“I made myself a hypodermic injection of a triple dose of morphia and sank down on the couch in my consulting-room….I told her I was all right, all I wanted was twenty-four hours’ sleep, she was not to disturb me unless the house was on fire.”
– Axel Munthe, MD, The Story of San Michele (1929)
When people in this country mention the opioid epidemic, most of the time it is in the context of addiction with its ensuing criminality and social deprivation, and the focus is on opioids’ medical complications like withdrawal, overdose and death.
But that is only one of the opioid epidemics we have. Far greater is the epidemic of largely compliant patients who take their modest three or four daily doses of opiates for pain that was originally described as physical, but which in many cases is at least as much psychological – not imagined, in fact often quite severe, but nevertheless without a physical explanation or available cure.
Stimulation of opioid mu-receptors in the central nervous system induces euphoria more reliably than it reduces pain. In fact low dose opiates have been shown to sometimes lower pain thresholds but at the same time allowing dissociation from the pain experience.
People who smoked opium in antiquity didn’t all have intractable pain to begin with; many had miserable lives, just like many of my countrymen today with health problems, low income, poor education, lacking social supports and limited prospects for even a sustainable future in a job market they cannot even begin to qualify for.
Most physicians have or know of patients who have remained on the same moderate or low doses of opioids for many years and never failed a pill count or a urine test. They show no addictive behaviors, but without their prescriptions they function less well. We are still tapering most of them down or off their pain medications because that is what we do these days in response to the more famous opioid epidemic and in an effort to have fewer opioids, legal ones, that is, in circulation.
Ronald is a 57 year old patient of mine with a bad back, diabetic neuropathy and generalized anxiety disorder. He has been off his 5 mg oxycodone-acetaminophen (paracetamol) pills for two years now, takes pregabalin for his neuropathy and escitalopram for his anxiety with a low dose diazepam as needed. Since he came off his pain pills, his anxiety has been almost paralyzing. Social stressors, like a move to a different neighborhood, sent him into a frenzy. Then he fractured several ribs moving his washer and dryer up the icy front steps of his new home. The emergency room gave him just a couple of days worth of his old pain pills.
“It was amazing”, he explained to me, “I felt a warm wave travel through my body and it was like I was being hugged and everything felt all right, like I didn’t have a single thing to worry about in the whole world, even my nerve pain seemed like it didn’t bother me even though it was still there.”
Next, he asked if he could stay on them, “just three a day”.
I shook my head no.
He has his three other pills that don’t work as well. But at least they’re not opiates.
A Country Doctor Writes: 
Despite the years of education and experience, our physicians are being minimized to an algorithm. This story relates the logic of why our physicians should be the ones making the decisions regarding the prescription that will best serve the patient.
Progress!
Happy New Year and thanks for your always excellent commentary. I look forward to another year of reading your work.
Better a benzo than an opioid?
Much less perssure to stop benzos but a close second. I get monthly emails from the prescription monitoring program about who is still on opioids, not yet benzo reports.
