I hope this second post about drugs will be enhanced rather than sabotaged by the fact that I'm presently high on hydrocodone (details below).
Mr. C is in his early thirties. He's a soft-spoken, slightly scruffy man who wears an air of simultaneous cageiness and vulnerability which I have come to recognize as a companion of lot of chronic pain. About ten years ago he suffered a serious, work-related injury to his lumbar spine. Basically his spinal canal was crushed in like a can, and now the deformed bone impinges on his spinal cord and the nerve roots that provide motor innervation to, and carry sensory information from his lower half. Over the last few years he has gradually lost function in his legs (and the ability to control his bladder), and become wheelchair-bound. His condition is, as you might imagine, agonizing, and he has only been able to control the pain with a succession of vertiginously increasing opiate regimes.
Patients like Mr. C. have a really big problem, which is that we (the Medical Profession,) have a complicated attitude to the morality of chronic opiate use. As far as doctors are concerned, we believe that giving drugs for “legitimate” conditions is a therapeutic imperative, but that giving them to “addicts” is fundamentally immoral. This is because we believe, of patients, that those who take drugs for legitimate conditions (defined, basically, as those for which we recognize an indication for the drug in question) to be morally neutral, whereas we think that people who take drugs because they are “addicts,” (which we might define as any reason we don’t understand or accept) to be basically immoral. Crucially, both of these distinctions presuppose that there is a clear line, which doctors can discern, and which divides the huge diversity of reasons people have for chronically taking drugs into “legitimate” and “illegitimate” subsets.
Today, Mr. C. and I met in interestingly symmetrical circumstances which made some trouble for this presupposition. Let me give a little background on the adventures which brought both of us to our specific positions in the Adult Medicine Clinic at 10:20 AM on this particular morning.
The last time I was on the wards, one of my interns admitted Mr. C to the hospital for urinary tract sepsis (a common complication of paraplegia). At that time he was under the care of a graduate of our program, whom I know and admire, with whom he had a "pain contract." These are pretty standard documents which are commonly used to legitimate chronic opiate dependency, and basically stipulate that patient X can have so much of drugs Y and Z a month, and that in return he has to submit to random urine testing and promise not to try to get drugs from anybody but the provider with whom he has the contract. They also stipulate that should his urine tests be suspicious or should evidence emerge that he's been "doctor-shopping," the provider has the right to terminate all narcotic prescriptions and, if he or she feels like it, stop seeing the patient. So he came to our team with all these dire warnings in his ED note about suspicions of "drug-seeking," and he also came complaining of excruciating pain. There was some initial controversy about what to do about this. While I know doctors who would have said, "Look, the best thing we can do for this guy is deny him all opiates and therefore reduce his dependence on them," I happen to be of the opinion that opiate dependency, whatever its etiology, isn't something you should try to fix during an acute hospital visit. I generally take the view that it is, in and of itself, a chronic medical problem - probably most closely analogous to diabetes, in the sense that trying to get somebody who's been using heavy doses of opiates for years over the course of a five-day hospital admission to stop is approximately akin to trying to cure somebody with type 2 diabetes by starving them for a week. In both cases, you’re just creating another medical problem – in these examples, starvation and opiate withdrawal, respectively. So my attitude to people who come into the hospital with opiate dependence and pain tends to be that they need more opiates than they usually get, not less - after all, by definition they have a higher tolerance for opiates than the average bear. If we want to get them off opiate medications, we first have to fix their underlying problem, and then we have to slowly taper the medications off to avoid upsetting withdrawal syndromes. I gave a short speech to this effect to my intern in front of Mr. C when he was admitted, and I have to admit that I had a mild sinking feeling when Mr. C. immediately asked me to be his primary doctor, and said that he wasn't interested in seeing my colleague any more.
The other important piece of background information is that I had a rather catastrophic bicycle accident last night. The entire front fork of my steel-frame bike broke in half while I was going about thirty miles an hour. I had just left the ICU on my way to a meeting, I was brought right back to the Emergency Department as a "Level 2" trauma (a recurring nightmare of mine was thus finally realized.) I got away with a mild concussion and some really impressive bruises and abrasions, and I was in a significant amount of pain until I got the Vicodin a friendly ED attending prescribed for me before I limped home.
