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Methadone and the Pained Patient1

I respect you as a professional audience, so I am willing to address you as I do my patients.  I may be tempted to wallow in polysyllables and convoluted concepts to impress or entertain you, but if what we do and say as clinicians doesn’t make simple sense it probably is worth little to our patient.

No patient comes into methadone treatment without having suffered severe and chronic pain.  Sometimes conditions like cancers or progressive arthritis are obvious causes of this patient’s pain, but other times it isn’t easy for us to see a simple underlying cause.  Sometimes it is clear the pain is relieved by the drug, and sometimes when we look calmly and closely we see the drug dependence itself sets up the pain.

So there may be a vicious cycle, one we can describe and understand.  Recent biochemical information illuminates impressions we have held for millennia that opioid drugs are attractive to us because they relieve my physical and emotional pain.

Our street heroin addict can be stereotypically recognized (“street heroin addict” because he may no longer live indoors; or “alley heroin addict” perhaps; often still a “penthouse heroin addict” despite the expense and destructiveness of drug dependence—especially if he is a dealer) whose vulnerability to pain and history of deep deprivation stimulate my working hypothesis that to be addicted to a “pain reliever” is evidence of unusual sensitivity or vulnerability to pain.

Though the surgical or medical “physically” pained patient appears to be dependent because of the painful condition, I begin to doubt that is so purely so.  He may come to appear and act very similar to the delinquent addict (“drug-seeking” and such), compared with the many other injured or afflicted persons who do not act drug-dependent.  The addicted person may be more sensitive to pain, and some pained persons may be more vulnerable to addiction.

We can avoid some unnecessary confusions by being cautious of the “mind-body dichotomy” which can lead us to psychologize or to somaticize addiction, in an unbalanced and un-integrated fashion attributing it only to mind or only to body.  As we have shown before, each of us is indeed an integrated individual (body, feelings, imagination, self-image developed in response to a unique life-history molded through the lens of a unique personality).

If as clinicians we perceive mere shallow facets of the patient we will never meet the whole person who is really there.  And our task is not merely to perceive but to interact with that real whole individual, and to serve him in a positive fashion determined not by his demands or impulses but by his own real needs (not the ones we wishfully project onto him).

For the chronically pained patient drug-free treatment may be a valid ultimate goal, but it is not always easy to achieve it.  Control of the number and amounts of drugs can only be done within a sympathetic and responsive clinical relationship.

I see each methadone patient as pained somehow, each chronically pained patient as somehow addicted.  Such is my own characteristic “idiom of absolutes”.  Others may prefer to see a spectrum of variably interrelated factors where I see these two monoliths side by side holding hands and playing leap-frog, the Snake of Pain and the Gorilla of Compulsive Dependence.2

I offer you vignettes of individuals I have known, not perfect examples of theoretical stereotypes but something of what each of them really is.  I describe each of these in terms of my understanding of her or his “physical” pain in relation to her or his “psychologic dependence”.  These case-notes are condensed, meant to stimulate questions more than to answer them.

Adam, a seventy-five year old man, has led a successful independent life involved in public affairs and commerce.  During his later years he developed arthritis, emphysema, anemia of undetermined cause and episodic abdominal pain, all of which had gradually prompted him and his physician to habituate him to opiates.  He has assiduously avoided any illegal drug involvement, but has continued on high doses of methadone, constantly pressing for increase of dose.  In a recent interview he spontaneously made association to an episode of more than seventy years ago, the accidental fatal poisoning of his two-year old brother with carbolic acid.  A daughter is characterized as an incorrigible iatrogenic addict.

