Thursday, March 30, 2017

The "Real Issues"

Earlier this month I wrote that I'd need more time to think about this issue of what's at the root of our drug problems. The other night I had the privilege of joining a speakers' panel of area complementary and alternative medicine providers at a graduate class of nurse practitioner students. One of the things that came through most clearly from all of us was the multifactorial nature of the human experience of health and disease.

Another thing that came out clearly was the dual nature of our relationships with physicians--I'll note that no physicians were on the panel. To be fair, I don't know if the instructor tried to bring a physician onto the panel, although I know who's who around here: It's likely that there simply wasn't anyone available. Both physicians whom I know actually "get" this are in various stages of retirement. One I know of would speak for one of my classroom panels at Penn State because I wouldn't pay him for it.

So that "dual nature", what about that? Well, we all agreed that physicians are often a key part of the healing journey for many people. Although most physicians I've ever know view themselves as the key part of any health journey--even though they receive little instruction in holism and therapies beyond Western biomedicine. So yes, they can be very important, but they are not the only part, and in some cases they aren't necessary at all. (In fact, sometimes they are an impediment to health!)

Conversely, trying to integrate our work with that of physicians? Well, we all agreed that's a fraught adventure, at best. After all, why would physicians, say, refer someone for Reiki? They don't even collaborate very well amongst themselves! We'd like to work more with them, but they view us as variously as unimportant parts of a plan hatched by eccentric patients, as cranks, or as nuisances. They don't understand energy medicine, chiropractic, spirituality, homeopathy, nutrition, art, dance, or culture.

Ok, ok. I'm painting them here with a rather broad brush, and I know for sure that some docs aren't described by what I'm saying here.

But don't underestimate the acculturation of physicians. Acculturation is the process of beginning with ordinary people and imbuing them with a certain cultural stamp. The acculturation process that physicians undergo is very powerful. Western biomedicine is the most powerful, and most important system. It treats diseases, and when it tries to prevent them, it relies on simple instruction to patients, which patients are expected to follow, and when they don't, physicians can feel absolved of responsibility.

It is prescriptive, and not just in the literal sense of writing drug prescriptions. Students are told they are the final word on matters of health and healing. They're "in charge". They are taught to act.

I have to say that, in person, the outward results of this acculturation are not uniform. Culture doesn't trump personality. But depending on the peculiarities of personality to yield a large crop of physicians who are spiritual, holistic, imaginative, and who think cooperatively with practitioners outside their own discipline is unlikely. Some medical schools are taking an approach closer to that proposed by Dr. Andrew Weil: a curriculum that cultivates such thinking as I detailed in this paragraph. But we're a long way from that being a universal educational goal in American medical schools.

Then there's the practical pressures faced by physicians once they graduate and begin practice. Pressures to produce revenue, pressures to adhere to "evidence-based-practice" guidelines that are based on population models, pressures to conform to a system that demands data, pressures to prescribe the newest, most expensive drugs, pressures to follow the law and also guard against liability, all of these bear on the poor guy or gal in the white coat who now works in a corporate-owned medical office in a gigantic health care system.

It shouldn't come as a surprise that most authorities estimate physician suicide at about 1 physician per day! Drug abuse rates are at or somewhat higher than the general population. So, considering both the social authority and power of being a physician and the expectations society places on our doctors, I don't find it that surprising that younger docs seem more willing to share, to collaborate with others .

Maybe they are just tired of having every-single-thing on their own shoulders. Maybe they want to spread the liability around. I don't know but whatever it is, I'm glad for it.

So like a lot of things, culture changes with time. So maybe the culture of American drug dependency will change with time too. My patients complain that doctors want to "prescribe a pill for everything" and yet so many American do just want a pill for everything. Is it any wonder we've ended up where we are?

Wednesday, March 1, 2017

Pain in the Age of "The Opioid Epidemic"

I've been doing some far-ahead prep for a class I will teach again this year in May to advanced nursing students. Pain management is a topic they're really interested in, and I think I've mentioned this previously on this blog. So I've been freshening my understanding of the topic since last year.

So I read this article by Betty Ferrell, really a transcription of a speech she gave to nurses at the American Society for Pain Management Nursing in 2005--fully a decade from today's "opioid epidemic," which came up on our radar around 2015 and continues today. I addressed this earlier last year (June 5) when I argued that the tide of medical opinion was changing and that as a result I feared pain would be undertreated.

So far, I haven't seen that. But then, so far, I haven't seen a whole lot of change in prescribing habits either. So maybe not much has changed on the ground yet.

