Throwing Pills at the Problem
“I just don’t want to be in pain.”
Stephanie grew up with childhood rheumatoid arthritis. This isn’t your dad’s sore knuckles from years of heavy work, but an autoimmune disorder that attacks the joints most commonly. It can lead to physical deformities and bone loss brought on by constant inflammation and destruction of surrounding cartilage. She’s used to persistent discomfort in her knee and toes, a grinding sort of ache that’s ever present. Despite the perpetual throb, Stephanie made it through high school using over the counter medication to manage her pain – even if all the Motrin she downed to take the edge off did give her a terrible ulcer.
In 2010, something changed about her pain. Suddenly it was everywhere, not just in her leg, but all through her body. “I know my arthritis,” she said, “and this wasn’t it.” Rushed to the emergency room, Stephanie didn’t receive the attention she was expecting. Oh, a doctor glanced at her medical history, but didn’t touch or remotely examine her. Instead, the ER doc wrote her a prescription for 100 pills of Vicodin, a powerful painkiller containing an opioid derived from codeine. That prescription had 10 refills on it. When Stephanie balked at the prospect of taking that much medication, the doctor brushed her concerns aside.
Pill design and color is purposeful. Attractive medications are easier to take because they appear like candy, a harmless bit of chocolate, when the truth is far from it. Photo Credit: Flickr
“He [the doctor] said you’re going to be doing it for the rest of your life, so you might as well start doing it now.” And that was all the push needed to toss her down the opioid rabbit hole. Twice per day doses of Vicodin immediately led to four, and quickly progressed to as many as 12 every 24 hours. The pain never left, if anything, it got progressively worse. Doctors tried an array of narcotics and opioids, always throwing pills at the problem, skirting around a diagnosis that might explain where the real issue lay.
That’s only the beginning of a story that gets so much worse.
Pain: How We Got in this Mess
Her tale is just one amongst the thousands caught in the swirling melee of wanton prescriptions and suspect medical studies that was the War on Pain – a catch phrase for a national turn in medicine to dole out painkillers as if they were completely safe and posed no risk of addiction to patients. Who in their right minds would believe medications in the same drug category as heroin would not turn patients into ravenous drug addicts with ever-increasing dose tolerances and unexplained symptoms? As it turns out, just about everyone, including some leading researchers and medical minds.
Opioid sales are in the billions of dollars annually in the United States. Pharmaceutical companies have every interest in keeping the prescriptions flowing. Photo Credit: Flickr
One of those loud voices for prescription opioids was Dr. Russell Portenoy, a New York pain-care specialist who championed their use for treating patients with chronic pain. A couple decades ago, Dr. Portenoy was the driving force behind a national movement dubbed affectionately as the ‘War on Pain,’ a shift in the treatment philosophies of physicians regarding drugs derived from the opium poppy. Portenoy, and several colleagues, pointed to research studies claiming that patients could take these medications with no maximum dosage for long periods of time and – get this – face minimal side effects.
Doctors around the country bought in, and sales of powerful opioids like OxyContin, soared. Fast forward to 2013, and deaths from the same prescription drugs touted by Dr. Portenoy and others now kill more people than heroin and cocaine combined in the United States. The U.S. Centers for Disease Control and Prevention estimate that 40 people a day die from overdose deaths caused by opioid medications. The majority of these fatalities are not drug addicts finding their pills on the street, but patients taking the meds as directed by their doctors.
“Up until fifteen years ago there really were none or very few long-term opioid patients,” said Dr. Adam Sackstein, medical director of the Pain Management Center in New Jersey. “The reason was the only patients on long-term opioid therapy were cancer patients. Those patients, unfortunately, tended to die….There was no experience of what happens to people and to their pain after they’ve been on opioids for a year, or two, or five, or ten. Now we know…it’s not so good.”
We live in a society that believes a pill is an easy solution to almost any physical problem. Physical rehab, and the hard work that comes with it, tends to receive more patient resistance. Credit: Flickr
In the wake of tens of thousands of deaths annually, Dr. Portenoy, having a few years to reflect, recently recanted his statements and support of prescription opioids in an article in the Wall Street Journal. Where previously, studies (cited by Dr. Portenoy) stated less than 1 percent of opioid users became addicted and that overdose deaths were exceedingly rare, now they appear as bunk science with small samples sizes and leaps in logic to reach their conclusions.
