Managing the Pain

  I recently got into a discussion on FB about rising heroin use and attendant ODs in the middle class. Some of the commenters had very personal and painful histories of losing family and the thread threatened to turn into a flame war. I dropped out, but the experience got me thinking and I decided to collect my thoughts on the matter in one place.

  To begin with, where I’m coming from:

  I very seldom use pain killers. I seem to have a rather high threshold for pain. Broken bones, muscle injuries, etc. don’t seem to hurt me as much as they seem to hurt others. That is undoubtedly the luck of good genetics. I also seem to have a very high tolerance for pain killers or psychoactive chemicals. I once broke two ribs and an arm and was in what I would call minor pain. The doctor prescribed 2 Percocet per dose and that pretty much made the pain disappear. I could drive, work, function normally. (It was actually a danger in that I would forget I was injured and would over-exert and re-injure myself). If my wife had taken 2 Percocet at that time she would have been in la-la-land. Different genetics.

  Back in my Greewich Village days I discovered it was possible to drop Acid and have no effect; I found that it took a lot of pot plus a bit of hash to get me even mildly stoned (and I didn’t like it, so it never happened again). Genetics again. I’ve known people to take the strongest painkiller they can get their hands on when they have a headache. They cannot tolerate ANY pain. (Or at least they act that way – I don’t know if they’re wimps or just hypersensitive). I know people who have lived with chronic pain for decades and are happy if medication makes the pain tolerable. My wife has spent the last 37+ years in chronic pain, often at a level of 7-10 on the 1-10 scale. She’s happy if her pain meds get the pain down to 5.

  People take drugs for various reasons; entertainment, relief from pain, escape from the harsh realities of their circumstances. Drug usage may or may not lead to addiction, depending on the person, the drug(s) and the circumstances. Handling addiction is a related but separate matter.

Medicine has failed:
  Chronic pain is badly under-diagnosed and under-medicated in this country. For one thing, pain diagnosis is largely subjective. Although recent fMRI studies show the possibility of firm ‘proof’ of pain, the equipment and methodology is still experimental and not ready for ‘prime time’ as a diagnostic tool. Untold amounts of Vicodan, Percocet and Oxycodone have been ladled out in relief of low back pain until it has become somewhat of a joke, albeit rather black humor. For a second thing, many MDs who practice ‘pain management’ do so as a adjunct to their specialty – anesthesiology or orthopedics. Those focused entirely on pain management are few and far between, and like any group, some are better or worse than others. A third issue is that the ‘drug war’ has scared many MDs away from treating pain aggressively and made even the true specialists very careful and meticulous with prescribing strong pain medication.

Bottom line:
  There are people in genuine pain who cannot get the relief they need through legal medical channels, particularly if the pain is chronic. They therefore turn to illegal channels. There are three problems with this. First, the purity/dosage of illegal drugs is always questionable and whenever a particularly potent batch hits the streets, we have lots of ODs. Second, being unmonitored and therefore uncontrolled, the danger of addiction rises significantly. Third, the illegality creates possible jail time, a felony record and severe reduction in the odds of getting one’s life back together.

  The nature, cause and treatment of addiction (of any sort) have been the subject of speculation, research, theories, practices, methodologies and wild guesses for at least the last 100 years if not more. Some programs work or appear to work, though sometimes it turns out they have no more effectiveness than a placebo. Psychiatrists prescribe Zoloft, Prozac and Cymbalta without asking if the patient’s life circumstances are depressing; Xanax, Klonopin and Valium without investigating the causes of a patient’s stress. Being in constant pain, being unable to work to or do anything which gives pleasure or satisfaction, being in poverty and always on the edge of financial disaster – maybe depression and anxiety are normal responses rather than mental illnesses. Maybe medicine (and society) should seek the cures elsewhere.

