Treating the Alcoholic with Opiates
It is widely accepted among pain physicians that a prior history of drug, including alcohol abuse, does not preclude the administration of opiates for the relief of pain. That is to say that past indiscretions do not demand that a patient should not be offered opiates for the relief of pain.
A 50-something-year-old man, an entertainer, came to me for treatment of his chronic back pain. He acknowledged years of alcohol abuse and then recovery through a treatment center some ten years before. With his recovery came depression. It was severe and somewhat treatment resistant. He was given several different antidepressants, and although his depression abated, they reduced him to emotional lethargy and torpor. That is when he came to me.
I prescribed Hydrocodone, a rather low order opiate. I wanted to relieve his pain, and I also suspected that his ongoing depression was probably the product of bipolar disorder. Opiates can be extremely good drugs for that condition, even in those with a past history of drug (alcohol) abuse. He prospered on my therapy, and it was almost immediate. Pain and depression both ameliorated. He handed me a note written by his wife. I want to share it with you because it documents the emotional travail of those who have suffered drug or alcohol abuse and who are forced by circumstance to resume drugs of potential abuse for a valid medical condition.
Dear Dr. Cochran:
Steve asked me to drop you a quick line to give "the wife's perspective" concerning your decision to add Hydrocodone to his current medications. Quite frankly, my initial reaction was to say "WHAT THE HELL???" and burst into tears! (By way of explanation, one of his more spectacular, long-term relapses was triggered by a migraine specialist psychiatrist giving him 16 Percocet a month.) So, to say that I was nervous and skeptical is grossly understating the case! However, the fact that I was even willing to listen to the rationale behind your decision indicates just how desperately concerned I have been about Steve's stubborn and debilitating long-term state of depression. He spelled out in detail what you said to him concerning the terms and conditions under which he was allowed to take his "drug of choice," and most importantly, what his accountability boundaries were and exactly what would happen if he misused it in any way. So with fear and trembling (on BOTH our parts), we decided to trust you.
The bottom line is this: I have never in 34 years of marriage seen a faster and more dramatic turnaround in Steve. For lack of a better description, I will simply say that "the grownup Steve" has been restored to this household – and trust me, that is the polar opposite of the Steve I see when depression leaves him numb and vacant OR the mean, rebellious "teenaged Steve" I see when the addict him is in control. He is currently calm and present. He is relaxed and engaged. His energy level and attitude have changed – up to this point he had been spending most of his time at home parked in front of the TV, wearily dodging all business calls and home responsibilities (not to mention the constant-complaining-factor has diminished considerably – he's much less of a big fat baby about his chronic back pain). I am seeing optimism and hope returning to his eyes, and he is once again – and possibly more than ever – the husband I love and respect, and the father that my girls adore. This might sound like I am overstating the case, but I can't emphasize enough what a HUGE change I have seen.
And most important to me, he is wide-open and accountable regarding the pills. We have worked out a system that does NOT include me acting as the drug police but does give me complete access to counting and/or monitoring the amount of pills he takes if I desire to do that. We check in with each other daily, and I should add that like any good card-carrying Al-Anon member, I am hypersensitive to any signs of overmedication in Steve. To be honest with you, I think the biggest deterrent in keeping him from resorting to the old addiction patterns of lying, hiding, and sneaking more pills is the fact that anything more than 3-1/2 to 4 pills a day results in a return to the kind of numb, flat-line feeling he is trying so hard to break free of. At this point more doesn't equal better, it just starts feeling like depression again.
Which brings me to the biggest question for you. What is the long-term plan regarding keeping Hydrocodone in the mix? Will it soon start requiring a higher dosage than his current 3-1/2 to 4 pills a day to maintain this balance? What will happen when/if the pills are discontinued? Obviously, my number one concern is that part of this regimen might lead to abuse ad relapse. We are both in a place right now of being uber-vigilant and rigorously honest with each other, but I have concerns that time and complacency could lead to a more relaxed view of what is truly the biggest gamble we have even taken with his sobriety. It has been incredibly difficult to trust my family and future to a man I have never even met, much less discussed this highly risky course of action with – it is a testament to you that Steve has not only been completely upfront with me from the get-go, but that we are both willing to step out in faith with this! I am so grateful that at least so far, your personal and professional judgment regarding the medical benefits and Steve's ability to handle a narcotic has been astoundingly spot-on. But I would be lying if I didn't say I now find myself in the surprising and unprecedented position of still being a little bit fearful that you will continue to write the Hydrocodone on a regular basis, but WAY MORE FEARFUL THAT YOU WON'T!
Go figure.
Best,
Steve's wife.
Write a comment
- Required fields are marked with *.
