Johnny Cash: "No. I’m not very brave because for five years I didn’t try to take the pain. I fought it. I had a total of 34 surgical procedures on my left jaw. Every doctor I’ve been to knows what to do next, too. To relieve me of pain, I don’t believe any of them. I’m handling it. It’s my pain. I’m not being brave either. I’m not brave at all after what I’ve been through, I just know how to handle it."
That is hard fought wisdom when it comes to dealing with chronic pain. In the previous few lines Cash had explained why he could not take pain medications. He described it being like an alcoholic not being able to drink alcohol. His pain started when his jaw fractured during a dental procedure and never healed appropriately. In Hilburn's biography (2), Merle Haggard is quoted as saying that Cash was at a chronic 8/10 level, using the typical 10 point pain scale for the last 8 years of his life. It is difficult to imagine how hard it might be to try to sing with chronic jaw pain.
Managing chronic pain in a person with a significant addiction problem is one of the most challenging areas of medicine. For the past 15 years, the USA has been in the midst of an epidemic of opioid painkiller use and accidental overdose deaths. This has been largely due to the effects of the politicalization of pain and pain medications starting with initiatives to prescribe more opioid pain medications for chronic pain and for acute indications that previously may not have resulted in that kind of a prescription. From what I can tell, the liberalization of opioid prescribing came about initially as the result of initiatives from the Joint Commission (JCAHO), the Veteran's Administration, and the American Pain Society. The initiatives can be viewed on this timeline.
The treatment of chronic pain is also viewed as a treatment that involves multiple modalities. It can certainly involve the use of various forms of pain medication, but physical therapy and psychological therapies are also mainstays of treatment. I have consulted in many situations where patients have had multiple surgical interventions for pain that have not been effective. I have never seen a person with 34 surgical procedures for the same pain. From a purely medical perspective, the treatment can involve opioid medications, but also gabapentin, pregabalin, and various antidepressants. Chronic pain is frequently associated with insomnia, anxiety, and depression and additional medical or psychological interventions for these problems is useful. Many people have strong biases about opioid medications and consider them to be the ultimate treatment for pain. Double blind, placebo controlled studies show that for neuropathic pain, the relief is moderate and generally equivalent to non-opioids. Unfortunately for many, that fact is not known until after the person has become addicted to the opioid.
The surgical approach to pain is gradually changing over time. I did a lot of neurosurgery during medical school rotations and in those days, there was a definite prosurgical approach to back and neck pain. Imaging studies were more primitive with a predominance of CT versus MRI imaging of the spine. I observed a lot of laminectomies and posterolateral fusions, using bone graft from a rib or iliac crest. I was also in the clinic and saw large numbers of patients coming back over time for chronic opioid prescriptions for continued pain that failed to clear up with the operative procedure. Our standard prescription in those days was Darvocet N-100s, a fairly low potency opioid analgesic that also contained acetaminophen. It was voluntarily withdrawn from the market by the manufacturer in 2010 after this labeling revision by the FDA in 2009 highlighting the risk of overdose, cardiac conduction abnormalities and fatal arrhythmias. In the course of psychiatric practice, I pay close attention to spinal problems. Spinal injuries are surprisingly common. Degenerative disease of the spine is also common and there is very little focus on spinal health and the prevention of these problems. In the people I have seen over the years, good prognosis spinal surgery in terms of pain relief generally involves a well defined lesion and neurological deficit in addition to the acute pain. Chronic unchanged pain is still an outcome after repeated surgery. At that point the question becomes, is there any medication that will reduce the level of pain. Some people will do well with chronic opioids, but the problem is that patients with addiction generally do worse and exposing more and more people to opioids is increasing the number of people with addictions. SAMHSA suggests the algorithmic approach in Exhibit 3-1 (3) above. The problem is that there is no good data for relapse, failure, or success rates after trying an opioid for chronic pain in a person with an addiction. My experience suggests that relapse rates are very high and success rates are very low, but I am seeing a population with a very high rate of addictions
The surgical approach to pain is gradually changing over time. I did a lot of neurosurgery during medical school rotations and in those days, there was a definite prosurgical approach to back and neck pain. Imaging studies were more primitive with a predominance of CT versus MRI imaging of the spine. I observed a lot of laminectomies and posterolateral fusions, using bone graft from a rib or iliac crest. I was also in the clinic and saw large numbers of patients coming back over time for chronic opioid prescriptions for continued pain that failed to clear up with the operative procedure. Our standard prescription in those days was Darvocet N-100s, a fairly low potency opioid analgesic that also contained acetaminophen. It was voluntarily withdrawn from the market by the manufacturer in 2010 after this labeling revision by the FDA in 2009 highlighting the risk of overdose, cardiac conduction abnormalities and fatal arrhythmias. In the course of psychiatric practice, I pay close attention to spinal problems. Spinal injuries are surprisingly common. Degenerative disease of the spine is also common and there is very little focus on spinal health and the prevention of these problems. In the people I have seen over the years, good prognosis spinal surgery in terms of pain relief generally involves a well defined lesion and neurological deficit in addition to the acute pain. Chronic unchanged pain is still an outcome after repeated surgery. At that point the question becomes, is there any medication that will reduce the level of pain. Some people will do well with chronic opioids, but the problem is that patients with addiction generally do worse and exposing more and more people to opioids is increasing the number of people with addictions. SAMHSA suggests the algorithmic approach in Exhibit 3-1 (3) above. The problem is that there is no good data for relapse, failure, or success rates after trying an opioid for chronic pain in a person with an addiction. My experience suggests that relapse rates are very high and success rates are very low, but I am seeing a population with a very high rate of addictions
In the absence of any markers of opioid addiction liability or reliable interview approaches a conservative approach is required and an extremely cautious approach is required if the patient has a known addiction problem. The comment on doctors by Johnny Cash is one that is best not forgotten. One of the reasons that opioids are prescribed in the first place is that pain is chronic and refractory to usual treatments. In some cases, years of trying multiple opioids and going through residential drug treatment centers has resulted in the perpetuation of chronic addiction and chronic pain. The algorithm above suggests the appropriate course of action for patients with that problem. They need to be tapered off the pain medication and typically maintain the medication is necessary. In many cases there is a significant amount of pain relief and improved function by tapering and discontinuing the opioids. In some cases, the ability to function improves because the addiction fades away even though the pain is no better.
Johnny Cash got to the point where he could be tapered off the opioids and make it on his own. That is a tough goal, but one that more people should strive for at least until there is a better solution to chronic pain and addiction. He also reminds us of the role of physicians in this process. My overall impression is that there are more physicians willing to draw the line and say: "I really don't think that another operation or medication is going to add much to what you have already tried." ..... but I don't think there is a lot of evidence to back up my opinion.
George Dawson, MD, DFAPA
References:
1: Barney Hoskins. Johnny Cash on the Gospel. Blank On Blank. October 1996.
2: Robert Hilburn. Johnny Cash - The Life. Little, Brown, and Company. New York. 2013.
3: Substance Abuse and Mental Health Services Administration. Managing Chronic Pain in Adults
With or in Recovery From Substance Use Disorders. Treatment Improvement Protocol (TIP)
Series 54. HHS Publication No. (SMA) 12-4671. Rockville, MD: Substance Abuse and Mental
Health Services Administration, 2011. (Figure 3-1 above is from page 34 of this manual).