Society has failed:
  The Rat Park Experiment from the ’70s was declared a proof that addiction is basically social, although it seems to me an over-simplification of the situation, as such initial breakthroughs often are. Its critics have chipped away around the edges but it remains clear that the social environment (in the broadest context) of individuals has a huge influence on whether or not they get addicted and their chances of successfully beating the addiction. And treatment methods which do not succeed in significantly changing the patient’s environment face a more difficult task and a higher failure rate. Sometimes a program is a blend of actions – AA meetings, buddy-system, half-way-houses, rehab centers – and it is difficult to determine exactly which victory or defeat is due to which particular ingredient of the process. Unfortunately, this leads to some very sloppy pseudo-science in evaluating various programs.

  Drug use for recreation has been around a long time – since we discovered alcohol and various esoteric plants. Initially viewed as a blessing from the Gods or a connection to Them, we moderns have taken out most of the inherent value of such gifts of nature and reduced them to mere relief from existential ennui. We get drunk because we’re unhappy or bored; snort a line of coke because we’ve got nothing better to do. Whether we become addicted or not depends largely – IMO – on how fucked up our lives are.

  Drug use for Escape-From-Hell is another thing altogether. In many segments of society, there is a deep and abiding pain. It comes from recognizing that you have no power over your life, no brighter future, no way to find satisfaction or joy or establish a meaningful life. This occurs in urban ghettos, in rural backwaters, in broken cities and countries and families. Drugs are an escape, and – unlike recreational users – these users are more likely to recognize the possibility of addiction – and be less likely to care. And much less likely to have access to ways of treating addiction. In all too many cases, treatment consists of jail rather than rehab at a luxurious center in Southern California.

  Recently re-reading Joe Bageant’s essays and his memoir, it is struck me how and why the underclass – white and black – is ravaged by drug use and abuse. It is also notable in his description of his youth ‘down on the farm’ that the conditions were not ‘ripe’ for such widespread drug use. There were undoubtedly a drunk or two, perhaps an occasional joint smoked in certain places, but by and large, drugs were not a social or community problem.

  Why not? In my view, because they had a community – people who understood and valued their world and their place in it, who valued themselves as part of that community and found pleasure and satisfaction in daily life and interactions with others, who felt what they did was meaningful and important. Their lives had purpose and meaning.

  Contrast that with the fragmented lives of so many people in the modern world. How many can actually say they do meaningful work? That their lives have purpose? That they are part of a community of shared values and goals? And as the economy tanks, debt rises and the empire crumbles, the once-secure Middle Class finds itself teetering on the edge of disaster. Fear and anxiety rise, futures vanish. Is it any wonder people escape into alternate realities when the view out their windows is so dismal?

  One other point is worth mentioning here. Drug use and sometimes addiction has been common in the military since Vietnam. Heroin production is up in Afghanistan since the Taliban lost control. Vets are coming home with PTSD, inadequate treatment through the VA, unemployment, homelessness. By sending an entire generation to war where they see – and often do – terrible things on a regular basis, we should not be surprised to find a lot of people whose lives have been effectively destroyed.

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  • Footnote:
      Regarding the issue of becoming habituated to opiates, thus requiring higher dosages, the argument has been ongoing for decades as to whether the body grows more sensitive to pain or is somehow processing opiates with less efficacy.
    I suspect some research via fMRI would settle the matter.
      I can’t prove it and don’t know if any research has been done in this area, but I strongly suspect that addiction begins where pain relief leaves off. This is based strictly on my own personal observations of several people dealing with severe acute pain or chronic pain.

      That is, if 40mg of Oxycontin brings the pain level down from 8 or 9 to 5, it won’t be addicting. If the patient (or doctor) wants the pain to disappear completely and ups the doses to 80 or 100, the pain will sharply reduce to perhaps 2 or 3 (discomfort rather than pain) but I suspect addiction will follow. Basically, if pain levels are low enough, the ‘leftover’ opiates induce euphoria and we’re on our way to addiction.

