…and back again.

The CDC guidelines on opioid prescribing just landed like a ton of bricks. The media blitz has begun.

They’re pretty straightforward. In the context of the most godawful opioid epidemic in living memory, you could probably guess the content without seeing them. Let’s try a game, shall we? Pick the item not included in the recommendations. The answer is at the end, NO PEEKING!


 

  1. Opioids are the work of Satan on earth.
  2. People who take opioids are likely to BECOME ADDICTED AND DIE.
  3. Nobody should ever take opioids for acute pain for more than 3 days or they could BECOME ADDICTED AND DIE.
  4. OPIOIDS = DEATH
  5. Ibuprofen is nice.

 

The answer is number 3; the guidelines actually recommend no more than 7 days of opioid therapy for acute pain.

OK. I’m exaggerating some.

My feelings about this, I admit, are a little paradoxical. I spend half my days withdrawing people from heroin and trying to get them into long-term treatment, and the other half dealing with folks whose pain treatment has gone completely to hell. I do all this in one of the most drug-ravaged cities in the country. If I found out what proportion of the inpatients I have seen over the years died in this overdose epidemic I probably wouldn’t get out of bed for a week. I have been up close and personal with the failures and horrors of opioids for my entire professional life.

To be clear, my discontent is not exactly with the guidelines and certainly not with their intent. Opioids were handed out as monotherapy way too often, with way too little evidence of long term benefit, and with remarkably little appreciation of long-term risks.

Here’s my problem: I don’t think the steady drumbeat about the dangers of opioids is as much a change of course as it is part of the same cycle that produced the epidemic in the first place. If that’s true, then I suspect we’re just setting ourselves up for the next one, a generation or so down the line.

Here’s my take on the history of these epidemics. On the upswing, generational forgetting sets in and the horrors of the last epidemic fade, and maybe some new thing happens. Perhaps there’s a newest-latest-greatest drug that’s “different.” Less stigmatized, believed to be less habit forming, or what have you. Perhaps a higher potency, cheaper version comes out. It could be any of those; but some combination of destigmatization, increased availability, a more behaviorally powerful drug, and perception of low risk gets a lot of people exposed.

At the crest, the drug spreads up the social ladder – suddenly it is not just the endemic population of impoverished, stigmatized “criminals” who are using it; it’s Aunt Effie who’s hooked on her pain pills. Alarm bells start ringing.

On the downswing, the stigma reasserts itself, new legal and regulatory controls are put in, and the drug’s perceived safety goes out the window. Any benefits are judged to be trivial relative to the risk and, in hindsight, any who believed otherwise are considered naive fools. The drug settles back into the endemic, stigmatized population and bides its time.

Thus we find ourselves at the crest of the opioid epidemic, and just starting to notice that we’re in the midst of a benzodiazepine epidemic, while happily skipping along as marijuana slides from illegal to pseudo-medical to accepted recreational. As to the latter, I don’t think it’s a coincidence how many people have been showing up in ED’s rip-roaring psychotic off the various synthetic cannabinoids that you can buy in a 7-11 these days.

Here’s what doesn’t happen: We never figure out what the actual risks and benefits of these @#&#^ things are. While in one generation we decide cannabis is the destroyer of youth and weigh down research; in the next that very lack of information allows anecdotes to fuel its return as a “treatment” for everything from glaucoma to nausea to mood disorders.

So now we’ve gone from “there is no top dose of opioids” to “over 50mg of morphine is the danger zone” in the last ten years or so, with barely a shred of evidence in support of either. Pop back over to those CDC Guidelines, and you’ll notice the evidence base for these recommendations is barely better than expert opinion. That being exactly the grade of “evidence” that led to the prior approach to pain that got us into this mess.

So the pendulum swings back. Again.

Where is the sweet spot between deadly ignorance and what have we done? What is the rational approach to the use of opioids?

We still don’t know. 

As physicians we are advised to take functional outcomes into account, when opioids have but moderate effects on chronic pain intensity and even less on function. We are advised to screen for risk of addiction when that entity is poorly defined for prescribed opioids,  and the instruments that purport to screen for it are poorly validated and barely break a sensitivity of 50%. It also doesn’t address the public health consequences of putting opioids in more medicine cabinets.

So are we any closer to preventing the next epidemic, once we work our way through the shattered lives, and death, and the secondary heroin epidemic, and the tertiary spikes in HIV and hepatitis and crime and all that misery? Are we finally going to learn something?

Oh, I hope so. I just don’t see it happening. In my more optimistic moments, I think there are opportunities to learn. There are testable hypotheses here. Here are mine:

  1. Long-term (years) chronic opioid monotherapy for chronic pain probably doesn’t work all that well, though it might do something.
  2. The endless pseudoaddiction vs. addiction debate will only be settled by (mostly) ignoring it and agreeing on identifiable, countable aberrant behaviors as bad outcomes.
  3. The risks of chronic opioid therapy depend intimately on how risk-averse prescribers are. When prescribers think it’s high risk, only the most carefully selected patients are exposed and adverse outcomes are minimal. That implies that in the opioids are evil era prevalence of bad outcomes will be low, which then primes the pump for the generational forgetting that can drive the next opioid epidemic, just like the success of vaccines opens space for the anti-vaccine movement.
  4. Attempting to treat chronic pain with a comorbid severe psychiatric condition without making treatment of the psychiatric condition co-primary (or, maybe even primary) is a losing game. So we have to fix the ridiculous divisions in our payment system.
  5. Standard addiction treatment systems are poor at managing people with opioid use problems and chronic pain. That has to be fixed or screening for addiction in this context becomes a circular mess. It’s a sick, sad thing when someone has to wind up switching over to street heroin to finally get into treatment for addiction, but that’s what I’m seeing aplenty these days.

