I had the same ‘love at first site’ reaction to opioids described by many people who become addicted.  My addiction began with a relatively weak opioid — codeine —but I still remember lying in bed as the effects of the substance drifted over me, easing the life-long depression that I had long accepted as ‘just how things are.’

I should make clear at this point that I do not mean to recommend that depressed people take opioids.  Unfortunately, every bit of relief that I found from opioids had to be paid back, in the form of sadness, loss, and despair.  There is some possibility that medicine will find a way to tap into the powerful mood effects of opioids at some point, but we are NOT there now.

For people who are thinking ‘I’m smart—I’ll find a way to tame the beast,’ I can only plead that you look beyond that feeling of uniqueness.  I was a pretty smart guy too. But a PhD in neurochemistry, honors in medicine, and board certification in anesthesiology offered no protection against addiction.  If anything, that advanced knowledge made me more difficult to treat.

The writer describes twelve years of sobriety, but she still feels as if something is missing.  Her situation is by no means rare;  I would guess that most recovering people feel the same way, in the weeks or months before relapse.  The standard diagnosis of her condition is a lack of ‘good recovery.’  People who work the steps would say that something is wrong with her program;  that she is not truly ‘turning things over’ (to her higher power), that she is no longer buying into her own powerlessness, or that she isn’t using her sponsor often enough.  And these things might be the case.  The Twelve Steps include a spiritual dimension that is intended, I believe, to help fill the emptiness that many addicts were filling with alcohol or drugs.

At the same time, the spiritual glow from twelve step programs is strongest, for most people, early in recovery.  It is difficult to hang onto the initial honeymoon that comes with step-based sobriety, even when working a good program.  There is also a difference between the mood effects of alcohol vs. opioids, so that the remembrance of using opioids is a more potent factor in relapse.  In other words, she may be doing everything right, and still feel lousy.  Some people recovering from opioid dependence feel as if they discovered a door that leads to happiness, only to learn, in treatment, that happiness is forever unavailable to them.

I would suggest the writer be careful about ‘euphoric recall’—the selective recall of our using days, when we filter out the worst minutes and hours, and cling to the great moments.  I wonder if that is what is going on, for example, when she recalls her relationship with her husband.  My question for her, if she were she my patient, would be whether her husband remembers things the same way;  that she was most ‘herself’ and most emotionally available during the days when she was using.

In treatment, we deal with euphoric recall by taking things ‘full circle’—i.e. remembering the relaxed feeling from pain pills, but then focusing hard to remember the rest of the story—the lying we did to protect our secrets, the paranoid feelings we had whenever our bosses called us to the office, the frantic digging through medicine drawers to avoid getting sick, and the guilt associated with spending the weekend in bed, when our son or daughter is playing soccer.

Yuck.

The writer wonders if she should consider taking opioids to treat her longstanding depression.  Specifically, she wonders if buprenorphine—a medication with unique opioid properties—would allow her to treat her depression without becoming addicted to the medication.  Buprenorphine has a ceiling effect at mu opioid receptors, such that the effects of the medication reach a peak and remain constant, no matter how high the dose is raised.

Her thoughts about treating depression with opioids deserve some consideration.  Some people experience severe depression that fails to respond to any of the medications currently on the market.  Alkermes is working on an antidepressant that contains buprenorphine and a second opioid ‘modulator’ designed to prevent physical dependence.  In a year or two we’ll see if they’ve hit a home run.

Patients on buprenorphine often tell me that they feel ‘better’ on the medication; they are less moody, less depressed, or more outgoing. I don’t know if these effects come from receptor interactions or if they are a consequence of removing the obsession to take opioids—or if that even matters.  Less moody is less moody!

Borderline PD is a very painful condition that stems from a combination of genetics and childhood experiences.  There is some stigma to the diagnosis, as people with BPD tend to be difficult to treat (something that drives doctors crazy!).  The condition is often misdiagnosed as bipolar, but the ‘mood swings’ in BPD tend to come over hours, rather than the weeks that characterize bipolar.  There is high comorbidity between BPD and additive disorders, including opioid dependence.

