Eyes Open in Pain Control and Avoiding Relapse

 I commend to you the first-person account of journalist/science writer Seth Mnookin in the June 9 edition of the Boston Globe, in which he recounts his experience of coming very close to opioid relapse in the course of his recent emergency treatment for kidney stones and the accompanying excruciating pain.

Mr. Mnookin handled the situation as recovering people are advised to do – he told his care providers repeatedly of his addiction (which had been in remission for over 15 years) to opioids, and arranged for his wife to hold and dole out his pills.  He was receiving treatment from Mass General, a renowned and Harvard-affiliated hospital among whose services are an addiction clinic (at which I was on staff way back around 1980) and Addiction Consult Teams to attend to patients across treatment units.  Yet, as his pain persisted because of complications/infection following surgery, he was given prescriptions for more and more painkillers, and was feeling worse and worse – eventually, he realized that much of his discomfort was caused by opioid withdrawal symptoms – his physical addiction had returned after all those years, despite the fact that he had only followed doctor’s orders (including those from a surgeon who had not noticed the addiction alert posted prominently on his medical chart).  At that point, he declined a further prescription that was offered.

For many years, surgeons and other physicians railed against the addiction worrywarts such as myself who expressed alarm at how readily addictive painkillers have been prescribed.  Supported by cherry-picked research information provided largely by pharmaceutical companies, they were damned if they were going to allow their patients to endure pain unnecessarily.  Painkillers have been offered to me personally at most ER visits, usually for very annoying but far from intolerable pain, and many

times by dentists after root canals and such (don’t get me started on how many hours I’ve logged in the dentist’s chair).  Over 30 years ago, after I wrenched my back and could barely stand up, I was introduced to Percodan (the predecessor to Percocet), probably in too high a dosage, and loved it so much, felt so happy with life, that I knew (because I was already doing addiction related work) that I’d better avoid it from then on, and that if I were to become addicted to something, opioids would be my drug of choice.  Even without a history of previous substance abuse (my interest in the field, dating back to college, was originally motivated by growing up in an alcoholic household), I was at risk.    Many times over the years, I have asked doctors and dentists why they showed so little caution in prescribing these medications.  Until the middle and upper class opioid epidemic of the last few years, and the publicity about all the overdoses, my comments generally elicited a kind of dismissive laugh. 

Of course, opioid medication is a godsend when necessary – some patients would probably not survive without it – but prescribers and patients alike need to reckon continuously with the relative risks and dangers of overwhelming pain on the one hand, and serious addiction on the other.  Quite often, a combination of non-addictive medications such as acetaminophen and ibuprofen can do a surprisingly good job of making pain manageable.  When it is insufficient, use of opioid painkillers should be kept to workable minimum, with eyes open to the emergence of withdrawal symptoms and/or craving even in individuals who have been in recovery for years.  

Treatment and abstinence can arrest addiction, but once the brain has been changed by repeated, addictive substance use, it is as if addictive brain circuits are dormant, but not erased – they can be reawakened.  I should also mention that there is a certain transferability to this awakening – for example, countless times I have heard from alcoholic individuals that using prescribed painkillers was followed within days or weeks by a relapse to alcohol, their substance of choice.  Be careful out there.

Is Rehab Back, for the Non-Wealthy?

Prior to the large scale entry of managed care into health care coverage (yes, I’ve been around long enough to remember), mental health/substance abuse professionals regularly referred actively alcoholic/addicted individuals to rehab.  In fact, the term “treatment” used to imply rehab, meaning typically a month-long program, often in a very nice setting.  In those days, insurance covered rehab routinely.   

Suddenly, with the advent of mental health managed care (which happened to come in most aggressively to Massachusetts, a high-utilization state), suddenly (a) most patient could not be approved for any kind of inpatient treatment and (b) inpatient care for those with addictions was usually limited to detoxification (less than a week, and only applicable to those subject to withdrawal symptoms).  As a result, the two most highly regarded rehabs at the time in New England (Spofford Hall in New Hampshire and Edgehill Newport in Rhode Island) both folded.  Those facilities that survived received much reduced daily insurance payments, and were not able to maintain the same quality of care and were not sustained in the same physical/aesthetic condition. 

I became accustomed, for over 2 decades, to telling families that their alcoholic/addicted members could only go to rehab if they had significant funds (and of course with no guarantee of success, since alcoholism/addiction is a condition prone to relapse).  Instead, they could get detox, if physically indicated, at times followed by 2 or 3 weeks at an outpatient day program.  (A couple of such programs provide basic lodging at a nominal fee and can be called “residential”, but do not offer the kind of 24-hour care available at a rehab – because insurance is paying mainly or solely for the day program at a fraction of the cost of inpatient treatment.) 

Although I have missed the days when people without a lot of money could be advised to “go to rehab,” I do understand the reasons why these changes came along.  Health care as a whole has become insanely expensive (largely because of technology in physical health treatment), and behavioral health treatment was the easiest to cut because it is so much less tangible than, for example, treatment for pneumonia.  In addition, at least half of those who were routinely referred to rehab had a good chance of doing well with a less expensive level of care.  (Not to mention self-help groups, a key resource that’s free!).  But in some cases, especially where less intensive interventions have resulted in frequent and repeated relapses, it became painfully obvious that the rich got better treatment.  Rehab costs range from something like $20,000 to over $60,000 for a month.   

But there seems to be some good news on the rehab front.  I have received no announcements from health insurance companies about any changes in coverage, but over the past year patients have begun to report to me that they managed to get covered for a month in rehab (typically in Florida), suggesting that their Massachusetts based managed care companies had developed contracts (meaning hefty discounts) with certain facilities.  Even more recently, a marketing representative from a new detox/rehab in Massachusetts itself told me that they have been able to serve patients covered by PPO or POS plans.  (In these plans, the patient usually has a deductible, after which insurance pays something like 80% -- but that’s much more than zero.)   

Why is this happening?  I can only guess.  Certainly, there has been increasing publicity about the impact of addictions, and it has become one of our governor’s prime issues as increasing numbers of individual die of overdoses.  (Suddenly managed care companies that used to allow me about 8 authorized outpatient visits at a time are authorizing many more, if the diagnosis is alcohol/drug related.)    So, to those of you whom I myself may have discouraged with regard to how much treatment you could get: don’t give up.  Call your health insurance provider and, if rehab is needed, try to get them to cover it.  And please email me to let me know how it goes, and if they covered a facility that was truly helpful.  The individuals and families I see need to know.