Between Pain and Addiction

October 1, 2007

All of us have heard the phrase "between a rock and a hard place," and many of us have been in the situation that the idiom describes. However, few of us (other than English professors) likely know the origin of the saying and even fewer of us know how it applies to clinical psychiatry. Delving into these seemingly unrelated queries will be the subject of this month's column.

All of us have heard the phrase "between a rock and a hard place," and many of us have been in the situation that the idiom describes. However, few of us (other than English professors) likely know the origin of the saying and even fewer of us know how it applies to clinical psychiatry. Delving into these seemingly unrelated queries will be the subject of this month's column.

Between a rock and hard place refers to a quandary or dilemma in which one must choose between two equally difficult, unpleasant, or unacceptable options. Most lexicographers trace the phrase back to Homer's Odyssey, which portrays Odysseus attempting to sail through a narrow passage in the Strait of Messina with a 6-headed monster on a rock (Scylla) on one side of the strait and another whirlpool-causing sea monster (Charybdis) on the other.1 Hence the more cultured version of our saying, "caught between Scylla and Charybdis."2 The ancient expression, even more than the modern, captures the feeling experienced by many psychiatrists and other physicians struggling to treat chronic pain and prevent addiction in the midst of a flood of mixed messages from government, professional organizations, and the media. In this essay, I will use the metaphor of Scylla, the dog-headed beast, to represent the problem of chronic pain which "devours lives" and Charybdis, the sea-spouting mouth, to symbolize addiction that "sucks humans down," to explore this ever more pressing ethical conflict.

Case 1: Scylla

Ms L is a former practical nurse who has chronic low back pain with radiculopathy-the result of motor vehicle and work-related accidents. Her pain has been relatively well controlled on moderately high doses of sustained-release oxycodone (OxyContin) for maintenance, short-acting oxycodone for breakthrough pain, and periodic corticosteroid injections during pain flares. Psychiatrically, Ms L has chronic posttraumatic stress disorder and associated depression from childhood sexual abuse. Ms L manages all her own activities of daily living, makes jewelry to supplement her pension, and volunteers for several organizations. She has no history of substance abuse and there is no documentation of aberrant behavior, such as early refills or visits to the emergency department on weekends. Ms L regularly attends physical therapy, pain group, individual counseling, and medical and psychiatric appointments. Recently, Ms L attempted to obtain her routine refill of narcotics. She was told by nursing staff that her primary care provider had changed and the new physician indicated he "would not prescribe such high doses of opioids and would begin tapering her immediately." While distraught over being forced into withdrawal, Ms L was even more indignant over feeling she was being labeled as a "drug addict."

In 2001, the Joint Commission on Accreditation of Healthcare Organizations implemented pain treatment standards that hospitals must meet for accreditation. A Veterans Health Administration directive, issued in 2003, described the assessment of pain as the "5th vital sign."3 Yet cases such as Ms L's are more the expectation in general medical and psychiatric care than the exception. An extensive survey, Chronic Pain in America: Roadblocks to Relief,4 reported that 9% of the US population suffers from moderate to severe chronic pain, a third of whom said that their pain is the "worst imaginable." Over two thirds have lived with this pain for more than 5 years and just over half-mostly those with moderate pain-feel their pain is under control. Many of these patients could not find a physician willing or able to manage their pain, with one fourth having changed physicians 3 times since onset of pain. The major reasons for switching doctors underscore aspects of the dilemma: the physician failed to take pain seriously, was unwilling to treat aggressively or lacked knowledge about pain, and most importantly, the pain was not sufficiently relieved.4 There is considerable evidence that women, minorities, and patients with mental illness, particularly those with substance abuse and co-occurring chronic pain, receive even poorer quality of care.5

Many factors, including lack of education and confidence, problems with health care access, pharmacy regulations, and cultural views, among others, contribute to the undertreatment of chronic pain, but it is the internal dispositions that underlie physician diffidence or refusal to treat chronic pain, at least with opioids, that are of most interest and least discussed.6 Some of these are relatively noble and clearly fall under the fundamental ethic to "do no harm," such as the genuine desire not to be responsible for iatrogenic addiction, reawakening a sleeping giant of past dependence, or facilitating illness behavior. Other motivations also appear to be realistic, such as the fear of professional censure or criminal action; certainly, some recent government actions and sensational press coverage promote these apprehensions.7