I am not a doctor. I am a pain management patient. Doctors don’t see their patients but once a month for how many minutes. They don’t see the everyday struggles that patients like me have to contend with. I have so many medical issues that if I didn’t have my pain medications there would be no reason to live. What are the statistics regarding patients that are lowered or taken off all pain meds that commit suicide? I have been on meds for over 20 years. Not 1 time have I taken them other than prescribed or given them to anyone. I pass all my drug tests and counts, I also have only asked once to bump up my meds due to an undiagnosed liver abscess. After it was taken care of 2 months later I was reduced back down to my normal amounts. The reason my doctor even looked for something more wrong was because I asked. He knew me so well that he knew my pain must have been more than I could handle because I had been going to him for so many years. That was 10 years ago. I moved out of state signed up with a new pain clinic which starting reducing me to the CDC standards which became a total nightmare. Yes they thankfully reduced me slowly but increased my pain each and every time. I have issues that can not be surgically helped nor do blocks and whatever else they continued to push on me (which on social security is hard to pay for) worked. They even lied to me that if I got a letter from my gastro that maintenance was my only option they would not reduce the next month. They still continued to reduce me. My last appointment my doctor released me cutting my meds in half because I asked if she cared about her patients. I guess I got my answer. She didn’t! She only cared that a bunch of numbskulls got together and systematically decided that all people should be rolled into one and all treated the same no matter what. Instead of treating each patient as an individual with individual issues and tolerances. Yes I see the other side of doctors being scared of losing their career. I also see patients hoodwinking them with pain and being prescribed medications they don’t need. Doctors need to make sure that they are not prescribing to drug seekers but in the case of a patient that has documented, test proven medical issues should work with the patient on their doses whether they exceed the recommendations or not. If you have medical documentation for that patient then what are you worried about? I have at least 3 reams of medical documentation that prove my maladies but it is not enough for some doctors, that the pain meds at the levels I was on was too much since the CDC’s limits. So whom does my family sue when I can no longer take the daily pain?, the CDC, or the doctor? And now the pharmacists are denying prescriptions, a third entity that is deciding they can chose for the patient and their doctor. So because some stupid idiots are overdosing because of their choice to escape life then everyone has to suffer. I guess my issue is your patient was on pain meds for 2 years right. Who originally prescribed them to him? You yourself said he doesn’t function as well without them. How long do you think it will be before doctors are going to be charged in patients suicides? He is 57, how much longer is he going to live?, especially now that his quality of life has been affected. What are the chances that he gets fed up with the pain, buys meds on the street and overdoses because of something else is in those meds. Are you legally responsible for his death? You may say no but some judge somewhere will say that you are at least somewhat responsible, and civil lawsuits proving responsibility in death seem to be more and more winnable considering they need less to prove this. Doctors need to realize that legitimate chronic pain patients don’t do the horrible things that are in the news. We don’t give our meds to other people, we make sure we know where are meds are at all times or we know that we will not have enough for the month or we suffer. I doubt that your patient will last very long if he has chronic debilitating pain. He will finally make a decision that will definitely end his suffering but may also end your career. If you are doing all the right things as a doctor by checking his prescription filling and have medical documentation that he actually has issues that warrant opiates then what do you need to worry about? Benzo’s are just as addictive and are sold on the street too, so in all actuality refusing to prescribe one medication and not the other technically makes you a hypocrite, and a doctor that cares less about treating the whole patient. Cares more about looking like your a pill mill than someone who prescribes medication because of truth and fact. I apologize if I have accused you of being anything other than a caring doctor. That was not my intention but in my defense I have had the best and the worst of doctors in the past and as long as your above reproach in your prescribing practices then what should it matter if you prescribe a pain medication to a patient that truly needs it. Doctors are running scared, but look at the DEA’s list of doctors charged with criminal acts. It isn’t full of doctors that did the right things it is full of doctors that are diverting for their own use, for monetary gain or definitely over prescribing. My first doctor that I spoke of was limited to a percentage of patients that he was allowed to prescribe to in his practice and he kept very close watch on this. Are these limits in your own practice as well? Are these limits imposed by the DEA or state mandated? I understand that the hippocratic oath is no longer as viable or adhered to in this world after all we are all just human beings. But, what happened to. Do no harm. Harm=prescribing unneeded meds to those that don’t need them but it also means prescribing meds to those who do. It is the doctors call I suppose but put yourself in your patients shoes. I myself feel quality comes before quantity. If I can’t enjoy what I have left in my life then I don’t want life!! Give me a pill for that or a quick moving train to end my suffering. My wish is that one day the powers that make decisions about other peoples heath and happiness get to send one day in my shoes. 24 hours should be enough: no sleep, constant pain somewhere in my body and tons of other issues. I would gladly let someone make all my decisions for me if they lasted the 24 hours without one time thinking how does this person do this each day much less 20 plus years. I now step of my soapbox and hope that someone in this country has enough sense to do the right thing about chronic pain issues that can’t be controlled any other way than having to take stupid pills to live each and every day! See I don’t enjoy it either but please tell me how do i function normally without them?