Bruce, a thirty-two year old male, had been heavily involved in street drugs, especially heroin, since early in his teens.  He had temporary success at being “clean” in a rigidly disciplined therapeutic community several years ago, in his late teens.  Subsequently he suffered a benign brain tumor which required neurosurgery, and later developed aseptic necrosis of the right hip (perhaps a result of intravenous drug use) which has required three surgeries for the placement of a prosthetic joint.  During the last several years of methadone treatment his physical pain has served as his excuse for continued additional illicit drug use.  He recently completely detoxified and is trying to maintain stability and sobriety on his own.3

Connie, a thirty-one year old female, characterizes herself as “a sociopathic hedonist”.  She is an equestrienne, severely injured as a teenager in a riding accident which required laminectomy (spine surgery).  She stubbornly rehabilitated herself, defiant of pessimistic professional prognoses; until recently she has been active as a trainer and a rider.  She became heavily involved in illicit drug use, especially after beginning methadone treatment (for that put her in a dispensing line with many drug professionals).  Always a histrionic and demanding patient, she recently opted for hospitalization to reevaluate conditions she had avoided looking at for years.  She increased her dose of methadone and added oral meperidine (Demerol).  Since that hospitalization she has eliminated the Demerol and reduced the dosage of methadone.  She has resumed training and riding for the first time in two years and now presses for rapid decrease of methadone dosage while continuing to complain of pain and disability.  She is considered to be improving.

Delia, a sixty-eight year old female was referred to the methadone clinic by her general physician who treated her for many years with much frustration.  Since the death of her husband two years prior she had become more withdrawn, had used many enemas a day, was taking a mixture of benzodiazepines, opioids, vitamins and cardiac drugs.  She managed to be cared for by her grown daughter, constantly complaining that she could not exert herself to activity or exercise without severe pain.  When take-home medications were tried as a matter of convenience she was unable to ration them herself, but seemed reassured when daily trips to the clinic were resumed.  Gradually she has reduced the types of medications to a fraction of the previous number, and has reduced enemas to one or two daily.

Edward, a thirty-two year old male suffers congenital osteochondrodystrophy which results in distorted and painful hip joints, exacerbated by carrying television sets out of second-story windows.  I first met him in the Neighborhood Health Program when he conned me out of hydromorphone (Dilaudid) with a story that he had just now come to town to seek orthopedic treatment.  A year later at the drug program he failed to recognize me.  At one time he pressed for maintenance on Dilaudid instead of methadone.  When methadone was resumed he continued Dilaudid procured outside the clinic (when he could get it), and he is now gradually being detoxified and excused from formal treatment to make his way on his own.  His treatment is not considered successful.4

Fiona, a twenty-five year old female had discontinued her studies of art and psychology several years earlier when she was rendered dysfunctional by symptoms of intermittent severe abdominal pain from endometriosis and the surreptitious enabling of drug dependency by her nurse/mother who supplied her drugs.  She seems to have avoided men (for sexual intercourse could be quite painful), but to have become increasingly dependent on male gynecologists to share the burden of her genital pain, increasingly demanding of them the promise to preserve her capacity to bear children in the distant future but in the meantime to extinguish her pain with ever-increasing supplies of drugs.  During her early treatment she appeared overly-cooperative but could not explain the presence of propoxyphene in her random urine screens.  Through most of two years of treatment she made gradual improvement in reducing her dependence on outside drugs, eventually eliminated methadone having substituted anti-inflammatory medications for episodes of pain.  She resumed school with some measure of success long before she had established control over her drug usage.

Gregory, a forty-five year old telephone lineman injured his back in a fall from a pole during an ice storm.  He is disabled by his pain and is dependent on Percodan prescribed by his physician (oxycodone with aspirin).  Maintenance on oral methadone at modest doses allowed him to manage his pain without the chaos of frequent trips to a distant city to see physicians.  The improvement seemed due to the consistency of his source of pain reliever within the boundaries of the law.  In the process of counseling much guilt and anger about being treated as an addict were reviewed and substantially set aside.

Hilda is a thirty-eight year old female who carries the diagnosis of porphyria (an inherited metabolic disorder which can cause much abdominal pain).  She was referred by her doctor because of her dependence on multiple medications.  Pain of her peripheral neuropathy was controlled with modest doses of methadone.  Important developments have allowed her to reduce her dose, to seek new job training and to get rid of an alcoholic husband—results of psychotherapy which is part of the methadone treatment structure.

