Can Minimalism Be an Antidote to the Opioid Crisis?

When I first started working in my primary care clinic after residency, I was adamant I was NOT going to prescribe long term narcotics.  Unless you’ve been living under a rock, I think most people are aware of the opioid crisis that is storming across America.  I’m talking about Oxycontin, Morphine, Norco, Vicodin, Percocet, etc.

During training, I already had my fill of drug-seeking patients in my residency clinic, ER and the hospital – there was no way I wanted to continue that trend in my new big girl job.  If anyone wants to talk about things that immediately suck the empathy right out of young doctors, I’ve got two words for you: Opioid abuse.

However, as with all things, nothing is ever black and white.  Most people asking for narcotic medications are regular people, just trying to get through their daily lives with less chronic pain.  After a few months of working as an attending, I met one such person causing me to rethink my approach to pain control.

The solution I came up with was quite the surprise.

---

A Case Study: W

W showed up in my clinic with a cane and a shuffling gait.  He was perched on the edge of the examination table with only his tailbone resting on the cushioned corner when I walked in.

“Good morning,” I greeted him.  “I’m Dr. M – it’s nice to meet you.  Before we get started, feel free to take a seat,” I motioned to the empty seat in the corner of the room.

“I’m more comfortable standing up.. I hope that’s ok,” he replied.

“Oh, no worries… well, what can I do for you today?”

Like an avalanche, his story tumbled out.  He was transferring care to me because he was very upset with his previous PCP.

W had a history of chronic back pain for the last 10 years for which his old doctor had been giving him Norco.  He attributed this to working as a welder for 30 years on barges and ships.  He stated with pride, “I actually work for a living.”

But one day, W started noticing his lower back pain was worsening and causing his balance to be off.  His legs were constantly falling asleep and he started tripping over things.  His bowel movements became very irregular, alternating between diarrhea and constipation.

The last straw came when he noticed he had peed on himself without realizing it.  W called his PCP, telling him the pain meds weren’t working and he needed something else, but instead of receiving help, he was made to feel like he was a drug abuser and was essentially cut off from his supply.

Deciding to bypass his PCP, W went to the ER hoping to get some pain relief there.  However, when he told the ER doctor his symptoms, they immediately ordered an imaging study which showed a herniated disc pushing directly on his spinal cord.

The fury in W’s voice betrayed him as he concluded his story,

“So, that’s why I’m here.  That doctor tried to tell me it was all in my head, but I knew something was wrong!”

As we discussed the details of his upcoming surgery later that week, I could tell he was holding something back.  W seemed on edge, and not just due to the discomfort from his herniated disc.

I had a sneaking suspicion but it wasn’t confirmed until the end of the visit when I closed with,

“What other questions do you have for me today?”

W had a guilty look on his face when he finally presented the ask,

“I’m on my last day of pain meds left from the ER visit, and my surgery isn’t for another 2 days.  Can you give me some Norco to help get me through?”

This seemed like a reasonable request – he had documented medical abnormalities on imaging, and he was only asking for 2 days.  But as I handed over the script, I knew it wouldn’t be the end of that story.

It wasn’t

Even after the spine surgery, W continued to have persistent pain.  After 3 months, his neurosurgeon finally got frustrated and punted the patient back to me in a way that surgeons do best: No evidence of further abnormalities correctable by surgery.  Follow up with PCP for ongoing pain management.

AKA Not my problem anymore.

It was time for me to decide: Was I going to take over W’s pain management or not?  All of the pain clinics in the area were booking out 6-8 months.  By that point, his narcotic prescription had only gotten stronger thanks to uncontrollable post-operative pain – if I cut him off now, he would certainly have withdrawal symptoms.

When he came in to the clinic to discuss what next steps were, he sat in the chair with a defeated slouch.  It deflated the air out of the speech I was going to give him about the horrors of narcotic medication – the addiction potential, the way it affects the signals coming from the brain to the diaphragm causing people to stop breathing on their own, the heroin epidemic.

But I knew none of that really mattered to him in this moment – in his mind, I was about to condemn him to a life of pain without relief.

