Pain and Suicide: The Other Side of the Opioid Story

Pain and Suicide: The Other Side of the Opioid Story | Pain Medicine | Oxford AcademicLynn R. Webster, MD – Mar 2014

A former patient whom I’ll call Jack came to me for help after three back operations. He was on disability because of his pain

I treated him for about four years, struggling all the while to get his insurance to cover his therapies. I tried to get him to see a psychologist, but his insurance would not pay for the service.

He was on what most physicians today would term a high dose of opioids and other medications. I wasn’t convinced that the higher dose was any more effective than a lower dose. He was mostly inactive and reported little improvement in pain or function while on his medication.   

A device was implanted in his abdomen to deliver medication directly to his spinal canal where it could be more effective, allowing me to reduce or eliminate his oral dose of opioids. I began to reduce his opioids per our agreed plan, but as we began the taper he claimed his pain was too severe

He simply could not tolerate the pain.

I insisted that we had to reduce his medication, that the medication being delivered to his spine should allow us to provide pain control equal to or better in effectiveness than the oral medications.

He had never over used his medications.

He had never showed any signs of drug abuse or addiction.

But I was concerned that if he continued on such a high dose, something terrible could happen to him. I also worried that I might be held liable.

During the third clinic visit of this process, he said, “I can’t live like this, Doc.”

Some people who say this are dead serious because their pain (or any other condition) is literally unbearable.

Without effective pain relief, our lives can become so limited and constricted and tormented that death becomes a reasonable escape. That we are forced into this condition by the withholding of an otherwise available solution to our pain (opioids) adds a factor of psychological torture as well.

It’s one thing to suffer because relief is impossible, but when relief is deliberately withheld because we are under the power of people who simply don’t believe we need it, the insult added to our injury can push someone over the edge.

I said, “It will get better,” hoping more than knowing my statement would be true. I counseled him that the pain may worsen for a while, but that—in time—this new regimen would be for the best. I heard his words but not his cry for help.

Three days later I got a call from his daughter. Jack had died from a self-inflicted gunshot wound. He left a note saying he couldn’t live with the pain anymore. He could not see a future. He had no hope. He had no life.

I had to ask myself if my concern for my freedom and licensure had led to this tragedy.

This was a moral dilemma for me.

And we have to remember that if a doctor is punished for appropriate opioid prescribing (promoting patient functionality) that other parties (DEA, CDC, PROP) find excessive, they lose their license and cannot help any pain patients at all anymore.

I could have continued to prescribe a high dose of opioid, but if he had died, even from a natural cause, the medical examiner might have said the death was an unintentional overdose from opioids.

Jack might have even intentionally overdosed and no one would know.

Deaths from opioids have become red flags for investigations. By contrast, Jack’s death by suicide was not widely recognized by anyone beyond his family and me.

I was tormented by the thought that he might have died because I was unable to help him escape extreme pain.

There is enormous pressure to limit the prescribing of opioids in noncancer pain patients today

our society has little comprehension of the nightmare experienced by people who live every day with chronic pain.

Dr. Webster seems to truly understand what chronic pain can do to our lives. Yet, even he was prevented from prescribing the life-saving medication we need (he was prosecuted from prescribing too many opioids).

To make matters worse, the U.S. healthcare delivery system is short on insurance coverage for the full range of interdisciplinary therapies that could make a difference.

As a result, patients are caught in the crossfire between law enforcement efforts and physicians who have fewer, and less effective, tools available to treat patients whose pain approaches levels unimaginable by most people.

I had been actively trying to reduce the amount of medication prescribed to many of my patients. Many patients opposed these efforts, claiming their medication reduced their pain and allowed them to be active.

In most instances I believed the patient, but still felt the risk to the patient of overdose and risk to me of regulatory sanctions was too great to allow them to remain on higher doses of opioids.

Nearly every day I would caution my patients that if they took more medication than prescribed, they could die. After a short pause, in a serious tone, slowly and intentionally, some patients would say something like,

“It would be OK. I am not living a life now. There are worse things than death.”

