnoses even if it does not limit your movement will torment you and may become chronic even when minor. That is the psychological overlay of pain; it is a top-down nervous system effect; the raw pain is a bottom-up effect, the bottom being the pain stimulus and the top the cerebral cortex that dials up or down the raw emotional response making it stronger or weaker depending on its threat to your survival and its limitation on your life. An example is the soldier in combat being shot by a bullet in the leg and not feeling its pain while, on the other hand the same soldier if he got the bullet in same spot in non-combat would feel it badly.
  Types of Pain (Not Inclusive but Typical Pains I've Experienced)
   A sharp electric shock-like pain that runs down the back or extremity and is worsened by cough or sneeze is an irritated spinal root. If you must see an M.D. for such pain, arrange a consultation with a neurologist in a University-HMO (Health Maintenance Org). Often in case of shooting pain down the back and into leg (sciatica) the cause is obvious (accident, too heavy lifting). It is worsened by starting movements (I call it "Tin Man" effect from the Wizard of Oz scene where the tin man needs to be oiled after a long lack of oiling and it takes time for the oil to loosen him up enough to move). It is often symmetrical (left and right sides equal).
  Sore or irritated feeling around certain joints – one or other shoulder, wrist, especially wing bone (scapula) may indicate important internal organ disease. Such pain in left shoulder or left wrist ought to lead to a heart check up. With one-sided hip pain, think Collapsed lumbar vertebra from osteoporosis or Osteoarthritis of hip. If a woman, think of a pelvic organ problem.
   Pain coming from a blocked tube in abdomen has as its most characteristic quality its wavelike pattern, building up to peak and letting-up over a minute with pain-free interval. The pain lasts as long as it takes the tube to get rid of its blockage. One type is renal colic; it is one-sided, each spasm starts in upper rear flank and rapidly goes around side of abdomen down into groin and lets up and new spasm builds up after painless minute. The type from intestinal colic occurs in the hour after eating. It goes from above downward and from your right to left, following the intestine contents passage. It is caused by movement of bowel contents and ends in a good bowel movement but, briefly, it can be rather severe. If intestinal cramp is too painful, or has nausea and vomiting, get to hospital emergency; it may be surgical abdomen.
  Pain from cancer is usually dull and continuous; it has emotional overlay as warning of dying.
Medication for Pain
  Medication for muscle, joint, bone and soft tissue pains should start with headache-dose (300-325mg) acetaminophen or aspirin (but note not to use aspirin if at high risk for bleeding or peptic ulcer), and with severe pain the secret of success is starting the max dose (600 mg acetaminophen aka Tylenol, and limit each to one dose a day, timed conveniently). But keep in mind before blindly medicating a pain to reasonably determine the cause.

   Warning!  Avoid places that advertise Interventional Pain Management. These are usually non medically controlled, commercial "clinics" with a hired staff of doctors or osteopaths who will write "scrip" for narcotics or popular mind-bender medication or, even worse, subject patients to invasive procedures like corticosteroid injections or even nerve ablation surgery.
Endorphin Pleasure
   A note about pain's opposite: pleasure. The word "endorphin" is used for chemical substances that cause pleasure and also as adjective for a type pleasure typically noted by first user of opioids. Endorphin pleasure may result from a good eating and one should note what foods and circumstance caused the feeling. It is more generalized, felt just beneath skin, at times described as a bubbling-up pleasure centered in navel,  breast nipples, and joint surfaces like knees and elbows. Warmth enhances the endorphin effect. (Sunlight on abdomen) For example, even in late April with the outside temperature moderate in Tokyo and no need for indoor heating, I notice my endorphin pleasure from a dose of pentacozine opioid enhanced by direct sunlight heat. Light in eyes seems to enhance painful effects and oppose endorphin effects. A darkened, warm room is the best room condition for enhancing body pleasure and opposing pain. (This,despite the observation, that direct sunlight can enhance endorphin feeling)

End Note:  Principles of Anti-pain Medication
Anti-pain medication either reverses the cause of the pain (eg, anti-inflammatory reverses inflammation, anti-spasm reverses the spasm) or is just general against pain (like opioids). The most useful pain medications are the anti-inflammatories. These divide into 2 types: cortico-steroids and non-steroid anti-inflammatory drug (s; NSAIDs). The cortico-steroids are used to reverse severe inflammation but they do not do anything quickly against the pain that came from the inflammation. On the other hand the NSAIDs are both anti-inflammatory and anti-pain and rapid acting (within minutes) and effective against the already existing pain of the inflammation. 
The NSAIDs are aspirin, acetaminophen and the standard NSAIDs. Aspirin and acetaminophen are not usually called NSAIDs although practically they are.        