There are problems, though, with recommending the writer start buprenorphine.  Buprenorphine acts similar to opioid agonists in lower doses, with the same addictive potential as oxycodone or heroin. In higher doses—doses above 8 mg or 8000 micrograms per day—the ‘ceiling effect’ eliminates interest and cravings for the drug.  People taking buprenorphine develop a tolerance for the medication, and tolerance implies physical dependence and withdrawal.

If the writer were to start taking buprenorphine, she would experience potent opioid effects from the medication, including euphoria, nausea, vomiting, and respiratory depression.  These effects could be avoided by starting the medication very slowly, of course, but there would be plenty of opioid effects that would stir up those old feelings from actively using.

The flip side of tolerance, of course, is physical dependence.  If the writer decided to stop taking buprenorphine, she would experience considerable withdrawal.  Many people on buprenorphine are profoundly grateful for being ‘saved’ by the medication, but eventually wish that they could ‘get off’ the medication—something that can be very difficult to do.  I believe that starting buprenorphine makes complete sense for a person struggling to stop opioids.  But I am very reluctant to ‘give’ physical dependence on opioids to a person who doesn’t already have it.

I’m realizing that this post may go on forever, so I think I’ll stop here for now.  If I’ve stirred up further questions, please post them, and I’ll take another shot next week!

Man relaxing in bed photo available from Shutterstock.

I have been a recovering addict for 12 years. I was addicted primarily to Lortabs (active ingredient is hydrocodone) and Ultram. I was never an extreme user but I was consistently trying to modulate my feelings and feel better. I also have been battling BPD (Borderline Personality Disorder) for a very long time which appears to be my primary issue. I have been married for 17 years and let’s just say our relationship is difficult due to my inability to be present and emotionally and psychologically sound.

As with most other addicts, I distinctly remember the first opioid I took, even though I don’t remember my first sexual experience. The opioid made me feel unlike I had ever felt– like I was “normal” in a way, and happy, which was unusual for me.

Since I quit using 12 years ago I have only had a few days, yes, days, where I have truly felt good, and that was after intense work with someone for hours and hours at a time to help me get through an intense emotional roller coaster ride. I will feel “normal and happy” for a few hours or maybe a day and then I feel the despair creeping back in. I cut my thumb the other day and the first thought that I had was, I wonder if this injury will be sufficient enough to allow me a Lortab? I just never feel right without an opioid in my system.

I have been researching drugs available to help me. I have tried many different antidepressants which were never helpful. I am wondering about a small dose of Suboxone (maybe 2 mg/day) which I have read may decrease some of the problems associated with BPD. I have been reading that persons with BPD have shown to have an opioid deficit and that 40% of those with BPD are addicts.

Over the last 12 years I have only taken a handful of narcotics (not at one time!) for legitimate pain. In fact, when I was using I really used a very small amount, like an average of 2-3 Ultram/day or 2 Lortab (5mg)/day. I was able to see how I could get my use out of control so when I found out that my brother was an addict I quit using.

I have gone to therapy consistently for over 7 years, I have been involved with the 12 step community and currently attend about 3 meetings per week, I work with recovering addicts 2 days/week, I meditate every morning, I pray, I read the Bible, and I still feel like s$#@. I have trouble remembering things, I get angry and can’t seem to control the inner dialogue in my head, I dissociate… but I can function in the outside world.

My marriage is a different story. (I am) unable to feel the love. Prior to me stopping my drug habit, I felt like I was able to be more ‘myself’ within my marriage. I was more relaxed and happier. I have a fantastic husband, but most of the time I don’t care.

Do you think that a low dose Suboxone each day could help me?

This is a great letter, for a number of reasons.  The writer is operating at a high level of function;  I made no corrections of spelling or grammar, and she expresses herself in a very coherent and organized way.  At the same time, she describes constant, severe suffering. One can understand, by the end of the letter, why people with BPD sometimes cut themselves, in an attempt to focus vague emotional suffering into focus of physical pain, or to gain a sense of control over their suffering.

