When the final choice is ….

Tale of Two Suicides; Lessons for Opioid Public Policy

http://nationalpainreport.com/tale-of-two-suicides-lessons-for-opioid-public-policy-8828356.html#comment-173850

David_J_Nagel_MD_2

For one it was the best of times, for the other, the worst.  At no time did the paths of their lives cross, but they shared the same fate, one most would consider a tragedy.  Their legacies, for pain and public policy, could not have been more different…

I knew one, only heard of the other; both dramatically affected my life.

Bob was a marine.  He had valiantly served his country, and he was proud of it.  His identity was so tied to his service that he could not handle the thought of being any less of a marine, a warrior… a man, whatever that means. His back injury robbed him of that identity, and he struggled in a futile attempt to regain that which he no longer was, or, at least thought he was.  Perception is reality, and his perception was that he was no longer what he wanted to be, needed to be.

Surgeries and elixers, therapies traditional and non-traditional.  All tried in a vain attempt to rid himself his pain.  All failed.  Some made his pain worse.

He used pain meds to numb the pain, but they couldn’t restore his manhood.  In desperation, he kept taking more and more.  After a while, he gave up the hope for a cure.  He was a broken man, not just physically, but also mentally and spiritually.  The meds gradually became a temporary reprieve from his painful reality.

I was his doctor.  I never really saw that brave marine.  Rather, I saw a broken, staggering man, subservient to the world his pain had created for him.   Our goal for any treatment is to improve one’s function.  For many, opioids accomplish that.  Not for Bob.

In Bob, I saw a gradually fading light, one I felt that I desperately needed to find a way to re-ignite, if not for him, then for me.  Being in his presence was so challenging.  I had two options; I could fight or take flight.  For me, the latter was not an option.  I decided to fight.  One day I tried to challenge that marine, suggesting he could use that bravado that had served him so well in the past to challenge his pain, to find a way to survive, to thrive despite it, and, in so doing, find a sense of meaning in his life that was missing.  That needed to be his calling and was his only option.  I never really thought there was another option.  I told him that I could no longer prescribe the medication for him as I saw it harming more than helping.  I promised to be there for him throughout.

It was so strange, but he was instantly transfigured into the warrior he once had been, one who could and would take control, just not in the way I envisioned.  He suddenly stood tall.  Walking over to me, he placed his cane at my feet, saying he no longer needed it; in fact never needed it.  I know he did not stand at attention or salute me, but it seems like he did, and that is my final image of him.  He turned and walked confidently out the door.

I never saw him again.  That night, he died by his own hand.  Suicide.  It doesn’t really matter how, he just did.  Could have been a gun-shot.  Could have been a car accident.  He chose to take every pill he had.  It was not the meds that killed him.  It was his misperceptions and his pain, neither of which he could tolerate any longer.  That is not how the coroner saw it; accidental overdose he ruled it.  Kierkegaard said: “Once you label me you negate.”  By failing to describe in detail the reason for Fred’s demise, he negated him, and, is so doing harmed so many others.

When we look at the roll call of those who have died from drug overdose, the numbers never tell us why.  We really do not know the true secondary morbidity and mortality of chronic pain.  There is evidence to suggest that patients with chronic pain are 2-3x more likely to commit suicide and that most would choose drug overdose as their preferred means.  How many of those who have died from drug overdose are trying to escape their pain?  It is an important question to ask, but one we fail to.  Mistakenly categorizing these suicides as merely drug related harms much more than helps.

There were no candle-light vigils for Fred.  He was gone, and quickly forgotten.  Most palliated their grief by rationalizing his demise:

“He’s a in a better place, one without pain.”

It is amazing how well mental gymnastics can serve to alleviate our uncomfortable and unwelcome feelings; there but the grace of God, go I??  No, can’t be so.

Absent his palpable suffering, most were actually relieved.

I stare at his cane as I write these words.

*   *   *

Billy was an adventurer, a thrill seeker.  He never really served anyone but himself.  I’ll give him a pass.  He was young and stupid, like I had once been.  It has been said that it is a miracle anybody survives adolescence.  The difference between he and I was I never intentionally challenged my mortality.

I never met Billy, but I knew plenty like him.  There is something we like, even admire, about thrill seekers, and Billy was no exception. All of his endeavors were greeted with accolades from those around him, whether he was getting or giving a head injury on the football field, breaking bones BMX bike racing, or whatever else he chose to do.  His parents were so proud.  The accolades were an elixir, one he longed for, no matter the setting.   He was addicted to them.  He was never one to back down from a challenge.  One day, his friend challenged him with some oxy’s.  So challenged, his fragile ego left him no out.  He took it.   80 mg.  Chewed it for the better high.  In short order, he was dead.

A young man lost, one with “his whole life in front of him.”  I struggle to understand what that actually means, but that is what we say.  Life is a gift, one we can use or abuse in any way we choose.  Our contributions to the whole of life are not measured in time, but, rather in the quality of our thoughts and actions.  We all make mistakes, but some, like Billy’s, are terminal.  Then there is no whole life in front of us, only behind, and all we are left with is a legacy.  Billy’s was not good.

It is customary to embellish those we lose.  Billy suddenly became a wonderful person, a role model, someone to emulate.  Awards were created in his name.  The community came together to mourn his loss.  His suddenly over-inflated image left no room for fault.  Someone was to blame for his demise, and it surely could not be him.  Doctors who prescribe pain medication and pain patients who can’t deal their pain took the fall.