The NSAIDs work best for pains from connective tissues like muscles, bones and other soft tissues that are damaged or irritated. When the pains come from muscles or bones they can be debilitating. In these cases an NSAID can be virtually life saving in terms of living a normal life. Aspirin has a special good and bad point. Its good point is: it affects the blood platelet aggregation in a way that weakens internal blood clots. But it also may cause hemorrhage in at risk persons and it may irritate the linings of the stomach and intestines. For a person who is taking aspirin already to prevent blood clot, the aspirin may be used in higher dose against pains. For persons who cannot use aspirin, the next choice is acetaminophen. And in its daily max 600 mg dose, it is safe, but persons who are at risk for liver disease (alcoholics) should avoid taking too much of it. Otherwise one of the standard NSAIDs may be used. 
Opioids are a general anti-pain medication which are not good against inflammation pain but useful against cancer pains. They are working centrally. Medically they are safe but in countries where they have been criminalized,or too strictly regulated their use may create an addiction. 
Opioids should not be used (as they often are) in a combination pill with anti-inflammatories. If you are going to use 2 or more types of anti-pain medication, each one should be sequenced (ie, first take the anti-inflammatory and then hours later the other type. Other pain medications fall into the category of anesthesia, analgesia, and anti-depression medications that work against pain. Then there are special migraine headache medications. These have only specialized use under supervision of a physician.

Chapter 5. Drug for Intellectual Work and for Recreation
Contents of the chapter in descending order.
LSD and other Psychedelic 
MethylPhenidate (Ritalin 
Opioid Addiction 
Pentazocine (P, trade name in USA, Talwin) 
The Stretch Effect 
Conditioning by Taste
OxyContin (OxyC) Slow Release 
Reason for Using Opioids 
fictional treatment of my morphine experiences 

Marijuana: Whether dangerous or safe, useful or recreational, a marijuana damages lungs from the smoking. But if you are dying of cancer, using marijuana may harmlessly relieve anxiety and nausea. Marijuana is like a minor psychedelic - your mind detaches from body but nowhere near as much as with LSD.

Cocaine is a strong stimulant with euphoria, and popular in the drug culture. But the risk of acute myocardial infarct or brain hemorrhage; the danger, expense and inconvenience of obtaining illegal, contaminated and denatured product; and cocaine’s effect to cause violent, irrational behavior – all are too high to pay for an effect you could get from a cup of strong caffeine coffee.

LSD and other Psychedelic: Here we deal with class of drug that puts its user's mind out of control. The street purpose to take it is to experience “trip.” As one who values controlled cognition above all else, I have no desire for psychedelic. Its danger is to make or worsen psychosis in borderline personality. I favor controlled experiments by scientists, exploring possible uses in psychoanalysis, creative insight and in terminal disease. But note the use of LSD in an unauthorized experiment on Harvard undergraduates that included the later unibomber, Ted Kaczynski, and may have produced a localized psychosis causing him to psychotically act out his free-flowing anger by his unibombing.

Amphetamines (Adderall is the popular form) are used to stop appetite or give euphoria or stop sleep. You get the effect cheaper with caffeine without the risk of blowing out blood vessel in brain.

MethylPhenidate (Ritalin) is used in attention-deficit hyperactivity disorder (ADHD) of children. Fashion models use it to stop appetite in order to lose weight and smoke-stoppers use it. Also, it is taken to up the IQ or other test score. As an adrenaline-like drug, its psychic effect is to focus mind for task at hand, and to strengthen motivation and energy. I used MP in 2.5 mg dose up to twice a day. At high dose, MP produces toxic psychosis or hyper-manic state. Its most frequent early sign of overdose is hyper-talk. What I noted (For self experiment see in Section 4.3 Medication) at 2.5 mg dose is that MP gave a few hours of high energy, like strong coffee. But I no longer use it, because the risk of blowing out artery in brain from sudden high blood pressure is not worth the caffeine-like effect.
Opium has been used medically for thousands of years. It comes from the poppy flower. Its fruit is small berry-size and -shape with edible seed at center. Small incomplete incisions in the immature fruit allow collecting and drying of white juice, which clots and turns black. Raw material is formed into lump, cake or brick that may be powdered.
Raw opium may be brewed as drink or smoked in pipe. Early medicinal forms are laudanum (alcoholic tincture of opium) and paregoric (tincture of opium spiced with camphor) for diarrhea.
   Morphine is the active chemical in opium into which other opiates are converted in the body, and it was isolated as chemical in 1806, followed by the closely structured codeine and heroin.
   Opiate is natural opium derivative and includes morphine, codeine, heroin, hydrocodone, oxycodone.“Opioid” now dominates the language. Originally, it meant synthetic drug that gave morphine effect. Now, it is any drug that shows a morphine effect and includes natural opiate and synthetic.

