I’ve been writing about my own progression from a person who seemed—at least on the outside—to‘have it all’ to a person struggling with opioid dependence.  There are so many aspects of the disease of opioid dependence that I hope to share through this blog.

I plan to describe the way I changed in response to becoming addicted to opioids—in ways that are virtually universal between all opioid addicts.  I will write about the different treatments for opioid dependence and for addiction in general, and describe how the newer treatments clash with traditional treatment approaches.  I’ll write about the current epidemic of addiction to pain pills that has resulted in a great many deaths of young people; a fatal epidemic that has killed multiples of those killed by more ‘mainstream’ epidemics like swine flu, yet continues to fly under the radar.

I’ll write about the approaches that are currently being discussed within the FDA and other governmental agencies to try to stem the epidemic; measures that will likely have significant effects on most physicians and on patients who struggle with pain disorders.

How is that for a teaser?! Today, though, I’d like to describe a pattern that I have heard described literally hundreds of times over the past few years; a pattern of opioid use that captured many of the addicts I eventually treated in my practice.  In earlier posts I described how my own problems developed from a series of small yet consequential bad choices, including self-medicating with cough medicine that belonged to a family member.  Most people who become addicted to opioids don’t do it by themselves—they are helped along by their physician.

As someone who has treated over 500 opioid addicts over the past few years, I am very familiar with a pattern that starts when a person strains his back, and goes to his primary care physician for help.  I cannot speak for all doctors, but I have worked in several states and regions of the US, in a range of practices and in several specialties (critical care, anesthesiology, psychiatry, chronic pain, ER’s, and OR’s).   I have heard countless doctors discuss the uncomfortable feelings that come up when dealing with this common type of patient-encounter.    I recognize, by the way, that I am over-generalizing in order to make a point.

Doctors generally want to ease the patient’s pain, but instead of feeling helpful, they end up feeling trapped by a no-win situation.  On one hand they know the dangers of prescribing narcotic pain medications.  There is always a risk of addiction, in spite of well-publicized but hard to believe studies that show low risk of addiction in patients who are prescribed pain medications.  Doctors know that there is little or no therapeutic benefit to pain pills for people with back pain, and that pain pills may mask pain and allow for greater injury.

Doctors fear that something they prescribe will be diverted and used illicitly, or that prescribing too often will cause problems with the Board or the DEA.   All of these considerations suggest that the doctor avoid prescribing narcotic pain medications.

But on the other hand, doctors know that the patient is expecting something for pain.  The doctor is anticipating an uncomfortable dynamic where the patient will be disappointed and angered by what he will or won’t receive from the physician.  The doctor does not have time for a long discussion, and besides, doctors were often the nerds in college who didn’t like confrontation.

They are not thrilled with arguing over medication with patients who may be bigger and stronger than they are!  And of course, the doctor wants to help; that is why the doctor went to medical school.  Saying ‘no’ to a person in pain is not an easy or pleasant thing to do.

In response to this dynamic the doctor makes a deal with him/herself; give the patient a little less than the patient wants, caution the patient about over-use of pain pills, and send the patient on his way.  Most doctors are very uncomfortable sending a patient out empty-handed, especially if the patient paid out of pocket for the appointment.  But giving a little less than indicated helps the doctor feel in control of the situation, and helps the doctor feel like society (and the doctor’s medical license) has been sufficiently protected.

In the next installment I’ll describe what often goes wrong.