I invite readers to stick with me on this one.  Spend some time reading the letter, as I believe that the writer does a good job of expressing where many of my patients find themselves.  There are a number of areas to take the discussion:The increased risk of addiction for someone who feels the way the writer feels, if she were to develop a chronic pain condition such as low back pain.

Whether it is appropriate to start buprenorphine or Suboxone in a person with a low opioid tolerance.

Whether buprenorphine or Suboxone should ever be used to stabilize mood—or to reduce EMOTIONAL suffering.

Which medications are helpful for BPD?

She is off substances now, but feels like she was more ‘herself’ when she was using…. she could tolerate closeness with her husband, and thinks she was ‘happier’ then.  Now she is active in the steps.  Which is the ‘real’ her?

I will discuss these issues in the next post, and I hope you’ll watch for it.

Depressed woman photo available from Shutterstock.

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.

For example… let’s say that grandma has a problem with pain pills, taking more than what is prescribed, going to multiple doctors, going to the ER for pain pills, etc.  Her children don’t like her behavior, so they stage an intervention, to show her the problems her behavior is causing.  At the intervention, they tell her how hurt her grandchildren are by her absence at their functions, and they explain the risks of her behavior.  They set her up at a treatment center, and she is shipped off for 30 days.

She may go to all of the groups and meetings in treatment, agreeing politely in every setting that she has a serious problem, and that she really ‘gets it.’  And that would be great for the treatment center; they would collect their $30K, and everyone there would congratulate each other on how compassionate and bright they are. And later, when grandma is doing the exact thing she was doing before treatment, the counselors would put the blame on HER, acting as if SHE has a problem for not sticking to plan—even though almost all of their patients end up the same.

I used to be a bigger fan of residential treatment. But at some point I let go of the fantasy of residential treatment as the ‘gold standard’, and accepted the real numbers.  It is easy to clean a person up for a month in a closed environment.  But in regard to long-term sobriety… residential treatment rarely works.  Sorry to say something so horrible—but that emperor, sadly, has no clothes.

So back to grandma… I would expect her to go back to the same behavior after treatment. Why, after hearing from all the family, would she do that?

Because true change is very, very difficult.

Besides, she has plenty of reasons to keep things the same.  She will likely think that the problem isn’t the use of pain pills, but rather that she didn’t hide things well enough.  Or she will assume that other people simply don’t understand what it is like to be 70 years old, trying to live with pain. She used to change the smelly diapers of these kids;  what could they possibly tell her that she doesn’t know?

And the major reason she won’t change?  For her to truly realize that her behavior is a problem, she would have to endure the shame for what was going on—and shame is a very strong motivator for denial.

In treatment, the team will try to try to break through that denial and have her admit, to herself, that she has a problem.  But that type of admission is rare, and only comes out when a person is desperate—and when there is no choice but to change.

But there are other ways to manage an intervention.  It would be best if grandma herself decides, at some point, that things must change.  How does that happen?  First, everyone has to stop enabling her.  If the grandchildren are angry that grandma didn’t show up at their birthdays, they should be allowed to express that anger—and when grandma protests, she is forced to hear why people are mad.  If grandma runs into problems with the doctor or pharmacist, nobody should help her sort things out;  she is left to juggle excuses on her own.  If she needs the ER for pain pills, she drives herself—or waits for a cab.

I chose ‘grandma,’ by the way, because I wanted to present the challenge of dealing with a person who deserves sympathy.  Nobody does her a favor by keeping her miserable.  Realize, though, that we are discussing addiction here;  I’m not suggesting that people abandon loved ones struggling with painful conditions!

The doctor should prescribe medications on a tight schedule, with strict refill dates that are maintained without exception.  Doctors are sometimes afraid to let people go into withdrawal, so they order ‘a few extra pills’ to get to the next refill;  medications should be long-lasting, so that withdrawal is uncomfortable, but not dangerous.  A short period of the medication- i.e. a one-week supply—will reduce the period of withdrawal.  If a person struggles to follow limits, the prescribing period is shortened until the person CAN follow it—even to the point of 3-day prescriptions with multiple refills.  If grandma complains about the multiple trips to the pharmacy, she is told that period will be lengthened if she sticks to the schedule— and shortened if she doesn’t.

