Pain and Desperation

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When was the last time you used any narcotics?  I think I took some of my mom’s cough syrup with codeine over a decade ago, when I felt like I might actually cough up a lung.  Before that it was one dose of Darvocet after having four impacted wisdom teeth extracted at age 18.  I don’t really remember much after swallowing the pill and lying down on the sofa.  I was given multiple opioids during knee surgery last year, but needed only Tylenol and Advil afterward.  Looking back on the post I wrote about that experience, I realize even more how I was influenced by this piece in the New York Times just a month before my surgery.  In it the author is reminded that pain serves an essential purpose, and it’s better that we not necessarily seek to obliterate it at every turn.

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Four or five times in the last two weeks, I have received calls from local pharmacies to confirm opioid prescriptions that I did not write.  They were all paper prescriptions for patients I have never met, caught by astute pharmacists who suspected fraudulent activity.  This is the first time it has happened to me, and I know many of my colleagues have experienced the same.  Pharmacies in the area have now flagged my name and license number, and they know not to fill any controlled substances without direct confirmation from me.

What a morass.  How did we get here?  It’s a rhetorical question, really, but not a simple one by a light year.  When I started my training, we were taught to consider pain the ‘5th vital sign.’  Every patient assessment included the cartoon face pain scale.  Anesthesiologists’ prioritized rubrick for pain control started with long acting opioids around the clock, then regular anti-inflammatories if no contraindications, then short acting opioids as needed for breakthrough pain.  In the hospital I never questioned this method, especially since I almost never interacted with these patients after discharge and was oblivious to follow up issues.

It was not until I started in practice that I experienced the multidimensional challenge that is pain control and opioid prescribing.  After 15 years I am still learning the layers of complexity, unique for every patient, and I see that even if we understand it (which I think we do not), most of us feel helpless to address it.

The pharmacist I spoke to today told me that his store’s standard procedure is to inform the patient that the prescription was proven to be fake, advise the patient not to attempt such an act again, and let them know that the prescriber is aware and the police will be contacted.  It was that last part that made me pause.  Because even as I intend to file a police report (as advised by my institution), the answer to the problem is not, in my opinion, rounding up patients with chronic pain and throwing them in jail.  In order of importance, I think the opioid crisis is first a social, then a medical, and only then, a criminal problem.

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Increasingly, we have become a society of immediate gratification and entitlement.  We want and expect a magic pill for and complete relief from whatever ails us—because it’s the twenty-first century for crying out loud, how could we not have that already?  Also, medicine has become increasingly transactional.  We, patients and physicians alike, experience ‘care’ in predetermined packets of protocol and procedure, and spend considerably less time in conversation, education, expectation setting, and actual caring.  The advent of the internet has accelerated this immediate gratification expectation.  It also gives many of us an illusion of connection through social media, when in reality, we are actually less and less connected to one another.

Pain results from myriad causes.  We all have varying thresholds for feeling and tolerating pain, which vary themselves depending on circumstances, mindset, expectation, and meaning making (think childbirth versus bike accident).  There are so many factors that impact our pain experience, including dehydration, sleep deprivation, low mood, and emotional and/or mental stress.  Loneliness, depression, anxiety, sleep disruption, suicidality, and substance abuse are all on the rise.  And all of these conditions lower our thresholds for pain and the harm it does to us.

For many, opioids are indeed the immediately gratifying magic pills.  But the magic wears off faster and faster, and both pain and the desperation for relief accelerate in the wake of short and long term withdrawl.  As physicians, we feel an intense desire to alleviate suffering.  Once a patient has experienced the profound relief (both physical and psychological) from opioids, it feels cruel for us to withhold them, even when we understand fully their risks and the long term harm they cause.  And we have less and less time to explore with and educate patients about adjunct pain management practices, such as mindfulness, biofeedback, and movement.  Everybody feels despairing and impotent, and this drives people to do things they might not otherwise do, like make a fake prescription for hydrocodone and try to get it filled.

I know there are real criminals out there, people not really in pain, who do this to make money—to take advantage of people in real pain.  I don’t know who’s who.  But the story I tell myself is that this is not most people.  What we need is a stronger infrastructure to address chronic pain at multiple levels—individually, in community, with policy, and culturally.  As I write this, even as a physician with a leadership title, I feel powerless and a little hopeless.

But maybe a good start, at the individual level, that we can each do the next time we look ourselves in the mirror or meet another human being on the street, is to just exercise a little compassion and generosity.  I assume that those patients presenting the fake prescriptions, if they are real patients, are not criminals at their core.  Pain makes us do unthinkable and unbelievable things.  I hope we can all help one another find better sources of relief and support.

Walk a Mile

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NaBloPoMo 2018:  What I’m Learning

These last 5 years, I have had the privilege of caring for designated leaders of all kinds—business leaders who also lead their families, their faith communities, their professional societies, and myriad other entities. I have studied and presented on the intersection of health and leadership, the reciprocal relationships between self-care and care of others.  Each day I ask probing questions of my patients’ habits of thought and action, and they answer with honesty and candor.  It’s particularly fulfilling when I hear, “Huh, that’s a good question, I’ve never thought of that before.”  In those moments, I feel I bring value beyond interpreting blood pressure and cholesterol results.