Stalling for time to decide what I was going to do, I asked him,

“Tell me about your day.  Why do you need all of this pain medication?”

Again, his story tumbled out in a blur.

Every day he wakes up at 4 am to get to work by 5.  Currently he was working in a 4×4 foot enclosure on a barge, wielding a welder’s helmet and a respiratory mask hooked up to a breathing tube in order to breathe clean air.  The majority of his day was spent either laying on his back or his stomach in order to gain access to what he was working on.  He had been working 10 hour days, 6 days a week for the last month since he was cleared to work again, but this was pretty much his life for the last 30 years.

No wonder this man was in constant pain!  I asked him incredulously,

“Why are you working so much after your back surgery??  You can’t expect to work 60 hours a week in those conditions without causing your body more harm!”

My training taught me to compare different narcotics by their morphine equivalents, the difference between long term and short term opiates, and how to manage opiate induced constipation.  But, what this patient needed was a prescription I couldn’t give.  He needed to cut back on work.  He needed a different job that wasn’t as physically demanding.

“What if instead of going up in your percocet dose, you cut back from 60 hours a week to 40?  Or maybe find a different welding job off the barge that doesn’t require you to put your body in all those awkward positions?”

“Well, we just bought a new truck so I have to pay that off.  Also, it’s Valentine’s day coming up, and the old lady wants me to get her this jewelry set she’s had her eye on for a while.  And the barge job pays the best.”

“How much is that gift going to set you back?”

“$2,000.”

$2,000.  How many hours of W’s life in a 4×4 foot enclosure did that translate to?  One week’s worth?  Two?  He was literally imprisoning himself in a cell of his own making, in order to prove his love to his wife by purchasing something that serves no other utility than to be shiny.

And what of that brand new truck worth maybe $30,000?  Was over half a year’s worth of work trapped in that box for 60 hours a week really worth it to him?

“Look, I can’t make this decision for you.  But I can tell you that your body is not going to last until retirement if you keep working the way you are.  We can keep putting a band-aid on your pain by keeping on with the narcotic medication, but eventually the band-aids aren’t going to be enough.  Even if you do make it to retirement, you’re going to be living with so much pain you won’t be able to enjoy it.

So I guess the question you have to ask yourself now is, is it worth it to you to work overtime for the next month in order to buy your wife something that’s just going to dangle on her wrist, or is it worth it to you to have less pain so you two can enjoy now and the rest of your lives together?”

 This was not the conversation either of us expected to have.

I wasn’t sure how he was receiving what I was saying to him – advice coming from me, a person who has never seen a hard day of real manual labour in my life.  Me, a person who as a physician has the privilege of living in the top 10% of income earnings in the U.S., telling him what to do with his time and money.  What could I know of his struggles?

As he left, I handed him the narcotic prescription refill and said,

“Just think about it.”

The next day, he called the office and asked me to write a letter restricting him to “just” a 40 hour work week.

---

Time is the currency of life

People generally don’t think about life in terms of exchanging time for money, but that’s what we do on a daily basis when we work.  When we make purchases with our money, shouldn’t we think about these purchases in terms of the time cost to our lives?

The more I thought about W’s situation, the more I thought about my own personal entrapment.  His wife’s request for jewelry for Valentine’s day was holding W hostage in a literal enclosure at work, costing him his health and personal freedom.

What things are holding me hostage in my “prison”?  Easy things come to mind like student loans and my mortgage payment.  But what other things have trapped me into continuing to work because I have to, not because I want to?  Do I really need another article of clothing, or a new shiny object to put in my earlobes or a new fancy car that does the same exact thing that my current vehicle does?

What could we gain in our lives if we stop chasing the next thing to purchase?  Would people stop pushing themselves at their jobs to the point of breaking down physically?  Would anxiety, depression and burnout rates cut down drastically?  Would we have more time to pursue experiences that actually leave us feeling happy and fulfilled?

Or would the economy collapse and we’d all be in a place of financial hurt?

I don’t have the answers to all these questions – but I do know this:

My “prescription” for a regular 40 hour work week resulted in a decrease of W’s pain and narcotic use, while his quality of life went up.

Both of us are much happier for it.