Introduction To My Next Book, to be entitled The Opiate Cure, Pain and the Bipolar Spectrum.
For those of you unfamiliar with my writings on the subject of chronic pain, I will briefly summarize them and in doing so introduce you to this work.
In 2004, I published my first book, Understanding Chronic Pain. I accepted the generally held belief that chronic pain could best be defined as pain that extends beyond the anticipated time of recovery from illness or injury. I pointed out, however, that when this happens there appears, almost invariably, a host of other symptoms in addition to the pain. These include disordered sleep, appetite, energy, mood, thought, memory, and even motor skills. I emphasized that these symptoms coexist so frequently with chronic pain that they must be considered inherent to the disease, and it matters not whether the painful state is fibromyalgia, headache, back pain, neuritis, arthritis, or whatever. Clearly there is great commonality among those who suffer chronic pain. For this reason and others, I suggested that although chronic pain may appear in a variety of forms, it represents a single core illness. I suggested also that the illness could be best considered a disorder of the mind. The reasons for this are several. Chronic pain is often preceded by the psychiatric disorders of substance abuse and depression and also very commonly by childhood trauma, particularly sexual abuse, which, as you may know, is the mother of many psychiatric diseases. Moreover, chronic pain often coexists with psychiatric illness including depression, panic, bipolar disorder, attention deficit disorder, post-traumatic stress disorder, obsessive-compulsive disorder, multiple personality disorder, and others. In my book I presented the case histories of people with chronic pain who were successfully treated by the introduction of psychopharmacy (drugs for the mind). I concluded that recognition and treatment of the coexistent (comorbid is the medical term) psychiatric disease could often relieve pain.
My book did well, and 2006 found me working on a second edition. In the main I was pleased with my work. My ideas seemed to be standing the test of time, at least as measured over a couple of years. Therefore, I made no major revisions in the new edition. Nonetheless, a couple of lines of thought were evolving. One related to the role of opiate therapy and the other to bipolar disorder. Let's take bipolar first.
I had written about a man whose recurrent back pain went away when his bipolar disease was treated with Lithium. Thus, I did appreciate a link between the two diseases, but I thought the effect was probably quite rare because (I believed then) the incidence of bipolarity in the population at large was only about two or three percent. However, as time went by, and I learned more about bipolar disorder, I began to recognize the very great frequency of bipolarity in my patients with chronic pain. Moreover, I found myself becoming more comfortable and confident in treating people who suffer both pain and bipolarity. The reader is advised that can be an intimidating combination. The victims of bipolar disorder are brittle emotionally, behaviorally, and also pharmacologically. Their responses to drug therapy are often adverse and unpredictable. Drugs that should make them better can make them worse. Moreover, there is a high incidence of drug abuse in the bipolar population. (Some 50 percent of heroin addicts are bipolar!)
It was in the summer of 2006 that I first learned of the emerging concept of the Bipolar Spectrum. Psychiatrists were recognizing that bipolar disorder was often linked, that is to say comorbid, with narcolepsy, migraine, attention deficit disorder (ADD), and obsessive-compulsive disorder (OCD). There was also increasing awareness that bipolarity and chronic pain in its many forms were often comorbid. I bought into the concept quickly because it fit with so many of my own ideas, but I did strike out a couple of times. I should have appreciated a link between bipolarity and migraine because I was seeing plenty of both, but I didn't make the connection. In but a short while, however, I realized that migraine is quite common in the bipolar, and it is often severe and treatment-resistant. The link to narcolepsy had escaped me entirely, but I did recall that some of my patients did complain of vivid, threatening dreams, a hallmark of narcolepsy.
I was sure the concept of the bipolar spectrum was correct. I accepted unreservedly the clinical link, that is, the simultaneous existence of some or all of these disorders in one person. And I knew also that there was very likely a genetic link. Bipolarity is often a familial disease, and many of my painful bipolars had children with ADD. Now, could there be a therapeutic link? That is, could the treatment of one disorder in the spectrum relieve the others? Particularly, what would be the role of psychostimulant (Ritalin is an example) therapy? The psychostimulants are indicated in the treatment of both attention deficit disorder and narcolepsy. What would be their place in the treatment of bipolar disorder, chronic pain in general, and migraine in particular? I knew I would find out pretty soon.