So I was in a fine position to appreciate the subtlety of Mr. C's situation and those of patients like him as I sat, listening to his story and feeling the hydrocodone kneading my painful shoulders with its warm, dulcet fingers. What struck me about my own state was that I didn't feel like I was on drugs. I just felt more like myself; I just felt the way Dr. Benway always wants to feel when he's in clinic: free from pain, interested in the patient in front of me, and free from the distractions which might impinge on that interest. Now, I know that the reason I felt that way was because I had taken five milligrams of hydrocodone and three-hundred and twenty-five milligrams of acetaminophen about an hour before I walked into the room. But my phenomenal experience was simply of feeling well, as opposed to the way I had felt when I woke up, which was injured. And this sense of well-being wasn't limited to my shoulder, or my face - it wasn't the case that there was a neatly delineable line between me and me plus the pain - it was all the same thing.
I realized, listening to Mr. C. telling me about how much agony he had been in, that the drugs do the same thing for him. It isn’t the case that there’s an easily recognizable, dose-related distinction between him feeling free from pain and him deriving a self-consciously sinful, sybaritic pleasure from the euphoric effects of fentanyl. His experience of his drug dependence is the same as my experience of taking the Vicodin – when he doesn’t have it, he feels a sense of incompleteness and discomfort which is very complicated. Sure, it involves a lot of physical pain, but it also involves the loss of self-esteem that comes with being an invalid, a gnawing preoccupation with getting his meds which elbows all the other things he might want to think about out of his mind, etc. When he takes his drugs, he doesn’t just feel pain-free, or just feel euphoric, he feels more like the self he wants to be. And the reason he has this cagey air is because he’s used to doctors not appreciating the complexity of the situation. He’s used to doctors who are constantly probing him, trying to get him to slip up and admit that he needs the drugs for something other than pure physical pain, because they feel that to give him medications for anything else would involve them in his immorality.
This forced me to appreciate viscerally what I had heretofore suspected intellectually, which is that he distinction we make between taking drugs because you're in pain and taking drugs because you're an addict is ludicrously simplistic and totally incoherent. Whether your pain is from a broken leg or a broken soul, whether you take opiates because you've become physiologically dependent on them or because you have an acutely painful condition that necessitates them, they do the same thing - they make you feel like yourself. There isn't a moral distinction between using opiates (or any drug) for psychic pain and using them for physical pain, because one's experience of all those forms of dis-ease in the moment are contiguous - as are the drug's effect on them.
The question a lot of doctors ask themselves when they see somebody like Mr. C. is "Does this guy have legitimate pain, or is he just drug-seeking?" They expect the answer to this question to help them establish what are called "goals of treatment" - if the pain is "real" the goal is the alleviation of pain; if it's "not" the goal is the termination of opiate dependency. The problem is that whether your a "drug-seeker" or a "legitimate" chronic pain patient depends far more on the attitude of your physician to your problem than it does on the problem itself. The question is, in that sense, circular; what the physician is actually asking is, “How do I feel about the moral legitimacy of this guy’s drug use?” And because it’s basically a question about the provider’s attitude, the provider can can turn either category of person into the other simply by relating to them differently.
I think this is clearly demonstrated by two examples, one from my experience and the other from the Medical Literature.
First, I referred earlier to Mr. C's air of cageiness and vulnerability - you see this a lot in people who have undeniably "legitimate" chronic pain, because anybody who is seen to ask repeatedly for increasingly high doses of opiate pain killers will get treated, even if it's in the most subliminal of ways, like a drug addict. There is always the background fear, in the provider's mind, that they are engendering or enabling addictive behavior. I have seen many patients end up in this situation - probably my favorite example was a young woman who was on chronic opiates for a thigh muscle infarction (viewers of the show House, MD will be familiar with this condition as the excuse for the protagonist's chronic opiate addiction,) and a soft tissue infection of her labia (even men should be able to imagine how painful that would be), who was repeatedly accused by the nurse taking care of her of being a "drug-seeker" because she asked, on schedule, for exactly the amount of pain medication which I had explicitly prescribed for her (and no more).
