As a solo-practice psychiatrist, I am more connected to the cost/value equation of my services than the typical system-employed physician. I’ve also written in prior posts about my concerns with modern psychiatry. I have worked in a variety of settings over the course of my career, and I realize that coming to an understanding of something as complicated as another person’s subjective life experience is a very difficult endeavor. At the very least, such an understanding takes time. It also takes a willingness to maintain the constant recognition that my perception may be wrong, and may be the result of my own bias. Finally, it takes a certain amount of intelligence. Over time, certain patterns of thought become apparent and easier to recognize– but these patterns are extremely complex, and trying to provide insight into such patterns, without causing a person to take offense, requires intelligence, patience, and tact.
I have come to the realization (a somewhat surprising realization, frankly) that psychiatry works, when practiced properly. I’ve come to realize that the ten-minute med check is worse than worthless, as a ten-minute glimpse of a person’s day is more likely to lead to the prescribing of a harmful medication than a helpful one.
On the other hand, if one has the time to sit and share small talk, then review the important issues occuring in a person’s life, and then discuss the problematic symptoms that the patient is experiencing…. then ask questions that provide context for the symptoms, and perhaps make a small suggestion or two in order to provide outside insight into the cause of the symptoms…then present the different medications sometimes used for the person’s symptoms, after first discussing whether the person would prefer medication over working on the problem through more ‘mindful’ approaches… then discuss the different side effects possible with each medication, and the likelihood that the medication chosen would be helpful…
Today on my radio show I mentioned my frustration with being ‘in my 50′s’, and the injury to my knee that happened while stowing stuff in the garage last night. She sent me the video below– and I got a kick out of it!
I have been kicking these observations around for the past year, and have been unable to find a big fish willing to ‘bite’. I truly believe that the observations below have the potential to dramatically change the approach to opioid treatment of chronic pain. Since I have a blog, I have a soapbox– so I’ll share the idea, and welcome comments in return. I do ask that proper attribution be provided if this article is shared.
Introduction:
Long-term opioid analgesia without tolerance, respiratory depression, or euphoria? Introducing the Holy Grail for chronic pain treatment!
Premise:
The miracle of opioid pain relief is fatally limited by tolerance, addiction and respiratory depression. Buprenorphine, when combined with a mu agonist, results in game-changing effects. Patients experience potent, dose-related analgesia from the agonist, but have NO euphoria. The therapeutic window is widened. Patients unable to control their use of a mu agonist alone gain that control when on buprenorphine. And most exciting, buprenorphine indefinitely anchors tolerance, maintaining analgesia WITHOUT DOSE ESCALATION. This finding offers huge implications for pain management.
Discussion:
Use of opioids for chronic pain has severe limitations. Tolerance removes the benefits of opioid analgesics over time. Worse, tolerance is associated with dependence and withdrawal. Many patients use additional doses of their prescription early in the month, then suffer through withdrawal while awaiting refills. Others find opioids through less-reliable, non-clinical sources.
At the same time, addiction to mu opioids is a nationwide epidemic. Reformulation Oxycontin has pushed many opioid users toward diacetylmorphine—brand name Heroin. Some physicians recommend avoiding mu opioids altogether for chronic pain (e.g. Physicians for Responsible Opioid Prescribing), while pain treatment advocates argue to ease narcotic restrictions.