The point of all of this is to make the person with the problem feel the consequences of their problem.  Too often, everyone else is aware of the need for an intervention, because everyone else feels the consequences—everyone but the addict.  The trick is to make the consequences hit the person who has the problem—and for everyone else to get on with life, until the person with the problem is sick and tired of those consequences.

Of course, every now and then an intervention turns out to be meaningful enough to get a person’s attention, and to spur change.  But in my experience those types of outcomes—the things we see on TV and in movies—are not the norm.

Intervention photo available from Shutterstock.

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.

Some people have responded to my prior posts with the opinion that the efforts to control narcotics by the DEA and US Justice Dept, for example in the Schneider case, will lead to similar problems in this country.  Frankly, I don’t see it.  Yes, there are doctors who fear prescribing opioids, some for good reason and some for reasons that are probably illogical.  But we are far from the situation described in the NYT editorial.

And that’s a good thing.

African child photo available from Shutterstock.

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.

Ms. Reynolds even paid for a billboard adjacent to the road to the courthouse, so that jurors could see, en route, the statement “Dr. Schneider Never Killed Anyone.” Some might see the billboard as ‘free speech’, but the judge presiding over the case was not amused. At the eventual sentencing, the judge gave both Dr. Schneider and his wife over 30 years in prison, hoping that the sentences would “curtail or stop the activities of the Bozo the Clown outfit known as the Pain [Relief] Network, a ship of fools if there ever was one.”

We already have enough drama for a made for TV movie. Actually there already is one, made by Ms. Reynolds, about her ex’s struggle over finding appropriate pain treatment. The hour-long film is called ‘The Chilling Effect,’ and can be found here– along with a number of vignettes about the efforts of the Pain Relief Network.

Make that the former Pain Relief Network. Ms. Reynolds was investigated by a Grand Jury, led by the same prosecutor who led the efforts against Dr. Schneider. After years of what she considered to be ‘vindictive efforts,’ she closed down Pain Relief Network, saying that the organization’s finances ‘were in shambles.’

Within weeks of closing PRN, Ms. Reynolds lost her life in a plane crash. Piloting the plane, and also killed, was Kevin Byers– Ms. Reynold’s romantic partner and also– get this– attorney for the wife of Dr. Schneider.

Our story ends in typical, made for TV fashion, with all of the loose ends tied up. The Pain Relief Network is gone, tragically missed by some, and considered ‘good riddance’ by others. Ms. Reynolds, tireless advocate or misguided fanatic, has left this world for the next. Left behind are the story-tellers; I will provide links to both sides, so that readers can have a true, balanced perspective. From the PRN side, simply go to their former web site, and you will find links to the archives. The archives contain links to stories in a number of publications, including Slate and the NYT– places where David and Goliath stories are repeated without much challenge, particularly for the Davids.

On the other side is a woman named Marianne Skolek, writer for the Salem News online site, who has little positive to say about Ms. Reynolds and PRN. For years she has chronicled the epidemic of deaths from Oxycontin, and she has also written a number of articles about the Schneiders, Reynolds, and PRN. One of the most chilling points in a story by M. Skolek is a a list of the patients who saw Dr. Schneider and who died shortly afterward. The pattern is clear; people in sudden possession of large numbers of pain pills, who took amounts sufficient to end their lives:

The story is not quite over. The Schneiders are now appealing their convictions, claiming insufficient counsel– namely that the romantic involvement of one of their attorneys with Ms. Reynolds created a conflict that led to poor counsel. In other words, they may have asked for mercy, had Ms. Reynolds not been cheering them and their attorney to place everything on the line.

As I’ve written many times, the use of opioids for chronic pain is a complicated issue, with no clear ‘good’ or ‘bad’ side. As in most of life’s challenges, the extremes of each position appear…. extreme. Ms. Reynolds believed that the Controlled Substances Act should be repealed; I find it difficult to understand how any educated person would adopt such an approach. But the extreme opposite side leads to enough fear, in physicians, to stifle the use of narcotic pain relievers in people who truly need such relief. As for me, I keep trying to straddle the wide middle.

