Understanding Chronic Pain

 
 

ATTENTION DEFICIT, NARCOLEPSY, BIPOLAR DISEASE AND PAIN 

The Bipolar Spectrum and Its Treatment with Stimulants 

      Ruth suffered bipolar disorder and with it, painfully arthritic knees.  Her therapist suggested she take a look at Understanding Chronic Pain.  She made an appointment in short order.

      "I was very taken by your discussions about the relationship between bipolar disease and chronic pain.  I would never have thought that my bipolar illness had anything to do with my arthritis."

      "Well, I am really not sure bipolar disease has much to do with arthritis, but it may have a lot to do with your pain.  Tell me about it."

      "My knees have hurt for many years.  I have had several arthroscopies and steroid injections.  They helped at first, but they are not working now.  I am told that I am bone-on-bone and will need knee replacements pretty soon."

      "What are you taking for pain?"

      "Mostly over-the-counter stuff – Aleve and Ibuprofen."

      "Has anyone prescribed opiates for you?"

      "No, they are reluctant to do that because of my bipolar disease.  My psychiatrist tells me that I am in a very delicate balance, and he is afraid that painkillers might aggravate my emotional state."

      "Tell me about your bipolar disease."

      "I have had mood swings all my life.  It seems that most of my family has the same kind of problem, always up or down."

      "Did you seek any kind of professional help for it?"

      "Not for a long time.  I grew up on a ranch in Colorado and going to doctors just wasn't our thing."

      "Keep going."

      "I went to the University of Colorado and graduated with a major in communications.  I moved to Chicago and got a job with a public relations firm there."

      "And the mood swings?"

      "They were always there, but I was successful with my career.  Most of the time I had lots of energy, and I was very creative.  My trouble began after my divorce.  I got very depressed and attempted suicide.  That was when I was diagnosed with bipolar disease."

      "Did you have spells of mania with hyperactivity?"

      "Yes, lots of them.  And terrible depression also."

      "Did you remain under psychiatric care?"

      "You bet I did.  My psychiatrist was really great.  He tried lots of different medicines, and with each of them I would seem to get better for a while, and then I would lose it.  We would then move on to another drug."

      "Can you give me the names of some of the medicines you took?"

      "Well I remember some of them.  I have taken Depakote, Tegretol, and Effexor, and there were others."

      "How about Lithium?"

      "Oh yes, I did take Lithium for a while, and now I remember.  I took Neurontin and Prozac also."

      "Ruth, let me ask you a question.  Have you ever taken a medicine that actually made you worse?"

      "Yes, I remember it well.  Dr. Reynolds gave me Lamictal.  It was supposed to be a mood stabilizer, but it destabilized me.  I became very depressed, and I had to go into the hospital for a week."

      "And then what?"

      "He put me on Lexapro and Clonazepam.  That has been the best combination ever.  That was five years ago, and I am still on those drugs. 

      "What brought you to this city?"

      "I remarried and moved here.  We have been here three years.  Except for my knees, things have been going very well.  My husband and I are planning to start up a new business.  "

      "Do you have a psychiatrist locally?"

      "Yes I do.  I see him every two months, and he has maintained the Lexapro and the Clonazepam.  I still have some mood swings, but they are not nearly as bad as they used to be."

      "What does your current psychiatrist say about your condition?"

      "He says that I am a rapid cycling bipolar, and that under no circumstances should I deviate from my treatment with Lexapro and Clonazepam."

      Ruth suffered Bipolar I disorder, the most severe expression of the disease.  Not only that, she was a rapid cycler with mood swings occurring not at intervals of days or weeks, but of hours.  Ruth had been a very sick woman for a long time.  Her recovery, or at least something approaching recovery, was really remarkable.  She was indeed in a delicate balance, and I was aware that almost anything I did might upset it. 

      "How bad is your pain now, Ruth?"

      "I would grade it a 6 or 7 on a scale of 10.  I am getting by, but barely.  You must understand, it is important that I am able to be on my feet.  Our new business will entail a lot of traveling to Europe and maybe even the Orient."

      "How are you sleeping?"

      "I am not.  The pain seems to get worse at night.  The sleep problem is new.  I slept pretty well up until about six months ago, and now I can hardly sleep at all."

