The safest thing for us to do, as doctors, is disassociate and depersonalize. We tell ourselves the patient’s suffering, from COPD or alcoholic cirrhosis or opioid addiction, is their own doing. Or more importantly, would never happen to us.
Or maybe we try to numb our empathy by memorizing the neurochemistry and behavioral science of addiction. But none of that works so well when the heroin addict is your beloved sister.
My sister’s long and winding journey to opioid sobriety has taught me a few things about being a doctor for all patients, not just addicts. She offers the following in the hope it’s helpful to us in some small way.
Her Story, Abridged
2004: Acute low-back pain led to a prescription of Vicodin (hydrocodone/acetaminophen) from an orthopedic surgeon. Ten (10) were prescribed along with dire warnings of misuse. She took three (3) and discarded the rest.
2005: Shoulder surgery led to post-operative pain. Percocet (oxycodone/acetaminophen) prescribed for several months.
2006-2011: Persistent pain after several more orthopedic surgeries led to Roxicodone (oxycodone), in gradually accelerating doses.
2012: Oral administration gave way to crushing and snorting (more immediate and potentiated euphoric and analgesic responses). Hospitalized for intractable pain. Fentanyl transdermal patches were prescribed in a well-intended effort to stop the cycles of euphoria and pain-rebound. She cut them into sizes that would fit under her tongue.
2014: Hard-to-find schedule II opioids and burned-bridges to physicians gave way to easy-to-find heroin. Fifteen minutes by car, at $10 per bag, each bag containing 3-4 doses, her habit eventually rose to 30 bags a day. Injecting was more economical (higher and longer-lasting highs), but her loving husband of 15 years would have found the needle marks, so she stayed with snorting. At 48 years old, she was a heroin addict.
2015: Enters rehab; sobriety achieved.
2016: A relapse occurs when Dilaudid (hydromorphone) was prescribed “to expedite discharge” after orthopedic surgery to repair a traumatic leg injury. The hydromorphone made her feel extraordinary; she could no longer tell the difference between desiring analgesia and desiring euphoria.
Advise From an Expert
We physicians love to speak of randomized, double-blind, placebo-controlled crossover trials to guide our diagnostic and therapeutic decision-making with patients. Eh. Here’s my sister’s advice to us:
1. “Be honest with patients. If you must prescribe opioids, say: ‘You might love this drug and look forward to taking it. If you become dependent, you will have a slew of problems and lose your freedom. We need to find a way for you to take the least amount of medication for the shortest amount of time, while keeping your pain bearable, rather than gone.’
2. “Keep the quantities at a minimum. Don’t write a script for Dilaudid for a month. Write it for three days. Then have me call you to check in about the pain. Is it less? Switch to (a lower morphine-equivalent) or NSAIDs. If patients know you will be available to speak to them (in follow-up), they won’t fight you for higher quantities.”
3. “Always prescribe acetaminophen-containing preparations. They are painful to snort or shoot.”
4. “Learn about addiction – the physiology, signs-symptoms, and the misery. It becomes all-consuming for us. Remember that 19th century pharmacy museum you and I went to in Texas? Although I knew intellectually the bottles of Laudanum were unlikely to contain something I could use, I stood there for a long time working out how to pick the cabinet locks. One day (my user group and I) heard that two of our (peers) died the night before of an overdose of a new (more powerful) heroin to hit the street. We all wanted to know where we could buy some. And by the way, speaking to me with condescension, malice or contempt does neither of us any good. It’s bad for your soul and professional fulfillment. And when you ignore my suffering, I will go to the pharmacist that understands my pain and does not require paperwork: my drug dealer. A little compassion wrapped around your ‘hell no’ can go a long way for both of us.”
5. “Opioid withdraw is torture. Don’t tell me ‘you won’t die from this pain or from withdrawal. Get dopesick for just 1 day, let alone 10, then tell me you’d rather live than die.”
Plenty of Blame to Go Around
Listening to my sister’s story and advice, I felt shame for the times in my career I violated her edicts. I recalled how badly I treated a resident in my training program 30 years ago, assigning him to 6 months of VA rotations for what I saw as a moral failing to get addicted to opioids after oral surgery gone wrong. Or my dishonesty or cowardice in dealing with addicts (“I’d like to give you more opioids, but I can’t”). Or being angry at the pharmaceutical reps of the latter part of the 1990s who assured me OxyContin wasn’t addictive or as addictive as other preparations. (It was their job to sell the drug any way they could; it was my job to do an independent literature review and protect my patients from harmful misinformation.)
Anyway, time to move forward. Thank you, sis, for being the wiser of the two of us.