A 2000 study of the New York Medical Society found that 60% of the 1320 respondents were concerned about being investigated if they used opioids to treat chronic pain for longer than a month.8 The final, and I would argue most powerful, internal obstacle that prevents physicians from providing adequate pain treatment is a fear that a patient will lie, manipulate, or betray the fiduciary trust of the physician. The narcissistic injury sustained when a patient takes more drugs than prescribed, has a positive random toxicology screen, or is found to be taking medications from another provider is greatly underestimated and much more intense when it involves narcotics, at least in part because of the paralytic influence of the pervasive "war on drugs."9

Case 2: Charybdis

Mr P is a 49-year-old unemployed former mine worker who was admitted to the inpatient psychiatric facility after making a suicidal gesture ostensibly because of his unrelieved chronic pain that "hurts all over." Records were replete with drug-seeking behavior such as insistence that "only Percocet helps" and failure to follow up with counseling or rehabilitative therapy. During the past year, Mr P had begun using a wheelchair and was rarely ambulatory because of the intense pain. Community providers had prescribed the maximum dose of acetaminophen and oxycodone (Percocet), along with benzodiazepines to treat what seemed to be intractable pain. Collateral information revealed decades of marijuana and alcohol dependence, with recent drinking to the point of intoxication and increasing cognitive deficits.

Comprehensive pain assessment, including neurological workup; cervical and lumbar MRI; physical therapy evaluation; and laboratory screening for rheumatological, metabolic, and other medical causes of pain was essentially negative. Pain specialists recommended humane tapering of opioids and benzodiazepines and aggressive substance abuse treatment. Cognitive and affective disturbances responded rather rapidly to reduction in narcotics.

In this case, both clinicians and patient have been sucked into the ever- expanding vortex of substance dependence with detrimental consequences for patient, family, and community. The 2005 National Survey on Drug Use and Health10 estimated that 4.7 million people had used narcotic pain relievers for nonmedical purposes in the month before the survey. Significantly, 60% stated they had obtained the drugs from a friend or relative, while about 17% stated they had received the drug from a doctor.10 A 2003 review of addiction rates among patients with chronic pain who were given opioids ranged from 3.2% to 18.9%, figures consistent with earlier studies.11

The threat of government sanction, although likely magnified in the minds of practitioners, is nonetheless real.12 As of 2005, 5600 physicians had been investigated on suspicion of drug diversion and more than 450 had been charged with illegal prescribing, drug trafficking, and even murder. Guidance from the federal government has been contradictory and intimidating, creating a climate of "high expressed emotion" characteristic of double-bind situations.13 The nadir of this confusion was the Drug Enforcement Administration's (DEA) 2004 retraction of its "frequently asked questions" document posted in the Federal Register, which had originally been seen as expressing a more moderate position toward legitimate pain medicine. The DEA indicated that the document contained "misstatements," particularly regarding physician practices that if misinterpreted could lead to increased scrutiny.14

A small group of rogue physicians running pain mills surely deserve the strong arm of the law and many others suffer from the woeful lack of continuing education, coordination, and communication between the historically separate and disparate pain and addiction communities. Others may lack the initiative, time, interest, or resources to perform the careful assessment, methodical monitoring, and intensive counseling required to safely and successfully treat chronic pain in patients using opioids, particularly those with a substance use proclivity or problem.15 However, the vast majority of physicians are simply trying to live out their oath of providing compassionate care to suffering patients.

Experts tell us that chronic pain is always partly subjective, and clinical epidemiology can never predict with absolute certainty which patient given opioids will return to the land of the living and which will go down to the street to deal death. This uncertainty places us squarely between the rock of abandoning the field of pain management and the hard place of prescription drug abuse. In my next column, I will try to chart a course between the 2 monsters and recommend psychiatrists as the most skilled pilots to navigate the straits of the dilemma.

References:

References



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