I’m appalled that in the 21st century, people in the supposedly most advanced country on earth are left in such misery from lack of appropriate medical care that they want to die.

These types of responses always frightened me. But they also gave me insight as to why some patients may overdose—and die. Pain for some people is hell. Without hope, there may be no reason to live.

In fact, opioids, like many medications, have serious risks. But we, as a society, have failed to recognize that the pain crisis is outsized in the United States and our available solutions are inadequate, and that limiting the use of opioids is not enough

We fail to accept that pain can progress to be more of a disease than a symptom and, as a consequence, the many people who suffer from severe pain become desperate without relief and, consequently, lose all hope.

Policy and medicine are at odds with each other and, as an unintended result, practitioners wind up abandoning patients with the worst pain due to the risk of treating them.

To me this is a calamitous outcome but, for some reason, does not generate many speech sound bites, much ink or broadcast time.

Physicians should not be derailed from trying to bring dignity to the lives of all people suffering from a life of dreadful pain.

Admittedly, we need better therapies. But until there is the political will to invest more in developing safer therapies, we cannot abandon our moral obligation to bring the best compassionate care available to people in pain.

Their lives may depend on it.

As much as I hate to admit it, I know that my life depends on the relief I achieve with opioids. I’ve been an active outdoorsy person all my life – it’s a large part of my nature and even biology.  Without regular exercise my depression and anxiety become unbearable.

4 thoughts on “Pain and Suicide: The Other Side of the Opioid Story

  1. BirdLoverInMichigan

    Although I’m allergic to opioids and must use lesser drugs to control my Ehlers Danlos syndrome pain, I’m heartbroken over this secondary layer of the true “Opioid Crisis.” It’s not just the misuse of these drugs by some reckless souls but also the underuse of them by those whose bodies are on fire which is what’s really at stake here, obviously. But, like mentioned above, decision makers cannot know the profound suffering of a chronic pain patient unless they become one themselves. Yet a little imagination could go a long way.

    What’s also present here is the inadvertent creation of another class of pain patient by these suffocating rules: The devastated physicians who not only see and feel the suffering of others on a daily basis and who try to comfort their patients but who’re now faced with their unsolicited role playing for the other team, the tormentors. What about their compounded psychic distress and potential suicidal thoughts from not being able to alleviate human suffering? Guilt stings the conscience as deeply as any injury hurts the body and is often longer lasting. Well, at least for those with normal connective tissue, that is.

    Silly me. I always thought pain was a bad thing which needed to be eliminated as much as humanly possible. Going forward, pre-med students perhaps should be warned they may find themselves forced to play a dual role of pain reliever and pain inflicter.

    Wonder if they could double bill for that?

    Liked by 1 person

    Reply
    1. Zyp Czyk Post author

      You bring up a good point, one about which doctors have been raising alarm the last few years. (See Moral injury and burnout in medicine: https://edsinfo.wordpress.com/2019/11/17/moral-injury-and-burnout-in-medicine/)

      It’s not just in pain management, but also in other areas where they are forced to deliver inadequate health care due to the corporate “policies” that dictate our healthcare these days.

      Since corporations are required to “maximize shareholder value”, as in this quarter’s stock price, our healthcare is in the hands of the new robber barons. The corporate overlords are running our social service systems into the ground by extracting as much value as possible into their own coffers.

      We can only hope they themselves will develop a painful syndrome or have a painful accident or surgery that remains forever painful as so many others have. Let’s see how fast they change their tune when subjected to their own shortsighted policies and patient “care” that’s been pared down to the absolute minimum.

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  2. Kathy C

    Science for Sale!

    We have to ask why these fact based stories have not been influencing medical or policy decisions. Webster and other have been at this for years, yet there has been little or no discussion in mass media. The blackout on stories like this, or those that reflect badly on the current healthcare system, are all by design. When we look at the “pain researchers” that the media goes to, the ones who have promoted themselves, we see that they never conflict with any industry tropes. They almost always repeat a few of them. They do not want to make any industry, potential funder uncomfortable.

