The Tolerance Problem
In my last post I described two common story lines in news columns about opioid dependence; the doctor-shopping pain pill addict and the pill-pushing physician. I described how the truth is more complicated than news articles often suggest. Doctor-shopping pain patients are in many cases people seeking relief for pain that they consider genuine, and it may be presumptuous for someone else to decide that their pain does not warrant treatment. And pill-pushing doctors, at least in some cases, may be the only doctors in a particular area willing to prescribe pain medication for those who truly need them; the doctors unable to turn away suffering patients, even to protect their own reputations and licenses.
Another scenario involving pain medication does not fall under either of the above categories; patients with severe, chronic, nonmalignant pain.
This issue receives relatively little press given the number of people involved and the extent of their suffering, probably because people in this situation struggle to get through each day, and have no extra energy or resources to lobby for sympathy. I will discuss one such patient, Tom, who has given me permission to write publicly in hopes that doing so will attract a solution that to date I have been unable to find.
Tom is a 45-year-old man who suffered severe trauma to his right arm ten years ago during a snowmobile accident. The accident caused the bundle of nerves that pass from the neck to the arm to be literally torn away from his spinal cord, leaving him with severe phantom limb pain of his dominant arm. For the past ten years time has experienced constant, dull, aching pain, and intermittent waves of sharper pain that feels like thousands of electrified needles piercing his arm.
During our appointments he holds his arm as if it were a baby, now and then doubling over and grimacing through the sharper spasms as tears roll down his cheeks. Over the years since the injury he’s been treated by a number of physicians following the pattern that I described with the fictional back pain patient; he was prescribed ever-increasing amounts of pain medication to keep up with ever-rising tolerance, until the prescribing physician discharged him for fear of getting into trouble for over-prescribing.
After each discharge, Tom went through one or two months of debilitating withdrawal, before eventually finding a doctor willing to prescribe pain medication and repeat the cycle.
I began treating Tom about two years ago. We initially tried to manage the pain using buprenorphine, a unique opioid medication that causes limited tolerance but also provides limited pain relief. We eventually changed to more potent opioids. We have tried a number of non-narcotic medications without significant benefit. He has even had a brain stimulator implanted, that despite multiple manipulations was not helpful and so now sits quietly in his brain, the power turned off.
As with so many other patients, the critical discovery that Tom awaits is a means to prevent tolerance to pain medications. It is tolerance that continuously pushes pain relief just out of reach. I would like nothing more than to provide him with enough pain medication to get through the day without crying out from his pain. But at the age of 45, Tom will likely be around for several more decades. If I increase his pain medication each year, he will end up at a point where no amount of narcotic will relieve his pain, requiring huge doses just to avoid withdrawal.
I have several patients with equally painful conditions who are equally at a loss for answers. More and more doctors opt out of this situation altogether by telling patients “I’m sorry, I don’t prescribe pain pills.”
How bizarre that medicine has progressed to robotic surgeries and other advanced technologies, or that medical science has yielded plastic surgical techniques that change the shape or appearance of a healthy body for the sake of vanity, at the very same time when some doctors see need, and find rationalization for, avoiding treatment of the purest form of human suffering.
Junig, J. (2010). The Tolerance Problem. Psych Central. Retrieved on April 25, 2015, from http://blogs.psychcentral.com/epidemic-addiction/2010/09/the-tolerance-problem/