This past week, I had the tremendous pleasure of seeing one of my brother’s articles on the cover of the December issue of Christianity Today as part of a feature on pain killers. While my brother has done a lot of writing for various places over the years, his article “How Realizing My Addiction Had Chosen Me Began My Road to Recovery” was particularly special to see. In it, he recounts his story of getting addicted to pain killers after a medical crisis, and details his road to recovery. Most of the story is behind a paywall, but if you want a full copy leave me a comment or use the get in touch form and I’ll send you the word document.

As someone who was intimately involved with all of the events relayed in the article, it’s pretty self evident why I enjoyed reading it as much as I did. On a less personal note though, I thought he did a great job bringing awareness to an often overlooked pathway to addiction: a legitimate medical crisis. My brother’s story didn’t start at a party or with anything even remotely approaching “a good time”. His story started in the ER, moved to the ICU, and had about 7 months of not being able to eat food by mouth at the end. His bout with necrotizing pancreatitis was brutal, and we were on edge for several months as his prognosis shifted between “terrible” and “pretty bad”.

Through all that, the doctors had made decisions to put him on some major pain killers. Months later, when things were supposed to be improving, he found that his stomach was still having trouble, and went back to his doctor for more treatment. It was only then that he was told he had become an addict. The drugs that had helped save his life were now his problem.

Obviously he tells the rest of the story (well, all of the story) better than I do, so you should really go read it if your interested. What I want to focus on is the prescribing part of this. When talking about things like “the opioid crisis”, it’s tempting for many people to label these drugs as “good” or “bad”, and I think that misses the point (note to my brother who will read this: you didn’t make this mistake. I’m just talking in general here. Don’t complain about me to mom. That whole “stop sciencing at your brother” lecture is getting old). There’s a lot that goes in to the equation of whether or not a drug should be prescribed or even approved by the FDA, and a shift in one can change the whole equation.  Also, quick note, I’m covering ideal situations here. I am not covering when someone just plain screws up, though that clearly does happen:

1. Immediate risk (acute vs chronic condition) In the middle of a crisis when life is on the line, it shouldn’t surprise anyone that “keeping you alive” because the primary endpoint. This should be obvious, but after a few years of working in an ER, I realized it’s not always so clear to people. For example, you would not believe the number of people who come in to the ER unconscious after a car accident or something who later come in and complain that their clothes were cut off. In retrospect it feels obvious to them that a few extra minutes could have been taken to preserve their clothing, but the doctors who saw them in that moment almost always feel differently. Losing even one life because you were attempting to preserve a pair of jeans is not something most medical people are willing to do. A similar thing happens with medications. If there is a concern your life is in danger, the math is heavily weighted in favor of throwing the most powerful stuff we have at the problem and figuring out the consequences later. This is what kicked off the situation my brother went through. At points in his illness they put his odds of making it through the night at 50-50. Thinking about long term consequences was a luxury he wasn’t always able to afford.
2. Side effects vs effect of condition The old saying “the cure is worse than the disease” speaks to this one, and sometimes it’s unfortunately true. Side effects of a drug always have to be weighed against the severity of the condition they are treating. The more severe the condition, the more severe the allowable side effects. A medication that treats the common cold has to be safer than a medication that treats cancer. However, just because the side effects are less severe than the condition doesn’t mean they are okay or can’t be dangerous themselves (again, think chemotherapy for cancer), but for severe conditions trade offs are frequently made.  My brother had the misfortune of having one of the most painful conditions we know of, and the pain would have literally overwhelmed his system if nothing had been done. Prescription drugs don’t appear out of nowhere, and always must be compared to what they are treating when deciding if they are “good” or “bad”.
3. Physical vs psychological/emotional consequences One of the more interesting grey areas of prescription drug assessment is the trade off between physical consequences vs psychological and emotional consequences. For better or worse, physical consequences are almost always given a higher weight than psychological/emotional consequences. This is one of the reasons we don’t have male birth control. For women, pregnancy is a physical health risk, for men, it’s not. If hormonal birth control increases a woman’s chances of getting blood clots, that’s okay as long as it’s still less impactful than pregnancy. For men however, there’s no such physical consequence and therefore the safety standards are higher. The fact that many people might actually be willing to risk physical consequences to prevent the emotional/psychological/financial consequences isn’t given as much weight as you might think. The fact that my brother got a doctor who helped him manage both of these was fantastic. His physical crutch had become a mental and emotional crutch, and the beauty of his doctor was that he didn’t underestimate the power of that.
4. Available alternatives Drugs are not prescribed in vacuum, and it’s important to remember they are not the end all be all of care. If other drugs (or lifestyle changes) are proven to work just as well with fewer side effects, those may be recommended. In the case of my brother, his doctor helped him realize that mild pain was actually better than the side effects of the drugs he was taking. For those with chronic back pain, yoga may be preferable. This of course is also one of the arguments for things like legalized marijuana, as it’s getting harder to argue that those side effects are worse than those of opioids.
5. Timing (course of condition and life span) As you can see from 1-4 above, there are lots of balls in the air when it comes to prescribing various drugs. Most of these factors actually vary over time, so a decision that is right one day may not be right the next. This was the crux of my brother’s story. Prescribing him high doses of narcotics was unequivocally the right choice when he initially got sick. However as time went on the math changed and the choice became different. One of the keys to his recovery was having his doctor clearly explain that this was not a binary….the choice to take the drug was right for months, and then it became wrong. No one screwed up, but his condition got better and the balance changed. This also can come in to play in the broader lifespan…treatments given to children are typically screened more carefully for long term side effects than those given to the elderly.

Those are the basic building blocks right there. As I said before, when one shifts, the math shifts. For my brother, I’m just glad the odds all worked in his favor.