Understanding Chronic Pain

The Opiate Cure

    Roy weighed over 300 pounds.  He was afflicted with that condition known cruelly as morbid obesity.  He was six feet tall, and he carried most of his weight in a massive upper body.  He had no neck at all.  It was just a mass of corpulence fixed to his huge shoulders.  He moved about slowly as he settled himself ungracefully onto the oak examining table that had many times before born the weight of the obese painful patient. 

      "You don't know me, Doc, but I remember you very well.  You took care of my father many years ago.  He died of lung cancer.  I am sure you don't remember."

      The mind of a physician is a strange place.  It has an almost preternatural ability to recall patients seen in the past.  It took a few moments for the recall to register, but it did.  I said, "I think I do remember.  Your father had brown eyes and dark black hair just like you, didn't he?"

      "Yes, that's right." 

      "But I remember your father as a lean and wiry man." 

      "That's right.  That's the way I looked before I got sick.  I have gained 160 pounds since then."

      Roy began his story and as he did, his eyes reddened and tears began to flow.  He was forty, a mechanic, married, and the father of two boys.  About age thirty he developed panic disorder and required treatment with Zoloft.  Two years before he came to me, he hurt his back in an industrial accident.  A ruptured disc was surgically excised, and his back and right leg pain disappeared, but only for a few months.  They recurred, worse than before, and Roy underwent a much bigger operation, the fusion of one lumbar vertebra to another to restore stability.  His pain did not abate at all, and in short order he experienced intense sweet cravings and gained weight rapidly.  Then, as occasionally happens in thick-necked people, particularly painful ones, he developed sleep apnea with heavy snoring at night and frequent attacks of somnolence during the day.  An operation was performed on his throat to open up the upper airway.  His snoring and daytime sleepiness improved but nothing else did.  His pain continued, and he became progressively depressed, speaking often of suicide.  He was subject to attacks of agitation and occasionally of violence, striking his wife and children.  His bipolar disease evolved rapidly, and he required several hospitalizations, some for extended periods of time.  Only after the employ of several different drugs was his psychiatrist able to achieve any control over his irascibility and mood swings.  When he came to me he was on Effexor, Clonazepam, Provigil, and the mood-stabilizers Zyprexa, Risperdal, and Trileptal.  He was also taking the opiate, Hydrocodone, four times a day. 

      Roy must have been a very sick man to require that much pharmacy.  However, the drugs were hardly touching either his depression or his pain.  I had to ask an important question.  "Did any of your doctors ever suggest electroconvulsive therapy?"

      "Yes, they did, but I was afraid of it.  I refused shock treatments." 

      "How are you feeling now, Roy?"

      "I feel horrible.  I can't do anything.  I can't drive a car.  I can't sleep.  I can't go see my kids play ball.  All I do is sit around and eat, and I am still gaining weight.  The doctors say it is due to the cortisone I have taken, and they tell me that some of the medicine I'm on causes people to gain weight."

      "Well, Roy, that is probably partly correct, but I suspect there is more to it than drug effect.  I think your weight gain is part of your illness."

      "Nobody has ever told me that before."

      My treatment options with Roy were limited.  He was, at best, in precarious balance, and even his pathetic state of being was achieved only by the administration of many different drugs.  I elected to consult with the psychiatrist and to introduce no drugs without her consent.  She was available and happy to take my call.  She recounted the history much as Roy had given me.  She commented that both she and her consultants very much wanted to do electroshock treatments, but Roy refused. 

      "Why so many drugs?" I asked.

      "That is what it took to control his mood swings.  He really has been a difficult management problem.  Do you have any ideas about what we might do?"

      "Only one.  He is on Hydrocodone for pain now.  I wonder, what would happen if we added morphine?"

      "You know, that is really not a bad idea.  We have tried to avoid using much opiate because we had enough problems without introducing them, but I am in agreement.  You go ahead and prescribe it, and I will help you keep a close watch on him."

