She sat uncomfortably in the exam room chair, grimacing with each shift in position. A new patient recently moved from California. Failed back syndrome is what his chart said. Three surgeries on the lumbar spine, and yet no relief. So they, her previous physicians, had prescribed pain medication in ever increasing doses. “I wouldn’t be able to function without it” she stated. But I wasn’t sure how she was able to function at all with it. The total amount was staggering.
Morphine 100mg tablets. Nine tablets each day
Oxycodone 30mg tablets. Twenty tablets each day
Fentanyl patches, 100mcg.
Alprazolam 1mg tablets. Four tablets daily.
There are pain management physicians whom I have spoken with who have seen even higher total amounts, but this was a first for me. We often express the total amount in terms of “Morphine Equivalent Dose.” In other words, what would the total milligram amount be if you expressed it in just morphine, at an equivalent dose? For this patient it would be over 2000mg of morphine every day. To put this in perspective, patients going home after major surgery are often given only 60mg per day for their pain. This patient was taking more opioid than most heroin addicts.
When I talk to my fellow physicians about cases like this they invariably shake their heads in disbelief and say something like, “You didn’t prescribe for her, did you?” Well of course I did. But in ever decreasing doses over time. It took more than two years to wean her down, and the process was complicated by yet another back surgery, but in the end it was successful. She is not off of her opioids, but her daily dose is now only 90mg instead of over 2000mg. And her anxiety is greatly improved after gently weaning her off the Alprazolam (Xanax®).
“But what about her pain?” you ask. That, of course, is the question every pain patient asks when they hear of fellow pain patients whose doctor “mercilessly” weaned them. And I have an unequivocal answer to that question. Her pain is better. Quite a bit better in fact. And she is enjoying life more. Traveling more. Interacting with the grandkids more. Thankful to be on less.
This case is representative of all that’s wrong and all that’s right about pain management and about how we as a society feel about opioids. This woman’s previous physicians clearly did not have a modern understanding of the limitations of opioid therapy. We know now that patients such as this are at tremendous risk of dying from the side effects of their mega-dose opioids. They are at risk for developing addictive behaviors or even full-blown addiction. And they are clearly suffering more pain as a result of their treatment. And yet some, legislatures and policy makers included, would accuse me of being part of the problem. After all, I prescribed very high doses of opioid for nearly two years. I prescribed Xanax and opioids together, something every “modern” physician knows we are not supposed to do.
This patient is what I call a “legacy” patient. Someone who was treated for pain “back in the day” when the use of high dose opioids was considered inevitable, necessary. The fact that we know better now doesn’t change the fact that she was exposed to high dose opioids for 20 years. What did that exposure do to her brain? Will she ever be able to live without opioids? That is a difficult question to answer.
The legislatures and policy makers will tell you that the “opioid crisis” has to be addressed through regulations. We have to stop prescribing so many opioids. Doctors have to be educated, punished even, to force them to stem the tide of opioid overprescribing. But on the other hand, opioid addicts need treatment. We need increased access to medication assisted treatment they say. Medications like Suboxone® and methadone need to be offered, sometimes as indefinite maintenance therapy, for those suffering from addiction. Medications that themselves are opioids.
Do you see the problem here? One set of chronic opioid users, those with chronic pain, need to be taken off their opioids. Another set of chronic opioids users, those with addiction, need to be treated with opioids indefinitely. Addicts, exposed to high dose opioids for years, have suffered “brain damage.”
Legacy chronic pain patients, also exposed to high dose opioids for years, supposedly have not suffered “brain damage” and need to be taken off their opioids. Doctors who prescribe Suboxone for addiction are to be encouraged. Doctors who treat legacy pain patients need to be discouraged.
Is the above an overstatement of the problem? Most certainly. And yet this is necessary in order to draw attention to something that is being lost in the debate about how to handle the opioid crisis. There are patients who have suffered undeniable harm at the hands of the medical profession and it is cruel to abandon them now. We need policies and practice guidelines in place that discourage the creation of new chronic opioid users while at the same time providing hope and a rational treatment plan for those impacted by our past ignorance. There clearly is a rational way to treat these legacy patients and I will describe that way in a future post.