I’ve been interested in leadership for a long time, and had opportunities to lead in various small ways through the years.  In January 2018, I was given a more visible title and designation than I had ever had—YIKES.  I was surprised and unsuspecting, though not totally unprepared.  And, like parenting, nothing can quite prepare you fully for the experience.  I spoke to a leader in my organization about a year ago, who expressed loneliness in his position.  I admit that I half dismissed the idea, thinking there should just be a way to balance collegial, friendly, and leader-led relationships.  I think I was about a week into my new role when I fully, viscerally, understood his perspective and humbly admitted my own loneliness.  I felt guilty and a little ashamed for my reflexive disregard for his confession of vulnerability—because even if I did not fully dismiss his experience, I did judge it.  And that speaks more to my own fear of loneliness and isolation than it says anything about him.

Thankfully, I did not wallow in guilt or shame for long.  “How fascinating,” I thought.  Being judgmental like that is not consistent with my core values.  These ten months have been a practice in navigating and managing that loneliness—cultivating relationships in new ways to maintain connection while simultaneously practicing the required discretion in information sharing.  Often I have felt profound humility (and now more embarrassment than shame) at how I thought I knew so much about effective leadership, mostly from the point of view of being led, and only sometimes as a leader myself.

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This fall Brené Brown saved me from further self-flagellation over my lack of skills and understanding of what it takes to be a good leader.  The thing I admire most about her is how she walks the talk of vulnerability and courage.  She shares her mistakes, missteps, and learnings so openly, and anyone who reads her books or sees her presentations gets to profit from it all.  I will always remember where I was, because I laughed out loud in sheer relief, when I heard her read from her latest book, Dare to Lead:

Over the past five years, I’ve transitioned from research professor to research professor and founder and CEO.  The first hard and humbling lesson?  Regardless of the complexity of the concepts, studying leadership is way easier than leading.

When I think about my personal experiences with leading over the past few years, the only endeavors that have required the same level of self-awareness and equally high-level ‘comms plans’ are being married for twenty-four years and parenting.  And that’s saying something.  I completely underestimated the pull on my emotional bandwidth, the sheer determination it takes to stay calm under pressure, and the weight of continuous problem solving and decision making.  Oh, yeah—and the sleepless nights.

I thought, well, if Brené Brown still had stuff to learn after assuming a new leadership role, then I’m doing okay!  I am both freed from self-imposed, unrealistic expectations of perfection, and also still responsible for continuing to practice self-awareness, humility, and honesty.

I have learned to look harder at the cynical stories I tell about my leaders, and seek to understand better the divergent and competing interests they must balance every day.  I can withhold judgment of their motivations until I have more information, and if I’m not entitled to all the information, I can decide how much I trust my leaders to act in my best interests, or at least in the best interests of the organization.  I can hold myself accountable to my own standards of honesty, candor, and integrity.  I can ask and challenge, inquire and resist (or accommodate), all with curiosity and respect, and making the most generous possible assumptions of others.

How lucky am I to have this remarkable learning opportunity?  To practice the skills I have observed, admired, and studied in others for so long, to own them.  I have walked a mile in these new shoes.  I have a few shallow blisters for the journey so far.  But the shoes are the right size, and the leather is softening.  I’m still feeling fit.  The path will wind and climb, and that’s okay.  I don’t walk alone; I have mentors and role models walking ahead and by my side.  So bring it!  We’ got this.

Incomplete Thoughts on Suicide

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Not selfish

Not thoughtless

Simply belief beyond shadow that no one will mourn you, people will be better off without you

Unimaginable for those who have not lived it

Most who try once don’t try again

So better to keep guns away

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One of my high school classmates killed himself when we were seniors.  He shot himself in the head at home.  He was the vice president of our Students Against Driving Drunk chapter (I was president).  He was a member of the National Honor Society.  He was well-liked, always friendly, generous, smiling, encouraging.  He was a nerd, and so was I, so I thought nothing of it.  I did not know him well, and I never asked him about his life, that I recall.  I have no idea whether he was bullied or what drove him to take his own life.

The morning we found out, our calculus teacher had to sit down in the middle of the lesson. She was overcome.  One of my other classmates got up and hugged her.  She had more presence of mind than I.  I can’t remember if it was that moment or later, or if it was our teacher or someone else altogether, who said something like suicide is ultimately a selfish act.  That it was inconsistent with our classmate’s character to cause so many people so much pain.  That if he had known how much he would hurt people by this act, he never would have done it.  I can’t say I had thought anything about suicide before then, and I have probably not thought enough about it since, but her words stuck with me.  I’m not sure I would have ever come to this conclusion.

The way I understand (think I understand) it today, suicidality is such dark state, a place so far removed from where we connect with our true selves and others, including (especially?) loved ones, that people really do believe that everybody else will be better off without them, that there is nothing worth living for.  I cannot fathom that kind of disconnection and loneliness.  It feels almost too scary to even contemplate.  I feel totally incompetent to address this kind of pain and suffering.

I saw this video recently and it moved me.  A young man jumped off the Golden Gate Bridge and survived; he tells his story of instant regret for the attempt, and gratitude to be alive.

I pray tonight that if anyone in my circle is feeling suicidal, I may say or do something to help them know they are loved, wanted, and connected, and to keep them with us long enough to get help.