  Warning Note. Because of the great controversy that has surrounded the use of opioids, there is a tremendous amount of prejudice against their use especially in the United States and even in Japan. I am writing the below with the attitude of a scientist who is both a physician and someone who has used and is using opioids successfully now at age 86. I don't ask you to believe everything I write but I do ask you to keep an open mind and not necessarily to believe the received opinion in the U.S.A against the use of opioids. 

Effect: Data come from my experiences with injecting self with morphine or with pentazocine (Talwin in U.S.A.; and Pentagin in Japan). I also used oral pentacozine (now sosegon), di-hydrocodone (same as hydrocodone, oxycodone [Perco-dan & -set]) and codeine. I find little difference among them in effect, withdrawal and tolerance. A point ignored in books is the importance of dose. Morphine is famous for its sleep. (Named for God of dreams) But this comes from observation of  high 10 mg dose when a patient is worn out by pain. Self-injecting 3-mg, I note within 2 minutes an alerting effect with high motivation to read, and it lasts an hour. Much data describing opioid effect comes from the reports of heroin addicts who overdose and are unreliable. And mention of morphine to alleviate pain emphasizes the importance of physical state in perception of effect. If one receives an opioid when wearied by pain, it is natural to fall asleep. But if one takes the same dose in non-sleep-deprived, healthy state it does not cause unpleasant sleepiness.
   Opioid tolerance is the gradually lessening effect for same dose and time schedule. Thus, a just-starting drug-user will notice the most effect and a long-time user the least. It depends on dose, and body chemistry of the user. In my many-year use of pentacozine at a daily dose level it took 5 years before the pleasure effect was lost due to tolerance.
   As a new user without any tolerance effect, 2 minutes after injecting self with morphine 3 mg, or pentazocine 15 mg, or drinking hydrocodone 2.5 mg on empty stomach, in rested state, I noted relief of anxieties (the usual back-of-mind, disturbing worries most of us have). And I noted energy and a desire to do chores. At this dose the opioid is good for reading, movie watching, or quiet thinking. Endorphin pleasure starts on same time schedule. First felt in knees, ankles or wrists, then abdomen, chest, neck and head; the deep to skin pleasure is best for 20 to 30 minutes after the dose. With continued use, tolerance develops and a similar dose gives little deep pleasure although it continues to relieve anxieties.
   Another effect is good patience to bear boredom by increasing the pleasure in solitary thinking. And, also, sought-after repose. Tolerance to this effect does not develop. Wear-off at the dose starts after 30 minutes. For a pentazocine injection, the effect may satisfactorily continue at lesser intensity for an hour.
   Concerning repose and sleep, an opioid is helpful. One experiences pleasant lie-down twilight state and the sleep is brief and at proper dose easily awakened from.
   Constipation is well known. Codeine is most; oxycodone close second. I find pentazocine causes no constipation. (If constipation is severe, digital finger removal of stool from rectum is very easy).
   User of opioid will find losing weight or keeping slim easy. Opioids do not lower appetite; rather a dose makes you feel so satisfied that you find it easy to pass up eating. But if you are motivated to eat, it increases the pleasure of eating.
   Sexual: Common knowledge states that opioids may cause impotence and decreased sexual desire. This comes from street heroin addict who takes other drugs and overdoses. My experience at moderate dose is that opioid improves orgasm pleasure and does not affect lust or erection.
