The opinions contained within this commentary are solely those of Daniel Brookoff, MD, PhD and are not supported or endorsed by Medical Learning Solutions or Cephalon, Inc. and its affiliates.
Dr. Daniel Brookoff received his medical degree as well as his doctor of philosophy degree from the University of Pennsylvania in Philadelphia. He also completed his residency in medicine and a fellowship in medical oncology at the University of Pennsylvania. Dr. Brookoff has held faculty positions at both the University of Pennsylvania and the University of Tennessee medical schools, and is currently the medical director of the Center for Medical Pain Management at Presbyterian, St. Luke's Medical Center in Denver, Colorado. In addition, Dr. Brookoff is the founding associate director of the Methodist Comprehensive Pain Clinic in Memphis.
Dr. Brookoff has authored numerous papers and textbook chapters on pain management, most recently "Chronic Pain as a Disease: the Pathophysiology of Disordered Pain" for the textbook Expert Guide to Pain Management, published by the American College of Physicians in 2005.
In order to comfort many of my patients with chronic pain, for years I have told them the story of Job from the Bible. These days not only do I tell my patients the story of Job, I also tell them the story of Elvis.
Elvis was born in 1935. He was a twin, his twin died at birth. Elvis had problems right from the start and it turned out he had a form of Hirschsprung's disease, and Hirschsprung's disease is a disease of the colon that really kept him from having normal bowel movements and things that he really didn't want to talk about. There are a lot of people with Hirschsprung's disease that survive into adulthood, and later on in adulthood they start to develop severe bowel problems, and that's exactly what happened to Elvis. He started seeking treatment because he didn't know what he had. In the 60s he was seeing a variety of doctors, some of them in California, some of them in Las Vegas. They were giving him all kinds of treatments, and one of the treatments that he got were anti-inflammatory steroids for the colitis he was developing. So people who survive into adulthood with Hirschsprung's disease will stretch out their bowel, will develop twists in their bowel, and develop a symptom like colitis. And this is what was plaguing Elvis when he met Dr. George Nicopolis. And it's kind of interesting because if you asked people what happened, they said that Dr. Nicopolis caused Elvis to be addicted and that's what he died of, and that is absolutely not true. And it just kind of mirrors a lot of what we go through either as pain patients, or as doctors taking care of pain patients, that it's hard enough taking care of the physical suffering that the stigma and humiliation really are not deserved, and they become an enormous burden.
The first time Elvis met Dr. Nick was in February of 1967. Elvis had suffered an attack of vertigo and had fallen in the bathroom and broken his rib. He came to see Dr. Nicopolis and one of the interesting things is from then on they developed this relationship that was kind of a father-son relationship. A lot of pain physicians develop very close relationships with their pain patients, and often that's the most important part of our treatment is having somebody they can trust and somebody who believes in them.
Elvis actually got better under Dr. Nick's care. When Elvis met Dr. Nick in 1967, he wasn't touring. He hadn't played a concert since 1958, which is when he went into the military service. He started playing concerts again in 1969. Despite that, he started to suffer worse and worse bowel problems. Because of a problem with the Hirschsprung's disease, which is a neurologic problem with your bowel, he developed a very distended and stretched out colon, and at one point developed something called a volvulus, which is real crisis where his colon actually twisted and he started bleeding and was nearly dead. And it was kind of interesting, I've seen the medical notes for that. What you do with somebody who has a volvulus is you take them to the hospital. Elvis went to the doctor's office and saw Dr. Nick and a gastroenterologist and they said, we need to take you to the hospital. Elvis was just absolutely terrified that they were going to do a colostomy on him, which is probably what they would have done, and to be Elvis Presley and to have a colostomy, I could see being kind of intolerable. When Elvis refused, the gastroenterologist said, "well we can stick a scope, you know, a rigid scope, in your colon and, because your colon is twisted, and if we twist it the right way, you'll be okay, and if we twist it the wrong way, it'll be catastrophic". Elvis told him to go ahead and do that, because his identity as Elvis was so important to him.
I remember looking at the medical chart for that visit and it's kind of sweat-stained and the note for that's really long. Usually when you write a note for a procedure it's a page or two. That note is 16 pages. And luckily they twisted the right way. So he made it through that crisis. It's kind of interesting, everybody makes their judgment of Elvis, who was a good person, loved his mom, a good Southern Baptist who didn't drink alcohol, much less abuse drugs. And they made all these kind of presuppositions about him. And really what he was trying to do was, to get treatment and still stay Elvis and maintain his real iconic image, and it's kind of interesting because his image continues to grow.