      I have seen people switching opiates by tapering off one and slowly replacing it with a different one. While pain levels rose as the first med was withdrawn (thus establishing the blood-level of the opiate was dropping), no withdrawal symptoms manifested in the 3-day interval of being unmedicated.

      Chronic pain is different from acute pain. Cells – or perhaps only nerve cells (I read report several years ago) – contain an enzyme whose level is normally low but which rises under trauma, then recedes to baseline when the trauma is over. Pain signals are transmitted only when this enzyme level is high. In the case of chronic pain, the enzyme level rises and falls, but no longer falls to the original baseline. For example – (not actual values; illustration only) – assume 10% is normal for the enzyme. Minor trauma raises it to 40% and the patient experiences minor pain. At 60% the pain is more severe; at 80% pain is very severe. In chronic pain patients, the enzyme drops only to 40%. A rise in enzyme of 30% no longer takes it from 10 to 40 but from 40 to 70. Effectively, the pain threshold has been lowered.

  • Ray, with all due respect, this thread about addiction is a muddle at best. Most who espouse expertise in addiction have no idea. They are sunk in the parochial dogma of the ignorance of the AMA.
    I had the pleasure of working (as a volunteer) at Dr. Charles Spray’s street clinic (Portland, Or) way back in the 70’s. His was the most successful program for getting Vietnam war veterans off heroine and back into a productive life. He did the same for many high school students on summer binges into the nether-lands of heroine.
    There is some recent, cutting edge work on addiction, which I think warrants a serious look. I was unsuccessful on my first attempt to locate the sources I’ve read, but will continue to look.
    I hope you will follow up on this thread; normally you post and ignore…

    •   Actually, most of the post is not about treating addiction, its about pain management – treatment and mistreatment – and about the conditions that are conducive to addiction, as well as the non-physical pain that is endemic and getting worse.

        And the point I made about most all programs being unscientific seems to me rather obvious. I’ve watched friends go thru AA and other programs successfully and unsuccessfully and attribute their success or failure to various aspects of the program. If a program works for A, what was it about it that worked and why didn’t it work for B? If the science was there and complete, these programs should have much higher success rates they they do. Their modest success rate is pretty much proof that they’re just trying what seems might work and hoping for the best. Sometimes it works; sometimes it doesn’t. And even when it does, they can’t be sure which part of the program was effective.

        From what I read about Spray’s clinic, a big part of it was just helping people in a wide variety of conditions and circumstances. In my experience, just having people care can go a long way to changing a one’s internal psycho-dynamic. I’ve known people to turn their lives around based on one contact, one new friend, one experience. The placebo effect is well documented and more effective than can be explained by statistics. One common aspect is that recipients of placebo treatment get a lot more individual attention that they might get from an MD writing a prescription after spending 3 minutes with his mind on the next patient. Maybe it’s the extra time and attention that helped?

        Addiction is only part of my topic and I have my own ideas about treatment. I would definitely appreciate any new work on addiction if you can find the info online. .

      • Point taken re: Pain Management. Pain is a universe unto itself, IME.
        The addiction bit stood out for me due to my long involvement with drug use; both personal and clinical via Charlie’s street clinic, Outside-In. I was a staff member for 3 or 4 years as a volunteer.
        While I’ve listened to Gabor Mate’ more than once, I can’t agree with his “theories” of addiction.
        I for one, categorically reject addiction as disease, wether it’s alcohol or other drugs.
        So far I’ve failed to find the one person who understands addiction; I listened to an extensive interview with him. Can’t remember where (it was two or three years ago). Sorry.

        • “…alcohol or other drugs.”

            One can also become addicted to ‘non-consumables’, to processes and activities, such as gambling and shopping and even (I’ve been told) sex. Since the physical substance is not present, this implies that psychological processes can constitute an effective mechanism to create addiction. The biology of it undoubtedly manifests via neurotransmitters which are known to be subject to mental processes. You can ‘think yourself sick’.

