Many years ago, I broke my ankle—tibia and fibula—in a fall from a horse. It was compound and comminuted, meaning one bone was sticking out of my leg and the bones were splintered. It was also displaced, cutting off the blood flow to my foot.
I got a morphine drip in the emergency room immediately but have no idea if it helped, because in the next few minutes (although it seemed like hours), the doctors “reduced” the fracture and I screamed incessantly, stopping only to breathe in. After they were done with that, however, the morphine kicked in and I fell asleep.
I then spent five days in the hospital, on non-stop Demerol injections—but not because I was in pain. They just brought them into the room. I would feel wonderful for five minutes, and then fall into a deep sleep. Physical therapy—so I could learn to use crutches—was always scheduled right before the next shot was due.
During those five days, I had no pain at all. I have no idea why the Demerol kept coming. I lost my appetite and basically just slept. Finally, I asked if I could go home. They said, “Not when you’re on these injections.” I told them to stop giving them to me; they did, and I went home the next day. I don’t recall any withdrawal symptoms or pain after I left, but I did lose those days.
The pendulum has long since swung from the automatic opioid administration I received to severe restrictions.
I recounted this experience to Mark A. Weiner, MD of the American Society of Addiction Medicine. He said that if I had had an addiction history (I don’t), my addiction could have been “activated.” Of course, this all happened long before the overdose crisis, and I don’t recall anyone asking me whether I had such a history.
As I reported for Filter last week, the pendulum has long since swung from the automatic opioid administration I received to severe restrictions on access. Pain patients routinely face stigma and discrimination; their doctors, fearing responsibility for addiction and consequences for their livelihoods, inappropriately cut them off from pain medications.
All patients who have used opioids long-term are physically dependent (which doesn’t mean they’re addicted). If they’re lucky, their pain physicians who are cutting them off consult addiction physicians about what best to do: Taper? Transfer to opioid use disorder medications like buprenorphine? Reverse the decision and keep them on opioids?
Weiner is a physician who works in this nexus of addiction and pain. Initially trained in internal medicine, he was boarded (through ABAM) in addiction medicine in 2010, working primarily with both patients with substance use disorders, and patients with addiction and pain. He’s not a certified pain physician, but works with the primary care and pain doctors who prescribe opioids—helping them “work out who’s who” and determine whether, when and how to taper patients off opioids.
“My main focus is to remind doctors to be compassionate to every single patient,” he said. A lot of that involves helping the doctors “figure out where their level of education ends.”
Determining Addiction—And Not Overreacting
So how does a physician considering a taper know if a patient is addicted? There’s no specific dosage or duration of use, said Weiner, who chairs the Pain and Addiction Common Threads Course for the annual American Society of Addiction Medicine meeting, and is also the fellowship director for addiction medicine at St. Joseph Mercy Ann Arbor.
Instead, “you have to ask a lot of questions, directly and indirectly, to determine how the medication is affecting people’s lives, what it does to them,” he said. “Their response can give you a good idea.”
For example, if you ask “How did you feel when you took your first opioid?” and their response is, “I felt great, I wanted to mow the lawn and go shopping,” that’s abnormal, he said. Opioids are a sedative.
According to Weiner, addiction is not a definitive reason to deny a person pain medication.
Tapering doesn’t work for everyone, and sometimes a switch to buprenorphine is appropriate. “Of the 152 patients that accepted to taper in my practice, 44 (29 percent) couldn’t because of intractable withdrawal symptoms,” said Paul Coelho, MD, medical director of the Salem Health Pain Clinic in Oregon.
“When patients are tapering slowly, and offered pauses, most can,” he told Filter. “But when withdrawal symptoms ensue, we don’t stop the taper and hold them on the dangerous dose. Instead, we transition them to buprenorphine. It works wonders in this circumstance.”
But beyond such determinations, according to Weiner, addiction is not a definitive reason to deny a person pain medication.
As illustration, he described a patient he is currently taking care of. She had a history of alcohol use disorder, starting in her 20s. When she was about 30 she developed chronic neck pain, and was put on methadone for this pain.
After eight years of methadone, her doctor said, “We have a new policy; we have to stop your methadone.” Her physicians tapered her, even though the pain kept going up, over a four-month period—a reasonable time for a taper for her, said Weiner. But she still had pain—and also a craving for opioids. She started buying heroin and injecting it.
“By the time I saw her, she was in the hospital, had an infection in her heart valve, and had a stroke,” he said. She was 57 years old.
Her addiction had been “activated” by the methadone, said Weiner—but there was still nothing wrong with giving her the medication. She needed it for pain. Now he is treating her with long-term buprenorphine.
Weiner does addiction medicine consults every morning in the hospital, where almost everyone is in pain of some sort. Opioids of course are present, and physicians have many questions for him.
“Opioids are very effective for treating pain,” said Weiner. “You can’t cut them off from everyone.” But most pain doctors, he added, agree that there is not much science behind pain, which is subjective.
“As long as the benefits outweigh the risks, you should continue them.”
“Opioids work only at the brain level,” Weiner continued. “The thalamus, the part of the brain where we think, processes pain, which is negative information. But it also processes negative emotional information. The thalamus has a lot of different knobs, and when you’re under stress, there is fear, which turns up the volume level.”
Individualized treatment is key, therefore. People always ask him what the maximum dosage of a particular drug should be, but he can’t answer. “You have to know the patient—like with a lot of things.”
Similarly, there is no simple answer to the question of how long patients who are on opioids for pain should stay on them. “As long as the benefits outweigh the risks, you should continue them,” is what Weiner advocates.
Doctors’ Fears and Opioids’ Limits
Weiner said he runs into very few patients for whom pain is completely eradicated by opioids. “Usually they are having some pain. But when I get asked by a pain doctor whether a patient should be taken off opioids, usually it’s because the doctor doesn’t want to write prescriptions for opioids anymore.”
The next question he gets asked is, “Would this patient do well on buprenorphine?”
It’s so obvious. “What they’re really saying is, they don’t want to write for painkillers anymore, period,” said Weiner. “It’s not an opioid medication failure.”
On the other hand, sometimes the medication has lost its efficacy. Just as tolerance can build for the euphoric effects of opioids, Weiner said, it also exists for the analgesic effects. Taking more and more isn’t always a good answer.
There is also the phenomenon of opioid-induced hyperalgesia—in which patients become more sensitive to pain because they have been on opioids.
Finally, he noted, there are patients for whom opioids are working for pain, but who have other opioid-related problems that they can’t overcome—such as toxicity from high doses causing sedation and respiratory depression, or the patient saying they can’t work or function.
Only by working with patients and taking a nuanced, individualized and stigma-free approach can pain doctors optimize outcomes.
Not too long ago, there was a belief that if someone took opioids for pain, it was impossible for them to become addicted. That is not true. Then came the widespread belief that pain patients have a high chance of becoming addicted. That is not true either.
It is only by working with patients and taking a nuanced, individualized and stigma-free approach to prescribing and tapering that pain doctors can optimize outcomes.
All those years ago, when I got the Demerol for the broken ankle, maybe the doctors knew what they were doing. After all, I had plenty of initial pain in the emergency room. And I didn’t get addicted just because I got prescription opioids for five days—the thought never even occurred to me.
If the same thing were to happen today, I wonder if I would receive anything at all.