ON MY MIND In My Own Words By Jim Shames, MD SITTING ACROSS FROM ME is a woman — Megan we’ll call her—in her early 20s. She looks a lot like my daughter, but worldweary. Her arms and her feet are scarred with dark lines, “tracks,” from years of heroin injecting. Her primary care doctor seemed to have missed those signs of drug use (she kept her sleeves down). She had been prescribed oxycodone and Valium for years to treat chronic pain and anxiety. Megan had long since resorted to selling those pills to get the heroin she needed. She wants to be done with all that now. Risky behavior started early in her life: smoking at 13, partying in her teens, doing poorly in school. When she was injured while intoxicated, her doctor prescribed her Vicodin. She loved Vicodin. The pills were gone in a few days. She could always get more. All her friends had them, and her provider wrote for a couple of refills, too. By the time she realized that opioids held her tight—in a way the pot and alcohol never had—it was too late to turn back. Pills were everywhere. Everyone knew of a doctor who would prescribe, and if not that, their parents were being treated for pain, and they had plenty of extra pills. Stopping was no longer an option for Megan, because the cravings and withdrawal were more than she could possibly manage. At a dollar a milligram, the price on the street for buying three to five oxy 30s for her daily needs were beyond her means. When supply ran short, heroin was a cheaper way to go. She convinced herself that as long as she was taking prescription pills, she wasn’t an “addict.” After that, as long as she was just smoking heroin, it wasn’t a problem. Only after years of injecting herself multiple times a day, and hustling for opioids wherever she could find them, did she admit to herself that she was hooked and in trouble. I have been the medical director at our local methadone and buprenorphine treatment clinic for the past 25 years. We have 700 clients. I see Megan and others like her every week. My primary job is as health officer for Jackson County Public Health, but I continue my opioid treatment work, in part, as a reminder of the toll our country’s misguided “pain” treatment has wrought on our society. It keeps me inspired to work on behalf of Megan and others, to educate providers about the power of opioids, and how, as healers, we can do so much better. So how could Megan’s life trajectory have been altered by us, the doctors, nurse practitioners, and PAs she met along the way? Œ Understand the power of opioids. We had been purposely misled by those who have made great profit from these medications (Google it) and we need to learn the real science concerning these drugs. Œ Understand pain. Acute pain is not the same as chronic pain. Cancer pain is really ongoing acute pain. Chronic pain is a bio-psycho-social phenomenon and needs to be approached that way. Œ Understand who is at risk of misusing opioids. Those with childhood trauma, sexual abuse, and/or PTSD are at a much higher risk of abusing opioids, and escalating their doses. People with substance abuse histories can easily lose control of the next drug that comes their way. These patients are desperate to make the “pain” go away, but it may not be the pain we think we are treating; we may be using the wrong tools, and causing harm. Œ Become a buprenorphine prescriber. Œ Create a system of assessment for all your pain patients. Sign up for and check the PDMP. Ask about substance abuse, mental health and trauma history. Get old records and perform urine drug screens. Keep yourself and your patients safe. Œ Understand about pain amplification. Some of us with chronic pain understand how to manage painful nociceptive input better than others. Œ Non-medication modalities can really help reduce the perception of pain. We need to stress those approaches for pain management. If insurance carriers aren’t paying for Assertive Community Treatment (ACT) therapy, movement therapy, peer support, or pain education, but are only paying for pills and procedures, then make them change. We are not powerless fluff in a large healthcare machine. We have influence. Œ Change the way you manage chronic pain. It takes expertise and time, more than any individual provider has available. It has to be done in a collaborative way and requires support, education, behavioral interventions, and physical rehabilitation. If we take too many short cuts in managing pain appropriately, we end up with too many Megans. And finally, understand substance abuse. It is a part of everyday medical care, whether we are aware of it or not. Learn how to approach addiction with nonjudgmental compassion, but also with clear appropriate boundaries. Because Megan really could be your daughter. Jim Shames, MD, is the Medical Director and Health Officer for Jackson County. He was instrumental in the formation of Oregon Pain Guidance, a collaboration of heath care providers in Southern Oregon that facilitate the appropriate and safe treatment of chronic pain. He was the recipient of the 2012 OMA Doctor-Citizen of the Year Award for this work. 22 Medicine in Oregon www.TheOMA.org
OMA Medicine in OR Winter 2015 2016
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