Opiates, Pain and Integration

(A 2016 piece about pain, from my final sojourn as Medical Director in Bucksport.)

We are witnessing a strange migration of restless tribes, moving between doctors and clinics, traveling great distances in search of what no one wants to give them anymore.

This eerie movement is steadily gaining momentum in our community, in our state and across the country. We can hear it in telephone calls, we can read it in records of patients looking to switch their care, and we can see it in the eyes of the hopefuls who hobble through our doors, looking for a doctor who will contradict their previous provider and reinstate the status quo: a steady supply of opioids for their pain.

The CDC has made new recommendations for opiate dosing and monitoring, and our state is legislating finite opioid dosing limits. Colleagues everywhere are tapering doses, scouring new and existing patients’ prescription monitoring reports, and aggressively enforcing their opioid contracts by doing more urine drug screens and pill counts than in the past.

Last week, two new patients no-showed for their first appointment after the intake nurse called them to make sure they were aware of our prescription policies. Yesterday, a new patient I sent home the day before to bring me her most recent oxycodone pill bottle called back saying it was empty. It shouldn’t have been. I offered to take care of her other medical needs but I let her know I would not be prescribing narcotics for her. I doubt she’ll be making the 45 minute trip again.

Most of the people I see looking for a new source of pain medications are of the baby boomer generation, grandparents and even retirees, and have been diagnosed with lumbar disc disease. Many carry the diagnosis of fibromyalgia, and almost all of them report symptoms of depression, anxiety and PTSD.

I also see a surprising number of adults with a diagnosis of attention deficit disorder, who have been cut off their prescribed stimulant medications. They were diagnosed as middle aged adults, not during their school years.

Most of these medical migrants seem to be singularly focused on finding a source for the prescriptions they have relied on for many years. Only a few, like the grandmotherly sixty eight year old woman I saw yesterday, say they want to manage their chronic pain and are willing to hear what options I can offer them. This woman had a large hole in her nasal septum from snorting cocaine decades earlier.

This particular woman told me that a month after she was cut off from her opioids, she actually had a three or four week stretch when she hardly felt any pain at all. Then, gradually, her pain returned. She didn’t have any idea of what made it go away and then return.

I told her she had just experienced the power of her own mind over the vicious cycle of sensory input and faulty interpretation of its significance. She eagerly accepted my offer to enroll in our pain management program that day.

She is one of the few new or prospective patients I have met lately who told me she wanted to experience less pain, rather than get a certain prescription.

Pain is a mysterious phenomenon. Our four session pain program, offered individually and not in groups, helps patients understand how pain perceptions work, and gives them a sense of control they never had before. Many participants voluntarily reduce their dose of pain medications after attending, and a large proportion of those on low doses get off them completely.

I introduce the basic idea behind the classes by telling my patients about an old Boy Scout trick:

Sitting by the campfire, you put a branding iron in with the embers and watch it get glowing hot. Then you blindfold the newest member of the troop and expose his arm. While you place the branding iron on a slab of bacon, making it smoke and sizzle, you touch the person’s bare arm with a smuggled-in Popsicle.

What sensation does the poor newcomer experience? Cold or heat?

The answer is intense heat, 99% of the time.

Pain exists in the brain, where noxious stimuli from our bodies are given meaning. The idea, and it is a vey powerful one, is that we can learn to change our interpretation of our own noxious stimuli. They are only nerve signals. Our minds, through our past experiences and because of our expectations, can change their character, intensity and significance.

Opioids do nothing to our aching backs, knees or feet; they just create a certain level of more or less modest euphoria that helps us reframe the meaning of unwanted nerve signals from our arthritic joints.

And now the pendulum is gaining momentum in its swing from one extreme to the other: Pain isn’t a vital sign anymore. Opioids aren’t safe anymore. They’re hardly ever indicated anymore. But we can’t just stop them without offering something else. We can offer an empowering understanding of how pain works, and we can help reduce the broader suffering that we used to speak of only in terms of physical pain.

50% of our patients who have completed the pain sessions have asked to continue seeing their behavioral health professional to work on other issues.

By speaking of pain matter-of-factly, we create a platform for also dealing with other kinds of suffering.

This is true integration of behavioral and primary care.