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Hey gang
I'm a chief psych res closing in on the final months of residency, and soon will be on my own with all the autonomy and associated responsibility that comes with leaving the nest.
With that in mind, I'd like to discuss a pt I encountered several months ago as a resident, as the details of his sad, but fascinating case, have left me in a bit of a tailspin as I've begun to question tenets of medicine that I thought were firmly established in my mind, and not subject to question.
I will call the pt "T" and his hx is far too long and complex for a thorough recap here, but I do want to discuss the few salient aspects that have left me on unfirm ground, just as I'm set to strike out on my own in private practice.
In short, T is an addict, specifically opioids. He is 40, extremely bright and charming, and had no hx of substance abuse at all until 10 years ago. T claims, and has compelling documentation, that since his teenage years he has sought medical help in nearly every specialty, to address a debilitating and constant depression that he's suffered with since teenage years. His depression made him completely disinterested in doing literally anything. His anhedonia was off the charts. He found no joy in anything, and wished for nothing in life, as he couldn't even conjure hypothetical scenarios which would bring him any joy. His thorough medical records support all of this.
Then....at age 30 T had a minor injury and was prescribed Percocet for the first time, and it was life changing for him. He describes it as "the first time I felt human since 17. I felt like i did before I got sick. I was hopeful,and I cried for an hour because it's something I thought I'd never feel again".
I know, I know....of course he felt like that, big boy was high-and that was my initial impression. T found a pain doc w very loose prescribing practices, so In short, T has been getting opioids legally through this doc for a decade, and freely admits that while he does suffer some physical pain, he takes the pain meds as a means to treat his depression. He's now been on daily opioids for a decade and his transformation is profound. He returned to college, found a passion for law, went to law school, and is now a practicing lawyer. Prior to starting opioids, leaving his parents house to go food shopping would be cause for celebration.
So T is not drug seeking from me, he's already getting more than he needs, but what he wants to know is why is he forced to exaggerate his physical pain to get the meds that help his debilitating depression. Why can't he just be honest about his symptom, and the relief he receives from this class of meds where all other Tx has failed (staggering assortment of SSRI's, And other antidepressants tried over the decades, ECT, therapy, even ketamine infusions..no benefit anywhere).
At first blush it's easy to counter that while these opioids may seem to help his depression, they are addictive, highly controlled, dangerous, and not indicated for Depression as no reputable study has shown opioids to benefit depression in the long run. But since when are we gun shy to write for drugs that have these downsides previously mentioned? Benzos are a prime example. While ideally we try another class of drugs to tx anxiety first, if the pt doesn't benefit, here come the benzos....and of course we all follow the strict recommendations that benzos are not to be given for longer than 6 weeks.
So getting back to my pt. The last thing I want to do is get any pt hooked on narcotics and so tx depression w opioids is simply out of the question...well that's how I used to feel, and I still feel this way..almost always
But right now I am having a hard time coming up with a compelling argument for why it would be bad medicine to give opioids to a pt with documented debilitating depression for decades which is refractory to everything...except the one thing I'm not supposed to give him. Yes he will become dependent, yes he will likely become tolerant which could lead to dose escalation, yes these drugs can be dangerous/fatal when abused. But do these risks justify denying the pt the only thing that works for him. Were he not to have access to these meds through his pain doc, is sending him back to a life of misery truly the right thing to do as a doctor?
So in short, assuming we believe such a pt has faithfully explored all known options, but to no avail, and if we accept that opioids provide long term relief of symptoms and improve quality of life, by what justification do we deny this treatment option, and beyond that, how could we call it anything but cruel to do so.
The risks of this class of meds are well known and don't need to be reviewed. However, we prescribe daily drugs with similar risks, including dependence and abuse. We constantly weigh these risks against the benefits and from there we arrive at a logical decision. How many of us would give this man what seems to help him when nothing else does? What am I missing that would allow the majority of us to send this man back to his misery rather than provide him this particular class of drugs?
I know I've put a lot of questions out there, and it's likely clear that my opinion is such a pt has the right, and thus we have the duty to provide ANY drug which we feel will benefit the pt. provided we deem the benefits outweigh the potential risks. At this moment..i would sleep fine giving a pt with the above hx a fentanyl jumpsuit if I found it provided sufficient relief, as I'm hard pressed to think of any potential risk of the drug outweighing the harm that would result from sending our friend back for a few more decades of miserable depression.
NOTE: It's not rare for me to be as convinced of something as strongly as I seem to be on this matter, only to be pointed towards something I'd not considered and consequently realize how truly off I was. I welcome All opinions and insight that would give me reason to reconsider my current convictions.
