Let them see CAKE

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A Pain/Addiction specialist’s review of the movie CAKE

January 24, 2015

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I saw the movie CAKE tonight. I felt it was my duty. I am, after all, a pain specialist.

I’d read that it was gritty, honest, and accurate, and that Jennifer Aniston was very convincing. I found all that to be true.

It’s the show’s first weekend in Louisville theatres, and the crowd at this 5:30 pm showing was decidedly mature, reverently attentive, and noticeably equipped with more walkers and canes than I’m accustomed to seeing at the cinemas. I almost felt like I was in a pain support group. Perhaps in a way, I was.

I went in expecting to not like the movie. And if it had been a movie just about chronic pain, then I might not have been won over. However, CAKE is not so much a story about chronic pain as it is a story about dealing with loss.

Claire, played by Ms. Aniston, initially comes across as an angry, bitchy, sarcastic, and self-centered woman, who clearly has legitimate pain and the scars to prove it. But as the story unfolds and it is gradually revealed to us the degree to which Claire’s life has been altered by tragedy, a sad empathy takes root.

It’s not that Claire doesn’t have people in her life who care about her. On the contrary, is seems that everyone in her life is trying to help her. In fact, I wouldn’t say there is a real villain in the story. Claire is struggling to climb a mountain. And we, like the people in Claire’s life, feel powerless to help. So we just watch, hoping she can hang on and have some sort of epiphany.

Where the movie begins, Claire is several months removed from the tragic event that caused her life-changing pain and loss. She is clearly living the chronic pain existence: from her pleasant but over-booked doctor, to the impersonal waiting rooms where she winces as her number is called instead of her name, to the group therapy from which she is “fired,” to her continuous pre-occupation with obtaining pain pills – often times via demeaning and risky methods.

As a pain physician, I felt myself wanting to treat her – wanting to provide for her a regimen that was not insulting, dehumanizing, or uncaring. And I hope all health care providers who see this movie are moved in such a way that they see their patients as people who, more than pain, are grieving over what they have lost: autonomy, freedom, happiness, self.

And despite the script’s inclusion of so many themes common in the lives of patients with chronic pain, I hope that those people in the audience who were there with their canes and walkers understand that this movie is only about one person’s journey – not theirs. We all suffer loss. We all have pain. We all have a journey. And the journey is specific to the individual. There are no villains, but there are mountains to climb.

I thought CAKE was a very good movie for general audiences -and a great movie for pain patients and pain care providers. My advice: just make sure you allow yourself some time to process it afterwards. Then you might find it really was a pain support group after all.

James Patrick Murphy, MD







Proclaim Pain Care Providers Day!

pcpd at courthouse

Another headline today. Another physician indicted. I read the phrase “faces life imprisonment” and it pierces my suddenly fragile psyche like a spinal needle. My resolve threatens to hemorrhage, figuratively but painfully, leaving me wondering why I do this. Why do I treat chronic pain?

doc charged

I’ve seen headlines like this too often. But I know the doctor in the headline this time. We work in the same hospital. And though I do not know details, I know him to be a solo practitioner willing to embrace suffering people, many of whom are among the most marginalized, downtrodden, and castoff. I hope and pray that truth and justice will prevail. But my confidence is fragile.

Yesterday, my fifteen-year-old son and I were driving in the car, and he asked about this doctor because it was “all over the news.” My son knows what I do for a living. He’s heard me lament about how frightening the heavy hand of regulatory oversight by non-medical types can be for us medical types. I can only imagine how news of another pain specialist facing life in prison must make him feel – how it must make my wife feel, my other children, my parents, my friends, my employees, my patients…all those who depend on me, care about me, love me.

But I don’t dare go into the deep dark honest place in my heart to ask how it makes me feel. I can’t. I have work to do.

I have “Mama P” in my exam room right now. Despite the indescribably painful metastatic cancer that has invaded her spine, she manages a warm smile, offers me her outstretched trembling arms, and we embrace. She is here and she needs me. And as my moist tears well up, I realize that, today, I need her. And I know, again, why I do this.

And I know what we must do to make sure that she and every other suffering soul has hope. We must let pain care providers feel our powerful and uplifting embrace – the embrace of the fragile people they serve – because, in reality, we are all fragile suffering souls. We all need each other.

m hug

Let’s do this.