   User may notice itching of forehead. It did not bother me. Also a tendency for runny nose.
  Withdrawal:  Its description is affected by observations in heroin addicts and varies from the worst – “cold turkey” with shaking, kicks, goose-bump, screaming and shouting, body ache; to the least - a mild achy, depressed state. Withdrawal is dose related. Also, it shows cross tolerance, ie, as long as one opioid continues to be taken, withdrawal from another will not occur. This is the basis of the methadone treatment.
Withdrawing, I experience several-day muscle ache worse in bed, and a longer abulia (lack of motivation). Most users are unknowingly self treating for depression, anxiety, or paranoia and when they stop medication the pre treatment neurotic symptom returns. Withdrawal severity is related to daily dose. On hydrocodone, I found weaning down to daily 5 mg (2.5 mg in double daily session) eliminated my withdrawal muscle ache and made psychological withdrawal mild, allowing caffeine to give motivation energy.
Availability:  In U.S.A., heroin is illegal and possession gets jail. Only a licensed and registered Medical Doctor with Drug Enforcement Administration (DEA) certificate can obtain and order morphine. And the doctor is under pressure to dispense or order morphine and similar opioid only for severe pain or as part of anesthesia. And must account for use in record, accessible to DEA.
   At lesser control are pentazocine, hydrocodone and under least control, codeine, which can be obtained and dispensed by licensed, certified M.D directly or by Rx (Doctor prescription) and may even be available OTC (no Rx) in cough syrups. If prescribing is excessive, records must be produced and explanation given. Easiest oral med from pharmacy via Rx with DEA number is hydrocodone and its like (Vicodin, Lortab, OxyContin). Relatively low level check is kept on the Rx drugs but every pharmacy checks a prescribing physician’s current DEA, license status and signature via computer before filling Rx.
   Opioid Addiction:  The key to addiction is difficult availability. Good analogy is to imagine if tomorrow the most popular anti-depression drug Prozac is declared illegal while other anti-depression drugs only are allowed under rigid limitation? We would create a new class of addict and criminal by removing a family of needed drugs.
   Criminalization of opioids and other drugs has consistently failed. In a nation with a more intelligent population than the U.S.A., like Switzerland or the Netherlands, opioids are legal and low cost by doctor Rx. Legalization of opioids would end gangster mob participation, markedly reduce political bribery corruption and lower all the medical complications presently seen with drug use. It would result in increased tax moneys, better social health and best society. I speak and write with authority as a physician with 25+ years of multiple opioid use and now at age 86 going strong and long, not despite using opioids but because I was lucky enough to obtain a legal, low cost supply and used the drugs according to my medical knowledge. Nonetheless, although what I am going to write is positive for my use of opioids it should be read in the context of my being a physician in Japan where opioids by prescription are not criminalized and are relatively easier to get than in the United States. I advise against using opioids in a place like the USA where it is criminalized and very hard to get legally because you will be creating a destructive addiction on yourself. (Even in a country like Japan which had a relatively relaxed attitude towards use of opioids; still, there is a strong prejudice against their use so that the situation is not so very different for the Japanese as the average American)