In all fairness and in a moment of seriousness, I applaud what the CDC is trying to do. What I really, really want is for us to stop the cycle of stupidly lyonizing these drugs, causing untold harm, then demonizing them in a panic. The problem isn’t whether they should be demonized or lyonized.

The problem is the stupid (and the panic).

In the absence of any new, real data; I’m afraid we’ll win the battle only to set the stage for the next one. I may still be alive, and maybe even still practicing, to see it.

Here’s hoping I’m wrong. What I’m seeing right now is a bloody disaster, and it would break my heart to see it again.

Those days.

The 26th Law of Psychiatry (The Law of Therapeutic Charity): Give yourself credit for being the one in the room.

I had one of those days.

I haven’t written about it much so far, but I spend a lot of my time helping people with a nasty genetic condition. It’s called sickle cell disease (SCD).

SCD is very high on the list of things you do not want to have. It’s caused by a defect in hemoglobin, but the main problem it causes is pain. Early on, it’s episodes of bonecrushing pain called crises. Later, for reasons nobody really gets, the pain tends to turn chronic. Chronic pain is not an easy thing to treat.

Most of my patients were told they wouldn’t live to adulthood, though now they have a 50/50 chance of making it past their mid-40s. With longer life comes more cumulative complications. Strokes, joint and bone damage, all sorts of organ injuries, blood clots, and on and on. Not everybody gets all that, of course. The disease is amazingly protean considering how uniform the cause is. That said, it’s a bad disease. Where there is brain injury and chronic pain, there is depression. Of course, it’s depression that’s harder to treat.

I have really, really good days. Walking three inches off the ground good days. Days when I see the first smile of the patient who’s been miserable for months. Days when, after uncountable complicated, ambiguous decisions; I push my head up over the waves and realize my patient has been out of the hospital for a solid year when he used to be in every month. Days when somebody who was utterly gorked on pain meds and in godawful pain finally comes out of the haze and gives me that stunned, “I think my pain’s actually better,” speech. Days when I’m pretty sure somebody’s way better off because of me.

Most days aren’t like that. Usually I don’t know if what I’m doing is working.

Part of that is just plain ol’ statistics. Clinical trials can tell you that if you do the thing for a large group of people, more of them will get better than if you don’t do the thing. They can’t tell you if the particular patient you’re doing the thing for will get better, or if he would have gotten better with time, with or without you. (If you just started singing a U2 song, shame on you. This is a serious post, you Philistine.)

Clinical trials also don’t enroll my patients. You can find a randomized trial with bajillions of people with major depressive disorder (north of 5% of the population). You aren’t going to find a single one with people with SCD (around 0.03% of the population), two strokes, bone infarction, bad kidneys, iron overload from multiple transfusions, chronic pain, and depression. There may be a dozen of those people in a given state, and they’re probably going to be in my waiting room.

I know that what I do works. I seldom know if what I’m doing is working. Such is doctoring.

With uncomfortable regularity, I find myself in a room with someone and we’re three tricks deep into my bag, digging around for numbers four and five. Thus it was on the day in question.

He’s been one of my flock for years now. Since then, he’s developed various painful complications, and his insurance is crap, so he can’t get some interventions that might help. He’s lived about three decades longer than he ever expected to live. He’s also got a grinding chronic depression, and partly due to all the dirt SCD does to your insides, our options for medications are limited and we’re already pretty deep into that bag of tricks. Some things are better – his mood has lifted some, he’s not holed up in his room all the time, he’s spending more time with his kids, and he’s more active than he used to be. Still, better ain’t great; and we both know it.

He and I share a certain sense of humor. We get on, he and I.

To wit:

“How’s it going?”

“Well, I haven’t thrown myself out a window yet.”

“That’s good. It would certainly reflect badly on me if you did.”

“I would hate to inconvenience you.”

Like I said, we get on. Aside from all the bad jokes, we’ve also had some serious conversations about suicide, and we’ll have another one at the end of this session. He’s been straight with me about what he’s thinking. He’s decided to stay alive, come what may. I’ve told him I’m never going to give up on him. That’s the understanding. He’s an honorable guy, with a lot of integrity under his rough edges. Or perhaps in his rough edges. I have decided to believe in him. He has decided to show up. So, on we go.

This particular day, he was dealing with an ongoing problem with his family. Underneath that problem is that he depends on them, and he’s not the sort who likes depending on anybody else. We talked it through, came up with some concrete things to try to improve his interactions. As he walked out, he said, “All right. I’ll give it a try.”

Then, “Thanks.”

There are times people thank you, and there are times people thank you. This was the latter. My chest ached. I watched him struggle out of the chair and limp out to make the next appointment. Everything I haven’t been able to do for him hit me, hard.

I had to give myself that talk. The one I give supervisees who are stuck between the simultaneous realities that you can always find another way to help, and that you never quite know if anything’s going to work until it does.

You are the one in the room with him. 

It might be that there are dozens of other docs out there who know stuff I don’t know, and who would have made a bigger difference. They’re not here. I still am, and I’m hoping if nothing else, that makes some difference all by itself.

So, on we go.