From the Patient Safety Committee
As a medical student and resident, Basem Attum, MD, MS, struggled with addiction. His four-part memoir, which begins with this article, provides an opportunity for each reader to examine his or her own potential for addictive behavior—whether to alcohol, drugs, gambling, sex, work, or something else. As physicians and surgeons, we focus on medicine and surgery as "cures," to the detriment of other coping strategies. We may also transfer those beliefs to our patients, perhaps unwittingly contributing to the growing epidemic of substance misuse.
Understanding how patients view medications and surgery can help shape discussions with them. The AAOS Patient Safety Committee has an online Pain Relief Toolkit with tips on safer pain relief strategies. For more information, visit www.aaos.org/quality/painrelieftoolkit.
Troubles started after surgeon lost self-identity as a fit, active athlete
I was ignorant. In my mind, only socially deprived people became addicts. I thought, "I'm a doctor. I'm educated. I'm immune to such problems." Boy, was I wrong. As an orthopaedic surgery resident, I became addicted to pain and sleep medication. I want to share my story to help other surgeons avoid the same pitfalls and to help others misusing substances to recover. I want to do what I can to abate the current epidemic of opioid misuse and help ensure it never returns.
Nothing in my childhood and adolescence would have indicated that I become an addict. My family was comfortable, I had loving parents, and no one in my extended family ever misused any substance. I was an athlete with many friends. I excelled academically and entered medical school.
I started Ambien when I was 20 years old because I was having trouble sleeping. I don't really remember any factors that contributed to my insomnia. However, it was sufficiently problematic that I asked my doctor for help. He sent me to a sleep specialist, who conducted an evaluation and recommended some behavioral modifications for improved sleep habits. I tried them, but was not satisfied with the results. I understand now that I did not give the behavioral modifications a chance.
My doctor then offered me Ambien, which I welcomed—I was being passive and thinking magically. I wanted the problem fixed. Ambien seemed to work well for me. I got back into a regular sleep pattern and only took it occasionally. My parents were aware, but not concerned. In hindsight, I wonder. Problems sleeping sufficient to seek medical attention suggest stress or distress that I didn't recognize. However, this episode reinforced my sense that medications could solve problems.
In my third year of medical school, at age 28, I began to experience some hip pain and was diagnosed with femoracetabular impingement with some mild degenerative changes. When I told my orthopaedic surgeon I was not satisfied with nonsteroidal anti-inflammatory medications and asked for something stronger, I was given an oxycodone/acetaminophen combination for the pain. My exposure and training in medicine had given me the sense that this was the natural progression for the treatment of pain. I knew the risks of opioid medications. I just didn't think it was possible for me to misuse them. I assumed that the problem would get fixed, and then I would stop taking the medications.
I also started taking Ambien again to help me sleep. I had researched it and didn't think it was habit forming—we now know better. But I didn't even consider that I was becoming dependent or addicted. I didn't think twice about using medications to help with sleep—it felt normal to me.
In part, I was taking the Ambien because the hip pain would wake me. But the stress of the situation was also a contributing factor. I had trouble turning off my mind. Some nights I would ruminate about my health. Other times, I would worry about performing well during my rotations. During these restless nights, I'd worry that missing sleep would affect my performance during my rotations. The sleeping pill enabled me to get a good night's sleep and did not leave me feeling groggy in the morning. I thought I could maintain control of my thoughts and my health through medication.
My initial prescription was for enough medication to take a sleeping pill every night of the week and an opioid 2 times a day for a month. I then refilled the prescription, but did not take the medication on a daily basis. Every few months, I requested a refill. I had no plan to stop taking these medications until after my hip surgery.
My doctors and I only considered two methods for pain relief: medication and surgery. We never discussed the downsides and risks of opioids and sleeping pills. We never considered other evidence-based approaches for improving sleep and comfort, such as mindset coaching and training (cognitive behavioral therapy and its derivatives). I thought it wasn't necessary because the pills were so effective. They had it covered.
I knew these medications were risky, but I told myself, "I am not someone who can become an addict so they aren't risky for me." I wasn't trying to get high; I was taking these drugs for a legitimate purpose. I thought I needed them to be healthy. I remember thinking that addicts don't have real issues, they just want to have fun and get high. That wasn't me, so I'd be fine. Now I realize that I was using the medications to fill a hole—one that could never be filled by chemicals.
Finally, I was offered surgery. Although I was told that the surgery might not save my hip, I was advised to have it in the near future to "prevent further damage." Unfortunately, this reinforced my maladaptive idea that I was broken and needed to be fixed; that I could not be myself if I continued to have pain in my hip.
I told the surgeon that I was beginning my third year of medical school and I wanted to finish most of the year if possible. He agreed and we planned the surgery for 5 months later. Meanwhile, I continued to take the oxycodone/acetaminophen.
Now, the nightmare began. Still in medical school, working and studying for my clinical rotations, I was terrified that the hip pain would never go away.
I was convinced that I could not be a surgeon and an active young adult as long as I had pain in my hip; for me, zero pain was the only acceptable outcome. I thought my only hope was surgery.
Next month in AAOS Now, Dr. Attum explains the aftermath of his surgery and how the ongoing stress of residency impacted his addiction.
Basem Attum MD, MS, is currently a research coordinator at the Division of Orthopaedic Trauma, Vanderbilt University Medical Center. He can be reached at firstname.lastname@example.org.