Billy’s parents took to the legislature to exact vengeance.  While few would ever be driven to action to help Bob, there were many who sought to vindicate Billy.  There are few things more motivating than a grieving mother’s wailing, and the legislators were not immune.  Soon, laws were being enacted in a vain attempt to “stop the carnage.” In a world fueled more by emotion than reason, the land of “feel-good law,” the law of un-intended consequences reigns supreme.   Soon, laws were passed.  Addicts still died.  Those in pain struggled to find someone with the courage to defy those laws and care…and they died too, but their cries went unheard.

*   *   *

It is unfortunate that discussion about pain management seems to come down to opioids.  However, our options are limited and they will always be a part of the pain equation.  They occupy their dubious position because of their un-predictable ability to help or harm.  Depending on personal experiences, individuals choose sides, and myopically define them as good or evil, black or white.  Nothing is ever so simple.  The aims of pain management and the treatment of drug abuse inevitably conflict, and that is the problem.  Somewhat paradoxically, despite their substantially smaller numbers, the cries of those who suffer from the ill effects of drug abuse overwhelm those who suffer from un-remitting pain, and the ramifications for public policy are huge.  However, it is not the addict in the street that inspires these modern day Spartans to win their legislative battles.  Rather, it is the Billy’s, the well off, the ones so like me and you that we seek to protect them, no matter who else we harm.  We certainly do not see a value in emphasizing the needs of those in pain, those we stigmatize, ostracize, and blame for their own infirmities.  They fight a losing battle in this legislative cataclysm.

We pay legislators to fix problems even if they are un-fixable.  Their chosen weapon is the creation of new law.  I would argue there are really three related crises in our culture:  addiction, chronic pain, and the excesses of government regulation.  I would argue that the last of these has created the greatest carnage in physical and human terms.  Still, legislators myopically seek to fix complex problems with generic, all-encompassing laws which cannot possibly cover every contingency and often create more problems than they solve.  In the world of opioid legislation, the results are unnecessary barriers to prescribing.  While it is not clear what the effect on drug abuse is, the effect on the pain patient and his or her doctor is huge.

Fifteen years ago, I initiated a process of creating a set of opioid prescribing rules in our state that I envisioned would protect the rights of physicians to prescribe pain medication and the rights of patients to receive them.  My role as a physician is to care for those who are suffering, and after careful risk-benefit analysis, it is often my responsibility to prescribe these medications.  It is somewhat ironic that most of the patients I care for would do anything to rid themselves of these medications, ones we share a fear of.  At the same time, addicts crave these medications.

As a physician, I have the right to assume that the person seeking my care is in legitimate need of help.  While I accept that addiction is an obsessive-compulsive disorder which creates great suffering for the addict and those around him or her, I resent that they would misrepresent themselves to me to obtain a legitimate drug for illicit use. Furthermore, I resent any attempt by legislators and law enforcement to create public policy to protect such individuals at the expense of my patients, something that is clearly happening.   I sought to create state rules which would emphasize the needs of those in pain, and, to some extent we kind of succeeded.

Recently, our state governor chose to dramatically alter those rules on an emergency basis.  Her motivation for doing this is open to question, and I will leave that to others to openly consider.   However, I was told the epidemic of death due to prescription and non-prescription opioid abuse was the reason.   To bolster her political position, she needed to do something.  To minimize public dialogue, initial discussions were held behind closed doors.  Had she been successful, it would have been extremely challenging for patients with any type of pain to receive care, acute or chronic, terminal or not.  There is no harder place to keep a secret than in the world of politics.  The word got out, and it was exciting to watch a unified front of pain management advocates from all persuasions challenge her and block the full effect of the proposal.

The battle has only started, and it is not just in the legislatures, and not just in my state of New Hampshire.  It is also in courtroom. In the chilling wake of a second degree murder conviction for Dr. Hsiu-Ying “Lisa” Tseng, accused of prescribing opioids in the course of her practice that led to the deaths of three patients, I, like many others feel lost and vulnerable. Deputy Dist. Atty. John Niedermann, who argued the case against Dr. Tseng issued the threat:  The message this case sends is you can’t hide behind a white lab coat and commit crimes.  A lab coat and stethoscope are no shield.

The definition of the word “crime” is not always clear, and it was not clear in this case either.  Medical decisions often harm more than help; sometimes a death results.  Is that a sad twist of fate or is it a crime?   Many details are missing, and I am not a position to judge the actions of the doctor or the prosecutor, but I am not willing to give the latter a pass.  While we would like to assume that prosecutors are un-biased individuals who put the needs of the community against their own, the reality is that is often not true.  More often, they are flawed, myopic individuals who often selfishly use their position to climb the legal ladder, often caring little for whom they harm in the process.  The problem is these individuals are powerful and their actions have great potential to harm or help  While I have no ability to assess Mr. Nierdermann’s motivations nor the merits of his case against Dr. Teng, his quite bellicose statement has sent shockwaves throughout the pain management community, threatening the legitimate care that many patients seek and deserve.

Am I willing to risk jail to do what I think is right?

In the wake of these deaths, we are in severe need of guidance.  Aristotle said the law is reason free from passion.  In seeking a balanced solution, one which respects the needs of all, we seek reason, but passion is the rule of the day. In doing so, we must attend to the needs of Bob and Billy and all those who suffer.  Such a solution comes about only with great thought, communication, and energy. However, anything less cheats those who suffer, be it from pain or addiction.

3 Responses

  1. EXFCELLENT post! Well said and thought-provoking.

  2. I agree great post! Definetly thought provoking and an eye opener about what challenges physicians are facing

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