He was calm and relaxed, and could think clearly. But after several hours as the drug wore off, symptoms crept back, he re-traced the outline of his descent and by the next morning, he was again completely severed from reality. He could remember his period of lucidity but could not return to it. He was admitted to a psychiatric ward for about two weeks. He emerged moderately improved, and I told him what I had actually done.
What has stayed with me is the realization that mental pain and physical pain have the same neurochemical representation in the brain, at least for opioids, for some people. One can see how this might complicate pain management.
It is well-known that depression often co-exists with chronic pain, and can even precede it. It is equally well-known that opioid abuse accompanies many psychiatric disorders. In a June 2016 New York Times editorial (“Can opioids treat depression?”), psychiatrist Anna Fels posits that opioids may be able to treat resistant depression as well as borderline personality disorder. We believe we can differentiate “legitimate” patients seeking relief from their pain from “drug-seeking” ones trying to relieve their anguish. Sometimes, the dividing line is nonexistent and confounded by the fact that it is illegal to treat mental illness with opioids.
Our willingness to use opioids to treat chronic noncancerous pain is only a few decades old. It has been a godsend for many patients, a gateway to addiction for some, and a problem for doctors trying to do the right thing. Guidelines are vague and often not evidence-based, and law enforcement, in its desperate attempts to stanch the overuse epidemic, has sometimes prosecuted physicians inappropriately.
Our society is awash with drugs, prescription and otherwise. Marijuana exploded into the middle class in 1966; cocaine did the same in the early ’70s. This did not involve physicians (nor did nicotine and alcohol). Doctors did accelerate their opioid prescribing during the 1990s when pain became the “fifth vital sign.”
Popular on our site: Top 10 workplaces for PCPs to earn higher salaries
But attempts to stem the epidemic with tighter regulations have been unsuccessful, and heroin and fentanyl are replacing oxycodone as street drugs. New York State initiated mandatory e-prescribing, in effect since March 2016, and there has been a 6.7% dip in the number of opioid prescriptions (per New York State Health Department). But, there are still record numbers of fatal overdoses (a 60% increase in New York City in 2016, according to the Wall Street Journal), the majority of heroin and fentanyl. New York physicians are sent a printout of all controlled substances we’ve prescribed each month, to remind us we’re being monitored.