Suicidal woman photo available from Shutterstock.

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.

More and more physicians pay lip service to ‘addiction as a disease,’ but most do not yet treat addiction as a disease.  The comments about diabetes are ‘right on.’ One could substitute a number of diseases to demonstrate the same point.  We physicians have few illnesses that we cure; rather we manage illness over a person’s lifetime— and opioid dependence is clearly a life-long illness.

To address a couple points in the message:  the active ingredient in Suboxone, buprenorphine, has been in clinical use for over three decades, and has established a clean safety profile.  Buprenorphine has not been used at the high doses employed for treating opioid dependence for quite as long, but even that track record is significant, i.e. 8 years in this country, and longer in Europe.  Most physicians would not consider an 8-yr-old medication to be a ‘new drug!’

The situation described in the message is, in my opinion, the result of several factors.   First and foremost, the reluctance to prescribe buprenorphine is a consequence of stigma.  Doctors prescribe new antidepressants, pain relievers, blood pressure treatments, and cholesterol-lowering agents with much less concern over ‘safety.’     I wonder, frankly, if safety is the concern—or whether there is an unconscious sense that patients addicted to opioids, or to other substances, don’t deserve an ‘easy way out’ of their problem; that sitting through a miserable detox is  a more fitting ‘treatment’ than a pill that makes things better.

I come to this cynical conclusion only because the alternative—that buprenorphine is ‘dangerous’—doesn’t make sense.  The risk of any medication must be compared against the risk of not using that medication.  As the message states, we know the risk of ‘not treating’ the woman’s husband!  Similar comparisons are used to justify the use of chemotherapeutic agents that have severe toxic effects, including the risk of killing the patient.  As I’ve written in prior posts, the fatality rate from untreated opioid dependence is as high as for many cancers.  So does it make any sense to withhold buprenorphine out of safety concerns?!

There are other reasons for doctors’ reluctance to prescribe buprenorphine. Many fear they will do something wrong, and run afoul of the DEA during an audit—a process that all buprenorphine-certified prescribers are subject to.   Some doctors feel pressure from friends and family members of patients, who often blame the doctor for keeping the patient ‘stuck on Suboxone.’  Some doctors want to maintain high patient turnover in order to keep money  coming in, since practices are ‘capped’ at 100 patients per certified physician.

Finally, I think many doctors see ongoing treatment as less satisfying than a ‘cure.’  They consider residential treatment the gold standard, and buprenorphine as a less-intensive alternative.  They buy into the idea that the addict can be returned to ‘normal’—whatever that is—if he/she works at recovery hard enough.  I understand the thought, as that is the type of treatment experience that I went through.  But on the other hand, the relapse rate for opioid dependence, after residential treatment, is very high. I myself relapsed after seven years of recovery, losing my career, and almost my life.  During my years as medical director of a large residential treatment center, patients discharged as ‘successfully treated’ often became repeat customers, at least until they lost their job and health insurance.  Some of them– too many of them–died.

I won’t get into the specifics of treatment;  I’ll leave that to her husband’s doctor to work out.  But I do hope that the doctor will give some thought to whether stopping this life-saving treatment is truly in the patient’s best interest.

To the patient’s wife– I encourage you to continue as an advocate, and I hope your doctor will understand your perspective.

Worried woman photo available from Shutterstock.

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.

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.

I was in a bad car accident a couple months ago, and was lucky that my car spun around backwards before hitting the wall between lanes at 50 mph. Most of the impact was absorbed by the seat, but for a month I had frequent spasms of the muscles of my lower back. Pain went from a theoretical topic to a constant, personal enemy of everything I wanted to do. Even this description is an understatement; there was a personal, ‘hurting’ component that led to a desperate feeling– regressed, depressed, weak, and alone.

