House MD: An analysis of chronic pain managed with opiate therapy in entertainment television. -Jemma Theivendran

From the Pain Relief Foundation website:

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House MD – An analysis of chronic pain managed with opiate therapy in entertainment television.
Jemma Theivendran
House MD:
An analysis of chronic pain managed with opiate therapy in
entertainment television.
Jemma Theivendran
Imperial College Medical School London
November 2007
For a long while, television dramas have been a gateway for bringing ideas of
medicine and healthcare to the masses.1 Whilst House MD ranks at the top of the
list, reaching 20.8 million viewers in the US2 (and more worldwide) by focusing
much of the episode on the diagnostic process of patients with rare conditions, it
also portrays the life of a chronic pain sufferer. Researchers often consult
practising physicians when researching the medical facts before placing them
into the plot3, but in the depiction of the fictional Dr. Gregory House as a chronic
pain sufferer, how much of it is true to life and how much can be attributed to
increasing the dramatic effect?
As well as using current research to determine the accuracy of the medicine, this
essay also contains some original thoughts from viewers of the show, as it has
been shown that the audience can differentiate between fact and fiction to
produce their own interpretation of the show.4 The survey was carried out via a
message board, the thread requesting any viewer insight into the portrayal of
pain and pain management in House MD.
Introduction
Chronic pain is usually grouped into cancer-related pain and non-cancer-related
pain. The latter is dealt with in this essay. Chronic non-cancer pain (CNCP) is
defined as a pain which persists after the expected time of tissue regeneration,
usually lasting greater than six months.5 The causes of CNCP are varied,
encorporating all the systems of the body, and a staggering 35% of the American
population have some form of chronic pain.6
Dr. Gregory House, the head of the Department of Diagnostic Medicine at the
fictional Princeton-Plainsboro teaching hospital, is described as a medical
genius, who delights in solving medical mysteries with his hand-picked team of
specialists. However, Dr. House avoids patient contact as much as is feasibly
possible, is brutally honest and cynical, and is constantly in pain.7
His pain is derived from an infarct in his thigh muscle caused by a thrombus
preventing blood flow. As this was misdiagnosed initially, the prevention of blood
flow caused necrosis of the muscle and resulted in vast amounts of pain. Dr.
House has the necrotic part of his leg muscle removed leaving him with chronic
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Jemma Theivendran
pain in his right thigh and the necessity to walk with a cane. Whilst muscle
infarction is a relatively rare differential for leg pain, the medicine is accurate and
thus provides the basis for a main character in constant pain.
The writers make chronic pain a central theme in the show and have portrayed
some of the trials faced living with the condition.
“No, I do not have a pain management problem, I have a pain problem" a
Dr. House is prescribed Vicodin - a drug containing acetaminophen and
hydrocodone. Acetaminophen (also known as paracetamol) is believed to relieve
pain by interfering with cyclooxygenase activity8 and on its own does not have
any qualities for addiction. Hydrocodone acts similarly to codeine in relieving
pain, though the exact mechanism is unknown. It is usually prescribed to relieve
moderate to severe pain in the short term. It carries a danger that it can be habit
forming - as with all opioid analgesia “repeated administration may cause
dependence”.9 Dr. House has been on Vicodin for at least 5 years. This may
have been decided by the writers to help depict a chronic problem to the
audience. The research paper by Maier et al (2007) is supportive of this idea
showing that in a study of CNCP patients on opioid therapy, 85% still used the
same level of therapy 5 years later.10
The reluctance to prescribe opioids for CNCP lies in the potential for the patient
to develop side effects, as well as dependency. Side effects include nausea and
vomiting, constipation, dry mouth, headaches and, less commonly, ureteric
spasm and difficulty with micturition.9 Dr. House experiences urinary retention
caused by ureteric spasm. His self-catheterisation to relieve the discomfort
caused by the urinary retention proved a highly dramatic scene.11 The side
effects themselves are medically accurate but self-catheterisation is highly
irregular practise and was included for heightened drama. The episode raised
awareness about side effects of opioid treatment as highlighted by a viewer.
“Pain medication might have harmful effects such as constipation, renal
impairment etc…these issues would be more important for someone in chronic
pain (such as House) as opposed to someone who is terminally ill.”12
The quality of life for a CNCP sufferer can be very poor as the pain can be so
debilitating that it prevents the sufferer from functioning in day to day activities,
but the side effects too may have an impact on daily life. Most find a balance
between pain relief and management of the side effects “accepting more pain for
a reduction in sedation and nausea”.13 This may go some way to explaining why,
although Dr. House is continuously on pain medication, he still suffers from pain.
Quality of life can be significantly improved with long term use of opioids10
indicating that, whilst it is understandable for physicians’ hesitancy in prescribing
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Jemma Theivendran
opioids for CNCP, some CNCP sufferers can not control their pain any other way
and it is vital that the patients’ quality of life is not compromised.