      "How is your energy?"

      "Oh, it is terrible.  I have a problem with fatigue, and I get sleepy during the day.  I suppose it is because I can't sleep at night."

      "Anything else?"

      "Yes, and this really bothers me a lot.  I can't seem to remember very well.  I just can't think like I used to be able to.  I am in a fog all the time – and I don't need that starting up a new business."

      "Did you ever have any problems like this back years ago when you were so ill with your bipolar disease?

      "Yes, I remember times when fatigue and memory loss were a problem, but these usually happened when I was depressed.  Right now I am really not depressed.  If anything, I am a little bit manic.  I am excited over the prospects for our business."

      Oh boy, I had to think about this one.  I didn't want to go to antidepressants or mood stabilizers.  Ruth had already been on most of them, and one of them, Lamictal, actually threw her into depression.  Maybe opiate therapy?  I chose not, but looking back on it, had I seen her but six months past the time I did, I would probably have done that.  I am glad I didn't, though, for I was about to learn something very important. 

      It may seem counterintuitive to use a stimulant for the treatment of manic-depressive illness because of the risk of inciting mania.  However, there was the prospect that it would benefit her fatigue, forgetfulness, and possibly even her pain.  So the risk must be accepted.  Remember, there is risk with all drugs.

      "Ruth, I am prescribing Adderall.  It is like Ritalin, and I am sure you have heard of that drug.  I really don't know whether it will work or not, but I want you to try it.  If it fails, we can move into opiate therapy, but I don't want to introduce any more antidepressants or mood stabilizers.  I am fearful of doing that."

      "Ritalin, huh?  Do you think it will make me manic?  Decongestants really make me hyper, and I avoid them."

      "Honestly, I don't know, but we will have to be very vigilant to that possibility.  Nonetheless, my instincts tell me it just might help you, maybe a lot." 

      "You are saying this medicine might actually relieve my pain?"

      "It could, it really could."

      "You know, I remember Dr. Reynolds suggesting many years ago that we might try Ritalin.  He was pretty high up on the food chain among psychiatric pharmacologists.  I respected him enormously, but I told him I was afraid of it.  However, if that is what you want, I am willing to take it."

      "Okay, Ruth, I want you to clear this with your psychiatrist.  It is very important that he knows what we are doing.  Adderall, 10 mg. daily, and call me immediately if you develop any signs of mania.  Back in 10 days."

      It was two months before I saw her again. 

      "My pain is worse, it is a lot worse.  I hurt all the time, and I can't sleep, I can't think, and I am fatigued.  Can you help me?"

      "Did you take the Adderall, Ruth?"

      "No, Dr. Rich told me not to take your medicine.  He thought it was too risky.  He told me I should increase the dose of the Lexapro."

      "Did you do that?"

      "Yes, but it has done no good at all.  I'm ready to try the Adderall.  Please write a prescription for the lowest possible dose.  Dr. Rich frightened me, but I have no where to turn, and I want to try it."

      "Okay, let's try Adderall, 5 mg.  Start out taking one a day, and after a week or so, if you are not having trouble, you can go up to two.  I want you to increase your Clonazepam also.  Another thing, Ruth.  I appreciate your coming back, and I appreciate the opportunity to treat you.  I know how concerned and perplexed you are, but I want you to be hopeful."

      She was wearing a beautiful smile when she returned, and she was eager to tell me what had happened. 

      "I am elated.  Within just an hour or so of taking my first Adderall, I could feel the pain leaving my knees.  Since that first day, they have hardly hurt me at all."

      "And your sleep, fatigue, and all the rest?"

      "Unbelievable!  I sleep through the night.  I wake up refreshed, and I don't get sleepy during the day.  There is something else, and we didn't talk about this, but I was having some really weird nightmares.  They have gone away now." 

      "How about your memory and your mental focus?"

      "Much better, I can stay focused now.  I wasn't able to do that before.  I must tell you that I feel so good, I am euphoric." 

      "Ruth, I am happy for your improvement, but you have me worried now.  That word, euphoria, coming from a bipolar scares me.  Are you getting manic?"

      "No, I have been manic hundreds, maybe thousands of times.  This is not mania.  This is pain relief.  This is recovery.  This is happiness.  This is euphoria." 