He started to develop terrible constipation and something called overflow diarrhea. So he had trouble moving his bowels and at the same time some of the liquid stool would overflow. There was an incident at a concert in Baltimore where he actually had what we call an accident, and that terrified him. And you can imagine Elvis having a bowel accident would be terrifying. Because of his accident, Elvis became very, very concerned about his bowels and started taking medicines that actually caused the blockages and the constipation to get worse. He took a medication called Lomotil®, and he insisted that medication be given to him at his own discretion. All his other medications, as it turns out, were very carefully controlled. So it wasn't like he was going out on the street buying drugs or asking for drugs. He was actually taking very little medication, but he did take a lot of Lomotil®. Lomotil® has two drugs in it. Lomotil® was developed in the 50s when they were trying to look for a pain-relieving narcotic and it's a drug called diphenoxylate. Diphenoxylate didn't relieve any pain, it caused constipation. But when it came out on the market, regulators were really concerned that you just can't let a narcotic out on the market even though it doesn't get absorbed. So they did something called the poison pill theory of formulation. So Lomotil® has two drugs in it. It has diphenoxylate and it has belladonna, an atropine-like drug. The thought being that people who took low doses of it would never feel the belladonna, whereas people who tried to abuse it, which are very, very few, would get belladonna side effects.
Elvis took this drug and took it in large amounts because he was absolutely horrified about having a bowel accident. And like I said, you just think of him living with that kind of terror and still going out there and performing for people and going to Vegas and doing concerts, and the poor fellow was terrified. If you look at the mode of death, he didn't die like a drug addict dies, because on his last day he was having problems getting his days and nights mixed up so he did sleep in kind of late. But then he ate breakfast and did several things during the day. He played racquetball, which is not something a lot of my drug-addicted patients do, and then he had friends come over and what did they do, they played gospel music into the night, which is something he really loved doing.
Then Elvis tried to do the hardest thing that he had to do every day, because he tried to have a bowel movement. And it looks like Elvis had not had a bowel movement for several weeks before the time of his death. And one of the ways we know that is he'd had a barium enema, in those days we did that instead of colonoscopies, where they put barium in his bowel. And we know that if you don't get the barium out of your bowel pretty quickly, it turns solid, like cement. And he'd had a barium enema more than eight weeks previously and had never gotten the barium out of his bowel. So he had a very stretched out bowel with a lot of barium. And hadn't had a bowel movement in at least two weeks, is on the toilet trying hard to have a bowel movement. And unfortunately he had taken a lot of Lomotil® right before that. The diphenoxylate in Lomotil® was stopping him from having a bowel movement. The belladonna in Lomotil® caused him to have an arrhythmia when he bore down. So as he bore down real hard to kind of push things out of his bowel, his heart slowed down and he had an arrhythmia called ventricular tachycardia which killed him. And he died on the toilet, which again, I take care of a lot of drug addicts and that's not how they die. They either die with a needle in their arm or they die in bed. He died on the toilet and he was taken to the hospital, and by the time he got to Baptist Hospital he'd passed on.
And it's just kind of interesting because he died at a young age. He was trying to be Elvis through his whole life and if you're Elvis Presley, that's what you've got to do. It's interesting, that's what his doctor did for him was he kept him Elvis an extra 10 years. He would have probably passed on sooner without Dr. Nicopolis's care. And Dr. Nicopolis kept his secrets.
Treating chronic pain is one of the most pro-life things we can do as physicians. And if we're being pro-life, we're doing the right thing, we're restoring people to their lives. So I just thought it was interesting to share with you the story of Elvis and his doctor. Like I said, Dr. Nick has told me that Elvis was his best friend and his worst patient. He was hard to deal with because he kept wanting to be Elvis Presley. But in his case, that was legitimate. And because of Dr. Nick's care, Elvis probably lived 10 years longer than he would have, despite a really terrible genetic illness.
One of the interesting features of that was, that's one of the secrets that never came out because Elvis was humiliated by his illness, which is really unfortunate. And your doctors are the ones who will keep your secrets when you pass on and everybody else is talking about you.