      I told Roy to continue taking the medicines as he has been, including the Hydrocodone, but that I was going to add morphine in the form of MS Contin.  I wrote a prescription for a 15 mg. pill and told him to take one every twelve hours.  If he found it helpful and wanted more, he could go up to two every twelve hours.  The prescribed dosage, a minimum of 30 mg. or a maximum of 60, are not really small doses of morphine, but by no means truly large.  I thought the risk was low, and the potential for gain was significant although I had no idea it would work nearly as well as it did.

      On his return, he told me he was taking 60 mg. a day and feeling much better, at least until a couple of days before.  The drug had allowed him to be more active.  He went into his garage, and for the first time in two years actually sat down on his motorcycle. 

      "When I did that, the pain all came back.  It got a lot worse.  I am afraid we are not getting anywhere at all."

      Again, the physician must expect and be prepared for reverses in the painful.  They are almost inevitable.  He must also be ever-hopeful and must share that faith with the patient because it is the lack of hope that most defines chronic pain.  It was highly unlikely that the simple act of lifting a leg, no matter how big it is, over a motorcycle and fantasizing about riding it would destroy a fused spine.  It is much more likely that it would do nothing more than sprain muscles unaccustomed to that kind of movement.  I told Roy that I thought we were just suffering a temporary backset.  I gave him a shot of cortisone.  I was not sure it would help, but at least I was doing something.  I told him to maintain his opiate therapy as before and come back to see me in a couple of weeks. 

      He returned with a big smile on his face.  "Doc, I could just hug you." 

      I said, "Please don't do that Roy.  You would kill me!"

      He laughed, maybe the first time he had really laughed in two years. 

      "I can't tell you how much better I feel.  I even got back on the bike, and it didn't bother me at all this time."

      "Roy, you are smiling and you are laughing.  It looks like the depression may be going away."

      "Yeah, Doc, it really is.  My moods aren't swinging like they used to.  I don't feel angry and agitated anymore, and my pain has almost gone away.  I think I can start getting off some of the other medicines.  I am not sure I need them anymore."

      "Let the psychiatrist call the shots on that one."

      "I saw her just a few days ago.  She was really impressed with how well I was doing. She said we would probably come off the drugs, but we would have to do it very slowly.  She wants to wait a while."

      "I agree with that."

      "Doc, there is something really amazing that is happening to me.  I am very proud of it, and I want you to know about it.  Since I started the morphine, I don't crave food the way I used to.  I have been on it a month now, and I have lost 20 pounds!"

      I have written before and will continue to write that when the right drug kicks in, everything gets better.  The morphine relieved Roy's pain, and that is what I hopefully expected to happen.  It also relieved his depression.  I didn't expect that, but I had heard of similar cases.  However, I never anticipated that morphine would arrest his violent bipolar mood swings and certainly not his pathologic appetite.  (Was that a symptom of his bipolar disease?  I wouldn't bet against it.)

      I have seen my share of clinical miracles, but Roy was unique in that the totality of his recovery was so unexpected.  It was an exercise in serendipity, which means discovery by accident.  It was an eye-opener for me.  Opiates for the treatment of mental illness!  I had never entertained the notion.  I had dedicated my professional life to relieving pain by treating, with psychiatric drugs, the mental illness that so often is its root cause.  I had never seriously thought about the converse, that by treating pain with opiates, I could cure mental illness! 

      A brief digression here.  I began my medical studies in 1955 and entered practice in 1963.  That span of eight years witnessed the birth of modern psychiatric pharmacy.  It still boggles my mind when I think back to it.  When I began, we had virtually no effective drugs for the treatment of mental illness.  When I completed my training, we had the first tranquilizers in the form of Meprobamate (older readers may recall the proprietary names Equanil and Miltown) and Librium, the first benzodiazepine.  We had the first antipsychotics, Reserpine and Thorazine.  Also the first antidepressants, the tricyclics Imipramine and Amitriptyline.   And a new anticonvulsant, Tegretol, for many years to remain the bedrock in the treatment of nerve injury pain and bipolar disease.  So great was the enthusiasm for the new drugs, my mentors, as best I can remember, never told me that before they came on the scene, morphine was sometimes used in the treatment of psychosis and mania and was occasionally quite successful – an effect that was called the opiate cure.      
 
