A recent question from a reader:

Do you believe in intervention of someone who does not ask or desire (to be clean)?

It is hard to predict human behavior; sometimes people rise to the occasion when all appears to be lost, and other times people who have everything going their way make surprisingly poor decisions.  But in my experience, real sobriety requires the addict to feel a profound need to change that comes from within.

That doesn’t mean, necessarily, that interventions never work—but the intervention should be set up in such a way that the addict or alcoholic—him or herself– comes to the realization that getting clean is the only option.

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A reader sent a link to a recent NYT editorial about the lack of pain medications in some countries.  The writer of the editorial injured his leg while traveling in Africa, and was dismayed to find that opioid pain medications were in limited supply, with only enough for patients admitted to the hospital.

The writer went on to describe a number of developing countries where pain medications are in short supply, and in some cases totally unavailable.  He described hospitals and clinics where he was visited, where patients await treatment for horrible injuries without so much as a tablet of Tylenol.

I don’t want to rewrite the editorial, and I cannot copy it, for obvious copyright reasons– so you’ll have to follow the link.  The story mentions the efforts of a group called ‘GAPRI’, for Global Access to Pain Relief, that tries to reduce barriers to effect pain relief measures in developing countries.

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Wow. I just read an email about a story that I was vaguely aware of– about a doctor in Kansas and his wife, who were together linked to scores of overdose deaths. But that is just the beginning. The doctor was supported, during his trial, by Siobhan Reynolds, founder of a nonprofit advocacy group called ‘Pain Relief Network.’ She started the group back in 2003, when her ex-husband was suffering from severe pain from a congenital connective tissue disorder.

He (the ex-husband) found relief in combinations of high-dose opioids and benzodiazepines, at least until his doctor, Virginia pain specialist William Hurwitz, was convicted on 16 counts of drug trafficking. The ex died, by the way, in 2006. Are you still with me?

The trial of the Kansas doctor, Stephen Schneider, went on for years. During the trial, Ms. Reynolds apparently helped support what she considered to be a ‘dream team’ of attorneys. She used the case as an opportunity to increase her visibility, encouraging the Schneiders to aggressively fight the charges against them on the basis of ‘patient rights.’ Ms. Reynolds, through the Schneiders, argued that suffering patients are being denied appropriate care because of a war, waged by overly-aggressive prosecutors, against doctors who prescribe pain medication.

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Below is an e-mail that I changed just enough to hide the person’s identity.  Every week, I receive messages that describe similar situations.

My husband has struggled GREATLY with substance abuse since in his 20′s; he is now in his mid-40′s. He is the kindest sweetest man and he is the BEST husband and father. When he is using he becomes someone he is not. We have run the gamut from jail to overdose.  Six years ago a friend introduced him to Suboxone and it LITERALLY gave him his life back. He bought it off the friend for years, where it was very expensive. Finally I brought him to a doctor a bit over a year ago. She is pretty adamant about weaning him off of Suboxone.

From experience, I know that 2-3 months after he stops Suboxone he will relapse. I strongly believe it IS a MIRACLE drug! I agree in the sense that if a diabetic needs insulin to save his life, you give it for a lifetime. My husband over the last 6 years has been the man of my dreams, the man I always knew he was. I have extreme anxiety because I know this doctor is just doing her job and trying to follow guidelines however my husband’s LIFE is at stake!  It’s not like if he stops this med he could ‘just’ have depression;  he could end up in jail, or worse. He has his life back. He is enjoying his family life as he should.

If this is what it takes for him to live a normal life then why not?  When we ask his doctor about staying on Suboxone, she says her concern is that we don’t know the long-term effects. She doesn’t want to keep anyone on any med without knowing what it could do. She says it hasn’t been on the market long enough. 

My husband had a SEVERE opioid addiction. He was taking 10-15 Oxycontin 80mgs a day and then ended up switching to 400mgs of methadone before he switched to Suboxone. He has found that he is comfortable with 4 of the 8mg pills per day. I believe it is because he was used to taking such high doses of opioids. He has tried really hard to decrease Suboxone for his doctor but I see the anxiety build in him. She says no one in her practice is on that dose. To be honest he was taking more when he was buying them from a friend but brought himself to a stable 4 pills per day when he started with the doctor. He and I both REALLY like her and would like to continue treatment with her. I wish I had a DVD of little clips of our life from before and after Suboxone. I am positive she would be floored. I am positive she would understand my concern. In my eyes my husband is back. He is such a beautiful soul and I hate to see that taken away from him yet again.

Doctor I read up at the top of this blog that you agree with a lifetime use. He currently has no noted side effects. Do you have any suggestions that I may present to his doctor? I dream of the day that she says it is alright for him to continue on this until maybe he chooses to wean if he so chooses to do so. That would alleviate SO MUCH stress on both of us. Please let me know what you think.