I think it’s fairly intuitive to most people that when you treat people who need drugs like drug addicts, they start to behave like drug addicts - because "behaving like a drug addict" simply means "employing whatever means are available to get a drug you need from people who don't want to give it to you." Your reasons for needing the drug are ultimately irrelevant to the patterns of behavior its need induces. If you deny somebody who has a "legitimate" condition, (like, say, reflex symathetic dystrophy or sickle-cell anemia,) access to painkillers, they will do all the things that "drug addicts" do in order to get the drugs, because they need them to feel like the selves they want to be, and there are few things more motivating than the prospect of being a person you can feel OK about. Or, to continue the diabetes comparison above, if you treated insulin-dependent diabetics like morally deficient criminals and denied them their insulin, you can be sure that you would observe all the complex behavioral adjustments which are currently held to be characteristic of “drug addicts” in diabetics, as they skulked around the shadier parts of town looking for their next “fix.”
And it cuts both ways - if you treat "drug addicts" like they have a medical, rather than a moral illness, they stop behaving "like drug addicts" (which is to say, in terms of the way I defined it above, that if you stop witholding the things people need from them they stop trying to subvert you in order to get them.) My second example is a large, multinational, randomized controlled trial (the "gold-standard" of medical research) which was published in the New England Journal of Medicine. The authors took a bunch of heroin addicts who were on lifelong methadone maintenance therapy (i.e., people who were so thoroughly dependent on opiates that their physicians had given up trying to cure their addiction and settled for trying to manage it), and randomized them to a group which continued to receive methadone, and one which received actual heroin. Their primary end-points were relapse to using street heroin, and getting arrested - which is to say, rather neatly, "behaving like a drug addict." The people in the heroin arm of the study had a significantly lower incidence of using street heroin and going to jail - i.e., they started behaving less like "drug addicts" and more like people receiving therapy for chronic medical illness.
So, sitting across from Mr. C. this morning, high on Vicodin, it struck me that there were two ways to play this. I could consider his opiate dependency a moral failing on his part, and try to whip him into shape - after all, he broke his last pain contract (under my watch,) and he clearly wanted me as his primary care doc because I expressed a willingness to give him drugs when he was an inpatient. Or, I could consider his opiate dependency to be a legitimate medical problem in and of itself, and recognize its full complexity, it's multiple determination by his "physical" pain, his "psychic" pain, and his long series of dysfunctional relationships with healthcare providers. Put more simply, I could ask myself one of two questions in order to determine my "goals of care:"
1) Is this guy a drug addict who's trying to manipulate me?
or
2) What would have to change in this guy's life so that he wouldn't need a daily dose of opiates that would stun an adult giraffe?
What struck me, (as I contemplated the difference between how I was feeling in the moment and how I had felt when I woke up, and the fact that I owed it all to Vitamin V,) was that the answer to question number 1 is obviously "Yes," and that the goals of treatment that answer would dictate are ones that are, equally obviously, not going to get either of us anywhere. I'd end up treating him with cold suspicion, he'd grow to fear and resent me, and eventually there would be some kind of bust-up and he'd go and find another doctor, and the whole grim cycle would start again. The answer to question 2, however, is not at all obvious. It will take a lot of getting to know one another, a lot of creative thinking, and probably some surgery to arrive at an understanding of how to turn his interior world into one that's not solely sustained by liberal infusions of hydromorphone. And trying to answer that question is likely to cast us both in much more interesting roles than the first - for instance, instead of making him a disempowered drug addict, it will require him to assume creative responsibility for his life and its direction; and it will make me something much more difficult and complicated than a reticent pusher. The first approach will keep us both in our pre-defined roles, and doom us to the same, stupid, pre-defined interaction – the second has at least the potential to help him become a person who’s engaged with and assumes responsibility for his health, and to help me become a decent primary care doctor.
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