Ivan, a thirty year old male, suffered a below-the-knee amputation of his right leg as a result of trauma of a motorcycle accident.  He had been treated in many prominent medical centers and multiple times at the state hospital and a state methadone clinic.  His first brief treatment course with us was unsuccessful because he never stabilized on methadone or eliminated outside drugs.  Despite his presenting as in pain and in desperate need of relief, his second course of treatment begun recently has been marked by “dirty” urines, missed appointments and many missed methadone doses.  Through his coordinator I have put him on a ten-day detoxification schedule.  Now he is interested in re-negotiating a productive treatment plan.

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New and delightfully coherent hypotheses help us bring together thinking about “physical” pain and emotional distress in terms of neuronal and biochemical functioning and specific molecules (“endorphins”, from “endogenous morphine-like substances”).5

When I am lecturing it is hard for me not to lecture, but when I am chatting with a patient it is easier to tell the truth.  I will address you as if you were a single real individual.

My “spiel” to the patient is meant to open the way for the pained patient to see his experiences are not weird, unique or incomprehensible; that they are understandable and that he can himself understand them.  If he can understand these things the clinic staff can understand him also, and he can begin to trust that their presence to him and their attention toward him are trustworthy, that they care about him.

The overall goal of reducing drug dependence is approached gradually in the methadone clinic, for stabilization of supply allows breathing room within which we can do “psychotherapy” (slow repair of capacity for human relationship by means of exercising authentic human relationship).  We save time by taking plenty of time, for after all, there must have been a hefty cause in the first place for the development of addiction.

Why do you find opiates so attractive, so helpful for your pain?  We’ve known for thousands of years it is so.  You may wonder why a poppy flower extract is so effective in human beings—aren’t those two species quite distant one from the other?

Not long ago this question led us to identify areas of the brain which take up opiates, and to identify molecularly specific receptor sites, places on a brain cell where an opiate molecule locks on to change how that cell works.  If there is such a receptor site there should be a molecule made by the body to fit it exactly, like a key in a lock.

In the search for such a molecule many biological chemists did much hard work with little success.  In retrospect we can see why that search was so difficult:  The opiate-like substances the body makes for itself are so powerful (perhaps 700 times more than morphine) that it takes only a very small amount to do the job, so there wasn’t much stuff to look for.  (Doctor Goldstein and his colleagues used about a train-car load of sheep pituitary glands ultimately to isolate a microscopic amount of what they were looking for.)  The real trick was that this substance is so sticky that about 99% of it stuck to the glassware in the laboratories.  They were trying to isolate 1% of a substance that occurred in a very small concentration in the first place!  Once the endorphin molecules were identified the story became easier for us to understand.

Your brain cells—especially those in areas of the brain that have to do with sensation of pain and your mood and your sense of well-being—become dependent on having those molecules available in the concentrations you have been used to.  You are right now manufacturing your own endorphins—those morphine-like substances which your pituitary gland produces in your brain, those molecules which are hundreds of times more powerful than morphine, those molecules which may be stimulated by exercise and result in what’s known as “runner’s high”.

If my brain cells have plenty of those molecules I can feel well.  But if the supply is much less than I have become used to I will suffer withdrawal.  If I put these tenth-rate poppy flower molecules into my brain (like heroin), my pituitary gland senses there are a lot of  molecules floating around that look like endorphins, so it stops making so many itself.

Withdrawal results in my brain being irritable all over, so the parts that control blood pressure, pulse rate, contraction of muscles and guts all become disorganized and all the old familiar symptoms result from that:  soreness and aching, runny nose, abdominal cramping, nausea, vomiting, diarrhea, goose flesh, sweating, yawning, sleeplessness.

Even though your brain may work better with its own morphine-like substances, once you begin to put in outside drugs it will leave off its own high-quality production and leave you scrambling for a supply of that tenth-rate stuff to deliver to your brain as soon as possible, like right through a vein (if you can find one).

If you suffer a condition that produces physical pain on top of your addiction, like a broken bone or kidney stones, you may need outside drugs to cloud the sensation of pain.  If you are already addicted (have “high tolerance”) you will require a lot more drug to ease your pain (but nobody will prescribe or administer the high doses you need, especially if you seem to be “drug-seeking”).