My opportunity came when a woman with arthritic knee pain was referred to me. She was bipolar, years on treatment with many drugs. She told me that as her pain had appeared and was progressively worsening, she had developed a problem with mood shifts (bipolarity), forgetfulness, want of mental focus, and distractibility (ADD). In response to my questioning, she reported that she had throughout her life been subject to vivid dreams. Moreover, she was fatigued and daytime sleepy (narcolepsy). I felt I had limited treatment choices. I certainly wasn't going to employ conventional psychopharmacy because she had already been on most of the drugs I use, and many of them had made her worse. That left opiates for her pain or stimulants for her attention deficiency and narcolepsy. Fearful (at that time) of opiates in the bipolar, I prescribed Ritalin knowing that it might precipitate mania but knowing also that any drug I chose might precipitate mania. It wasn't a very attractive choice, but I thought it was the best. The only other option was to tell her I had nothing to offer, and I don't like doing that. Her recovery was sudden and total. Within but days her pain was relieved, her distractibility diminished, her energy restored, her sleepiness overcome, and in short order her nightmares went away. Astonishingly also, her mood shifts were arrested.
Encouraged, to say the least, by her response, I continued to pursue the role of psychostimulant therapy. I encountered a young woman with accelerating migraine and also anxiety and with them the appearance of nightmares. Again, the improvement with stimulant therapy was dramatic. Her migraines disappeared, and her anxiety level was diminished. I was also to discover later that her dental phobia was totally abated. She could attend, under the sponsorship of my therapy with Ritalin, a dental appointment without fear or anxiety. Next I encountered a patient with migraine who also suffered obsessive-compulsive disorder, which was only partially responsive to treatment. She reported very threatening dreams. I introduced stimulant therapy, and not only were her migraines and dreams diminished, but her obsessive-compulsive disorder also.
It had not taken long to validate, at least in my mind, the concept of the Bipolar Spectrum. It made bipolarity bigger and more complex than I had thought but also more vulnerable. There were more points of attack.
Now, back to opiates. In Understanding Chronic Pain, I had largely neglected, perhaps even disparaged, the use of opiates. I worried (probably too much) about addiction. A bigger issue was that the opiates, I thought then, were rather ineffective in the treatment of chronic pain. Such was my enthusiasm for the role of psychopharmacy that I wrote that the victim of chronic pain can actually get well or nearly so with those drugs. The victim of chronic pain did not get well with opiates, only a bit better until it was time for another pill. Nonetheless, one cannot be a pain doctor and not use opiates, and as time was going by, I was becoming more knowledgeable about the opiates and more aggressive in their use. Whereas formerly I had chosen to employ the weakest, and presumably least addictive, opiates, I had, with increasing experience, begun to employ stronger ones in bigger doses and often in combination. I finally realized that the generous prescription of opiates can reduce human suffering, and that, I concluded, should include bipolar human suffering.
A man who had endured multiple spinal operations and was chronically back painful was referred to me. He had become extremely obese, for chronic pain is often a food-craving, weight-gaining disease. With his pain he had evolved, as is so often the case, into unstable bipolarity with depression, suicidality, and periods of manic hyperactivity and anger requiring hospitalizations and on one occasion, incarceration. He was under psychiatric care, receiving multiple drugs without much success. I was not attracted to giving him more so I elected to simply prescribe morphine for his pain. Within days his pain was relieved, and his mood was stabilized in a manner he had not known for years on conventional therapy. Moreover, his lust for sweets was abated, and he started losing weight rapidly.
Next, a woman in her 40s who had been raped and shot in the neck by her ex-husband. The carotid artery was damaged but surgically repaired without incident. The bullet, however, remained lodged in the vertebral column and surgery to remove it would carry a high risk of paralysis. She remained neck painful and required the use of a thick collar to prevent painful neck movement. Within a few months of her assault, she developed post-traumatic stress disorder with anxiety, depression, and terrifying flashbacks to the event. She attempted suicide and required a hospital admission. While there, her mood shifting bipolar disorder was recognized and treated. However, in spite of aggressive psychiatric care with many medications, she remained anxious, angry, mood unstable – and painful. I prescribed Morphine. On her return she reported that she didn't hurt quite as badly, but that little else had changed. I probably should have increased the dose of Morphine. It was helping a bit, and she was having no significant side effects, but for reasons still uncertain to me, I elected to add another opiate, Methadone. On her return, she was unencumbered by the collar. She moved about gracefully and she told me with a radiant smile that I had cured her. The pain was gone, and her anxiety, depression, and mood shifts also. Moreover, she was no longer having flashbacks.