I TRY to remember those feelings now, but I think pain patients are correct when they say that people without chronic pain cannot fully understand their plight. I think the mind deliberately represses the memory of pain, perhaps in part to assure that women are willing to have a second child and propagate the species!

Before getting into my ‘on the other hand’, I want to assert that I am as sensitive to people and their feelings as anyone, and I am confident that I have my patients’ best interests at heart.  I know that, because I know how hard I work, and I know about the tears I’ve shed with patients.  I feel the need to assure readers of my compassionate nature, so that I am not attacked for what I’m about to say!

I have had patients who clearly did worse ON pain pills than they were doing OFF them.  They had pain as genuine as any other person’s pain—at least from any external vantage—and had no greater propensity to addiction than other patients.  But when they started potent opioids, they became LESS likely to attend functions, not more.  They were more comfortable, but they stopped trying to work.  Instead of going to work and telling me how hard it was, they quit work and became more comfortable—but also more disabled.  All the time, as their lives worsened by any objective measure, they told me how grateful they were for my practice…. even as I felt guilty for what was happening to them.

That last bit is the oddest thing; as their lives got worse, they thought more highly of opioid treatment. They would tell me how great it was of me, to be willing to help them.  Their lives became more one-dimensional, and spouses left.  Hobbies ceased. Depression became more and more difficult to treat.  All of these things made the pain medication even MORE important, making me even more of a ‘good doctor’ in their eyes.

I suppose the above phenomenon is what makes people so prone to falling into the hands of over-prescribing doctors.  I know about ‘doctor feel-goods’ and have always been determined to avoid THAT type of practice, so I worked very hard to prevent dose escalation.   I worked with patients to find the dose that relieved ‘enough’ of the pain, and then stayed at that dose.  I did the usual things that opioid prescribers are supposed to do—such as drug tests, avoiding early refills, and never replacing lost or stolen medications.

One interpretation of the loss of function in some people on opioids could be that the underlying condition worsened in those patients.  But I don’t buy that answer for the following reason.  In a few cases, the patients’ desperation led them to get off opioids… and in those cases, the pain didn’t worsen—it got better.  The desperation, by the way, consisted of always feeling lousy; recognizing their loss of activity and energy, recognizing their refractory depression; recognizing the miserable withdrawal that woke them from sleep each morning.

And then there were other patients who believed me when I shared the stories I just described, who tapered off opioid agonists onto buprenorphine.  In some cases, the buprenorphine alone relieved need for other narcotic pain relievers.  One person described feeling better in many ways—except in regard to her pain—and she returned to opioid agonists.  She still lives on the fence, wondering if she is better ON opioids, feeling miserable, or OFF opioids, feeling clear-headed but in pain.

The result of my experiences as a doctor treating pain has been how it should be, at least in my opinion; my treatment approach has evolved, and I believe I am at least being more honest with patients about what they should expect, if not more helpful in relieving their pain.

I welcome more comments.  I do ask that people avoid insults and comments about how lucky they are to have someone other than ME as their doctor. I’ve received enough of those types of comments during this series that I realize how angry some of you are. Instead, I ask that you try to understand what I’m saying—that for SOME people, opioids do not add to life; they subtract.  There are no easy answers on this issue.  As a teacher of medical students, my hope is for a generation of students who use knowledge and empathy in a flexible way, to find the best approach for each unique patient—rather than succumbing to dogma.

In another decade or three, I’ll likely need someone like that!

Man with back pain photo available from Shutterstock.

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. 

Where does it go?  I can’t say for sure.  But the humility needed in order to ask for help while passing through the door is suddenly replaced by the need for secrets—secrets about everything.  As soon as I relapsed, nobody could be trusted. Nobody would understand me.  I was on my own.

Contrast that with the experience of a patient on buprenorphine who recently relapsed with heroin.  I realize, of course, that I am talking about a couple people and making broad generalizations.  But I have seen examples that support theses generalizations in several cases, and the examples have consistently followed the paths that I’m about to describe.