Let’s start right now.

Let’s make PAIN CARE PROVIDERS DAY happen.

npcpd hands screen

Pain Care Providers Day is March 20, 2015, the first day of spring. It will be a day to recognize our caregivers from all walks of life who do what they can to ease the pain of others.

Ways to make this day special might include dropping off a nice thank you note for your therapist, baking some cookies for the clinic staff, sending flowers to the person who schedules your appointments, blogging, or writing a letter to the editor in support of better access to effective pain care for all. Unleash your creativity and spread the message.

A powerful way to raise awareness is by asking your friendly neighborhood municipal leader to officially proclaim March 20, 2015 as Pain Care Providers Day.

A proclamation is a formal public declaration often written by government officials to commend individuals or to raise awareness of upcoming events, celebrations, and issues of significance.

the med school ap

Pain Care Providers Day is a prime opportunity for us to secure proclamations honoring our caregivers from all walks of life who labor, often under duress, to alleviate suffering in our communities.

Here’s how it can be done…

  1. Identify the best person/office to approach for the proclamation, such as: city leaders, state representatives and/or members of congress.
  2. Contact the offices to request a proclamation.
  3. View official websites for instructions on how to submit a formal request; a form may be available for online submission.
  4. Use the draft proclamation language below as a guide for submission with the understanding that the final language may change to conform to standard protocols.
  5. If possible, meet with the official for the signing of the proclamation. Take a photograph and obtain permission to use the photograph to further increase awareness of Pain Care Providers Day.

We can’t just want it to happen.
We have to make it happen.

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WHEREAS, PAIN is a universal feeling, which for millions becomes chronic, impacting every facet of life; and affects more Americans than diabetes, heart disease and cancer combined; and is cited as the most common reason Americans access the health care system; and
(Ref: 1, 2; see comments section)

WHEREAS, there exist regulatory, legal, institutional, financial, educational, and geographical barriers that impede access to pain care; barriers that contribute to increased suffering along with feelings of despair, futility and shame on the part of people with pain; and
(Ref: 3, 4, 5)

WHEREAS, in the face of this national pain epidemic there is less than one board-certified pain specialist for every twenty thousand pain sufferers; and these pain specialists are subject to tremendous stressors, leading to a high rate of professional burnout, interpersonal difficulties, suicidal tendencies, and even life-threatening physical harm; and
(Ref: 6, 7, 8, 9, 10)

WHEREAS, because of the shortage of pain specialists, the vast majority of our nation’s pain care must remain the duty of a vast array of dedicated but increasingly anxious medical professionals, kindhearted laypersons, and overburdened loved ones who bravely and compassionately persevere in treating pain as best they can;
(Ref: 7)

NOW, THEREFORE, I, [name, title], do hereby proclaim March 20, 2015, the first day of spring, as PAIN CARE PROVIDERS DAY throughout [city or state name] and encourage our citizens to recognize all who professionally, clinically or emotionally offer more than their expertise -that is, they offer their hearts- and therefore are deserving of our gratitude, encouragement, and support so that they might carry on, empowered to provide care and comfort to those suffering.



Please use social media to the fullest extent and tweet with the hashtag #WhyPCPD


If you want to connect personally with me about Pain Care Providers Day, I can be reached at: paincareprovidersday@gmail.com

Thank you. I’m feeling stronger already.

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The Quintessential Pain Care Provider

My dear friend, Debbie Tichenor RN, passed quietly and unexpectedly from this world on New Year’s Day 2015.

For more than twelve years, Debbie and I worked side-by-side, sometimes head-to-head, and always heart-to-heart. She was the quintessential pain care provider, possessing a unique abundance of clinical know-how, moral fiber, and you-can’t-outwork-me ethic. I trusted her with my business, my career, my family, and my life. She helped so many, loved so many, and will be missed by so many.

Today it would be my honor to participate in Debbie’s eulogy. And though I dearly wanted to serve in this role, I feared the challenge might overwhelm me, because Debbie was no longer here for me. You see Debbie was one of my vital touchstones. We shared core values, and I could always count on her for honest, intelligent, and constructive feedback. This time, however, I feared I was on my own. And my words, at best, would fall well short of the tribute due this humble angel of mercy.

