After recently posting Beware of the Holy Trinity, Dr. Thomas Sachy contacted me with concerns for knowledgeable clinicians that carefully consider the complexities of “individualized therapeutics”, and of course the patients that might benefit from the “Holy Trinity”. Of course, I respectfully acknowledge his concerns and advocate for clinicians that are savvy in pharmacotherapeutics and who understand those complexities, benefits and risks of the various therapies, especially when the end recipient, the patient, stands to benefit from such expertise. I therefore responded to Dr. Sachy and suggested he prepare a guest post. Hat’s off to this scholarly physician who did just that as his comments are reminiscent of when Yoda trained Luke Skywalker to fight against the Galactic Empire. Only in this case, the “Empire” is often a universe of lawmakers and politicians who know little about the science of treating pain. Many thanks to Dr. Sachy for commenting on “the other side”. Here’s what he had to say…
All chronic pain practitioners benefit from wonderful pharmacological review articles such as Beware of the Holy Trinity By Dr. Jeff Fudin. I am always in need of review and since a significant minority of my patients are prescribed one form of the “Holy Trinity” or another, this review was much appreciated. I am a neuropsychiatrist who practices pain management. And so, I am tasked with treating mental as well as physical pain. I understand completely however, when a pain practitioner is reticent (or violently opposed) to prescribing anxiolytic benzodiazepines, and/or carisoprodol; or when the mental health specialist is concerned about opioids. Dr. Fudin has laid out the pharmacological science behind the risks of these three medications being prescribed together, and we should all be familiar with the negative inferences that are associated with the “Holy Trinity”.
Being a psychiatrist/neuropsychiatrist (heavy on the neurology), I tend to be more “open” minded, and willing to accept the patient’s point of view when it is reasonable. And so, I have recently asked several of my “Holy Trinity” patients to describe in their own words, what benefits or side effects they have experienced with their medication regimen, outside of any other psychopharmacological medications they receive from me, as well as their baseline opioid based pain control. Of course, I enquire about their well being with their/my medications on EVERY visit. Outside of the shared concern for somnolence as a side effect of their medications, here are the responses from 4 of my recently seen patients who certainly differ in age, sex, ethnicity, socioeconomic status and education:
- Patient JP, a 59 year old Caucasian female, some college, – employed as a civilian project manager by the United States Air Force. Diagnoses include chronic pain syndrome due to a history of bilateral ankle avascular necrosis and subsequent left ankle fusion, due to a history of Crohn’s disease/chronic steroid treatment. She also has a history of anxiety disorder and insomnia. She has been prescribed (by me) a combination of hydrocodone, carisoprodol, and alprazolam in varying doses since 2007 (10 years). Holy Trinity Pro: “I take my Soma after work. It decreases the muscle spasms in my legs. These spasms will keep me from sleeping. My Xanax calms my nerves. My pain will cause me to ruminate about it more. Pain will also cause me to have crying spells. Xanax significantly reduces my crying and I don’t focus on my pain nearly as much.”
- Patient KD, a 49 year old Caucasian male, high school graduate – employed ironworker/boilermaker (nuclear power), with diagnoses including cervical/lumbar degenerative disc disease with associated chronic pain syndrome, and anxiety disorder/ insomnia. He has been prescribed (by me) a combination of hydrocodone, carisoprodol, and alprazolam in varying doses since 2008 (9 years). Holy Trinity Pro: “The Soma decreases my muscle aches and stiffness. Without it I would not be able to prepare for work or go to church. The Soma decreases muscle pain that is not helped significantly by my hydrocodone. Xanax on the other hand decreases my irritability and anxiety. I can cope much better with work and other stress because of my Xanax. Soma does not help with that at all.”
- Patient TB, a 48 year old Caucasian female, high school graduate, – homemaker, and mother of two. Diagnoses include chronic low back pain, fibromyalgia, depression, and panic/anxiety disorder. She has been prescribed (by me) a combination of hydrocodone, carisoprodol, and alprazolam in varying doses since 2014 (3 years). Holy Trinity Pro: “Soma in combination with my opioid pain medication treats my pain better. They clearly work better together for me. Xanax obviously decreases my stress levels. Xanax really decreases my panic attacks in a way that Soma and my pain medication cannot even begin to do.”
- Patient SI, a 38 year old African American female, non high school graduate, – disabled. Diagnoses include chronic pain syndrome due to cervical and lumbar degenerative disc disease status post anterior cervical discectomy/fusion, hypertension, morbid obesity, leukoaraiosis, major depression, severe anxiety, and insomnia. She has been prescribed (by me) a combination of oxycodone, hydrocodone, carisoprodol, and alprazolam in varying doses since 2011(6 years). Holy Trinity Pro: “Only Soma helps with the tightness in my neck and shoulders. My pain medicine does not help that at all. And if I did not take Xanax for my nerves I probably would have killed myself by now…”
It is important to note that though carisoprodol has anxiolytic effects, none of these patients thought that it was interchangeable with or could be supplanted by their prescribed benzodiazepine as a means of anxiolysis. And of course, none of these patients felt that their benzodiazepine was as effective for muscle relaxation as their carisoprodol (though I have many patients using diazepam for just this). So here we have it. In spite of the known risks of this combination of meds, some patients can and do benefit from an opioid, carisoprodol, and a benzodiazepine in combination. And certainly, the reason for this has to do with individual genetic/neuropharmacological factors in each of these patients that were highlighted by Dr. Fudin in his article. As we have all seen of late, words have consequences. Unless they are doing wrong with their medications, patients should not be called or considered substance abusers because they need a certain kind or combination of medications to function, if not survive. And out of a humane concern for others, theoretical concepts of risk reduction should rarely trump empirically observed reduction of suffering.
Dr. Thomas Sachy MD MSc is a neuropsychiatrist who practices pain management in the greater Macon, Georgia area. After completing medical school at the Medical College of Georgia in Augusta, Georgia, Dr. Sachy completed a residency in Psychiatry and a fellowship in Behavioral Neurology at the Medical University of South Carolina in Charleston. He also completed a fellowship in Forensic Psychiatry at Emory University in Atlanta, Georgia. Doctor Sachy has been practicing neuropsychiatry and pain management since 2002. His professional interests include pain and neurodegenerative conditions, and the psychopharmacological management of both. As a Forensic Specialist, Dr. Sachy has been qualified as an expert witness in Forensic Psychiatry, Neuropsychiatry, and Pain Management. Dr. Sachy is a member of PROMPT, he is a manuscript reviewer for the journal Pain Medicine, and he is the author of “Use of Opioids in Pain Patients with Psychiatric Disorders” (The Journal of Practical Pain Management. Volume 10, Issue 7, September 2010).