Dr. Rory and his Gazelle

Dr Rory is a psychologist in southern Missouri.  He is seventy years old and has spent his life helping others with their problems.  He’s not the average psychologist.  Dr. Rory completed a post-doctoral program in Advanced Psychopharmacology and is board certified in Medical Psychology – making him as or more knowledgeable on the subject of psychoactive medications as most physicians.  Gazelle is his wife of many years.  Dr. Rory had been treated at a small medical center along with his wife and had been happy with their physician and care.

Then the physician decided to cut back on his workload and leave more to the advanced nurse practitioner.  This may not have been a problem for the average patient.  But Gazelle was not average.  Gazelle had been healthy until the age of four, when she started to have seizures and was placed on phenobarbital.  Phenobarbital acts on the gamma Aminobutyric acid (GABA) receptor, which helps control the brain’s inhibitory systems. It’s kind of the opposite of glutamate.  Glutamate is used throughout the brain to increase neuronal excitability, a panencephalic excitatory system if you will, and GABA is the same for inhibition. All processing areas of the central nervous system use these two neurotransmitters. I may have made up the word “panencephalic” by the way.  Other neurotransmitters are usually specific to certain systems.

The phenobarbital was successful until she got older.  At the age of fifteen they had to add clonazepam to control her seizures.  This combination worked but they tried to change her to Depakote, and it was not well tolerated.  Over the years they tried things like Tegretol and other antiepileptics with nothing working better than clonazepam.  Eventually they got her down to just the clonazepam and she was stable on that for forty years.

During this time Gazelle developed another problem, unrelated to her seizures.  She developed pain in all of her joints and indeed over her entire body.  This was an aching constant pain.  Her doctors had trouble figuring out what had caused it.  I’m sure they checked for rheumatoid arthritis, polymyalgia rheumatica, and any other autoimmune condition with a blood marker attached to it.  But Gazelle remembered that her symptoms had come on shortly after an organophosphate pesticide had been sprayed over a crop near her home and the duster had inadvertently sprayed her house with it entering her windows and choking her.  Organophosphates are known to cause a condition now called organophosphorus ester-induced chronic neurotoxicity.  Organophosphates are essentially nerve agents. It’s like Sarin or VX.  These chemicals can permanently lock onto acetylcholine receptors so strongly they kill the neurons. Depending on someone’s genetic makeup, they can be very susceptible to even low doses of these.  Pesticides are weaker than chemical weapons of course but a very low dose in the smoke from “burn pits” have been implicated as one possible cause of “Gulf War Syndrome”.  I applaud her physicians for recognizing this condition back then.  This was 1986.

Trigger point injections and physical therapy didn’t do much and she was sent to pain management.  Doctors started her on Tylenol #3.  Tylenol #3 is of course APAP and codeine.  Codeine is a natural opiate found in the poppy plant and is chemically called 3-methylmorphine.  It is fairly weak in its original form, but the cytochrome P450 enzyme 2D6 turns codeine into morphine in the liver.  Some people can’t metabolize codeine, while others metabolize it very fast.  So it can stay in the system for a long time, or be gone in a few hours, not working much at all, or hitting hard and fast, depending on your personal genetics.  These are the details that politicians, bureaucrats, and law enforcement ignore when they insist that a patient’s treatment wasn’t “usual”, meaning average of course.  No doctor has ever seen an average patient.

Codeine failed and she was changed to Vicodin, which is of course hydrocodone, and it worked well for her for seven years.  The liver processes hydrocodone into hydromorphone, which is sold under the name Dilaudid.  Good for pain patients with liver problems as, unlike hydrocodone and APAP, it is metabolized by the kidneys. Then she was in a pedestrian-vehicle accident where a shopping cart was hit by a car and flipped into the air over onto her.  She suffered injuries to the hips, lower back, right knee, and left shoulder.  There were no fractures, but this seemed to fire up her pain syndrome and make it much, much worse. By 2001 her life was spiraling into constant severe pain.  She was the victim of assault in 2001 and suffered head trauma that left her unconscious for 24 hours (before meeting Dr. Rory by the way). Over the years they adjusted her medication, switching to morphine, and, in accordance with the thinking of that time, “titrated to effect”, ending up at 600mg a day, which is 600 MME.  This is, of course, a lot, but she was under the care of a specialist and did well on that dose.

Over the next decade and a half, she was able to slowly taper down to 180mg a day.  Twice the CDC’s caution level for primary care doctors, but again, she had seen specialists and had been fine at 600 MME, so to argue that 180MME was unreasonable would not seem logical. But that is not how some politicians, medical boards, federal attorneys, and law enforcement see it.  180 is twice 90 so no matter how you get there they want it down.  The CDCs 2022 revisions seem to address this, but the above parties don’t care, which means the doctor is stuck doing what is medically and ethically correct, or risking criticism and even prosecution.

Then, the clinic did something that seemed strange.  They asked Dr. Rory if he would prefer a male provider.  He said he would have preferred it, but it was no big deal, probably thinking about that annual prostate exam no doubt.  This was the only excuse the clinic needed.  Dr. Rory and his wife received a letter basically dismissing them both from care at that clinic, because Dr. Rory had asked for a male provider, and one was not available.  Phone calls were made by the doctor and his wife, explaining that there must be some misunderstanding.  But at first, the clinic refused to take them back.  And I think I know why.

The problem was that Gazelle is on both a benzodiazepine and an opiate.  Every quarter at least, her insurance company will send a reminder to the clinic that she is on both of these, acknowledging that a risk-benefit analysis might find them necessary and that it is up to the doctor, but in truth, it is not.  It is up to the jury.  These warnings have been used in court to argue to a jury that a doctor “ignored” the risks, even if there is documentation of deliberation and a risk-benefit analysis.  Just like doctors have been convicted of putting patients “at risk of addiction” by prescribing opiates – which could only be avoided by prescribing no opiates at all.  Not making the medical decision that outside agencies think is the correct one can cause problems.  That left Gazelle, for a while, a medication refugee, prescribed a few weeks’ worth of medication and left to find another specialist.  Good luck with that these days.

Dr. Rory was able to intervene on her behalf, notifying them that Gazelle had in fact, tried to taper down from the clonazepam and had seizures that put her in the ER.  Withdrawals from prescribed medications are not a sign of addiction.  They are an expected consequence of long-term use.  Sadly, none of this matters when doctors are too terrified to do what evidence-based medicine tells them is right for their patients.   Dr. Rory, who only has cardiac problems, had no trouble finding a new physician.  But if a knowledgeable medical expert like Dr. Rory cannot find care for his wife, what chance does anyone else have?  What about all the other patients, abandoned by their physicians out of fear, justified, I might add, that they might be targeted?  While we cannot be certain of the answer to these questions for every patient, we can be positive that the current state of affairs is putting patients at risk, and while the government tracks anyone who died within thirty days of receiving an opiate prescription, it does not track those who die within thirty days of their medications being stopped.