Nevertheless, knowing that I owed it to my dear friend, sometime after midnight I began writing, not certain where it would lead. Hours passed, and as I fell into and out of exhaustion, the words on my computer screen gradually began to resemble verse. By 5:45 am I had composed a poem – Debbie’s poem. And when I read it aloud, alone in my room, I felt her presence, knew we had written it together, and knew I was not alone.

My sincere wish is that this poem for Debbie provides comfort to those who miss her, inspiration to those who never knew her, and encouragement to those who aspire to be like her. She was, is, and always will be the quintessential pain care provider.


A Poem for Debbie


When she was born it’s right to say,
A blessing came to earth that day.

To ease our pain and bring us love,
Directly from the Lord above.

 A daughter, mother, wife, and friend,
With caring that would see no end. 

A nurse who’d go the extra mile,
Who always met you with a smile. 

If she was anywhere you were,
Then you were family to her. 

And could expect, as from God’s grace,
The blessing of her warm embrace. 

With such profound humility,
Her skill defied futility. 

And when she faced what most would fear,
With love and hope she’d persevere. 

But tending to the quiet needs,
Might count as her most noble deeds. 

And though this blessing we now miss,
God comforts us in knowing this… 

If love defines a life’s treasure,
She lived a life beyond measure.



~Written with your help, my dear friend,

January 6, 2015


The Voyage of the Big E


The voyage of the Aircraft Carrier USS Enterprise
January 5, 1988 – July 2, 1989

Lieutenant James Patrick Murphy (that’s me) was one of two Carrier Air Wing Eleven flight surgeons assigned to the USS Enterprise battle group. I was the “attack doc” from Naval Air Station Lemoore California, and my counterpart, Lieutenant Commander Michael Menendez was the “fighter doc” from NAS Miramar California. I was twenty-eight years old, fresh out of training at the Naval Aerospace Medical Institute in Pensacola, and preparing to leave my beautiful wife of two years to deploy with five thousand men for at least six-months.

It’s been 28 years since I made my first journal entry on July 5, 1988.  Incredibly, I managed to write in in it every day… right up until the “Big E” pulled back into homeport Alameda, California on July 2, 1989.

big e journal

Over the next six months, with the help of this recently salvaged musty green three-ring binder, I will recount my journey on board the most powerful nautical vessel mankind has ever known… and by looking back, perhaps chart a course for journeys to come.

Anchors aweigh!

uss enterprise under bridge

January 5, 1988 (0545) It is impossible to describe how I feel right now. I’ve never had to say goodbye and really mean it. It’s a damp dark Alameda morning, which in a way makes is easier… The glad handing and the “How’s it going?”s haven’t begun in earnest yet…only a matter of time.

(2040) Quickly the real world dissipates. It was surreal today. A state of mild shock. No energy on my part. Now is when I really need to understand the “one day at a time” mentality. These people will become my family. There is a sense of “This is really it,” which can be felt in the demeanor of everyone.

I went out on the flight deck and watched the preparations for departure. At 0700 the theme from “Rocky” was played on the 1-MC. We were really leaving. This is one of the few times I’ve really had to suppress my emotions. The best thing I can do, depressed as I am, is just to go to bed early.


January 6 (1402) The latest key issue revolves around the little refrigerator I mentally beat myself up trying to decide whether or not to buy. It seems the XO (executive officer) has outlawed all stateroom refrigerators. This means that for the first time this cruise I will have to live above the law.

(2134) I was looking our over the sea, watching the flight ops. The ship began a 360-degree turn, slowly, as it does on occasion for no apparent reason (for turning’s sake). The sun was reflecting brilliantly off the ocean and the light, the warm sun, shone in my face and fell across my body. I felt the warmth and at that moment a sense of relief tempered my low-grade depression, and I felt good for the first time since I stepped on the ship. Perhaps it was God’s doing. I’m not sure, but I did feel something at that moment. I felt a sense of relief that this ominous task was finally being done. I’m really doing it. The worry is over. The doing has begun.



January 7 (1044) We go off Spuds time at 1900 today. “Spuds time” refers to the Pacific time zone. Adele and I each received “Spuds MacKenzie” watches for Christmas. We synchronized them on 4 January, and I have vowed not to change it until I return. So in about eight hours I’ll officially be on “cruise time” from a Spuds standpoint. I’ll take off the watch now, and when I ceremoniously put it back on it will be a happy day.