I had, within the course of but a month, seen two unstable and painful bipolars whose disease was totally and suddenly arrested by the administration of opiates. Both of them were clinical miracles, and one does occasionally see a random clinical miracle. But two nearly identical miracles in one month are not random. I did some research and discovered that in the first half of the twentieth century, before the advent of our contemporary pharmacy for psychiatric disease, Morphine was sometimes used for the treatment of depression, mania, and delirium. Occasionally it worked. The effect was called the Opiate Cure.
Once again the Bipolar Spectrum was validated. Just think about it. By the employ of a stimulant in persons with narcolepsy or attention deficiency and the employ of an opiate in persons with chronic pain, I had not only relieved the pain of arthritis, migraine, a multiply operated low back, and a bullet in the neck, I had also cured or ameliorated bipolar disorder, obsessive-compulsive disorder, attention deficit disorder, phobia, post-traumatic stress disorder, narcolepsy, and even obesity! It beggars the imagination that all this could happen in only five patients. But it is true.
I knew I had to share these stories, and I began my second book to be entitled Curing Chronic Pain. To a remarkable extent, I was learning as I was writing. So rapidly coming were new experiences and new ideas that at least a third of the material presented in the book I did not know when I began writing it. Indeed, I found it difficult to end the book because almost daily, it seemed, there was a new experience and a new insight. Fortunately for me, the learning curve, which had been ascending at great velocity over the course of a couple of years, has slowed a bit, and that is good. It has given me time to gather my thoughts and process what I have learned. It has also given me time also to increase my database. My population of patients with chronic pain and the bipolar spectrum on treatment with opiates or stimulants (and sometimes both) has grown from a few dozen to a few hundred. I have come to embrace the concept of the Bipolar Spectrum and more importantly, its clinical application. By understanding the scope of the disease and its very common association with chronic pain, I am better able to treat both.
The acceptance of my ideas by those who I have treated, usually quite successfully, for chronic pain and bipolarity has been enthusiastic. Others who have read my books or visited my website have also been accepting, and I will shortly share some of their emails with you. Among the medical community, however, acceptance has been much more hesitant. There are, I believe, many reasons for this – some good and some not so. One is the sheer improbability that stimulants, and especially opiates, can relieve such a host of different psychiatric disorders, even those that were resistant to conventional therapy so quickly and so totally. It is too good to be true, and, therefore, it challenges credulity. Moreover, if it is indeed true, why had we not recognized it sooner? The opiates have been around for millennia, stimulants for over a century. If their effects are as dramatic as I have written, why did we not see it? Actually, we had. The use of opiates for the treatment of mental illness was widely practiced throughout the western world, perhaps most so in Germany, but certainly also in the United States. I will remind the reader that the only other treatment for severe mental illness in the opiate era was the prefrontal lobotomy, the surgical destruction of a portion of a person's brain. With the development of electroconvulsive therapy in the 30s, and then effective psychopharmacy in the 60s, both the opiate cure and the prefrontal lobotomy were consigned to oblivion. The prefrontal lobotomy fortunately so. The opiate cure – well, one wonders.
A bigger issue relating to the acceptance of opiate therapy for psychiatric disorders lies in our medical and societal attitudes toward the drugs. All agree that they are necessary for the relief of acute pain, and nearly all agree that they should also be employed in the long-term treatment of chronic pain. Nearly all also agree, the author and a few others excepted, that they have no other real clinical utility beyond the relief of pain. Moreover, they are dangerous to the person who uses them regularly because he will become addicted and to the doctor who prescribes them because he will lose his license. The extent of this fear cannot be overstated, and that is why so few doctors use opiates generously and, therefore, why so few doctors have the opportunity to witness the opiate cure.
I was 20 years a pain doctor, prescribing opiates regularly, before I witnessed it. It was an exercise in serendipity (finding something good that you are not looking for). It was a chance discovery, but it was also, I believe, providential. It came at a time in my career when I had recognized the frequency of bipolarity in my painful patients, and when I had discovered the enormity of the bipolar spectrum, and when I was learning to administer opiates aggressively. The two unstable bipolars who experienced the opiate cure were not merely case studies. They were a message that there was a link between the bipolar spectrum, chronic pain, and perhaps uniquely to those disorders, opiate therapy. My patients got better because they were bipolar, and they probably also had pain because they were bipolar. Curious, and perhaps ironic, that the opiates, drugs that I had disparaged in print but four years before, were suddenly becoming my bedrock for the treatment of the painful bipolar, and there are an awful lot of those out there.
