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    The opioid pain paradox

    I was recently discussing the complexities of opioid management of chronic pain with a medical student, when I recalled the following story:

    Well over 30 years ago, a friend of mine—a fellow I grew up with—was in the throes of a nervous breakdown. While this is not a term indexed in many psychiatric texts, it was a painfully accurate description of his circumstances.


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    He had made, perhaps hastily, a life decision that he had become uncomfortable with and the deterioration began. A bit hypochondriacal by nature, he began with physical symptoms. As I was his doctor as well, I became involved.Robert Bobrow, MD

    Over several months, his ailments multiplied until they overwhelmed him, and he became delusional as to their etiology. Although he had medical knowledge (he was a licensed physician’s assistant), he believed he had neurosyphilis destroying his nervous system and that he was having myocardial infarctions in rapid succession. Although he did not believe his symptoms were psychological, he had reached the juncture where admission to a psychiatric in-patient service was imminent and inevitable.

    Holding a thread of hope that I could somehow thwart his decline and keep him out of the hospital, I decided to give him a shot of meperidine (Demerol—popular at the time), wondering if it might somehow render him susceptible to reason. This was the early 1980s and opioids were not yet being used for chronic noncancerous pain, nor were they the societal mega-scourge that they are today.

    I doubt I’d have tried to do this within the current zeitgeist.

    His dad, whom I had also known since my childhood, brought him to my office. He knew, and consented to, what I was about to do. I told my friend I was going to do a lumbar puncture to relieve pressure on his brain, and in his condition, he was eager to have this done. I put him on his side, knees up, as if to do an LP, pinched the skin over his lumbar spine, and give him 50 mg subcutaneously.


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    Within minutes, his illness started to abate, and within half an hour, it had completely remitted. He was lucid, his old self. He could see the delusions for what they were, and found it absurd that he could have had neurosyphilis or a fusillade of infarctions.

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    Robert Bobrow, MD
    Dr. Bobrow is a Clinical Associate Professor of Famiy Medicine at Stony Brook University, Stony Brook, NY. He directs an Opioid Overdose ...


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    • Anonymous
      Some of us have been in medicine long enough to remember when Darvon and Darvocet, Fiuricet, Fiurinal, and numbers of other non-opioid and non-addicting medications were commonly used effectively to treat pain. Interestingly, all those alternatives to opioids were removed by the FDA just as the pharmaceutical companies all announced "bigger and better" oral formulations of opioids to be released. This all occurred simultaneously to each state's medical boards suddenly dictating physicians to be ultra-conscious and responsive to "PAIN" symptoms from patients. On hindsight, obviously none of this was an accident and none of it occurred in a vacuum. The fact that the FDA cooperated by removing the competitors to those new oral opioid meds remains very disturbing. Now that there is new litigation in the works, regarding the pharmaceutical aspect of our current opioid epidemic, perhaps people will begin to really delve into how this situation evolved in our country.
    • [email protected]
      Bob, I cannot offer you professional feedback, as I am not a medical professional. But as an engineer and a patient on the recovering end of a very long and painful journey, it is my opinion there is no simple solution to this dilemma. We would term it as a higher order, or multi-dimensional, or whatever works. But maybe I can offer you my perspective. I was injured in my last combat tour. A simple, almost embarrassing grade 2 or 3 tear of multiple muscle groups in my calf (Soleus, Gastroc, and plantarus). As a leader, I had to endure the pain to see the deployment through. Sadly, it went downhill from there. The scar tissue and fascia required a four-compartment fasciotomy, and eventually it plugged the popliteal opening and began killing the nerve. Every step was like an ice pick sticking into the center of the calf. Finding a doctor willing to treat the pain in a sequential, planned, and caring manner seemed to be the hardest challenge of all. Since these are not just sympathetic nerves, blocks would just waste the muscle. I was literally begging orthos to help find a way to end the hell I was in. Even the chainsaw in my garage was tempting one day. FINALLY, a pain specialist took a risk to treat the pain with carefully dosed NORCO and targeted bupivocaine blocks to identify the location of the deinnervation and we got it released. By that time, CRPS symptoms had begun, and we had to work fast. The popliteal opening had almost completely closed and scar tissue was adhering to the tibial nerve all the way to the sympathetic branches. The only thing that kept me from putting a bullet in my brain was a caring doctor willing to treat the pain with multiple approaches, a plan, and yes, a simple narcotic. That NORCO was a significant contributor to saving my sanity, and possibly my life. I wasn't depressed because of an imbalance. I was enduring nerve pain 24/7 I wouldn't wish on anyone. Through this adventure I met several of the most uncaring, mistrusting, and acutely accusing medical professionals I never thought existed. Even when faced with an OBVIOUS, well-documented need, the fear of treating patients with pain has taken an almost medieval level of fear. Fear of being raided by state police. Fear of being charged with murder if a patient overdoses. It doesn't have to be this way. Now that we're done, I actually have what feels like a criminal record. After begin gutted like a fish last year for a burst appendix, I was given FIVE norco. FIVE! Why? Because they saw I had a history of being a pain patient in the mandated narcotic tracking system. No one asked about the history. Not one discussion of pain. If I had access to heroin that week, there would have been no question I would have used whatever I could get my hands on. I wonder how many give in to suicide. I can assure you this fear is harming patients because I lived it. There was a time doctors took an active role in managing pain. You protected patients from the alternatives by giving them MANAGED care. Now you send them home with Ibuprofen and if they are lucky, they are told to suck it up. And we wonder why there has been a surge of narcotic addiction, especially in blue-collar working states. If you want to quell the crisis, you must work to return to taking care of patients. Had I known then what I know now, I might have traveled to France to have my leg removed below the knee. Because the only other option was a needle from the street. This needs to be fixed.

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