Anyway, Farrell's speech focused on the the ethics of pain treatment, and talked about nurses' presence when ministering to patients in pain--we're not doing our best when we're just slinging pills around. She focused on the story of pain. It's one thing to treat acute knee pain after having a surgical repair following an accident. You take your pills for a few days, do your therapy, and things get better pretty quickly. You forget about it pretty soon.

It's another thing to suffer chronic pain. It's unlikely to go away. It's trickier--I mean really--the neurology of chronic pain isn't the same as acute pain. Farrell tells the story of a patient who wonders when the meds will stop working. What will she do then? I've seen this: patients in this sort of pain enjoy brief moments of relief, hours, days, or weeks...and then things go unstable, the meds need to be changed. A colleague of mine, her husband recently had a "pain pump" installed. This implantable device pumps pain medication directly into the spinal cord. It's a big, permanent step. The story of the pain changes. It is now never, ever going completely away. And the man? He's now part cyborg. My colleague views it as a change for the better for him, but it's also hard for him to cross that border into knowing the permanence of it, as symbolized by the machine implanted in his hip.

The other side of this epidemic is the still-large number of overdoses from both prescription opioids and from heroin. The latter is often because people get hooked on Vicodin and Norco and Percocet when they get it from their doctors. Why is this?

In our effort to not undertreat pain, we started handing out large amounts of narcotics for everything from back pain to sinusitis to dental pain to acute injuries. Some people "liked" the feeling that came along with the drug. It's not always that they got "high"--some of them just report feeling "normal" for the first time.

I've shared with students that some people may be genetically deficient in producing their own native opioids, endorphins. Could it be that the incidental prescription for Tylenol#3 (with codeine) after a wisdom tooth extraction leads them to a contact with a chemical that fills in their deficiency? We tend to think of such people as weak, or that they like to party. That's true sometimes, I guess, but mostly it seems that some folks just find that the dentist's prescription puts them in a state of mind that they find more normal than they've felt in a long time.

Is it any wonder then that, lacking an ongoing source of prescription opioids, they might turn to heroin. In the TV series Mr. Robot, the character Elliott, played by Rami Malek, begins the series taking morphine he gets on the street. He also buys Suboxone, a drug he can take later to relieve the symptoms of withdrawal. His character isn't a party-head. Really, he has social anxiety and a sense of separation from others around him. He's medicating.

I've had patients who self-medicated with all sorts of things. We hardly understand psychopharmacology, after all. So why not expect people to experiment on themselves, to try to free themselves from dependence on a medical system that views them as enemies of good order? I get this all the time in class. I am teaching a course on substance abuse that I have taught several times before. The students (most anyway) begin the course in this state of mind: We know what's good for you.

And yet those same students always confirm the general lassitude of physicians when tackling this complexity of human psychoneurology. Some docs easily and readily over-prescribe habit-forming drugs. Others routinely look for reasons to withhold them. I'm not saying all docs are bad. I'm just saying that most docs are like most people, flawed. Problem is, they hold a powerful key.

In 2013 the Diagnostic Statistical Manual came out in its 5th edition. The "DSM", as people in psych call it, is the manual of psychiatric diseases. It details the criteria for diagnosing people with "depression", "generalized anxiety", "bipolar disorder" and so on. Trouble is, we don't have a real understanding of the underlying pathology of these "diseases".

In Hashimoto's thyroiditis, we know the immune system attacks the thyroid gland. In strep throat we know that strep bacteria cause an infection. In juvenile diabetes, we know that the insulin-producing cells of the pancreas die off. We know the pathology, and so we know what we have to do to fix it, and we can predict how people will respond to medicines for these diseases.

We have no such certainty in diseases that reside partly in that 3 pounds of tissue between our ears. So depression, bipolar disorder, anxiety, alienation, and chronic pain are all...well, mysteries. Even today, the DSM-5 does no more than catalog behaviors so we can label people for insurance reimbursement. It doesn't tell what's really going on, and our efforts to medicate are, at best, educated guesses.

If you think patients don't know this on some intuitive level, you're wrong. That's why people experiment on themselves. I'm not excusing the bad behaviors of addicts. I am indicting the lack of imagination, compassion, and depth among people in my own industry.

So pain management in this time of high anxiety about narcotics, pain management in an age of rising numbers of overdose deaths from those narcotics? I don't think any of this is going to get at the real issues.

That's pretty grim. I'll have to give this some more thought for another blog.