 
 

      A year or so ago I was attending a woman with severe spinal pain.  I was treating her with morphine in the extravagant dose of 300 mg. daily.  Nonetheless, her pain, she told me, was insufferable, and she requested something – anything – to give her relief.  I elected to add a second opiate, and I chose Methadone.  I don't know why I did it.  It had never been one of my favorites, indeed I had used it but rarely.  Nonetheless, something, Providence perhaps, directed me to try the drug.  I prescribed it at the rate of 10 mg. three times daily, a test dose to see if she could tolerate the drug. 

      She returned at the appointed time and said, "It is working.  It is really working.  I am almost free of pain.  I can't tell you how much better I feel." 

      "I am astonished, Joan, I am truly astonished.  I certainly didn't expect that kind of response, but I am happy that you are better." 

      "I am astonished, too."

      "Are you taking it as I prescribed, three times a day?"

      "No, I am taking it only once a day.  That is all I need.  I haven't even tried to go up on that dose."

      "Say what?" 

      "I am only taking one pill a day.  That is all I need." 

      "You are taking only 10 mg. of Methadone.  That on top of 300 mg. of morphine, and you are better, you are a lot better?"

      "Yes, absolutely.  I don't hurt anymore, and there is a certain calmness that I feel.  I guess relaxed is the word.  Before I started the Methadone, I always felt frustrated and irritable with my pain.  That has all gone.  I am grateful to you." 

      "Joan, let me hear this again.  You took one pill, and you felt so much better that you didn't feel the need to even try a second one?"

      "That is correct.  One pill a day is quite enough."

      Oh my God!  A woman's bitterly painful life had been transfigured suddenly and totally by taking one Methadone pill a day. 

      Joan's response to Methadone was, by any measure, unexpected, atypical, and bizarre.  But I feed on the atypical and bizarre.  They are my sustenance.  I had learned something that might turn out to be very important, and I stashed it away, certain that when the right time came, I would try the morphine and Methadone combination again. 

      A word now about Methadone.  It was synthesized – that is, made from scratch – in Germany in 1937.  Unlike Hydrocodone and Oxycodone, which are semi-synthetic, the opium poppy is not necessary for its manufacture.  Methadone has the most erratic metabolism of all the opiates, and its clinical effect is sometimes unpredictable.  Nonetheless, it is an effective painkiller, easy to manufacture, and relatively speaking, dirt cheap.  It has several curious features, and the best known is its capacity to diminish cravings for heroin.  It is widely employed for that purpose, and there are Methadone maintenance clinics in every major city in this country that administer Methadone to heroin addicts in recovery.  Another curious feature of Methadone, referenced early in this book, is that in addition to being opioid agonist, it is a glutamine antagonist.  And remember, glutamine is the neurotransmitter that we believe is responsible for mania, panic, pain, and almost certainly many other bad things.   
 
 
 

      Alice walked into the examining room with excruciating slowness.  She was wearing a thick collar about her neck and a stocking cap pulled over her head so low that her face was hardly visible.  She was helped onto the examining table, an activity associated with grimacing, wincing, and an occasional cry in pain.  She was exhibiting her suffering.  I asked her to remove her collar and her cap.  She did so slowly, protecting herself from painful movements.  I took the opportunity to scan the referring doctor's brief letter.   

      Dear Dr. Cochran

      I am referring Alice Driver to you for consultation regarding (1) neck pain, (2) depression, (3) anxiety syndrome, (4) post-traumatic stress disorder, (5) fibromyalgia, and (6) headache.  I am not comfortable prescribing controlled substances for her, and she is requesting pain medicine.  I am willing to release her to your care.  When you have completed your evaluation, I would be interested in your impressions and recommendations. 

      Sincerely, 

      Roy Conner, MD 
 

      Well, it turned out he had missed a couple, but it was a pretty good start.  I looked at my patient, her face and head now exposed.  She had a large surgical scar on the right side of her neck, and her scalp was adorned with electrodes attached by wires to a miniaturized electroencephalograph (EEG) for recording brainwave activity.  I knew I was in for an interesting visit, and I asked her to tell me about her pain. 