It becomes a vicious cycle, a “Catch 22”.  You will not feel okay without frequently renewed outside sources, but you cannot produce adequate inside supplies of the good stuff (endorphins) while you are using outside supplies.  So, why not just “say no” and stop the outside junk?

Transition from drug-dependence to natural internal stability doesn’t happen quickly or by accident.  “Cold turkey” abrupt withdrawal usually is too much of an ordeal to tolerate, so withdrawal obstructs long-term improvement.  Rapid detoxifications (like while you are sedated into a deep sleep) don’t change anything but concentrations of molecules; your brain may be cleared but who you are is unchanged.  Rapid detoxification may be helpful in some fashion, but it is not treatment of your addiction.

When you have had these conditions for a long time or when your triggers to use are far from simple, hard to control, methadone or buprenorphine maintenance can give you breathing room to stabilize your life and to diminish your drug dependency.

When you are addicted you cannot be in control of your drug dependence.  Ironically, in order to gain control you must temporarily give it over to someone else.  If you are dependent on opioids, methadone or buprenorphine may be a good tool to help you regain control, but only within a treatment program you can trust.

Some pain is unavoidable.  One goal of treatment is to come to accept some measure of discomfort as a part of your life.  Without drug we tend to fall into the destructive habits of whining, complaining, blaming others.  Such demandingness alienates precisely those persons whose help we need.

I have never seen any addicted person control or successfully taper his own supply of drugs, though it is conceivable (so I don’t think you can do it on your own “will power”).  I have never seen anyone recover from an addiction through controlling, critical or sadistic therapies; but I’ve certainly seen some recover to spite such abuse.

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1Prepared for a professional conference May 20, 1982.  Technical details change from one day to the next; but basic clinical phenomena do not change.  We still use methadone as we did then, and we use other molecular and treatment tools.  Our choice is the same as it always has been, to improve the patient’s problems of pain (to identify and ameliorate it) and drug dependence (to be liberated from it).  Or otherwise to abandon the patient, to leave him to the police, the courts, the prisons.

2 As in “To Be a Patient” where I see absolute fear of death and its concomitants rather than the ambivalence of the patient Doctor Reiser sees.  Maybe as a child I read too much Edgar Allen Poe.

3 He may have made progress this time, as evidenced by his maturity as a parent and as a patient.  Because he felt ashamed not to be able to help his third-grader with her homework, he returned to school to study for his G.E.D.  As a token of his appreciation he presented me with an engraved plaque which I value more highly than any of my diplomas not because he praises me but because I know he wrote the text (very skillfully disguising the socially unacceptable nature of the disease I was treating), carefully spelled each word correctly and insisted the engraver do a perfect job of it.  Quite a feat for the fellow who couldn’t even do third-grade homework.  The text:  “NATHAN POLLACK, M.D./thanks for taking care of all our scrapes, bumps, colds, etc., for explaining so we understand your medical terms, for taking time to visit your patients, for all your call backs from your pager, and for understanding the people in your saturday groups./we are grateful to have a person and friend in this world as kind and thoughtful as you.”

4 His then-girlfriend also was a patient at the methadone clinic.  I saw her recently (twenty-five years later) when she was my patient at the state prison.  She recognized me.  She reported they had been married happily and stably through the interim even during their several individual prison terms, that he is well, attending home and children as she finishes her current sentence.

5 Of course in the past quarter of a century we have seen more intricate detail of  many neurotransmitters and the interrelated parts of the brain and peripheral nerves within which they have their effects--a complex picture indeed.  But the clinical phenomena we observed thousands of years ago, and the molecular picture given to me at breakfast one day by Avram Goldstein (awarded a Nobel prize for his isolation of dynorphin) are older valid pictures from which these current ones have cascaded.  So, I don’t need to change the following old description of the moving parts of the Magic Machine (neurons and neurotransmitters) and the overall effects of its powerful journey through the mine-fields of real life (emotions and behavior).

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