This patient—call him ‘Paul’—told me about his relapse before I even mentioned that I would be asking for a urine test.  In fact, he was eager to tell me about his experience, as if he looked forward to getting it off his conscience.  “I have to tell you that I really screwed up last week,” he said. When I asked him what happened, he said that a friend was in town who he hadn’t seen for several months, and the friend stopped by his house.  With little warning, his friend pulled out a bag of heroin and a couple clean needles, tossing them on the table, and saying ‘let’s fire up.’

After shooting up, my patient immediately felt disappointed in himself.  Unlike in the old days, he felt nothing from the heroin.  While his old friend nodded next to him, my patient only wondered what the heck happened—and immediately wanted to talk to me about the situation.

There are programs out there that would discharge a person for relapse—and in those programs, I would not expect the same type of honesty from patients.  I don’t get the logic of such programs, and I become angry when I think about them.  As I’ve said before, if a person relapses, that person NEEDS help—not abandonment!  I believe that the proper approach to treating addiction can be found in almost all cases simply by considering opioid dependence to be another chronic illness.  And if someone with heart disease overexerts himself and comes in with chest pain, we don’t scold him and boot him from treatment!

I found it incredible that ‘Paul’ wanted to talk about his experience.  He explained how he felt when his old buddy contacted him, and we discussed ways to avoid meeting up with ‘old friends’ in the future.  He discussed the urge to escape when he saw the paraphernalia—to escape from life’s responsibilities—and we talked about how difficult it can be to simply tolerate life sometimes.  And most interesting to me, as a psychodynamic psychiatrist, he talked about a complicated set of thoughts and feelings that came up when he saw the drugs—questions about who he was, about shame, about the heavy load that comes with doing the right thing, and about the pressure of not letting people down.  Those are all big issues, I said as I agreed with him.  How much easier, at least for a few moments, to just be ‘nothing’—to have no expectations about one’s self!

We talked about the challenge of being ‘someone’– of being proud of one’s self.  It feels good to do the right thing– but it also feels bad.  Am I letting my old friends down, if I do better? I suggested that he might watch the old movie, Ordinary People, where a younger brother struggles after surviving an accident that claimed the life of his brother.

Before buprenorphine, people struggled with opioid dependence largely on their own.  Yes, we had twelve step groups—and still do—but twelve step groups place the responsibility to get one’s act together squarely on the back of the using addict.  Many people in AA or NA will say that “AA is a selfish program.”  It has to be.  When one relapses, one is left with his own distorted insight, accumulating consequences until, hopefully, he finds his way back to the pathway established by the simple program of the steps.

On buprenorphine, relapse doesn’t mean loss of insight.  Things are not always rosy;  I have had patients who got stuck in a pattern of chronic relapse that was difficult to straighten out, even though each ‘relapse’ caused little or no psychic effect from the drug being abused.  But in many cases, relapse on buprenorphine stimulates a deeper investigation of what is missing from the person’s life,and a renewed effort to gain what is missing.

This assumes, of course, that the person is not simply tossed from treatment for the relapse.  In that case, other people are left trying to figure out what happened—when the obituary appears a few months later.

Depressed man photo available from Shutterstock.

The title and  first paragraph of the article:

Generation Rx:  The Use and Abuse of Prescription Pain Medication

A generation ago, it was considered medical heresy to prescribe strong narcotics to people with chronic pain.  But, a new way of thinking about pain made it more acceptable for doctors to prescribe these drugs. Along with that came the arrival of long-acting opioids like OxyContin, Duragesic, Hydromorph Contin and others – drugs that when used as directed, were supposedly less likely than short-acting narcotics to lead to addiction.  I know, because I taught many doctors how to prescribe narcotics responsibly.  And in the interests of full disclosure, some of those lectures were paid for by the very drug companies that stood to make large profits from the sale of the medication. 

The podcast can be downloaded in mp3 format by clicking here.

A second article, about the role of doctors in creating the epidemic, can be found here.

Thank you to everyone for your comments– and as always, I encourage you to keep them civil.  This topic engenders a great deal of anger in some people, but posts that do nothing but insult other people will be removed.

Doctor and prescription photo available from Shutterstock.