Month: October 2014

Borderline Personality Week: sympathy for the devil

Borderline Personality Disorder has an absolutely awful reputation.  Many therapists refuse to see them.  It’s considered absolutely immune to treatment.  They make up a disproportionate number of visitors to crisis chat, and an even more disproportionate number of high frequency callers (we don’t diagnose, but often people share their existing diagnoses).  A fair chunk of our training is about how to handle them, even though the way to handle them is “exactly the same as everyone else, be sure not get lazy enforcing boundaries.”

I’m not a counselor or psychiatrist (yet), but here’s a model I’ve found really useful for BPDs: they’re stuck with the coping skills of a teenager, forever.  At age 14, right before I got my third or fourth period, I was terribly upset over something.  Whatever it was, I knew even as I raged that I was not actually upset over that thing, I was upset because Hormones, and eventually they would subside.  And that made me even angrier, because here I was so upset over something I knew didn’t matter.  Or maybe just because my Hormones had a new target.  Either way, it was super unpleasant, which made me unpleasant to other people, and I was incredibly grateful when that part of puberty subsided.*

BPDs never get over that.  I talk to some extremely self aware borderlines- people who’ve done years of regular therapy and a full course dialectical behavior therapy and many hospitalizations and drugs.  You don’t hear much about this group because they work very hard to keep the symptoms of their BPD hidden.  But for all that, they are- at 30 or 50 or 70- in the emotional place I was when I was 14.  Subject to violent emotional storms they can’t control.  And it’s not their fault.  If it could be changed through effort, it would be changed by now.  You could dump those emotions on “normal” people and they would react approximately the same way, because lashing out and withdrawing are perfectly sane reactions when your body is telling you you’re about to be kicked out of the tribe and eaten by lions.

Not everyone does all that treatment, of course, and even these gold star BPDers are probably very difficult to have a serious relationship with.  But this framing and the clear boundaries of a crisis chat I find it very easy to fulfill the promise of the service, which is to give them a space to be heard without being judged.  I can empathize with the pain they’re in even if it is something internal that inflicts it on them.   And I hope that one day we find a more successful treatment than insurance-billable Buddhism.

*I also enjoyed when my mental image of my body caught up with my near instantaneous physical development and I stopped hitting myself on all of my parents’ beautiful antique furniture with dangerously pointy corners at hip height.  14 was a rough year.

Pain, part 2: Options for Treating Pain

Anesthetic (e.g. Novocain):  This is a very good option for when you need to block an extraordinary amount of pain in a very specific area for a short period of time (e.g. dental work).  However, as someone who received nerve damage from surgery that exactly mimics the effects of local anesthetic, I can tell you that it is not a long term solution.  Feeling nothing is actually very weird, and makes it easy to injure yourself.

Non-steroidal anti-inflammatories (e.g. ibuprofen):  These are great for occasional use, and have their place for long term pain caused by inflammation (e.g. arthritis).  But they carry some heavy risks for long term use.  One, inflammation is often a helpful reaction.  Topical NSAIDs helped my cat’s pain but retarded the growth of blood vessels in the eye which ultimately made the problem worse*.  Suppressing a fever can prolong illnesses.

NSAIDS are also hard on the stomach, which is bad for everyone, but especially bad for someone like me, who has long running stomach problems that interfere with my ability to absorb nutrition.  I completely wrecked my stomach with naproxen the week before surgery.

COX-2 inhibitors are a subclass of NSAIDs that target pain pathways more specifically, while sparing the gastic pathways that cause so many problems.  The problem is they also increase the risk of coronary events, to the point many were taken off the market and others restricted to single use post-surgery.  They’re so out of favor for pain relief that the three different medical professionals I begged for dental pain relief didn’t think to suggest them, even though I have many gastric risk factors and essentially no coronary risk factors.

Even before realizing COX-2 inhibitors might be perfect for me, I was very angry that they had been taken off the market.  The coronary risk was limited to a small subset of patients, of even of those, some might very well choose to live a shorter life in less pain, because pain is depressing.

Non-NSAID analgesics (e.g. tylenol and asprin): You know how new drugs like to advertise themselves as “safer than asprin?”  That’s because asprin is actually pretty dangerous.  Not super dangerous, but dangerous enough it might well be denied FDA approval today.  Asprin is also a blood thinner, which is great for coronary patients but terrible for dental patients because it can melt the blood clot protecting the surgical site, leading to dry socket.  Some descriptions down play dry socket, but it is in fact both extremely painful (because it exposes a nerve to open air), and dangerous (because it leaves the wound open to infection).   Tylenol is the world’s worst way to commit suicide, because there are several days between the point of no return and actual death, and they are extremely painful.

Opioids (e.g. heroin): I’m told these are super fun for some people, but I have had many different kinds over the years (as one dentist after another fucked up trying to fix my mouth), and I hate them.  The milder ones (everything short of percoset) do nothing for me, and the stronger ones (percoset) are so supremely unpleasant I would rather be in pain.  The only exceptions were when I was literally dying of norovirus, and whatever opioid they gave me was apparently integral to me not dying, and when I got dry socket.  And even with dry socket, I only took them to sleep, because they were just so awful. I refused to even get a prescription this time, because they just don’t work for me.

But even for people who find opioids tolerable, they have serious risks.  They depress respiratory function, cause constipation, and reduce mental function.  They’re insanely addictive on a chemical level- which doesn’t mean everyone who takes them once is hooked forever, but does mean that most people who take them will go through an unpleasant withdrawal period, no matter how “legitimate” their reason for use.  People develop tolerance to the pain relief faster than to the negative side effects, and quitting them may leave them in more pain than they were when they started.  For all these reasons, opioids are pretty much exclusively used for acute pain management and terminal patients.  Doctors who stray outside this risk serious sanctions from the DEA and FDA.  Even if I found opioids tolerable, there is absolutely no way I could have safely used them for the months of surgery + recovery I am going through.