One viewer was unhappy with the balance between story-telling and medical
fact, stating that although Dr. House may “questionably manage his pain, there
isn’t a reasonable pain management approach being promoted on the show”14
which is an important point as it does not portray any solution to the problem
faced by Dr. House. In some ways though, the show has done well by
highlighting the trials faced by chronic pain sufferers who are on opioid
analgesia. A chronic pain sufferer echoed this view by stating,
“House M.D. as far as I am concerned portrays life as it is with chronic pain and a
substance that allows you to have some sort of life instead of a mere existance
...” 15
"They [pills] let me do my job and they take away my pain" b
House MD endeavours to address the issue of physical dependency and
addiction – the first meaning the body has become tolerant to the drug but the
patient still maintains functionality in daily life at the higher doses, and the latter
meaning the patient has a psychological dependence on the drug and will
continue to take the medication regardless of loss of functionality.16
From the time Dr. House presented to the hospital with the pain, he has always
been shrouded in questions about addiction. When he first presented, the
residing doctor debated whether or not he was a drug seeker and hesitated to
give him necessary pain medication, during which time Dr. House injected
Demerol into his thigh himself.17This highlights the plight suffered by many
chronic pain sufferers who require pain relief but, due to their physical
dependence, are questioned by healthcare professionals wary of drug seekers.
Chronic use of opiates can cause the patient to develop tolerance to the drugs as
the P-glycoprotein molecules which pumps the opiate out of the circulation is up-
regulated. Therefore, more of the drug is required to reach the brain through the
blood-brain barrier to have the same effects.18 This is supported by other studies
which describe antinociceptive tolerance due to prolonged opioid use and the
consequent increase in dose required by the patient to produce the same amount
of pain relief.(10, 19)
Dr. House does not appear to adhere to the dosage policies of Vicodin – taking
the pills as and when he requires. Hocker (1994) showed that one of the
problems with prescribing opium derivatives to CNCP patients is “prescription on
request rather than time-scheduled therapy”.20 House MD shows, perhaps, a
more extreme form of “patient controlled analgesia”, but as Dr. House is
medically qualified, it appears that, for some time at least, his colleagues trust his
judgement. As the series continues, Dr. House’s colleagues express concern
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Jemma Theivendran
about the amount of Vicodin he is taking, worried that he may be addicted. They
challenge him to a week without Vicodin in the episode aptly entitled “Detox” and
during the episode Dr. House experiences withdrawal symptoms - chills, nausea
and a severe increase in pain. 21 His colleagues may have been right to be
concerned as Ives et al (2006) showed that opioid misuse can complicate chronic
pain management with 32% of patients recruited to the study committing opioid
misuse.22 Though his colleagues may have been expressing concern for his well
being, there are ethical questions behind their challenging him to stop his
medication.
"To leave a person in avoidable pain and suffering should be regarded as a
serious breach of fundamental human rights".23
A viewer seems to agree with the principal of not allowing a person to suffer in
pain.
“[his colleagues] do not appear to even consider his pain when discussing his
"addiction" i honestly would argue that putting a patient with chronic pain through
detox is a form of torture.” 14
Although Dr. House could have taken Vicodin at any time during that week, the
peer pressure his colleagues placed on him became the over-riding factor,
causing him to forgo his pain medication and remove elements of functionality
when performing his job in favour of winning the bet. The combination of the
severity of his withdrawal and his obvious requirement for Vicodin cause some
viewers to question the clarity with which the show portrays chemical
dependency.
“There is a difference between addiction and dependency. Something I think the
show has done a poor job about making clear.” 24
The withdrawal itself was highly dramatic and brings about the question of
whether Dr. House is addicted as Cowan et al (2001) showed that only 9.5% of
pain patients experienced withdrawal symptoms on discontinuing the therapy.25 It
could be argued that Dr. House is in the 9.5%, especially as his pain
management therapy is much less restricted than a standard patient, whose
dose is monitored by the prescribing physician. In addition, according to the BNF,
severe withdrawal symptoms can occur if the medication is withdrawn abruptly, 9
which was the case with Dr. House. Both patients and physicians are apprehensive
about addiction and misuse when using opioids in pain management therapy. As
fewer physicians are confident in prescribing opiates to CNCP patients, less is
known about the dosage-tolerance relationships and withdrawal symptoms.
However, prescribing opioid analgesia to CNCP patients derives more benefit
than harm.25
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At the end of his "detox", when asked if he had learnt anything, Dr. House
replies, "I said I was an addict. I didn't say I had a problem. I pay my bills, I make
my meals, I function." 21 Viewers have sympathised with this, stating that it is an
accurate depiction of how chronic pain sufferers cope with their medication.