Anyone who reads this blog knows that I agree with most of the opinions expressed in the email.  I know how horrible things are for active opioid addicts—and for the families of active opioid addicts.

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I’ve described the ongoing debate over use of opioids for chronic pain, and shared information about a group of physicians who are attempting to reduce the damage caused by careless over-prescribing.  Their attempts have created some backlash, as described here.

Feel free to comment in response — here or there, or both!

http://seattletimes.nwsource.com/html/localnews/2012873602_drugs12m.html

Pills photo available from Shutterstock.

Thank you for your comments about my post about treating chronic pain with opioids.  I was in the middle of adding a response to one of the comments this morning, when I decided to elevate my response to a post of its own. Starting a new post might, I hope, keep the discussion going… and besides, I was struggling to find a stopping point!

Here are highlights from the comment I was responding to this morning:

My aunt can attend family functions and be active in her children’s lives WITH the medication. Before she was put on methadone she couldn’t function at all and just lied in bed wanting to commit suicide… I definitely don’t think function is improved by withholding pain medication… I have experienced pain and… I know that when I’m in pain I don’t function well but if I take something for that pain I do. I had a bad headache earlier today and all I wanted to do was to lie on the couch… I think it would be extremely cruel for a doctor to not give me medication that would relieve that pain… Isn’t it as much worth to give opiates to pain patients to save their lives as it is to give them to addicts to save theirs?

One thing I’ve noticed, as a 50-something doc, is that it is one thing to talk about pain, and something else to experience pain.  I’ve had thoughts on occasion that the injury I’m suffering at a given time is there, in part, to remind me of what it is like for my patients–who generally are much worse off.

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A recent experience with a patient helped me realize the dramatic difference in the treatment of opioid dependence, in an era of buprenorphine.

I randomly drug-test for a wide range of substances.  I don’t test because of a lack of trust for patients;  I test because before the era of buprenorphine, insight—a more fundamental character trait than honesty– would rapidly change after relapse.  Almost immediately after the onset of an opioid high, the people using lost insight into the big picture and saw only what needed to be done right then—to cover up evidence of the relapse and avoid experiencing whatever shame-inducing consequences would likely come their way.

I was one of those people who experienced that rapid loss of insight after my relapse, back in 2000. For years I had attended AA and NA, attending hundreds if not thousands of meetings over seven years.  I remember comforting myself that ‘if I ever get off track, at least I now know where the door is to get back.’  I didn’t realize that at the instant one relapses, that door becomes nowhere to be found. 

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I have asked for permission to repost an article from the web site of CBC Radio, and I’m waiting for their answer.  In the meantime, I’ll provide a link to the article, along with a teaser.  The article also refers to a podcast of a Town Hall event featuring Dr. Andrea Furlan, a pain specialist from Toronto, Christine Bois from the Centre for Addiction and Mental Health (Canada), and Detective Shawn White, an expert in opioid diversion in Eastern Ontario.

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As a solo-practice psychiatrist, I am more connected to the cost/value equation of my services than the typical system-employed physician.  I’ve also written in prior posts about my concerns with modern psychiatry.  I have worked in a variety of settings over the course of my career, and I realize that coming to an understanding of something as complicated as another person’s subjective life experience is a very difficult endeavor.

At the very least, such an understanding takes time.  It also takes a willingness to maintain the constant recognition that my perception may be wrong, and may be the result of my own bias.  Finally, it takes a certain amount of intelligence.  Over time, certain patterns of thought become apparent and easier to recognize– but these patterns are extremely complex, and trying to provide insight into such patterns, without causing a person to take offense, requires intelligence, patience, and tact.

I have come to the realization (a somewhat surprising realization, frankly) that psychiatry works, when practiced properly.  I’ve come to realize that the ten-minute med check is worse than worthless, as a ten-minute glimpse of a person’s day is more likely to lead to the prescribing of a harmful medication than a helpful one.

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Just a quick note– A group of researchers from Boston University School of Medicine weigh in on the issue of opioid prescribing in an online editorial available through this link.  The editorial appears in the Journal of General Internal Medicine, and I do not know how long the link will be active.  All such articles are copyright-protected, keeping me from posting them here– but the link operational for non-subscribers, at least for now.

In short, the editorial calls for several measures for patients prescribed chronic opioids, including monitoring for abuse, greater education, and creation of databases to prevent over-prescribing, doctor shopping, etc.

Thank you to everyone who chimed in with opinions about the PROP letter.  I shared the comments with the people at PROP, and those who read the comments saw an interesting exchange between the a couple of physicians from that group and a physician from pain-topics.org.  Hopefully the letter and comments– along with the other articles I’ve highlighted– will help provide an understanding of the current debate over using opioids for chronic pain.

Backache photo available from Shutterstock.