January 8 (2016) Sometimes I really feel like I’m in a prison. Other times I think I’m lucky to get the chance to have the experience of a lifetime. I ate dinner tonight with three daddies-to-be. When I said I had been thinking about Adele and having a baby, they all laughed and agreed: “Well if she has a baby now it won’t look like you.”



January 9 (2105) I participated in a FOD (“foreign object debris”) walk down today on the flight deck. I began to feel good about being on the ship (Feeling “good” means merely not feeling “bad”). Then just as quickly I realized how fragile my world really is – how helpless I am to change things back in Hanford (CA) – how impossible it would be for me to come to Adele’s aid.

And just now I’ve realized that I am coming to her aid, and to the aid of millions of others in some way, by being where I am. My job here keeps her free there. It keeps my (unborn) children free – just as my father’s four years in the Navy and his cruises helped keep me free and allowed me to be who I am. Let me not forget. I am always connected. My efforts always count for something.


January 10 (1144) I was saddened as I pondered the world map that was on the wall of the makeshift chapel (the library, actually). I was saddened because I realized again that I have only been given a tiny slot of time to live in the evolution of time. When I thought about how early explorers (e.g., Christopher Columbus) must have viewed the world, how much it has changed, and how much it will continue to change, it makes me want to be there. Be somewhere. For more of it.


I was standing on the bow of the ship yesterday. It was cold, damp, and windy. But there was a warm moistness in the air as well. Anyway, I observed how much the Enterprise rocks up and down, side to side, in the water. I must say it is incredulous that anyone even resembling a Viking would have tried to venture out across the sea in, of all things, a wooden boat! And the most amazing thing is that this all happened not too long ago – from a world history sense.

We haven’t even been gone a week yet.



January 11 (1410) I have just crawled out of my little time machine – a two and one-half hour nap. Fact: the more you sleep, the less time you are on cruise. I had been dreaming when, I guess, another “cat shot” from three feet above my head (i.e., my bunk is situated just below the flight deck) woke me up…but only slightly. I kept on dreaming. In my dream a high school friend, Dale, came to our house, and I heard him tell Adele of a “revelation” he had after reading a book that day. The revelation: “I don’t want to die alone.”


January 12 (1130) Eat less, sleep more. That’s the slogan for the day. That’s going to be the theme to this cruise. We’re pretty close to Hawaii now. The sky is crystal clear and the sea is deep dark blue – a log flume at Six Flags sort of blue. Shimmering like sapphire.

“Distinguished visitors” are onboard and that means a number of things. That means the food will be better. It means we’ll have a break from all those general quarters drills. It means there may be one or two women on the ship, which means you can’t be a carefree man and run around in your underwear.

Yesterday I got my first letter from Adele, dated January 5th – the day we left port. It made me feel so good. Today, most importantly marks the end of the first week away. Only twenty-five more to go.


January 13, 1988 (1242) The Beach Doc rides again! I’m taking a helo off to Barbers Point, Hawaii on the island of Oahu, in order to take in a suicidal patient. And bring back as much medical supplies as I can get my grubby little con-man flight surgeon hands on.

sun e

Only fitting that I go to the beach (i.e., any land is considered “beach”) on the very day that the parachute rigger of VA-22 gave me my new nametag sporting the call sign: “Dr. Sun E. Beach.”


January 14, 1988 (0956) Well, the Beach Doc did NOT ride again. The helicopter did not come out to get us because we were greater than 70 miles off the coast. The “Distinguished Visitors” sure got off with ease though… and the helos that came to pick them up sure didn’t bring any mail.

It’s a belly-aching sort of day. The ship is rocking side to side and I can’t understand why. The sea is as smooth as glass. I went out on the catwalk with my dentist friend, Dick Koo. We marveled at the sea. I’d never seen it so placid, so blue.

The best thing I did yesterday was talk to Seaman _______. The chaplain sent him to me to “evaluate” for depression. I believe he just misses his wife. And, by the way, she laid it on him before he left to the tune of “If you go on that cruise, I won’t be here when you get back.” I managed to talk him into a good mood. I’m not sure how. But I did.

