“I feel like a caged animal” — My patient offered me this lens through which to view his life seeped in chronic pain. For him, pain dictated his entire sense of being — it was something that simply could not be distilled down to a single value on a 10-point scale. The cage represented the restriction of life and the boundaries within which he was allowed to experience, let alone enjoy, even the most mundane of activities. It also represented a loss of control. Long before our paths crossed, this patient had access to high doses of prescription medications that danced with the mu-receptors in his brain and dulled his senses. From the time he woke up in the morning, to the time he went to bed at night, these pills offered transient entry into a perceived life of freedom.
However, somewhere in the intervening years, the line between freedom and captivity became blurred. Questions of safety were raised as doctors struggled to define whether this patient was controlling his pain, or was being controlled by his pain medications. He was ultimately diagnosed as having an opioid use disorder. Thus began a long tapering plan that slowly drained this man of what little semblance of sovereignty he had in his life. He felt he was being backed further and further into this “cage,” whose walls were now personified as his doctors, who were locking him in and throwing out the key. This is the situation under which I first met this patient in clinic.
When it comes to treating chronic, noncancer-related pain in the context of a burgeoning opioid epidemic, I feel weak and disempowered. It is my primary care Kryptonite. Although we have many great multi-modal treatment options, it can be incredibly challenging to impanel patients who, at one time or another, received chronic prescription opioids. Currently, no fancy blood test, imaging, or invasive procedure exists that can objectively measure the physical and emotional burden of pain. Patients, therefore, are beholden to the subjective disposition of doctors who must decide how to treat pain, and in whom. So, when disagreements arise with patients on this topic, as they often do, it can mean the difference between a good day in clinic and a hellacious one.
Today’s trainees are grappling with a crisis that is in large part attributable to yesterday’s standard of practice. It is one of the many toilsome aspects of general medicine that pushes trainees to choose specialty over primary care. In April of this year, I was fortunate to attend C.R.I.T., a conference on addiction medicine run by top leaders in this field from Boston University. The conference is designed for chief residents, fellows, and faculty mentors to gain immersive training in managing substance use disorders. The experience also involved learning best practices for supporting residents in taking care of these patients who, while challenging, incur a substantial amount of stigma from healthcare providers.
One poignant take-away from this conference came from the keynote speaker, Michael Botticelli, a former director of the White House Office of National Drug Control Policy who also struggled with addiction. To paraphrase his comments, he stated that, as doctors, we no longer have the luxury of choosing whether or not to deal with pain or addiction. This epidemic affects all of us and, as such, we all have a responsibility to get informed and to treat patients as safely and empathically as possible.
In the short time we’ve known each other, my patient has already managed to run me through the gauntlet of emotions. He’ll offer me glimpses into the depth of his suffering then immediately blame everyone from distant relatives to Barack Obama. Although I have learned to set strict boundaries with patients on my tolerance for diminutive language, I recognize how opioid use disorders can destroy even the most beloved of personalities. It might just take a stronger effort on the part of physicians to see the human beings stuck behind the thick veil of this particular disease. I hope that, with time and trust, my patient and I can work together to find a way out.
Ashley McMullen is an internal medicine chief resident who blogs at Insights on Residency Training, a part of NEJM Journal Watch.
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