I learned a great deal from Dr. George Dawson’s recent post on the letter he received from the Surgeon General about how doctors can help “turn the tide” on the opioid epidemic. George and I are both psychiatrists but I didn’t get a letter from the Surgeon General. That’s probably because I’m not an addiction specialist, do not write prescriptions for opioids, and do not provide primary care. That prompts the question about why the Iowa Board of Medicine requires mandated CME documentation from me about opioid management of chronic pain–but let that pass.
George’s post also led me to Dr. Nora Volkow’s January article in the New England Journal of Medicine about the disease model of addiction, which I thought was very well done (Volkow, N. D., et al. (2016). “Neurobiologic Advances from the Brain Disease Model of Addiction.” New England Journal of Medicine 374(4): 363-371). I think Dr. Volkow’s explanation of addiction being at the extreme end of the spectrum of substance use disorders helped me understand part of the rationale for considering addiction a disease.
I think part of my hesitation accepting the disease model of addiction comes from my learning in residency about The Perspectives of Psychiatry model of psychiatric illness, written by McHugh and Slavney, which was operationalized in Systematic Psychiatric Evaluation by Lyketsos and Chisolm. In the book they describe a way of viewing psychiatric disorders from the Disease, Dimensional, Behavioral, and Life Story perspectives. Although it’s oversimplifying the concepts, the Behavioral perspective is distinct from the Disease perspective in that the disorders tend to be of goal-directed behaviors, with addictions being the main example. The authors consider them some “combination of physiological need, conditioned learning, and choices.” They consider the Disease perspective disorders as manifestations of a “broken” part, more like delirium, schizophrenia, or bipolar disorder.
This has made sense to me for many years and it’s still taught to our residents nowadays. Not everybody agrees with the model. On the other hand the perspectives aren’t necessarily mutually exclusive and I think Volkow’s spectrum concept of addiction and the Disease perspective could probably be reconciled with each other.
Moving on to the new Black Box Warning for combining opioids and benzodiazepines, I’ve been wondering how effective this method of educating clinicians and patients will be for reducing the tendency to use both, say in burn surgery departments in many hospitals around the country. Of course, I have cautioned my colleagues about this practice because I find it’s often associated with the onset of delirium. In all fairness, I think the reasons for using both classes of drugs in the extremely painful “tub room” burn wound management routines might be that the opioid helps manage the excruciating acute pain while the benzodiazepine may help minimize the anticipatory anxiety of the process and dulling the memory of it afterward.
The tendency to prescribe opioids for some patients after relatively minor office-based procedures is, just as George points out it in his blog post, part of the problem. However, I was pretty impressed with my dentist who recently performed a tooth extraction and suggested I take an over-the-counter nonsteroidal anti-inflammatory agent. I took one or two doses and got along just fine. However, that was not my experience many years ago when I had my wisdom teeth pulled. It was a painful experience and, although it’s hard to remember exactly what I took for post-procedure pain control, I’m pretty sure it was an opioid.
But it wasn’t long after my recent tooth extraction that I was back to eating regular food without any problems.
I also owe a big thanks to George for making available the Turn the Tide link. You never know; maybe if more doctors used things like the Pain Treatment Toolbox, we could make dent in the opioid epidemic.