Archives for December, 2011


The Debate Continues

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! Pills photo available from...
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More of a Painful Topic

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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Relapse in an Era of Buprenorphine

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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The Value of Psychiatry(?)

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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