Pentazocine (P, trade name in USA, Talwin; in Japan, Sosegon) with which I had many-year experience, has pleasing effect at low to moderate dose (to 15 mg) but at higher dose produces dysphoria (bad feeling). This prevents overdose. Can be taken orally or injected, but its pill in U.S. has been mixed with a receptor blocker naloxone hydrochloride (TALWIN NX contains in tablet, 50 mg equivalent pentazocine base and 0.5 mg equivalent naloxone base). Purpose of the mix is to prevent drug abuser from using crushed tablet powder to get injection high. Naloxone guarantees bad injection effect for opioid addict and no opioid effect for injection user. When taken as tablet by mouth, naloxone is rapidly deactivated in stomach allowing pentazocine to have the usual oral opioid effect. Another Talwin product is compounded with aspirin (TALWIN COMPOUND) or acetaminophen (TALCEN) neither of which is mixed with naloxone. In Japan it is available as sosegon.
   Pentazocine is imperfectly absorbed by intestine, especially if mixed with food so that standard 50 mg swallowed tablet is equivalent to 15 mg SubCutaneous (SC) injection dose. But note my use of sublingual (under tongue).
   Injection Pentazocine in U.S. is produced as TALWIN Injection 10 ml multiple dose vial, 30 mg P base per ml. It is Schedule IV drug according to DEA regulation, which means it can only be obtained by state licensed, DEA certified physician.
   Pentazocine is advised as painkiller and potency is 30 to 60 mg injection equivalent to 10 mg morphine. In the mid to late 1990's I experimented by injecting myself with pentazocine up to 15 mg on max schedule of once every 24 hr. My frequency use varied from once a day for months to none in recent years. For injection I used either the Japanese pentazocine product PENTAGIN, which came as single injection ampoule at 15 mg, 0.5 ml injection or the U.S. TALWIN Injection, using 15 mg, 0.5 ml injection, allowing me 20 injections per 10 ml vial.
   Injection is SubCutaneous; into fat between skin and underlying muscle of arm, abdomen, buttock or front thigh using insulin type syringe with small diameter #29 short needle.
   My minimum rules were: Frequency never more than once a day and max dose 15 mg.
   I used the injected pentazocine for approx 1-hour session where I read, studied, wrote and watched movie for review. I did not use for pain.
   Concerning effect of pentazocine or other opioid I have used, keep in mind it is an effect of a particular dose and under particular circumstance not comparable to street drug user overdosing or patient in pain. The difference I note is due to mode of administration – injected versus oral. Both injected morphine and pentazocine have more rapid onset and more powerful peak effect compared to similar oral doses. Both show similar tolerance with continuance.
   Oral Use of Pentazocine: Since 2002, I started using 25 mg tablet of Pentagin (Now, named,  Sosegon) cut in half (12.5 mg dose) on 4-hr schedule to make my life efficient and happy after age 70. It replaced injected pentacozine and other opioid and was sufficient for my need with no constipating or other side effect. In 2006 I started cutting the pill in quarters and using the quarter-pill 6 mg dose. I note after years of use and a stable level of tolerance that the 6 to 12 mg under-the-tongue dose within 5 minutes relieves impatience and anxiety and allows a pleasant 30 minutes of thinking and rest. Time that passed boringly starts to pass more pleasantly with good thoughts shortly after I put the 6 mg dose under my tongue. Most recently I was hospitalized for an orthopedic problem and had to limit to one 25 mg a day and had no problem with withdrawal symptom. In hospital I found it useful against the boredom of enforced bed rest. Using the 25 mg pentacozine pill taken under the tongue until dissolved (5 minute interval) at maximum every 12 hours gives the most efficient 24-hour, one-pill use. Each time you take the pill you will experience 3 to 4 hours anxiety-free, paranoia-free, good thinking  that continues at lower level in the few hours after. I did not find it useful for pain although it relieves chronic pains; I took it for peace of mind and anxiety-free relaxation with good thinking. It may be used once a day to twice a day depending on stresses and mental state of each 24-hour period. In my old age and especially during my recent time in hospital bed it has been a good drug against boredom. But I still find the 1/4 cut pill (c.6 mg) most useful for use when traveling or if low supply. Recently, I had a person who never took the drug before put a quarter of a 25 mg pentagin in her mouth. She immediately strongly complained of the very bitter taste and needed a couple of glasses of water to even partly clear the taste. And at 30 minutes she still noted the moderately bitter taste and no other effect. Her increased taste acuity is probably due to her youth versus my age but her lack of response to medication effect shows the importance of individual variation. First, test a drug effect on yourself using minimal dose; do not trust book descriptions.
The present Rx for Sosegon in Japan may be renewed and repeated not more frequently than every 14 days.  For codeine, not more frequently than every 30 days.

