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When chronic pain, addiction and mental illness intersect

Dr. Charles Reznikoff and his colleagues at HCMC have created a multidisciplinary, team-based care center for the hospital’s chronic-pain patients.

James Marthaler’s history with morphine began in 1993 after he was diagnosed with hereditary pancreatitis, a rare and chronic condition marked by progressively painful and damaging bouts of inflammation.

James Marthaler’s history with morphine began in 1993 after he was diagnosed with hereditary pancreatitis, a rare and chronic condition marked by progressively painful and damaging bouts of inflammation. He began taking mild doses of morphine to manage the pain. Over time, however, a number of life factors came into play that complicated his use of the drug.

Marthaler, who was 30 at the time, was frightfully aware of the perils ahead: His sister had died from the inherited disease, his father was sick and dying from it. He knew that with each bout of inflammation, more damage would be done to his pancreas. And he knew he was at high risk for pancreatic cancer.

His troubles accelerated: The St. Thomas graduate, who was once considered a “fast-tracker” in the corrections field, became unable to work and was placed on disability. One of his two young sons also developed the inherited disease. His marriage began to fall apart. He was diagnosed with major depressive disorder.

“I would do everything I could to get myself out of bed in the morning and get my two sons to school,” said Marthaler, of Faribault, Minn. “And then I would curl up in a ball on the couch, and take my morphine and disappear. I have no memory of entire blocks of time during those years.”

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At first, Marthaler took morphine for two or three days at a time during the bouts of inflammation. Eventually, he was taking 250 milligrams three or four times a day (“one dose of which would kill me instantly today”) – as much to numb his mental anguish as to manage his pain. For a while, the morphine lifted the burden of “getting through a divorce, the guilt of having my son genetically bound to this condition, not being able to work, my failure as a man.” He tried visiting a therapist now and then, but “the morphine took over.”

The relief it once offered morphed into a death wish.

“There were a couple of occasions where I sat on the side of my bed with a shotgun in my hand,” Marthaler said.

A look in the mirror

Marthaler’s disease progressed just as he had feared, and he was diagnosed with pancreatic cancer in 2007. It was then that he learned of a University of Minnesota surgery, pioneered in the 1970s, that offered promise.

Surgeons performed a pancreatectomy and islet cell auto-transplant, which involved removing Marthaler’s pancreas, isolating the islet cells (which secrete insulin), and injecting them into his liver. The procedure relieved him (and his son as well) of much of the pain while keeping his body’s insulin-producing function largely intact.

But by this time Marthaler’s morphine addiction was 15 years in the making. He knew he couldn’t shake it on his own. He had tried it more than once, and the experience was “beyond words.” He also knew he could no longer run from the truth: “I remember looking at myself in the mirror in the bathroom. I was taking a handful of morphine, and I realized that I no longer had a reason to take this drug.”

His experience, as unique as it was, was being mirrored across the country in an escalating, decade-long public health crisis: a near doubling of the number of opioid prescriptions for pain visits (from 11.3 percent in 2000 to 19.6 percent in 2010), and a quadrupling of the number of prescription painkiller overdose deaths (from 4,030 in 1999 to 16,651 in 2010). The trends became, in the words of UC Davis pain specialist Scott Fishman, M.D., “entwined like the twin serpents in the caduceus.”

Detangling the pain

The challenge for care providers, as they respond to the national crisis and address the dilemma of people like Marthaler, is to more accurately apprehend the interplay of pain, opioids, mental health and addiction. And to help their patients do the same.

Charles Reznikoff, M.D., an internal medicine specialist and addiction medicine subspecialist at Hennepin County Medical Center and assistant professor of medicine at the University of Minnesota, has embraced this challenge with brisk resolve. He and his colleagues have created a multidisciplinary, team-based and coordinated care center exclusively for the hospital’s chronic-pain patients on opioids, who number at about 350 at any given time. Of those, about 20 percent also struggle with mental illness and/or addiction, Reznikoff says.

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“For the lucky few, the treatment of pain is as easy as injecting a joint,” he said. “But for many people, the treatment of pain requires multimodal delivery of care,” including psychologists, physical therapists, addiction counselors, pain doctors, pharmacists, nurse practitioners and nurses. As important, he said, “you need to have a clinic that’s there for you … people you recognize or who recognize you, people who are nonpunitive and trying to help you but who also can set limits with you. In other words, you need a relationship.”

The center’s services are available to HCMC’s 30 primary-care doctors as well as the 60-70 medical trainees rotating in and out. All of the players across the board meet weekly to discuss complex chronic pain cases, Reznikoff said.

Dilemma for both doctors, patients

The pain/addiction/mental health dilemma is felt on both sides, Reznikoff said: Primary-care doctors can be “terrified of addiction and fearful that their patients might be manipulating them or lying to them.” Patients, in turn, often don’t have a vocabulary for what they are experiencing. For example: “If a patient has serious anxiety and they’re in pain, sometimes they’re anxious about their pain. Sometimes their anxiety makes their pain worse. So, are they anxious about their pain? Anxious because they’re in pain? Or just anxious? Or just in pain? How to keep things differentiated is an incredibly delicate discussion.”

