Suicide and Suffering In the Elderly: We Must Do Better
The Los Angeles Times recently ran a front-page story about an 84-year-old woman living near San Diego, California, who was in so much pain that she committed suicide by ingesting sleeping pills and then suffocating herself with a plastic bag. Her 88-year-old husband refused to stop her and watched her die “because he couldn’t stand to see her suffer in pain any longer.” This was her second attempt at suicide.1
The media and political buzz is, of course, that the loving husband has been jailed and is waiting for the San Diego County prosecutor to decide just what crime he has committed. Of course, the real crime is that the poor woman didn’t get satisfactory pain relief. Relative to her pain care, the only comment in the news article was that her doctor did everything he knew to do.
My first question, which remains unanswered, is, “What medical management was used?” Had the patient seen a pain specialist? Did she indeed get a trial of high-dose opioids and non-opioid adjuvants? Another question, which continues to perplex me, is, “Does aging or neuroinflammation reduce and/or render receptor sites in the central nervous system (CNS) unresponsive to any medication, including opioids?” Unfortunately, I’ve had a few older diabetic patients with peripheral neuropathy (more than 80 years of age) whose pain I simply couldn’t relieve—even with high-dose opioids.
One of the more demoralizing and thought-provoking studies during the past decade is one showing that glial cells in the CNS activate and cause neuroinflammation with tissue destruction.2 Also, brain scans clearly show that severe chronic pain patients lose CNS tissue mass.3 Sadly, CNS cellular destruction means loss of receptors and unresponsiveness to opioids and other pharmacologic agents. Despite what critics of opioids may wish to hear, a loss of CNS receptors will likely call for higher-than-normal opioid dosages just to get a minimal response to prevent suffering and suicide.
The message here is clear: we need to keep moving forward to better understand the CNS loss of tissue and receptors in aging patients and those with centralized pain. Suffering and attempted suicide should never occur because of a failure to prescribe an adequate dose of opioids. Contrary to what some people may believe, there is no upper limit to opioid dosages listed in package inserts or in the Physicians’ Desk Reference (PDR). The range of opioid dosages needed to relieve suffering and prevent suicide is extremely wide. One patient may need 40 mg of morphine and another 4,000 mg of morphine. The causes for this differential are multiple and include genetic metabolic defects, loss of CNS receptors, and pain severity.
Practical Pain Management has long had a steady view on opioids. All the arguments about whether opioids are useful are foolish. Opioids are only to be used when non-opioid treatments fail. Are we to withhold opioids and let the patient suffer or commit suicide? There are established and proper guidelines for opioid prescribing, which have been promulgated by many professional and scientific organizations. In particular, the Federation of State Medical Boards has the gold standard opioid-prescribing guidelines. A summary table of these guidelines is given here (Table 1). Opioid prescribing doesn’t need much debate. Hold off on opioids until all else fails. When you need them, however, use them to the fullest. Don’t welch on dosage. This is a doctor’s way to prevent suicide and suffering. Just do it.