And because I’m working my cat into everything: he doesn’t like opioids either.  Even after having four teeth pulled he fought me on taking his medicine, and then he just stood around in a stupor and drooled.

Tricyclic antidepressants: This is a cutting edge use of a very old drug.  I was prescribed topical doxepin by the doctor who did the research proving it was useful for oral pain- and even then, he was researching a different kind of oral pain.  It had some ugly side effects: I fell asleep immediately upon taking it, and couldn’t stand being touched (anywhere) the next day.  It left some numbness that lasted indefinitely- when I ate spicy food I could feel in my throat where the liquid had trickled down.  On the plus side- it left some numbness that lasted indefinitely.  That was a huge improvement over the shooting pain I’d had before.  I eventually stopped because the permanent effects had boosted me to the point it didn’t hurt that much, and the side effects were getting worse, but it was overall a great experience.  If I hadn’t found something better it’s what I’d ask my doctors for now.

Capsacin (aka spicy food): This really only works for dental pain.  When you eat capsacin it activates all your pain receptors at once.  Which hurts a lot, but then you’re good for a couple of hours.

Cannibidiol (i.e. marijuana): This one isn’t as well researched as the others because it’s illegal at the federal level (although, I must stress, legal in my state for both medical and recreational use).  But everything we know about it is awesome.  People tend to use THC and marijuana interchangeably, but that’s not true at all.  Any given strain can very in the amount of THC and CBD, and some strains may not have any THC at all, or the treatment may not activate it.  THC causes a lot of the symptoms traditionally associated with marijuana use, like munchies everything being funny.  CBD causes nerves to stop hurting for no reason, and may do a bunch of other awesome things like reduce inflammation, encourage bone growth, decrease anxiety, fight cancer, and (I can only assume) whiten your teeth while you sleep.  There is essentially no way to kill yourself with it** and there’s no physical dependency.  I used this off and on after all three surgeries, and my use naturally trailed off after each one.  It either doesn’t have any effect on me mentally, or the effect was less than the pain it was stopping.

THC may work synergisticly with CBD.  In my case it makes me sleepy, which is a terrible trait for a recreational drug but an amazing one for convalescent therapy.

A note for dental use in particular:  you are not even allowed to use a straw, so you definitely cannot smoke anything.  The nice people at the medical dispensaries have precisely dosed pills, and if you are lucky, CBD tinctures.  These are meant to be taken sublingually, but if your pain is in your mouth you can apply them to the area and everything stops hurting really really rapidly.  It gave me an amazing sense of control over my pain and enabled me to take more risks, in terms of eating and talking to people, which really sped up my recovery.

I don’t want to get too much on the “yay marijuana” bandwagon, because it’s entirely possible that as its usage becomes more widespread we’ll find out it has some rare but nasty side effects too.  But I do think it’s a travesty it is treated as worse than ibuprofen or alcohol, when it is clearly better.

*I think his infection was also resistant to the first antibiotics they gave him.

**Weirdly, this may be true for humans but not pets.  When I investigated using CBD to treat pain from my cat’s corneal ulcer, I discovered that we are pretty sure there is no amount so high it can kill your pet in one sitting, but chronic use may lead to something resembling serotonin syndrome (aka the reason you have to be so careful when taking MAOI inhibitors).

Pain, part 1: Pain is bad.

This seems obvious, and yet we as a society seem to have chosen to ignore it.  The problem is not just that pain is painful, although that is a terrible start.  It’s how pain effects you.

Humans on the whole are remarkably adaptive.   Parapelegics can emotionally bounce back from spinal cord injuries in two months.  One of the very few things human beings never, ever adapt to, meaning they produce a permanent lessening of happiness, is pain.  Pain (and long commutes) will continue to depress your happiness forever.  If you lose a limb, phantom limb syndrome is actually a vastly bigger threat to your happiness than the physical disability.

Pain also effects what you are capable of doing.   In the months leading up to dental surgery, I felt like Harrison Bergeron; I had to race to finish my thoughts before shocks of pain broke up the chain entirely, and I couldn’t have a thought that took longer than the space between shocks.  I couldn’t really enjoy books anymore.  I clung desperately to the feeling of accomplishment I got from “finishing a seven season TV series”, because I really couldn’t do anything else. * This is depressing in general, and endangered my ability to keep the job that gave me the money to fix the problem.

Then there’s what fear of pain does to you.  Imagine if every time you socialized, there was a 10% chance you received massive convulsing shocks that took days or weeks to recover from.  That would probably depress your socializing a lot more than 10%.  Now imagine that applied to everything you ever do.  And that fear made the effect worse.  It would take series efforts of will to even hold a job, much less a full and satisfying life.  And while any given bout of socializing could be dismissed as a luxury, human beings inevitably get depressed when deprived of social contact entirely.

Pain makes it harder to treat the root cause of problems.  Exercise helps back pain, but back pain makes it hard to exercise.  I couldn’t get my cat to accept eye drops for his extremely painful corneal ulcer until I started giving him pain medication.  It only took two days for the eye drops to help enough that he no longer needed pain medication, but without those two days he might very well have lost the eye.

So I’m going to proceed from here in the understanding that pain is not only very bad, but often a bigger threat to people’s total well being than physical limitations or even fear of death.

*In fact, you can track my discovery of useful pain relief and when the root problem was fixed via my blogs and my goodreads queue.  I cannot tell you what a relief it is to be able to enjoy reading again.