Thanks guys-
I'm a chief psych res closing in on the final months of residency, and soon will be on my own with all the autonomy and associated responsibility that comes with leaving the nest.
With that in mind, I'd like to discuss a pt I encountered several months ago as a resident, as the details of his sad, but fascinating case, have left me in a bit of a tailspin as I've begun to question tenets of medicine that I thought were firmly established in my mind, and not subject to question.
I will call the pt "T" and his hx is far too long and complex for a thorough recap here, but I do want to discuss the few salient aspects that have left me on unfirm ground, just as I'm set to strike out on my own in private practice.
In short, T is an addict, specifically opioids. He is 40, extremely bright and charming, and had no hx of substance abuse at all until 10 years ago. T claims, and has compelling documentation, that since his teenage years he has sought medical help in nearly every specialty, to address a debilitating and constant depression that he's suffered with since teenage years. His depression made him completely disinterested in doing literally anything. His anhedonia was off the charts. He found no joy in anything, and wished for nothing in life, as he couldn't even conjure hypothetical scenarios which would bring him any joy. His thorough medical records support all of this.
Then....at age 30 T had a minor injury and was prescribed Percocet for the first time, and it was life changing for him. He describes it as "the first time I felt human since 17. I felt like i did before I got sick. I was hopeful,and I cried for an hour because it's something I thought I'd never feel again".
I know, I know....of course he felt like that, big boy was high-and that was my initial impression. T found a pain doc w very loose prescribing practices, so In short, T has been getting opioids legally through this doc for a decade, and freely admits that while he does suffer some physical pain, he takes the pain meds as a means to treat his depression. He's now been on daily opioids for a decade and his transformation is profound. He returned to college, found a passion for law, went to law school, and is now a practicing lawyer. Prior to starting opioids, leaving his parents house to go food shopping would be cause for celebration.
So T is not drug seeking from me, he's already getting more than he needs, but what he wants to know is why is he forced to exaggerate his physical pain to get the meds that help his debilitating depression. Why can't he just be honest about his symptom, and the relief he receives from this class of meds where all other Tx has failed (staggering assortment of SSRI's, And other antidepressants tried over the decades, ECT, therapy, even ketamine infusions..no benefit anywhere).
At first blush it's easy to counter that while these opioids may seem to help his depression, they are addictive, highly controlled, dangerous, and not indicated for Depression as no reputable study has shown opioids to benefit depression in the long run. But since when are we gun shy to write for drugs that have these downsides previously mentioned? Benzos are a prime example. While ideally we try another class of drugs to tx anxiety first, if the pt doesn't benefit, here come the benzos....and of course we all follow the strict recommendations that benzos are not to be given for longer than 6 weeks.
So getting back to my pt. The last thing I want to do is get any pt hooked on narcotics and so tx depression w opioids is simply out of the question...well that's how I used to feel, and I still feel this way..almost always
But right now I am having a hard time coming up with a compelling argument for why it would be bad medicine to give opioids to a pt with documented debilitating depression for decades which is refractory to everything...except the one thing I'm not supposed to give him. Yes he will become dependent, yes he will likely become tolerant which could lead to dose escalation, yes these drugs can be dangerous/fatal when abused. But do these risks justify denying the pt the only thing that works for him. Were he not to have access to these meds through his pain doc, is sending him back to a life of misery truly the right thing to do as a doctor?
So in short, assuming we believe such a pt has faithfully explored all known options, but to no avail, and if we accept that opioids provide long term relief of symptoms and improve quality of life, by what justification do we deny this treatment option, and beyond that, how could we call it anything but cruel to do so.
The risks of this class of meds are well known and don't need to be reviewed. However, we prescribe daily drugs with similar risks, including dependence and abuse. We constantly weigh these risks against the benefits and from there we arrive at a logical decision. How many of us would give this man what seems to help him when nothing else does? What am I missing that would allow the majority of us to send this man back to his misery rather than provide him this particular class of drugs?
I know I've put a lot of questions out there, and it's likely clear that my opinion is such a pt has the right, and thus we have the duty to provide ANY drug which we feel will benefit the pt. provided we deem the benefits outweigh the potential risks. At this moment..i would sleep fine giving a pt with the above hx a fentanyl jumpsuit if I found it provided sufficient relief, as I'm hard pressed to think of any potential risk of the drug outweighing the harm that would result from sending our friend back for a few more decades of miserable depression.
NOTE: It's not rare for me to be as convinced of something as strongly as I seem to be on this matter, only to be pointed towards something I'd not considered and consequently realize how truly off I was. I welcome All opinions and insight that would give me reason to reconsider my current convictions.
Thanks guys-
