man with back painThank 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.

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.