    One of the more highly promoted “researchers” Beth Darnell, I know, I am sorry her name keeps coming up, but she is a darling at NPR. Her media profile is high, due to her shameless marketing, and academic connections. As a “pain psychologist’ she does not have to discuss the medical realities, she is not a doctor. Also psychologists do not have the same limitations to their marketing that physicians do. There are still a few vestigial, but unenforced laws and regulations, that regulate physician marketing. The FTC has not caught up with the online marketing, even when it has serious public health ramifications.

    Her Program, should be qualified For financially secure while women with help at home undergoing minimally invasive surgeries, in a competent fully staffed surgical facility. She chose subjects that did not have an infant at home, they might have to lift, or who had to return to their stressful job at a big box store. Subjects with past trauma, or an abusive husband would not have qualified for the study. This subjects “pain flared up” in art class with “brush strokes.” So entitled that she could even take an art class. I am sure she did not have to haul firewood in to keep warm or do her own laundry. Choosing the entitled for these studies, distorts the findings and is blatantly deceptive.

    “Saxe, the former Stanford lecturer, took medication sparingly in the days after her October 2018 surgery. During the months that followed, there were times when the pain flared up, such as after hours of precise brush strokes during art classes. But Saxe, who now feels better, took it all in stride with the aid of the mental techniques she learned in the program.”

    Darnell also has ties to the APA, that helps market her products, and amplify her media and social media presence. The so called opioid epidemic, elevated her career, her book marketing, and online presence. Since she is very careful in criticizing anything the industry find uncomfortable, she is a sought out speaker. The industry loves her take on the psychological and mind body connections. They have for decades now, found ways to flip this narrative, to blame the patients. When the so called opioid epidemic, was covered by the media, and it became public knowledge, the pharmaceutical companies, blamed patients, and physicians, while demonizing the addicted. This was a carefully planned PR device, to take attention away from their activities. Darnell’s work did not conflict with any of this, in fact it reinforced it.

    Some of these academic/marketers have come out with statements about opioid tapering, after they weaponized it. States are creating even more draconian guidelines than the CDC guidelines, which were based on media amplified “studies” and misinformation. Of course since none of this was based on science or facts, there were unintended consequences. The death rate went up, pain patients turned to suicide, and the people with addiction kept dying too. Even though the facts appear to be coming out, in a few media articles, the alternate facts are still being used in mass media.

    https://www.mercurynews.com/2019/12/28/stanford-offers-a-mindful-approach-to-pain-relief/ The false narrative here, is that pain is not serious, and it can be wished away. She is selling her new program, “My Surgical Success.” Among a select group of patients this appeared to reduce the number of pills the subjects took. The study is unscientific, yet it is being marketed and promoted here. I doubt that all of the surgeries, are complication free, unless she chose only patients in a certain category, and income level, with support at home. She chose patients who would provide a positive outcome. There is evidence that a lot of surgical patients are so frightened of opiates, or for whatever reason do not take them, this would have made her “study” have a positive result. There are so may ways to rig these studies, and the public has no idea they are being played.

    Of course the articles contains the conflated numbers, in order to make this sound more compelling they mix deaths from prescribed opiates, stolen prescribed opiates, suicides, and dangerous illegal street drugs.
    “These powerful painkillers have led to a severe addiction crisis that has ravaged many parts of the country. More than 130 people in the United States die each day from opioid overdoses, according to the U.S. Centers for Disease Control and Prevention.”

    This is what happens when they treat a public health issue, like a marketing opportunity. In marketing the negative consequences can be left out, just like they left out the suicides, and other negative consequences. This country used to have laws and regulations on health marketing.

    Here is some interesting reading on the corruption of academia, by industry interests.

    https://bostonreview.net/science-nature/david-michaels-science-sale?

    Liked by 1 person

    Reply
    1. Zyp Czyk Post author

      Misleading research is the norm these days because money is controlling almost everything these days. That’s fine for clothes or cars, but when even social services are being privatized and corporatized, a line has been crossed. Social services and profit motive are incompatible.

      That last link is perfect and I may be blogging about it soon,

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