The next steps are not always immediately apparent: Some patients may legitimately require an increased dose of opioids, while other long-time users have developed opioid-induced hyperalgesia (increased sensitivity to pain) and no longer respond to their medications. They may need to detox with the help of methadone or buprenorphine/naloxone and find alternative treatment methods. Some may be referred for residential or outpatient addiction treatment. Others may need the help of a psychiatrist or psychologist for treating pain driven by anxiety or depression. And others may need to address potentially fatal interactions with other drugs they are taking, especially benzodiazepines. Or various combinations of all of the above.

It’s important to stay open, says Reznikoff, to ask patients about the stressors in their lives and understand the lens through which they view their pain. “You can’t close the conversation down on someone,” he said, “or just stamp your fist down and say no.”

‘A toxic combination’

Another case in point illustrating the dilemma is that of Bridget, a white-collar professional in rural Minnesota, who (fearing stigma) asked that her last name not be used.

Bridget’s pain began after a fourth surgery for endometriosis that damaged the wall of her intestines. Her prescription for OxyContin not only relieved her post-surgical pain, it also relieved her longtime symptoms from anxiety and panic disorder. For a little while, anyway.

In short order, Bridget doubled her daily dose of painkillers, and was taking them along with the benzodiazepines that had been prescribed for anxiety. “I was not necessarily being honest with my doctor at that point,” she admits.

Things were not good at home. Her husband, a returning Iraq War veteran, was having issues of his own.

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“It was a toxic combination,” Bridget said. Everything was magnified: pain, anxiety, daily panic attacks, and depression. Bridget lost her job, and spiraled down the rabbit hole.

“There is so much shame in being addicted,” she said. “My mental health certainly was the biggest player, but I couldn’t at that point look at it rationally.”

More painkillers = more pain

Both Bridget and Marthaler turned to Reznikoff for help. And both were able to withdraw from their prescription painkillers with the help of Suboxone, the brand name for buprenorphine/naloxone, a partial opioid agonist that reduces cravings and withdrawal symptoms without creating euphoria (and whose politics and efficacy have been in the limelight of late). As much as they credit Suboxone, they give greater credit to Reznikoff, for his frankness, openness and ability to break down the issues – hard as it was for them to hear him sometimes.

“The pain was not going to get better no matter how much OxyContin I took,” Bridget said. “And the more I took, the more my pain would be present. He [Reznikoff] explained that to me, and of course I didn’t believe him at the time – that the drugs were actually causing me more pain than helping me at that point. It made me a little angry and wary of him.” But his lack of judgment won her trust, she said.  “I don’t know how that happens, how you couldn’t at least show some judgment, because I’d never had that before from any health-care provider.”

Said Marthaler: “What always impressed me with Charlie is his pure honesty. He doesn’t play any games with people. He is extraordinarily bright but down-to-earth. I remember him being tough, though, telling me very clearly that it was going to be a long road, and that in order to start on the Suboxone, I would first have to stop using the morphine and start to go into withdrawal, which terrified the hell out of me.”

Every day, better at coping

After intensive dialectical behavior therapy (DBT) to manage her anxiety, Bridget has returned to work, and peace has been restored to the home front. She sees Dr. Reznikoff once a month, a requirement for patients who are on buprenorphine/naloxone.

“Every day I get better at coping with things that happen in life and setbacks,” she said. “Every day I feel more empowered to do these things without medications. It’s not like you get better overnight. It’s hard work. It’s constantly being aware of your feelings and emotions and being honest and open about them.” Her long-term goal is abstinence, she says, “and to be where I am now: healthy, mentally healthy.”

Marthaler is also back to work, supervising mental-health professionals for Rice County. His two sons are grown and thriving, one a chef and one a college student. He and his wife have renewed their marriage. He started Suboxone at 32 milligrams a day in 2005, and is down to 1 milligram a day. He sees a therapist and finds solace at his potter’s wheel. He teams up with Reznikoff for presentations on pain, mental health and addiction for various audiences, including at the University of Minnesota and hospitals and clinics across the state “for anybody who wants to learn.” His story is one way of giving back, he said.

“When I first started to get clean, an older woman told me, ‘Some day, James, you’re going to be happy and grateful for all you’ve been through.’ At that point, I could have strangled her. Today I find that so true. If what I’ve been through can help one person, if one physician could reconsider how they can handle chronic pain and opioids, if one person struggling could think maybe I could do it, that’s enough for me.”

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Pain on both sides

Reznikoff continues to advocate on behalf of those who struggle with chronic pain, mental illness and addiction. It is not his agenda to refuse opioids to people in pain, he says, but neither is he an incautious prescriber.

“There’s pain on both sides of the equation,” he said. “An overly liberal prescribing habit of opioids relieves pain in some and causes pain in others. And those affected by pain are those with a history of addiction. In all of this, someone needs to advocate for those with addiction and mental illness – to say, be cautious with your opioids. Because these folks have a hard time articulating their pain, a hard time managing their pain meds, and are more at risk for consequences including overdose death. And then the family members of those who overdose suffer tremendously.”

(Reznikoff’s caseload is full, incidentally, and he has no financial relationships with pharmaceutical companies to disclose).

Next week: In the classroom with Dr. Reznikoff.