A Cautionary Tale of Prescription Pain Medicine.

My first experience taking a pain medication was when I was 26. I asked a friend if he had any Tylenol for my headache.

I was working in my first year of the residency program in Anesthesiology at Johns Hopkins Hospital and enjoying a night off watching television with a couple of friends. I was suffering with a bad headache all day and was just trying to ignore it, but to no avail. That evening, I finally decided to find something to relieve it. Matt went to get some Tylenol but came back with Tylenol with Codeine, saying that it was all he could find in his mother’s bathroom cabinet. Mary Lou immediately told me not to take it, but I eschewed her comments and took one. Thirty minutes later, I still had the headache and thought it was a good idea to take another. It was after all, only codeine, 1/10th as strong as Vicodin. It’s not really used to treat severe pain anymore, I told myself. Ever faithful, Mary Lou again said “don’t”. Despite taking more, I still had no pain relief and I ultimately went to bed.

The story doesn’t end here, but let me give you some interesting background.

Johns Hopkins Hospital is even more impressive in person than it is in reputation. It’s a beautiful place filled with pictures of medical messiahs and heros. It has the unmistakeable air of compassion and competence and historical greatness. Everyday I was reminded of how fortunate I was to have the opportunity to work and learn amongst the most intelligent and capable of doctors. The first day of my residency training was unforgettable, but in a totally unexpected way.

It was 6:00 in the morning and all the residents, fellows and attending physicians were in the Grand Rounds auditorium which was a huge amphitheatre with stadium seating and a stage at the base. This is where in the 1800’s, the famous doctors Halsted, Cushing, Blalock and others would perform procedures in the “operating theater” on patients in front of an audience of students and doctors who learned their techniques. Out onto the stage walked a string of distinguished looking physicians with their white coats on and one by one they told their stories. “My name is Dr. Jones and I’m a drug addict, my name is Dr. Andrews and I’m a drug addict, etc.” Chills ran through my body and my heart broke for those doctors whose lives and promising careers were ruined by drug addiction. Ruined by the wrong decision at the wrong time that set off a chain of regrettable and irreversible consequences. The common theme behind their downfalls was that they were tired and stressed out and wanted to sleep and feel better. They tried some of the medications that they had to give their patients and that was the beginning of the end.

As anesthesiologists, we have very easy access to any and all controlled substances (narcotics, propofol, sedatives, etc.) because we use them in our anesthetic treatment plans for patients undergoing surgery every day. We have access and perhaps more importantly and dangerously, we have more knowledge and a higher comfort level than anyone on how to use them and avoid potentially lethal side effects. The disease of addiction; however, is such that the irrational use along with physical tolerance and dependence causes even the most knowlegable of us to keep chasing the “high” that inevitably leads to overdose and death. A woman in the residency class behind me was found dead in the ladies restroom with an I.V. in her ankle one night while she was on call. Certainly she hadn’t anticipated that outcome when she was heading for work that day.

So, back to my story abou taking Tylenol with Codeine for a headache…

Even though the medication hadn’t helped my headache, I awoke the next morning feeling like I was in Nirvana. I had this amazing feeling of calmness and well-being and of feeling loved. There was a breeze coming through the window and it felt like a wave of happiness caressing my skin. I couldn’t grasp anything to worry about! As a type A person, there’s always something to be concerned about, real or imagined. I had never experienced a feeling quite like that before and it was beautiful– at least for about an hour. Shortly after waking up, I got into the car to get breakfast. I became so nauseated after driving only a mile that I had to pull the car to the side of the road to throw up and up and up…That was the perfect example of both the high and the low of a narcotic pain medicine. I also realized with great clarity how anyone can become enamored with and addicted to the euphoric effect that these medications have. It became obvious how a medication can quickly become a drug if used in the wrong way for the wrong reason. I recalled those doctors from my first day of residency and was reminded of the lament, “But for the grace of God, there go I”.

Today, prescription medication overdose is the leading cause of any accidental death. Unfortunately, the very same medication that is used to improve function and quality of life for someone in chronic pain, is a loaded gun in the wrong hands. Statistics (and anectodal reports) show that teenagers are stealing pain medications from parents and grandparents and then passing them around at parties like Skittles. It’s not uncommon for an elderly patient to tell me that they took a friend’s pain medication “to try” but they have no idea of the name of the medication or dose that they took. There is a general feeling of indifference and a cavalier attitude regarding the danger of narcotic pain medications and this is alarming. Patients become upset that they can’t have their usual alcoholic cocktail and use pain medications. They fail to tell their doctors that they also take other controlled medications like Xanax or Valium that are prescribed by other physicians. Some patients say they’re taking certain pain medications when they’re not and say they’re not when they are. It seems that the general public, as savvy as they are with their internet medical knowledge, has no idea that these medications can make you stop breathing. They don’t realize that the higher the dose, the more potent the medication, and that mixing it with alcohol or other drugs makes the possibility of overdose and death exponentially more likely.

Unfortunately, chronic pain and addiction oftentimes exist side by side. As human beings we’re wired in a way that makes us prone to addiction to pain medications. It’s no one’s fault. It happens and there is treatment, but a person must be willing to accept that the problem exists in order to get help. It is important for physicians to treat each person as an individual and develop a treatment plan based on a specific cause of pain. As physicians we have a responsibility to our patients to prescribe the safest medications for the greatest benefit and lowest risk at all times. Some patients are not good candidates for narcotic treatment if they have specific risk factors for addiction and/or their behavior is consistent with addiction. Everyone deserves relief from pain, but no one deserves a Percocet prescription upon demand. Patients who say, “I know what’s best for me” usually don’t.

Everyday I do my best to take care of people and relieve pain. The medical training and the M.D. license that I have is my most valuable and important achievement. It is also the most difficult goal I’ve ever accomplished. I will not be that doctor who would even remotely consider the notion of selling her prescription pad or her ethics. I have the highest respect for what it means to be a physician. It is my obligation to uphold the ideals of my profession and to help and never harm a person who comes to me for treatment.