            IMO we error in making a too-precise distinction between body and mind, particularly when several thousand years of investigation and contemplation have failed to provide a good definition of exactly what Mind is. I tend to view it a a continuum; on one end physics, chemistry, biology and on the other end purely a process. We’re learning more about the brain – they recently discovered a previously unknown connection between brain and the lymphatic system, which exposes the brain to influences from the immune system, including inflammation – but they’re no closer to understanding Mind than they were ancient Greeks and perhaps less so. Maybe in a future post I will elaborate on my ideas on Mind and the body/mind connection as it pertains to mental (and physical) health.

          re: Gabor Maté:
            He was unknown to me, but a quick Google and some reading both of his views and commentary thereon by other professionals inclines me to agree with you. He oversimplifies and over generalizes from his own experiences.

            I think part of the problem he (and others) have in attempting to understand human behavior generally is the rather unscientific way many approach problems (and it’s not limited to psych or medicine – physicists and you and I do it if we’re not careful). It seems that no sooner does someone discover A than he feels compelled to build an entire world based on his ‘discovery’, instead of merely jotting down that A exists and continuing to investigate until he has accumulated A + B + C + ….Z .and has enough information to speculate with some authority. Instead, a half-baked theory is built which is then modified, supported or destroyed. This detracts from its usefulness and actually inhibits research and thinking on the subject. IMO the sensible and scientific approach is to accumulate facts uncritically, without attempting to either force them into an existing worldview or to construct a new worldview. Eventually, enough facts will surface that a reasonable, useful and testable explanation becomes obvious and we can progress from there.

          “I’ve failed to find the one person who understands addiction.”
            Making this statement implies that you do understand addiction. I would be interested in hearing your views on the causes as well as effective treatment.

            • Addiction is not a disease; it is a choice. We get addicted to the thing (drug of choice) we like. And yes, I agree, non-consumables can be addictive. Again, we make choices for the things we like. This is just another way of saying the things that give us pleasure.
              Belief enters into the equation; generations of propaganda and misinformation; not only by the government; but by the AMA and faux science.
              A close (at the time) friend became seriously addicted to cocaine (snorting). He went to an AA (AA won’t take “drug addicts”) equivalent for drug addicts. His mantra after treatment was; “I have a disease, it’s not my fault. He became the equivalent of a dry drunk.
              I was stunned by his total lack of responsibility for the choices he made. This is also true for AA.
              Well Ray, I hope this reply helps.

              In any event, without understanding the mechanics (so-to-speak) of addiction there can be no cure. Answers can be gotten from people who have, for instance, cured themselves (key point) of alcoholism (or any other of the myriad addictions) and can now drink socially. The same is also true for opiod or opium based drug addicts. This I know for a fact.
              I’m not advocating throwing people into seclusion; but rather finding experienced guides who can help as needed.
              Society on the whole is in a hopeless morass with almost all social services either cut or eliminated. But in a certain sense, it doesn’t matter, because their solutions are not solutions at all. Band-aides and fairy tales are all there is.
              So, this puts the impetus on the individual and requires self education, self awareness, and freedom from dogma. One must also face/understand the choices made in the beginning and one’s present situation; then, choices can be made for the future path. It’s worth repeating; one can only cure ones self; no one can do it for another.
              On the one hand it’s so simple; but on the other, it’s wrapped in ignorance and obfuscation.
              The individual, whose name I cannot remember, is pretty much in line with the above.
              There is also some interesting work being done with psilocybin mushrooms, peyote, Ayahuasca, and LSD in curing addiction. IME, these are useful tools.

    I definitely agree that groundbreaking work is being done with hallucinogens – it’s a damn shame the govt cut off all research for so long. Having dabbled a bit in that area many years ago, I understand its potential as a therapeutic tool.

