Sunday, June 12, 2016

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.