If not Vicodin, then ... what?

January 11, 2007 10:55 PM

[HouseMDFilter] What *are* the options for treating addiction in patients with severe chronic pain? (Spoilers for the January 9th episode and

In the TV show, one of the major subplots is House's addiction to Vicodin. This is explained as having begun 5+ years ago when he experienced muscle death in his leg, which resulted in high levels of pain at the time and (I believe) continuing to the present.

In calling him an addict, is the implication that his pain is no longer real, but is now a physical dependency on the drugs? Or is his pain still as real as ever, but his physical dependency is 'too strong'? Or perhaps he has two issues going on - pain, treated by Vicodin, and an addiction fed by an overavailability of Vicodin, and his behavior and personality are seen as symptoms of the latter. Or his Vicodin-seeking behavior - hoarding the drug, stealing it, etc. (Too many 'or's. I'll stop now.)

Then assuming he is addicted, what would his options for pain management be? In a Season 1 episode, Cuddy tells him that there are other ways of managing pain, but it's not clear what these are - presumably if there was a nonaddictive method of treating pain, that would have been the original treatment. I can't imagine that anything less effective than the narcotics House is on would be acceptable to a patient with that kind of pain. Are there alternatives that are considered more acceptable because there is less of a risk of psychological dependence, at the cost of a greater physical dependence (in contrast to Vicodin, which is the other way around), or a difference in the euphoric effects?

Note: I'm aware that there are a broad range of opinions on pain management, ranging from the relatively prohibition-ish attitude of the DEA to the more permissive attitudes of some pain management doctors, including some who have been accused of acting as 'prescription mills'. But I suspect there's more to this than that.

(One last thing, as long as I'm here - Wikipedia says that buprenorphine is not administered orally. Wouldn't someone have noticed that the pills were Vicodin, or something other than buprenorphine?)

posted by spaceman_spiff to health & fitness (16 answers total)

There are a bunch of doctors who review and comment knowledgably on each episode of House here. I'm sure they've touched on this.
posted by nicwolff at 11:27 PM on January 11, 2007 [3 favorites]

Specifically this review which goes into a bit of detail about the differences between dependence, addiction and pseudo-addiction. The biggest objection seems to be first that the show screws up by mixing and matching these terms at random, and that vicodin is an inappropriate drug for the kind of long-term chronic pain that House is in.
posted by Silentgoldfish at 1:19 AM on January 12, 2007

Wikipedia says that buprenorphine is not administered orally

I'm sure that's wrong; my partner's had buprenorphine in tablet form, although you're supposed to dissolve them under the tongue rather than swallow them; maybe that's what wikipedia means.

(Yeah, I've just checked the wiki page and it says "or as a sublingual tablet". Presumably there's a nomenclature difference between "via the mouth" and "under the tongue". *shrugs*)
posted by Leon at 2:12 AM on January 12, 2007

Is House ever actually shown swallowing the things? The nearest I can recall is a shot from S1 where he throws the pill in the air and catches it, but there's still no reason why he can't manipulate it under his tongue.
posted by twine42 at 4:38 AM on January 12, 2007

Leon: yeah, I saw that too. Still, when you have a whole episode based around a possible confusion in drugs (cough medicine with ... colchi-something - a round yellow pill) based on their appearance, it seems a bit convenient to say that there would be a visual match between the two so easily found. And I would guess that taking a sublingual tablet looks different from swallowing a pill.

Artistic licence, I suppose.
posted by spaceman_spiff at 4:39 AM on January 12, 2007

I really despise the disservice shows like this do towards chronic pain sufferers.
Using the term "addiction" is inherently wrong and it just fuels additional ignorance in the general public.Chronic pain suffers are dependent on certain medications to simply try to have some quality of life and the recreational high/enjoyment addicts may chase is not even in the equation.

I am a chronic pain sufferer due to having a load of drywall dropped on my head/neck from 4 stories high.After attending numerous pain clinics/surgeries/psychiatrists etc I am left with taking Fentanyl/Oxycontin and Morphine Sulphate for life.There is no good warm fuzzy feeling to the doses taken daily by sufferers,it may just take the edge off.Contrary to popular views the meds do not remove all pain even in massive doses.Despite this reality patients are constantly bombarded with ignorance both from the public and medical practitioners.

Shows like this just make life even harder and people will treat patients like addicts and assume they do it for the high and or assume a lot of the pain is in people's minds.Going to emergency rooms is a joke as either they assume you are there to try and get meds all the time or they will not give any even once they know you are truly suffering in case you *gasp* abuse them!!IMHO this attitude is supported by Government agenda of "The War on Drugs". God forbid anyone ever need an opiate for real!After all ,as I have heard doctors say "pain won't kill you".

Due to shows like this and other propaganda I personally have had to suffer in agony when my doctor went on holidays (without me knowing) and was unavailable for my monthly scrip renewal .NO doctor will step in an prescribe something in interim as again *gasp* you might be an abuser or even more ludicrous a seller of your meds.The entire mentality in this realm needs to drastically change but I hold little hope as daily occurrences remind me that once you are injured,society for the most part has no more use for you and for the most part could care less.

I try not to become bitter and full of hate but attitudes like this show make the fight harder and harder.There is no reason shows like this could not show things in a more accurate light but then again that would not meet the governments agenda.

A good documentary on the subject.


Morphine on trial

One other comment: While legitimate chronic pain sufferers are treated like crap, addicted people are equally discarded and and dis serviced by the current attitude in that realm.People need to realize true addicts are suffering as much in their own way and it is a disease.Perhaps society could worry less about the evil opiates and treat people with dignity for a change.Some countries are at least progressive about this .

