Death By Pain Pills

He was a pale faced, somewhat overweight 50 year old with a tired demeanor.  He had a treatment resistant depression and I had asked his primary care physician to run some tests.  He complained of not just lower back pain, but pain in all his joints, and I wanted to rule out autoimmune illness; things like rheumatoid arthritis, or even lupus. I also told him to review his pain meds with the doctor.

He claimed 8 months of sobriety from what had once been a pretty heavy alcohol habit.  Who knows what is real or true?  He had told me he had a couple “little relapses,” not unexpected in that sort of problem.

“The doctor says I am an addict and I am going to die from my pain meds, because I take too much of them.  I told him if he would give me better ones or stronger ones, I would not have to take so much.  It is his fault.  I really hurt.”

I had not expected this response.  I asked him what his pain meds were.

“I get percocet on a prescription,  It is not enough.  I need all the ketoprofen and ibuprofen stuff I can get, and that is over the counter.  I need this stuff.  I am actually trying to work for a living.”

I was concerned.  He had a serious risk of death from his pain meds. “I think your doctor was right.  You can die from this stuff.”

First the Percocet.  Highly addictive, with opioid content,  from Codeine to Hydroxycodone, the form of the opioid mattered little.  But his doctor was smart enough to realize if the patient was abusing, then the part of his Percocet that was most likely to kill him was not the opioid but—the tylenol. In my head there was a song.  Kind of like Billie Holiday’s “Good Morning Heartache” except it came out “good morning liver failure.” People persist in thinking that over-the-counter drugs are harmless. They may be in most cases, when people take them at or below the doses listed on the label.  This man told me he just kept taking them until the pain stopped,

Despite the gentle, measured tones of mainstream medical folks who talk about the effects of tylenol on the liver, I remember patients who tried what they thought were halfhearted attempts at suicide by taking a “bunch” of tylenols and ending up in intensive care trying to inhale Mucomyst, often slowly wending their way back to psychiatric patient with a healthy fear of tylenol and sometimes, alas, not.

But wait; there’s more. He took all of at least one non-steroidal anti-inflammatory he could get. The statistic of 10,000 deaths from nonsteroidals worldwide has been stuck in my head since the early 90’s.  I was looking for something more recent when I found the last entry on this page: 7600 deaths annually in U.S. alone must be climbing. People get ulcers.  If this process that eats away at stomach wall is close enough to a blood vessel, it erodes and the patient dies. I have a vivid memory of having taught a class in a massage school. Several of my students were veterans.  One hand shot up the minute I said that these things were deadly. “But they gave them away like candy in the Navy clinics.  “They can’t be that bad.” I looked him straight in the eye; he was in the front row.  “They are.” “You’re kidding,” was the best retort this man could come up with. “I am afraid that the things the military does to you are not always things that are the best for you.  I was in the military, too, and I know at least a little about these things.  And I have spent many years taking care of veterans, too.” This was not a guy I could argue with on the molecular level.

Yes, my current patient could have easily killed himself dead with abuse of either of his pain meds, and he seemed to be abusing both. I told him I agreed with his current MD, which surprised him. “I thought you were too smart to agree with anybody.” “Only if they are right, and this guy is.”

I recommended a pain specialist, and looking on the internet if he didn’t believe me. He said he just wanted to stop the pain.  He obviously wasn’t much for research. I told him his therapist could help with non-drug ways to deal with pain. He did not believe such things existed. First he needed the belief of possibility, I told him.  Then helpful things could and would happen.

The hardest thing in the world to do is still to change people’s beliefs.