I was really gladdened to see that the drug overdose epidemic has hit the presidential debates. This past month, during a Republican presidential debate, a question that seemed to be about more police action was answered with the positive response that addicts need treatment due to an illness. The Democratic candidates have addressed the problem as well. I saw a 60 Minutes report recently on the new “Drug Czar” that noted he was in recovery himself. The media coverage continues to highlight the problem.
As a physician, I feel it is important to address our role in the current epidemic, which causes 18,000 deaths a year. To put this in perspective, this is a 747 airplane going down doing weekly. This is why it is important and proper for this problem to be addressed at the national level. As physicians we are asked by patients to prescribe pain medication to ease their suffering. This important medical and societal role is a must, and we are given the responsibility to do it. However, in fact, household surveys actually find that over 50 percent of people who have used an opioid drug actually got it from a friend, who got it from a doctor. At a talk I gave at UCSB, we heard from some students who emphasized how safe people think these “packed, dispensed, products” are. This is part of the problem. As a society we would do well to treat these drugs with more caution. There are suggestions to lock up this category of meds if you have them at home or to turn them in to drug drop off sites.
However, there is another problem which must be brought up: the issue of physician training to prescribe opioid medications for pain. We are given a lot of training to treat acute pain. People come to the hospital with acute injuries or we operate on them, and they need pain relief. This is the core of physician training with regard to pain management.
We are not given training about chronic pain. Over the past 20 years that I have worked in the area of addiction, I gradually received more and more requests to assess the management of chronic pain in patients who were on pain medication but still in pain, still depressed, still not functioning or feeling well. Were they just addicted, using the drugs to get high? Should we detox them? Did they just need more meds to get “on top of their pain”? Should we increase the dose? Should we be using other types of medications to address the pain? Were they just depressed and needed more antidepressant? Were they depressed because they couldn’t do what they did before and couldn’t connect to people in the same way as they had before? Or, were they using the medication to manage not only the pain but depression, anxiety, grief, loss, and other emotional injuries? Having examined hundreds of patients with chronic pain, I realized that I had to assess for each of these questions to really get a handle on what was going on with each individual.
Some chronic pain is very clearly chronic acute pain. For example, untreated rheumatoid arthritis can create active inflammation in the joints, and rheumatologists can measure the level of inflammation. Injured nerves in the feet, from diabetic neuropathy for instance, can be measured by neurologists for function or dysfunction of those nerves. The most confusion arises around injury to the spine, which is a very primitive part of us — fish have spines — and can have pain due to injured joints and disks, pinched nerves, and pulled muscles and tendons. But the spine is also a much more emotionally innervated part of us, and pain can be expressed in the spine when there is emotional injury as well as physical injury. Just as stress can cause the heart to pound, or result in ulcers for some and sweat for others — we even speak of “breaking out in a rash” from stress — but the spine, from the neck to the tail bone, can also react to our stresses and emotions. Dr. Jack Sarno wrote about this in his book Healing Back Pain (Warner Books, 1991), and he emphasized the role of unexpressed anger as a source of back pain and the need to help the patient express that anger.
In taking hundreds of histories, I have also been impressed by the role of post-traumatic stress disorder as a condition that can lay the groundwork for pain that does not get better. I have often asked why pain gets better in one person after an injury and not in another. Sometimes, there are mechanical explanations, but often, I have found, the person with persistent pain had a nervous system that was in a heightened state of alarm prior to the injury or in response to the injury.
Post-traumatic stress disorder is a response to trauma in which the person becomes hypervigilant in order to prevent that trauma from ever happening again. Often they are troubled by nightmares or flashbacks, and they want to avoid anything that reminds them of the trauma. It appears that when this activated nervous system is injured, it is harder for the pain to subside because the whole nervous system is in a state of alarm. Hence, to deal with the pain, one needs to first help the person relearn how to feel safe and how to let down the defenses that are controlled by the past and are no longer helpful.
In other cases, I have found that the person with chronic pain had difficulty setting boundaries. He or she was the best worker, the over doer, the perfectionist. Never wanting to disappoint. Hating arguments. Always wanting to please and keep others happy. The individual had learned to turn any angry feelings off and, as a result, didn’t know how to set a boundary. The result was that after injury, the person could no longer keep up the prior level of excessive functioning. Once the patient learned to set boundaries, the pain began to get better.
We have found that disorders like fibromyalgia, a generalized pain condition, shares some features of post-traumatic stress disorder. Both have elevations in the spinal fluid of a neurotransmitter, Substance P, which causes an upregulation of pain transmission in the spinal cord. Both conditions cause a difficulty getting deep sleep at night. To help tune down this hypervigilant nervous system, the FDA has approved medications such as Lyrica (pregabalin), an anti-seizure medication, and Cymbalta (duloxetine) and Savella (milnacipran), both serotonin and norepinephrine reuptake inhibitors that can be used for depression.
Migraine — which can be inherited as well as the result of injury — occurs in some patients once or twice a month, and in others more than 50 percent of the month. In those who suffer it less frequently, there is no evidence of increased rates of depression or trauma, but for those who experience it for half the days of the month or more, we have seen that more than half of these patients have had prior trauma and depression. So, not only do we need to use medications that help stop the migraine, and there are some that can decrease migraine frequency, we need to help the patient learn to help his or her nervous system release the grip of hypervigilance, learn to set boundaries, and grieve what has happened to truly provide a complete approach to this disorder.
Grief can also amplify pain. One of the stages of grief described by Elizabeth Kubler-Ross in her book On Death and Dying is the stage of Anger, which includes pain. This comes right after the first stage of Denial. Often an injury changes a person’s life to such an extent that the individual connects to people differently. Certainly this is true of injured athletes, who in one instant suddenly are never who they were before and worked so hard to achieve. If they successfully grieve that loss of function, they come to recognize that they once made a choice to get good at something so it would connect them to people; in their recovery from injury, they then make a new choice to connect to people in a new way. It takes time to make this change.
Depression of any type is known to augment pain. And, pain can augment depression. We have found that the level of pain and disability after spinal surgery is predicted by the level of depression and anxiety prior to the surgery.
So, back to us physicians. Medicine for the past 100 years has made unbelievable breakthroughs. Medications have solved thousands of medical problems from pneumonia to cancer. Anesthesia allows surgery, which not only saves lives but transforms them. But we have lost sight of how the emotional part of us heals and that this is part of medicine; it should not be considered alternative medicine.
When the patient who is on opioid medications states the meds are no longer working, but there has been no new injury, the physician needs to ask, what is driving the tolerance to these medications? Tolerance is a property of the nervous system. Stress, grief, anxiety, anger, depression, PTSD are all states of alarm in the nervous system that can aggravate pain. And, it needs to be said, this is real pain, real suffering.
Opioid medications can tune the aggravated pain down temporarily, but the nervous system can soon become tolerant, and it takes more meds to bring down the pain. It is this scenario that needs to be part of medical education. More pain does not necessarily mean that more opioid pain medication is indicated. When confronted with a patient who has chronic pain, we need to address not only the mechanical aspects of the pain but systematically address the emotional amplification of the pain and, just as importantly, teach the emotional tools that a person needs to learn to help rebalance his or her nervous system.
It is my belief that all chronic pain deserves a thorough physical, as well as emotional, evaluation and treatment, if we as physicians are to appropriately play our role in society as the prescribers of opioid pain medications.
Dr. P. Joseph Frawley is an internist and addiction specialist, and co-medical director of Recovery Road Medical Center.