Pain and Suicide: The Other Side of the Opioid Story | Pain Medicine | Oxford Academic – Lynn 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.