“The amount of pain that he feels is torturous while he is not medicated. If he
were truly addicted to Vicodin and simply took the pills for the high he would not
be able to function….The people who try to tell him that he is addicted have no
idea for they do not feel his pain.” 26
“And everything's the leg? Nothing's the pills? They haven't done a thing to
you?” c
It is difficult to distinguish how much of Dr. House's personality is attributable to
his pain or his pain management. It is alluded to in previous episodes that he was
never really happy and avoids contact with patients as much as possible. It could
be argued that if Dr. House's pessimistic attitude is not caused by his pain, but is
used to enrich the character, and if this is not clearly defined, then it could,
perhaps, represent a negative image of chronic pain sufferers. Studies are
conflicting with regards to personality changes and opiate therapy. Pappagallo
and Heinberg (1997) state that there is a misconception that opioid therapy
causes depression and personality changes27, whereas the BNF states that
opioids can cause mood changes9. There may be disagreement with change in
mood associated with the medication but chronic physical pain itself can cause
depression and change in personality. Blake et al (2007) shows that CNCP is
associated with psychological impairment and depression28, and a study
revealed that 71% of CNCP patients were depressed.29 This correlates with the
experience of one viewer who stated:
“House is pretty dead on with the pain issue. My grandfather…is in chronic pain.
When he is in pain, he can be very nasty and he does say nasty things to
everyone, takes it out on us.” 30
This indicates that Dr. House's personality is not necessarily a misrepresentation
of chronic pain sufferers, and as well as enhancing the character, may in fact be
medically accurate.
Interestingly, patients who were single had a higher role emotional score29 which
could explain why Dr. House's pain increases with the return of a former girlfriend
(who is now happily married). Dr. House is concerned that the Vicodin is not
sufficient at managing his pain and requests spinal anaesthesia from his
supervisor. Though sceptical about the increase in pain, she injects him and his
pain promptly ceases. She reveals to him that she injected saline, a placebo, and
concluded that the increase in pain is psychological. Studies have shown that
depression may increase physical pain31 and this has been attributed to the
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Jemma Theivendran
connection between physical pain and depression, and neurotransmitters
serotonin and norepinephrine affecting them both.32 The writers created a
storyline that is both entertaining and backed by medical literature.
“Is there a TV anywhere? General Hospital starts in eight minutes.” d
The media has a responsibility to accurately represent medical information even
in the fictional setting. Studies have shown that entertainment can be a more
successful medium at providing information about medicine in comparison to the
news. In some cases, it is not evident as to what is fact and fiction and, as Turow
(1996) highlights, viewers can come away with false expectations.1
It is evident, therefore, that the portrayal of characters like Dr. House needs to be
accurate. This is highlighted in the case of a viewer, whose own doctor used Dr.
House as an example.
“I was discussing possible medications today with my physician and the
possibility of becoming addicted. To my surprise he used House as an example.
My doctor claims that the portrayal of House is the most accurate he has ever
seen.”26
Studies show that viewers can be influenced by entertainment television in their
expectations of modern healthcare, examples being the optimistic outcomes of
CPR and comas (33, 34). However, the very nature of House MD demands an
intelligent audience to keep up with the level of medicine and science involved in
the drama, and consequently the viewers have formed their own opinions about
chronic pain and its management.
Conclusion
House MD appears to accurately portray the life of a chronic non-cancer pain
sufferer who, perhaps controversially, finds functionality through management of
his pain with opioids. Dr. House is used as a reference point for chronic pain and
has increased the profile of an otherwise less commonly considered condition.
Conveying chronic pain is a complex process – language and physical
movements are limiting and, whilst other forms of disability are visible and
obvious, pain is an internal process. Viewers appreciate the limitations of
illustrating pain via television. A viewer writes:
“Do not forget that the most profound aspect of pain is its inexpressibility in the
transcendence of the confines of subjectivity.”35
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Hugh Laurie as Dr. Gregory House.
Both the writing and the acting explore various aspects associated with chronic
pain, most obviously the relationship of the sufferer with his medication.
As with all medical television dramas, a responsibility is upon the writers to
accurately illustrate aspects of medicine whilst maintaining the dramatic effect. In
the case of the production team of House MD, not only do they produce a high
quality and, for the most part, accurate medical drama, but allow a deeper
appreciation into the complexities surrounding chronic non-cancer pain.
“The show is a reminder that people should be more careful about making
assumptions on chronic pain patients, and that pain is subjective and only the
patient can say what hurts or not.” 36
This is perhaps most poignantly highlighted in a conversation between Dr. House
and a patient.
Patient: How many of those [pills] are you taking?
House: I'm in pain.37
Word Count: 2729
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37. Jacobs K, Shore D, Attanasio P, Singer B, Sackheim D ‘ DNR’ Season 1, Episode 109 [DVD
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a. Jacobs K, Shore D, Attanasio P, Singer B, Sackheim D ‘ Occam’s Razor’ Season 1, Episode 3
[DVD footage]
b. Jacobs K, Shore D, Attanasio P, Singer B, Sackheim D ‘ Detox’ Season 1, Episode 11 [DVD
footage]
c. Jacobs K, Shore D, Attanasio P, Singer B, Sackheim D ‘ Detox’ Season 1, Episode 11 [DVD
footage]
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footage]
Image available from http://www.buddytv.com/articles/house-hugh-laurie.jpg [cited 8 July 2007]
HOUSE MD belongs to Heel and Toe Films, Shore Z Productions and Bad Hat Harry Productions
in association with Universal Media Studios and the Fox TV Network. Katie Jacobs, David Shore,
Paul Attanasio, Bryan Singer and Dan Sackheim are executive producers.
Opinions of the viewers reproduced with their permission