Two days ago I was up on one of my favorite places on the ship – the “Admiral’s bridge.” There’s really not much on the Admiral’s bridge but an exercise bike and a big bay of windows.

adm brige

So I’m up on the Admiral’s bridge where I can usually be alone, but this time there’s this regular looking guy on the exercise bike.  I didn’t recognize him, so I kindly asked him who he was and whether or not he was civilian or military. He kindly told me he was the ADMIRAL (i.e., RADM Glenn). Definitely military. Not a good start for me. But by the time we parted we were the best of friends. I’ve got a way with Admirals.


Want more? The cruise continues at: http://VoyageoftheBigE.com



va22 jt

A Year of Confluential Truth


2014 was the first year that I really began to discover social media.

Looking back, I find it revealing rediscovering which of my Twitter messages and WordPress.com blog posts piqued the most interest in 2014.

As expected, most of my “retweeted tweets” (Try saying that ten times fast!) related to popular issues such as: healthcare reform, our drug abuse epidemic, sports, holidays, and the passing of iconic celebrities.

However, my heart was also warmed by your responses to my attempts at creativity and inspiration. It’s been fun.

I am continually trying to hone my communication skills. And while I don’t always get it right, I always love connecting with you.

You inspire me. And because of you I will do my best to share ideas with substance, purpose and hope.

Thanks for going there with me.

WordPress.com has prepared a 2014 annual report for Confluential Truth. Click here to see the complete report.

And in the comments to this post I have listed my “Top Twenty Retweeted Tweets” of 2014.

See you next year!

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Or if you prefer, here are the links…

The Top Twenty Retweeted Tweets of 2014





4/17/14, 6:10 PM (58 retweets)

It costs your doctor $58 just to process your insurance claim. OUCH! Guess who’s getting well.


4/22/14, 4:49 PM (50 retweets)

An inconvenient truth. Even casual marijuana use causes brain damage. Sorry to be a buzzkill



6/6/14, 12:30 AM (47 retweets)

70 years ago 6:30 am Normandy
“For he today that sheds his blood with me shall be my brother” – Shakespeare #DDay70



5/5/14, 12:20 PM (42 retweets)

Treating pain can be painful
#doctorburnout #painphysician #ChronicPain #painmanagement



7/20/14, 1:18 PM (38 retweets )

Can’t believe #JamesGarner ’s only Oscar nomination was Murphy’s Romance (My personal favorite).
Miss you #Maverick



3/28/14, 1:17 PM (36 retweets)

Hey Cats! Time to go under the knife! #CardNation #BeatUK#MarchMadness #Sweet16 #CardChronicle #CCBM #BBN #L1C4



8/12/14, 12:11 PM (35 retweets)

Good-bye Robin. We ain’t never had a friend like you. #RobinWilliams#CarpeDiem#seizetheday



4/27/14, 11:29 AM (34 retweets)

it is impossible to think about yourself when you are locked into thinking of someone else


11/22/14, 1:40 PM (30 retweets)

Card March South Bend style
@CardChronicle #L1C4 #GoCards #BeatNotreDame #CardNation #UofL #Louisville #GameDay



5/9/14, 11:51 AM (30 retweets)

is not what you
it’s who you



4/26/14, 10:37 AM (28 retweets)

Pain affects more Americans than cancer, heart disease, and diabetes combined. #paincare



8/13/14, 12:27 AM (26 retweets)

Chronic #pain patients have 2X the risk of #suicide
Don’t overlook #depression



5/11/14, 6:30 PM (26 retweets)

Thou art thy mother’s glass and she in thee
– Wm Shakespeare #BringBackOurGirls #MothersDay https://twitter.com/jamespmurphymd/status/465619939022225408/photo/1


7/17/14, 7:50 PM (26 retweets)

I chose TODAY to #giveblood.
Please #ChooseYourDay and save a life.
(800) 448-3543



6/23/14, 10:57 AM (26 retweets)

This does not have to be our default future.
But only if we have physicians willing to lead.