      "There is a bullet in my neck.  They say they can't remove it.  I would be paralyzed if they did.  I am in constant pain." 

      "How did it happen?"

      "My ex-husband shot me."

      "Was it an accident?"

      "No, he was trying to kill me."

      She told me that her carotid artery had been damaged and that she required emergency surgery.  The artery was successfully repaired, but the bullet had lodged deep in the neck in the vertebral column and could not be surgically removed.  This had happened some seven years before.  Remarkably, she had been able to go back to work on an automobile assembly line.

      "Wasn't that painful?"

      "Yes, but I had to work.  I had to have some income, and it was really a good job." 

      "You can't work now, can you?" I asked, stating the obvious.

      "No, I had to retire two years ago."

      "Because of the pain?"

      "Well that was part of it, but I had another problem.  I became very nervous, and I started dreaming about being shot.  Sometimes the memory of it would come back to me out of the blue."

      "Flashbacks?"

      "Yes, flashbacks.  They told me I had post-traumatic stress disorder.  I got very depressed, and I tried to commit suicide." 

      Stress disorder need not appear immediately following the stressor.  It may, and often does, find expression years removed.  Alice told me that her anxiety and depression came on when she started talking to friends about her assault.  She had kept those thoughts and memories to herself for several years, but then when she started sharing them with others, she became very ill and increasingly painful.

      "What are you taking for pain?"

      "Nothing, I am on so many medicines already the doctors are afraid to give me pain drugs."

      I looked at her intake history and saw the drugs listed – Effexor, Abilify, Lamictal, Seroquel, Diazepam, and most recently Lyrica.  Aggressive psychiatric polypharmacy for sure.  The employ of four mood stabilizers suggested there might be something more than stress disorder.

      "Did any of your doctors tell you that you had bipolar disease?"

      "Yes."

      "When was that diagnosis made?"

      "After I attempted suicide."

      "When was that?"

      "About six months ago."

      "Have you always been moody, up and down?"

      "Yes, for a long time."

      "And the drugs – are they helping your moods?"

      "Yes, they are helping some, but I am still up and down."  And then she looked at her boyfriend. 

      "She sure is up and down.  Sometimes she gets real angry, but I know it will pass away."  He patted Alice on the shoulder. 

      "Alice, how is your pain now?  Pretty bad?"

      "Yes, it is really bad.  It's the bullet in there.  Can you help me?  Can you give me something to relieve my pain?"

      "Probably, Alice, but another question.  Your doctors are doing brain wave tests on you even as we talk.  Do they suspect that you have some kind of seizures?"

      "Yes, they began when I was in the hospital.  I started having passing out spells.  I would just go blank, and I wouldn't know what was going on around me."

      I directed my attention to the boyfriend because the victim of convulsive seizures usually is unable to recall the experience.  Valuable information can be obtained, however, from an observer. 

      "Have you ever seen a seizure?"

      "Yes, I have seen lots of them.  She goes blank, and then she stares into space.  Her eyelids kind of flutter, and then her eyes turn up."

      "How long do they last?"

      "A few minutes.  I put a cold washcloth on her head, and that seems to help."

      As I have written many times before, what a strange disease is chronic pain!  There was so much more to Alice's discomfort than a bullet lodged in the neck.  Equally important, perhaps even more important in the evolution of her pain was her bipolar disorder, post-traumatic stress disorder, and almost certainly pseudoseizures. 

      There are many types of convulsive seizures.  All are attended by an alteration of consciousness and many by muscle jerkings that can be quite violent.  In occasional cases, muscle contractions are less dramatic and consist of a few repetitive jerks or semi-purposeful movements of the extremities.  Sometimes there is no abnormal movement at all but only a blank stare.  Alice, perhaps, had the latter, but the appearance of epilepsy at this stage of her life was statistically improbable.  Moreover, very few seizures are attended by fluttering eyelids, and very few seizures get better with the application of a cold washcloth to the forehead.  I was quite sure that her EEG would turn out to be normal. 