I have read about some interesting research on Capsaicin and it looks like some decent progress is being made.Cannaboid research as well is coming to the forefront.Psylocibin work done by MAPS look revolutionary but again "The war on drugs" needs to end so viable sustained research can be put forward.
It has been at least in my experience ,opiates are one of the few current pain relief methods that actually are workable.

i have had surgeries/cortisone epidural's and injections/physiotherapy/ Psychotherapy/Ayeurvedic techniques etc and in the end,sometimes the damage is there for good and one needs to manage it as best as possible to retain "some" quality if life.

I REALLY do despise governments and people without pain telling me what substances I can put in my body and when. If I am fortunate enough to find a substance that helps me with no lateral harm,how can anyone justify stopping me?

It all boils down to the old adage of walking a mile in someone's shoes.

Sorry if this seems like a rant.Obviously the subject effects me deeply.
posted by plumberonkarst at 6:07 AM on January 12, 2007 [6 favorites]

Just FYI, the whole thing with House's addiction to Vicodin is supposed to parallel Sherlock Holmes' addiction to opium. It's not supposed to be a realistic portrayal of real pain patients - it's supposed to be dramatic tension between his brilliance and his addiction. They just modernized it a bit.
posted by GuyZero at 7:04 AM on January 12, 2007

Nitpick to GuyZero's comment: Holmes problem drug was cocaine.
posted by justkevin at 7:19 AM on January 12, 2007

I'm interested in this topic also, as I have several clients in prison with chronic pain (one who was injured in combat as a Marine). These guys get treated worse than animals in prison -- put on opiates at times with one doctor, then switched to another doctor who pulls them off cold turkey, causing black outs and vomiting. We write letters, report the conduct to the appropriate authorities, and nothing changes.

One question I have -- is there a "real" (as opposed to war on drugs) problem with treating chronic pain with opiates over time? I have heard that there can be a problem over time in which the person can need a higher dose, but the higher dose is dangerous?
posted by ClaudiaCenter at 9:24 AM on January 12, 2007

Chronic pain management is one of those subjects that even within the medical field is misunderstood and difficult to get good treatment for. It's a rough road I feel lucky not to have traveled to have pain all the time and on top of it be treated like a criminal (more so if you're unfortunate enough to have a job injury and are subject to the scrutiny/surveillance of workers' compensation companies).

The media misunderstanding is widespread. I recall a Bay Area physician being arrested for some kind of drug offense, and the local TV news reported in shocking tones how his pain management patients were actually addicted to narcotics, when really, it's like saying that diabetics are addicted to insulin.

Better hospitals/doctors subscribe to a pain management philosophy in which it is unethical to allow someone to endure pain if you know there is something you can do to treat it. There are long-term medication strategies that work for people (for instance, a long-term pain medication like Oxycontin that must build up in the system over time, supplemented by a faster-acting drug for transitional or breatkthrough pain day to day). A lifetime on such medications is not exactly a pleasure, and you have to consider that whatever negative effects of long-term drug use are going to be less a concern in the face of psychologically crushing and physically debilitating pain and disability that make the idea of normal life but a dream.

Unfortunately, it's one of those things that a lot of people can't understand until they face it personally, but it is certainly one of those areas in which is inhumane to deny appropriate relief to those who need it in an effort to crack down on abusers.
posted by troybob at 1:44 PM on January 12, 2007

I made an FPP about medical pain management, which rather predictably was in the bottom quintile in terms of number of comments or other expressions of interest.

The link is to an AMA free continuing medical education page; it's designed to take about 12 hours to read through the whole course. That's because this is one of the most complicated, difficult and misunderstood topics in medicine. There's no easy answer to any of the questions the original poster is asking.

Once you've read through those courses, you'll be in a position to start learning about what is actually going on. I've heard a great deal about how House brings this issue to the public eye. Here's my take: A television drama is never going to address these issues in any kind of a realistic way. Chronic pain can outlast even the 48 minutes of a major TV show's episode, and chronic pain is not pleasing, entertaining, elevating, or uplifting. It's not even interesting enough to sell household products on a weekly basis.

Chronic pain doesn't make a person a brilliant physician, either. In general it disables people and makes them unable to go about their business. Using it as a lazy TV writer's shortcut to character development serves only to trivialize the problem.
posted by ikkyu2 at 2:26 PM on January 12, 2007 [2 favorites]

I see that the AMA has taken down their free online course. If I find a reasonable substitute, I'll link to it here.
posted by ikkyu2 at 2:29 PM on January 12, 2007

I've seen medical issues I am familiar with handled in a way that made me slap my forehead, so it shouldn't surprise me that it's not handled in a very realistic manner. I guess I was just looking for the grain of truth that it's based on.

Thanks for the thread-link, ikkyu2.
posted by spaceman_spiff at 4:46 PM on January 12, 2007

Everything Plumberonkarst and Ikkyu2 said. It's sexier to vilify those drugs and treat everyone who's taking them as an addict than to recognize that there are millions of people who struggle to get through and make a living through severe, unrelenting, untreated pain, because anyone who needs pain medication is treated as an addict looking for a cheap high.
posted by Cricket at 6:22 PM on January 12, 2007

I'm confused - what does buprenorphine have to do with anything? The generic for Vicodin is hydrocodone...
posted by IndigoRain at 1:34 AM on January 13, 2007

IndigoRain - the buprenophine was used in the last episode while House was in Rehab. He was supposed to be taking it, but he made a deal with the rehab attendent and was given Vicodin instead.
posted by saffry at 8:58 AM on January 13, 2007