4/21/14, 2:58 PM (26 retweets)

FYI: pain patients are NOT addicts
#addiction is a brain disease



4/17/14, 12:25 PM (25 retweets)

Lunch thought #417: Nuts are like the methadone of dieting – By the time craving stops you’ve probably eaten too many



11/16/14, 12:41 PM (24 retweets)

Life is only offered one semester.
You’d better take it.
~ Nov 16 1978
#premed @WestminsterMO



7/5/14, 10:38 PM (22 retweets)

This was the scene tonight on the border between #Kentucky and #Indiana
#Bigfourbridge #L1C4



5/7/14, 4:04 PM (22 retweets)

need you
to be
this physician
and you
to be
this person
emerge again




‘Twas the Fight in Our Clinic

orange jumpsuit

It was right before clinic and all through morn,
Not a patient was hurting, nor feeling forlorn.
The stocking of meds on the shelves was with care,
In hopes that ridiculous pain would be rare.
The front desk was nestled all snug in their seats,
Collecting the copays while smiling so sweet.
And I in my lab coat, scrub top, and a glove,
Had just settled in for the job that I love.

When out in the hall there arose such a clatter,
I sprang from my chair to see what was the matter.
Away to the window I flew like a flash,
Tore open the shutters and covered the cash.
A man on a quest, who did not like a “no,”
Gave bluster and chaos to our status quo.
When what to my watering eyes did appear?
But my signature forged on a pad that was near.
The villain prescriber had written so quick,
I knew in a moment it must be some trick.
I asked him his name and just why he had come,
But all he could say was he had to be on…

On Morphine, on Codeine, on Oxy, on Contin,
On Soma, on Xanax, and lots of Neurontin!
Don’t stop for the chart. Don’t stop in the hall.

Now right away! Right away! Write for it all !!!

As dry heaves that before a wild emesis fly,
When I met this intruder I thought I could die.
So onto the restroom I coerced him to…
Pee into a cup that might give me a clue.
But then, in his tinkling, I heard through his bleating,
The faucet, the flushing and knew he was cheating.
As I pulled back my hand and was turning around,
Through the window the specimen came with a bound.

I was stressed by his sight, and I thought for a while,
That his clothes were an orangey prisoner style.
A stencil of words were in print on his back,
When I asked him about it he called me a quack.

His lies, how repugnant; how simple his tally -
Prescription pain pills to sell in the back alley !!!

He had a clear package tied up with a bow,
And the powder inside was as white as the snow.
A piece of lead pipe he held tight in his hand,
And he swung it at me as he started to stand.
He had a gaunt face and not much of a belly,
And I shook when he laughed ‘cause his breath was so smelly.
He was stealing prescriptions, I thought to myself,
And I cringed when I saw him reach into the shelf.

A wink of his eye and a poke to my head,
Soon gave me to know I had something to dread.
He said he had come to us straight from his “work,”
And turned ’round to face me and called me a jerk.
He gave me the finger, then fingered my nose,
‘Til both of my nurses, they stomped on his toes.
He sprang to his car when we asked about jail,
And away he did run with the cops on his tail.
But he heard me exclaim, ‘ere he drove out of sight,

No prescriptions for you, because we do it right!

022812 police-chase





While drug diversion is certainly no laughing matter, I couldn’t resist poking a little fun at some of the bumblers who have chosen this “career” path.

Here’s hoping that you have a joyous and pain-free holiday season!

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Treating pain patients like addicts?

Treating pain can be simple or complex.


The simple approach focuses on cause and effect.


Remove the cause of pain and the effect is…relief.

This often works when the cause is clear, i.e. acute pain. Just ask the lion with the thorn in his paw.


But chronic pain is often more complex.

Nature tries to smooth out rough spots; this is called “adaptation.” So when the brain is exposed to prolonged painful stimuli, or to foreign chemicals, such as opioid pain pills, the brain adapts.

Two examples of these neuroadaptations are:

(a) tolerance – the need for increasing doses to maintain the same effect; and
(b) physical dependence – the need to keep taking a drug to ward off withdrawal symptoms

The presence of drug tolerance and physical dependence does not mean the individual is addicted to the drug.

pain not addiction

Addiction is a life-threatening disease of the brain’s reward circuitry, typified by a persistent destructive preoccupation with satisfying an unhealthy craving for a substance or behavior.


Addicts will often develop tolerance to drugs of abuse and develop physical dependence. And they experience withdrawal symptoms when these drugs are leaving their bodies. But tolerance and physical dependence (and withdrawal symptoms) are normal expected physiologic adaptations that can also occur in non-addicted people who take their medications as prescribed.