The Stretch Effect: Several minutes after taking a dose of pentazocine, if I stretch arms above head tautly, I get pleasure directly in the stretched muscles. A sign of good endorphin effect from an opioid dose.

Conditioning by Taste:  especially with sosegon but also with other opioids, I have found that the bitter taste of the quartered pill under the tongue if used all the time, conditions me to get a good reaction to the opioid. It is like Pavlov's conditioning. Initially, the unconditioned stimulus is the sosegon's chemistry that reacts with the body to cause pleasure but quickly it gets linked with the bitter taste of the sosegon so that if one did an experiment and just took a quartered pill that look like sosegon and had a bitter taste, one would get the reaction to sosegon that I get from the chemistry. 

Codeine aka Codeine phosphate: recently I started getting prescription access to Codeine as a small package 20 mg powder. It is easy to get in Japan and inexpensive. I experimented and I found it is a study-helper but it also enhances sleepiness. A good thing about Codeine is that one can use it "surgically", ie, in a very exact fashion (20, 40, 60 mg) for short periods like one hour, that does not have strong sleepy or other bad side effect and that wears off after one hour. I found that the ideal dose-use of Codeine is to put the powder from 20 mg package under the tongue and hold it there while you think pleasant thoughts.
Oral opioids abused ignorantly are: Vicodin and Lortab [(di)hydrocodone bitartrate], oxycodone under the name Percocet, which is oxycodone with acetaminophen (APAP); it comes as – oxycodone 5 mg/APAP 325 mg, oxycodone 7.5 mg/APAP 500 mg, and oxycodone 10 mg/APAP 650 mg.  Also comes as Percodan, which is oxycodone 4.8315 mg with aspirin 325 mg per pill; and codeine (usually with aspirin or APAP). Oxycodone also comes in 7% alcoholic elixir or syrup (with guafenesin, e.g., Hycodan and other opioid cough syrup). The fluid vehicle leaves no choice but to swallow. Keep aware that many oral opioid pills have either an adult aspirin or APAP (acetaminophen; doses see above). It is not wise to take an aspirin or an APAP in the same pill with an opioid as is commonly done because it is too easy to overdose on the aspirin or the acetaminophen. If you take one or the other for pain or other reason, take as a separate aspirin or acetaminophen pill and keep the opioid as single-drug pill.

OxyContin (OxyC) Slow Release
Approved by the FDA in 1995, OxyC has risen to top sales in 2018. It comes in pill doses 80 and 160 mg and is free of Aspirin and APAP in its most popular pill. The opioid is oxycodone. Addicts crush it and make injections and overdose orally by taking too much or by absorbing it by mouth. The 80 mg dose is too high for new user to get safe recreational effect. If you prefer OxC, use a pill cutter and experiment with fractional doses of the 80 mg pill, starting with the ¼ (20 mg or one quarter pill) dose. For highest efficiency and economy, try mouth absorption rather than swallowing the pill. (Under tongue or chewing) Never inject it. You may note on the prescription-insert a warning against such mouth-absorption use because with 80 to 160 mg pill it could lead to overdose, especially in non-tolerant new opioid user. But that is due to the company making pills with excessive milligram dosage for mouth absorption and can be prevented by cutting the pill in fractions.
   As of mid 2012, an oxyContin pill or capsule was designed so that if a user tries to crush it up in order to snort or use for injection it will turn into a jelly-goo. I have no experience with it so not sure if this affects cutting the pill into halves or quarters.

Reason for Using Opioids:
I have dealt with opioid used for study or anti-depressive or anti-anxiety by giving my experience. Its use as preventive of suicide or other death fears or stage fright is based on observing the powerful anti-depression effect. A person with a deadly diagnosis of cancer or other mortal illness, by using opioid as I advise, should benefit by the enjoyable intervals --- relief of anxiety, depression, pain (add an aspirin or an acetaminophen) or paranoia during the dose interval --- as his or her life is ending. Especially in old age, opioids could be a blessing.
   Anyone who uses opioid in U.S. or where it has been criminalized or made difficult to obtain has the problem of creating an addiction due to difficulty in obtaining. Unless one has a secure source through a cooperative physician, it is best not to depend on opioids in such places (Like the U.S.A.).

For fictional treatment of my morphine experiences click the below hyperlinked chapters from, the Slim Novels 2 and 12 and read separately. Specific chapters to click on and read are below.

  • 4. (24-25) Opium Sanity
  • 4.(26-27) House of Mamka/Opium Wisdom
  • 12.(0-1) Slim Novel 12 Intro and Chapter 1
  • 12.8 The Problem Getting Morphine
  • 12.(11-13) Ali Explains - A Walk on the Wild Side
  • 12.(21-22) Bronx Wilderness with Pizza and Spaghet...
  • 12.23 Morphine Moment - Forest Primeval
  • 12.24: A Walk on the Wilderness Side
  • 12.29 Morphine in a Meadow
  • 12.33 Dear Miss - Could You Help Me to Die?
  • 12.34. Suicide Should be Painless
  • 12.36 Helping Dan Die - The Morphine Effect
  • 12.37 Ali's Alone Day
  • 12.39 Dan's Alone Day - Life at the End of Its Te...

  • End of Chapter. To read on next, now, click 4.6 Alcohol, Secrets of a Drinker Doc

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