The opioid pain paradox

I was recently discussing the complexities of opioid management of chronic pain with a medical student, when I recalled the following story:

Well over 30 years ago, a friend of mine-a fellow I grew up with-was in the throes of a nervous breakdown. While this is not a term indexed in many psychiatric texts, it was a painfully accurate description of his circumstances.

 

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He had made, perhaps hastily, a life decision that he had become uncomfortable with and the deterioration began. A bit hypochondriacal by nature, he began with physical symptoms. As I was his doctor as well, I became involved.

Robert Bobrow, MD

Over several months, his ailments multiplied until they overwhelmed him, and he became delusional as to their etiology. Although he had medical knowledge (he was a licensed physician’s assistant), he believed he had neurosyphilis destroying his nervous system and that he was having myocardial infarctions in rapid succession. Although he did not believe his symptoms were psychological, he had reached the juncture where admission to a psychiatric in-patient service was imminent and inevitable.

Holding a thread of hope that I could somehow thwart his decline and keep him out of the hospital, I decided to give him a shot of meperidine (Demerol-popular at the time), wondering if it might somehow render him susceptible to reason. This was the early 1980s and opioids were not yet being used for chronic noncancerous pain, nor were they the societal mega-scourge that they are today.

I doubt I’d have tried to do this within the current zeitgeist.

His dad, whom I had also known since my childhood, brought him to my office. He knew, and consented to, what I was about to do. I told my friend I was going to do a lumbar puncture to relieve pressure on his brain, and in his condition, he was eager to have this done. I put him on his side, knees up, as if to do an LP, pinched the skin over his lumbar spine, and give him 50 mg subcutaneously.

 

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Within minutes, his illness started to abate, and within half an hour, it had completely remitted. He was lucid, his old self. He could see the delusions for what they were, and found it absurd that he could have had neurosyphilis or a fusillade of infarctions.

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