Furthermore, in the American Psychiatric Association’s authoritative Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, tolerance and withdrawal symptoms are no longer counted as criteria for diagnosis of substance use disorders when occurring in the context of appropriate medical treatment with prescribed medications.

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In pain sufferers exposed to opioids for an extended period of time, drug tolerance and physical dependence can extend to brain structures that control stress, anxiety, pain, memory, emotions, judgment, critical thinking, and even the ability to experience joy. These patients may not be addicts, but if and when they are in withdrawal they sure feel like addicts. They may need the opioid for more than just pain relief; they may need the opioid just to feel “normal.”

depressed patient

If not addiction, then what is this complex neuroadaptation to long-term exposure to opioids? In a 2012 commentary article from JAMA Internal Medicine, Doctors Ballantyne, Sullivan, and Kolodny referred to it as “complex persistent opioid dependence” (JAMA Internal Medicine September 24, 2012, Vol 172, No. 17):

Dependence on opioid pain treatment is not, as we once believed, easily reversible; it is a complex physical and psychological state that may require therapy similar to addiction treatment, consisting of structure, monitoring, and counseling, and possibly continued prescription of opioid agonists.

I concur.


For years in my practice, my colleagues and I have treated chronic pain patients, many of whom are stable and functioning well on opioids. Interestingly, many will describe their pain as severe (i.e. “ten out of ten”) but in the same breath say they are doing “OK.” We have had a measure of success at tapering some patients to lower opioid doses, but a significant number simply will not function well at lower doses.

How can this be?

I believe the answer is in their neuroadaptation. To my understanding, long-term pain coupled with long-term opioid use appears to alter the way one’s brain experiences pain. It is almost as if the pain level is “locked in” and will not fluctuate significantly regardless of interventions (e.g. physical therapy, biofeedback, injections, adjunctive medications, or even more opioids). In this sense it is similar to how a patient with phantom limb pain can have real pain where the limb once was. In both situations the pain experience is determined by complex interactions between multiple nerve pathways – far from simple cause and effect.

Therefore, when treating complex persistent opioid dependent patients (“CPOD”) the most beneficial course might be to shift focus from the conventional drumbeats of: (a) trying a steady progression of new treatments; and/or (b) tapering off the opioids “at all costs.”

I would never suggest these pain patients abandon efforts to achieve more relief and improved function. But I am suggesting, as do Doctors Ballantyne, Sullivan, and Kolodny, that the better therapeutic approach may be to view their care through the lens of Addiction Medicine in addition to that of Pain Medicine.

asam book pic

CPOD patients might be well served by care plans influenced by principles outlined in The ASAM Criteria from the American Society of Addiction Medicine.

asam crit screen

In this paradigm a patient is assessed in six categories or “domains.” Care plans are determined by severity in each domain. With CPOD patients the six domains would look like this (i.e.,“ABC & RRR”):

  1. Acute issues
  2. Biomedical issues
  3. Cognitive and behavioral issues
  4. Readiness to comply with the program
  5. Relapse potential to aberrant behaviors
  6. Recovery environment for ongoing safe use of opioids

Consideration of these six domains assists the clinician in formulating a treatment plan with the most appropriate structure, monitoring, counseling, and use of opioid medications.

For example, a patient with chronic pain who presents for continued use of opioids and is assessed to be stable in five domains but has not adequately addressed his or her diabetes. The diabetes is a biomedical issue that left untreated could jeopardize safe use of opioids. In order to move forward with the plan of care, optimizing this “biomedical” domain becomes a priority.

Treating pain can be simple or complex. When the cause of pain is known and removing the cause is expected to result in pain relief, the decision whether or not to include opioids in the plan of care is straightforward. However, when long-term suffering and opioid use lead to significant neuroadaptations and the development of complex persistent opioid dependency, the best course of action may be to offer these non-addicted pain patients a plan of care modeled after that which has been shown to be effective in treating addiction.

Those afflicted with the disease of addiction suffer biological, psychological, and social harm. Respect, dignity, and science are the pillars of treatment. Success requires ongoing partnership between the patient, caregiver, and support group.

This plan of care can also work well for complex persistent opioid dependent pain patients. They may not be addicts…But you can treat them that way.