      Pseudoseizures, as the name suggests, mimic convulsions but are not real seizures at all.  Rather, they are a psychologic reaction to stress appearing in the form of blackouts.  As traditionally defined, the pseudoseizure is not a conversion reaction, but it is awfully close.  The neurologic loss is not vision, or strength, or sensation.  It is consciousness.  I have already written about pain behavior and conversion as but another of the many expressions of chronic pain, and prognostically a good one at that. 

      As bad as it all seemed, I was very hopeful, even confident that I could help Alice.  I couldn't remove the bullet from her neck, but I am not sure that had all that much to do with the pain.  Remember, after her injury, she was able to go back to work assembling automobiles.  It was only when she quit trying to repress the experience and shared its dreadfulness with her friends that her bipolarity, post-traumatic stress disorder, and severe pain appeared.  The reader is reminded of the story of Eve in Chapter 12.  She started getting better when she finally began to talk about her past trauma.  Alice got worse when she did.  It is hard to understand, but that is the way it goes. 

      What to do?  What options were available to me?  Her bipolar disease, her depression, and anxiety were only marginally controlled with by the employ of four different mood stabilizers.  I didn't want to toss another vegetable into that particular stew.  It was time, I decided, to see what I could get out of opiate therapy in another unstable bipolar. 

      Alice replaced the collar around her neck and the stocking cap as I wrote a prescription for MS Contin.  I gave her a low dose.  One most always go slowly and carefully.  As she left the examining room, her pain behaviors intensified, and she walked hesitantly with the assistance of her boyfriend, grimacing with each painful step. 

      I saw her two weeks later.  She told me the brain wave test was normal (expected in pseudoseizures).  She still exhibited her painfulness with hesitancy of movement and protective posturing, but there was a difference.  It wasn't quite as striking as before, and her boyfriend had something approaching a smile on his face. 

      "How are we doing, Alice?"

      "The medicine is helping.  I am sleeping a little bit better, and I don't feel quite as nervous." 

      "She is better," said the boyfriend.  "She is more even."

      "The pain, Alice – how is the pain?"

      "It is still pretty bad.  The medicine takes the edge off, but it is still plenty bad.  What can we do?"

      Perhaps I should have simply increased the dose of morphine.  It was helping her, and she was tolerating it.  Why not just give more? 

      Let's look at the cards I was holding at that point in time.  I had witnessed Roy's resurrection with morphine and Joan's with Methadone on top of morphine.  Experience with two very atypical patients should hardly dictate treatment strategy, but it certainly could influence it.  Besides, I had another card, a very good card.  I knew, at least in theory, that bipolarity and probably pain are driven by the neurotransmitter, glutamine.  I also knew that Methadone antagonizes glutamine.  The time had come. 

      I prescribed Methadone 10 mg. every eight hours.  The dosage I was employing, it should be emphasized, was really quite modest for a bullet-in-the-neck pain. 

      I saw her next a couple of weeks later.  She came in with a huge smile on her face.  She was free of her collar.  Her gait was unencumbered, and she did not step up on to the examining table – she hopped onto it.  She said her pain was gone, her sleep restored, and that her flashbacks had gone away.

      "She is a lot nicer," said the boyfriend. 

      Alice laughed and said, "the medicines are the perfect combination, absolutely perfect.  Everything is better." 

      "Tell me about it."

      "Within a day of starting the Methadone, I could tell I was different.  My pain was much better, and my mood was even.  I didn't feel depressed at all.  This is the best I have felt in a long time.  And you know what?  My seizures have gone away."

      I re-wrote the prescription and watched in absolute astonishment as she walked out of the examining room quickly and gracefully, exhibiting no suffering, no pain behavior at all. 

      Please recall the referring doctor's note in which he wrote "I am not comfortable prescribing controlled substances for her."  Such is the fear engendered in physicians by the unstable mentally ill.  And he was a pain doctor!  Unlucky him.  Lucky me. 

      I knew I had discovered a new weapon, perhaps an incredibly powerful weapon.  I resolved to use it cautiously, and for the time being, only when all else had failed.   
 
 

Last Updated: Feb 28, 01:42 PM

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