Thursday, December 22, 2011
Transfer Of Addictions
It was true that his foot looked swollen and bruised. But the xray was negative and there was no reason to expect a more sinister process. He stubbed his toe; no more, no less.
But James had a problem when it came to pain.
Or had he just become a victim of our medical system?
There was a time when James was not strung out on pharmaceuticals. Alcohol was his poison then. But he got into a car accident and suffered a knee injury. The DUI was the least of his problems.
The MRI of his knee was normal but his pain was excruciating. Visit after visit to his internist and orthopaedist left him with a medicine cabinet full of narcotics, which he felt good about because at least he was no longer drinking.
The custody agreement for his son required regular breathalyzer testing. But they couldn't fault him for taking the medications his doctor prescribed, could they?
By the time he came to see me, he was taking several norco and oxycontin a day without relief. I reviewed his MRI and lab tests skeptically. When I explained that in the absence of pathology I wouldn't accelerate his dosing, he almost fell out of his seat.
It never occurred to him that maybe the medicine wasn't helping. Our conversation went something like this:
What is your level of pain when on medication?
What is your level of pain without medication?
We argued back and forth, month after month. Each time I prescribed less pills.
Finally when the courts threatened to take his son away, James got serious about kicking his medication habit. He got admitted to the hospital and was treated for withdrawal.
The next few months were difficult. James struggled with daily activities. He found a job and spent more time with his son. I would be lying if I said that he didn't have pain. But he learned to use more mature coping mechanisms. He attended physical therapy, acupuncture, and biofeedback.
He was making significant progress, or so I thought.
And then he disappeared.
Six months later he waltzed through my door with a large medication list. As I silently read through the consult note, I felt my eyes popping out of my head. He had seen a pain specialist at the local university and was again using large doses of narcotics.
We were back to square one.
I buddy-taped his bruised toe and sent him on his way. I assumed shortly after leaving the office, he would be on the phone with his pain specialist.
We've created a nation of junkies. The tide began to turn when the government made pain the sixth vital sign. The miserable and wretched learned that they could stop cowering under illicit and costly activities. Now all they had to do was show up at the doctor's office where kindly nurses would check their blood pressure and pulse before serving up the perfect lob:
Are you in any pain today?
Why yes I am!
Instead of protecting the cancer ridden and orthopedicly adventurous, we have turned our offices into dispensaries.
Unfortunately we still haven't come to terms with the fact that narcotics do not treat psychic pain. Furthermore, they are particularly poor at relieving chronic orthopedic conditions.
So the treadmill continues. We use pain medication inappropriately. The human body becomes use to it and then needs more. Minor traumatic injuries become emergencies.
And as a nation, we transfer our addictions.
Posted by Jordan Grumet at 11:11 AM
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In my humble opinion, I think pain is one of the most complex challenges any physician will face. While not a Physician, I have worked within the field of addiction for a number of years.
It appears that James has the disease of addiction. He simply traded one drug, alcohol now for a pharmaceutical drug. James might also have a long history of addiction in his family which would give him a greater chance of being genetically predisposed. I believe 12 step groups can be a critical aspect of treatment, now if it was only that easy for patients to admit to "being powerless!"
Thank you for highlighting that fact that we don't have great pain relieving options for those with chronic orthopedic conditions. Kelly @rawarrior and Dr. West @westr address pain issues often in their arthritis tweet chats through Twitter. I also learn a great deal about pain from Dr. Jim Cleary
I agree our country has a huge mess in this area. I have been directly impacted because one of my prescribed medications, not a pain medication, is back ordered because the FDA fears it might be used inappropriately so it has placed a cap on the manufacturing of the medication until the beginning of the new year.
Thank you for addressing such a complex and important topic.
I appreciate you and your work.
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