      I’ve only known 2 ex-alcoholics I would consider ‘cured’ – able to drink responsibly. The rest are/were indeed ‘dry drunks’.

      The issue of choice is undoubtedly a major component and it’s easier to get addicted when society says your addiction is socially acceptable (smoking, until recent years) than when it’s not acceptable. This does not address the issue of why some people choose behavior which leads to addiction and why others avoid such behavior. All behavior, all choices have consequences. We see the obviously bad consequence of overusing alcohol or credit cards or drugs but we do not see what’s going on in their brains, the endorphin rush the shopper gets from buying a new necklace, the adrenaline high the gambler feels while cheating in a high-stakes poker game with mafiosa. We (and they) see the negative results but we don’t see the positive feedback that keeps them in the self-destructive pattern.

      Choice? I’ve known a musician who used to combine heroin and amphetamine once or twice a week for 3- 4 months while touring, then stopped for the next 8-9 months, unaddicted. I mentioned elsewhere here my own teen experience with booze and my choice (to put it very mildly) to stop. I also mentioned that I quit smoking after 45+ years not because I suddenly developed more will-power (I’d tried unsuccessfully several times before) and not because I even chose to quit. One day smoking simply became ‘ego-dystonic’. That is completely a mental construct, a change in viewpoint, in self-image. I did not choose to stop smoking. I just stopped being a smoker, and there’s a world of difference. The two really cured ex-alcoholics similarly did not choose to stop drinking. They just stopped being alcoholics.

      I would hesitate to compartmentalize any human behavior as purely physical or purely psychological or purely emotional – or purely anything. We humans are a mix of physical, mental, emotional, social, cultural, societal, spiritual – buffeted by many forces, some of which we do not recognize, others we know but often do not acknowledge and some we badly misinterpret. There’s no such thing as human behavior that is not an amalgam or all our aspects. While various physical and mental and emotional aspects of being human may indeed facilitate addiction, all aspects are affected and under the right stimulus or guidance can help treat addiction. It would be a mistake to toss all our therapeutic eggs in one basket and ignore the value of the whole person – and society and culture are part of the person and may therefore offer keys to cures.

    Regarding what is or is not a disease;
      Whether labeling something as a disease frees one from personal responsibility is not really the point. What matters is whether it is productive or counterproductive to look at a problem in a specific way.

      Some regard depression as a disease, usually treating it as an imbalance of neurotransmitters, others treat it as purely psychological problem and still others dismiss it as the sign of a weak mind which could be overcome if the patient would just “suck it up and stop feeling sorry for yourself”.

      It’s well worth an hour to listen to Robert Sapolsky’s lecture on Depression.
    Besides a good explanation of depression, it gives a lot of food for thought on the whole body, mind, emotion, chemistry, psychology of being human.

  • Ugh, depression; one of the biggest scams in the world.
    As one who is depressed from time to time; I view depression as normal and a healthy response to life’s vagaries. I do recognize clinical depression differently. i suspect that it is less common than the AMA and big pharma would have us believe.
    Disease is a multi billion (trillion?) dollar business and it’s a proven fact big pharma has invented/created new diseases. Follow the money.
    I have a holistic view of the mind/body; one follows the other.

    I do have a quibble with falsely calling something a disease that is not. It’s just factually incorrect and further clouds the issues at hand. This guy I knew was told his cocaine addiction was not his fault is just ludicrous, IMO. He clung to that like a life raft and it wasn’t long before I’d had my fill and broke off the relationship (it was really never a friendship).

    Smoking: I smoked from the age of 15 til 62 (with many attempts in-between); I got on a plane for a visit to America and didn’t start again; to this day. No withdrawal, no craving, no problem.

    I think we agree for the most part. Maybe some minor quibbles here and there.

    • My compassion is tempered by the knowledge that in large part what we are seeing is poorly educated white men finding out that being white and male isn’t so potent an advantage as it used to be.

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