      My concerns about Ruth's euphoria were certainly appropriate.  Victims of bipolarity can express their illness in many ways, including a feeling of energized well-being.  However, hearing the bipolar utter the word euphoria no longer bothers me now because I have heard it so much.  It is an expression of the flight to health and the achievement of wellness in people who have not known that experience for a long time.

      "Any down side to the medicine?"

      "Almost none at all.  The first few days I felt a little nervous and jittery, but that has all gone away."

      "Ruth, have you seen your psychiatrist since you started the Adderall?"

      "Yes, he told me to keep taking it.  He said he was glad you tried it.  Let me tell you something interesting.  I have seen my orthopedist.  He told me he has seen a number of people with very painful arthritis get better with drugs like Ritalin and Adderall."

      "I do find that interesting.  He must be a very observant doctor.  You can tell him I said that.  Let me ask you another question.  If I recall correctly, you told me your moods were still shifting even with the Lexapro and Clonazepam.  Has that changed any since you have been on the Adderall?"

      "Yes, that has been truly remarkable.  I really feel very even – no highs and no lows.  That may be the most remarkable thing of all except for one other thing that I really don't understand." 

      "What's that?"

      "Within a day of starting the Adderall, I lost all craving for cigarettes.  I was a pack-a-day smoker, and I have not had a cigarette the past month.  I don't miss them at all.  Can you possibly explain that to me?"

      "Well, perhaps yes.  You have had bipolar disease for a long time.  I suppose you know something about neurotransmitters." 

      "Yes, quite a lot."

      "You may have heard of the smoking cessation drug, the antidepressant Wellbutrin.  It stimulates the release of dopamine, and that seems to diminish the pleasure derived from smoking cigarettes.  The Adderall you are taking is a different drug, but it also stimulates dopamine.  That may be why it helped you stop smoking.  Amazing stuff, isn't it Ruth?"

      "Yes, amazing."

      Okay, reader, I did take a chance giving a stimulant to a bipolar, but I feel like I am taking a chance anytime I prescribe a drug, especially to a bipolar.  Fortunately, though, Ruth and I were greatly rewarded.  She got well, and I learned something important.  I was sure that Ruth would not be the last painful bipolar that I would treat with a stimulant. 

      I need to emphasize the suddenness of Ruth's recovery (she was better in hours), and most importantly, the totality.  Her many and varied symptoms, knee pain, fatigue, sleeplessness, daytime somnolence, nightmares, want of mental focus, mood shifting, and cigarette addiction to boot went away virtually simultaneously under the sponsorship of a single drug, and that administered at a very low dose!  It was a clinical miracle, and thanks to Ruth and several other painful people who submitted to my take-a-chance therapies, I see comparable miracles with remarkable frequency now.  I will explore these in the chapters that follow, and I can't wait to get there, but first we must discuss the bipolar spectrum. 

      Psychiatrists now believe that bipolar disorder is a spectrum of diseases.  It encompasses the classic mood swinging Bipolar I and also Bipolar II, in which the amplitude of the swings (they might better be called shifts) is less dramatic.  Another part of the spectrum is attention deficit disorder.  The other is narcolepsy.  To review that subject briefly, it is a disorder characterized by daytime sleepfulness, sometimes coming in sudden attacks.  It is associated with hypnagogic hallucinations, sleep paralysis, and also the curious phenomenon of cataplexy, which describes a sudden loss of muscular tone, often in response to startle or emotion.  It is a brief interval of paralysis, sometimes causing the victim to fall to the floor.  Recovery, however, is almost immediate. 

      Learning that bipolarity was, at least in theory, a spectrum of diseases, or perhaps better, a single core illness with multiple expressions, was a revelatory – and comforting – discovery to me.  It fit my recent experience with Ruth like a hand in a glove.  She had features of the entire spectrum, narcolepsy, attention deficit disorder, and Bipolar I.  And all the bad things went away with the administration of the stimulant Adderall.  It was beginning to make sense.  Bipolarity is a broad spectrum indeed, and its expressions are many and varied.   Nonetheless, there is a single core disease, and that is why everything got better with the administration of a single drug.  I was beginning to understand why, when the right drug kicks in, everything gets better.