The opioid pain paradox

July 10, 2017

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

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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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.

 

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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.”

 

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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.

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Harm reduction via opioid agonist substitution therapy, decriminalization (as in Portugal), or supervised injection facilities has been a measurable reality. Yet more money is spent on enforcement despite its failures. People tend to self-medicate, and depending on their varied brain chemistries, have turned to alcohol, stimulants and opioids, even food, just to feel “normal.”

 

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The specific opioid antagonist naltrexone is used to treat alcohol addiction and is a component of a diet pill (Contrave), suggesting multiple pathways to opioid receptor activation. To be free of pain, emotional and physical, has become the Holy Grail of our culture, and doctors have been conscripted to join the search.

My friend, now in his late 60s, is currently doing well. He has intermittently been prescribed antidepressants, and had one more short psychiatric admission years later, precipitated by the stress of his wife’s losing battle with breast cancer. He had a brief flirtation with opioids when he found they could calm him down, but quickly realized the folly of this, and desisted. He is to this day grateful that I tried so desperately to keep him out of the hospital those many years ago.

My medical student seemed quietly upset. She will likely not look to treat chronic, opioid-requiring pain patients, and will refuse their care or refer them out, as so many of us feel compelled to do.