For Dr. Sackstein, who sees 70 to 80 chronic pain patients a week in his practice, controlling what the War on Pain has created is a herding cats type of public health crisis. Many doctors, in his experience, have simply stopped prescribing opioids in the wake of overdose deaths, arrests, and malpractice claims due to some physicians who chose to make a living “essentially selling prescriptions.”
We’ve seen this practice in our own law firm while representing the families of patients who’ve died as the result of doctors’ wanton prescription of high-dose opioids. These drugs shut down patients’ bodies a piece at a time, all the while their physicians continued to dole out medications that they knew would lead to addiction and likely cut patients’ lives short. Going after these doctors to secure money damages for the families left behind – and reporting them to state licensing boards for revocation – is tremendously satisfying. The work helps ensure we root out doctors posing as prescription salesmen, and leave more room for those healthcare professionals who are going about their business in an ethical, patient-minded manner.
“We’ve created God knows how many thousands of iatrogenic and narcotic dependent patients who are out there in difficult situations,” said Dr. Sackstein, “because it’s increasingly difficult to find people who are willing to prescribe medications. The use [prescribing] of opioids, at least in my experience, is being reined in.”
From Patient to Drug Addict in 120 Easy Pills
After Stephanie’s primary care physician suffered terrible injuries in a bicycle accident, she had no regular doctor to see so she could continue receiving her pain meds. At first, she had little to no success. No physician was willing to prescribe painkillers in large enough quantities to suppress her pain for any length of time. At the time, Stephanie said, she was 120 pills of 10-mg Norco (Vicodin) and Methadone every 10 days. Desperate, she began to physician shop seeing as many as eight doctors on a rotating basis to get her prescriptions filled so she could at least function.
Many patients taking painkillers have legitimate illnesses. The long-term effects of rheumatoid arthritis lead to the type of disfigurement pictured in addition to constant discomfort. Photo Credit: Wikipedia
“It didn’t last very long,” she said. “Nobody [doctors] wanted to do it [prescribe] more than twice. I’m like a drug addict fighting for drugs every ten days.” Unable to make the pain subside for long, she sought outside help, including more pills. Stephanie bought Oxycontin on the side, then Tramadol – both potent opioid painkillers. The side effects of the meds led to weight gain and worsening depression, then difficulty walking. She tried pain management courses and meditation, but still ended up using a walker followed by a cane to help her mobility due to her unending pain.
The psychological symptoms those dependent on opioids for long-term pain treatment experience are no different than those suffering with alcoholism or addiction to illegal drugs. Renee Liebowitz, counselor and director of Synergy Counseling Group, sees clients with prescription drug dependency struggle with their easy availability and mixed societal messages. She said,
“As hard as it is to get through to patients and explain to them that they are an addict, it is even harder to get through to society, and the families, and the parents, and the community that this is real.”
About half of all clients Liebowitz sees in her practice suffer with some form of addiction. “I’ve definitely come across clients who’ve gone physician shopping,” she said, “and have gotten prescriptions for oxycodone from three to four different doctors and they’re able to cash in all those prescriptions.” Many, according to Renee, get hung up on the legality of prescription meds as a testament to their safety. Some use it as a crutch to prop up their addiction, and those are the ones who typically don’t stay long in therapeutic programs or seek help in a meaningful way.
In 2010, prescriptions for Vicodin rose to 130 million in the United States alone, according to Pharmaceutical Executive Magazine. Photo Credit: Flickr
“Society feels like legality has something to do with addiction,” Liebowitz said, “and they write off addiction…when something else is in charge of you, more than you are in charge of it, you’re addicted.” Apart from doctors prescribing opioids, the willingness of patients to take what in years past would be drugs reserved only for those near death, perhaps rests on the myth of ‘legality.’ Users believe the drugs to be legal, and they have prescriptions for the meds, so obviously the prescriptions are not causing anyone any harm – least of all themselves.
It’s a tough time to be a doctor, a patient, and a therapist, but who has it the worst?
Your Drug Dealer Wears a White Lab Coat
Sooner or later, doctors running “pill mills” attract the attention of the Drug Enforcement Agency (DEA) or the U.S. Department of Justice (DOJ), which brings another easily recognizable acronym into play – the FBI. Arrests have risen in proportion with the number of prescriptions written for opioids in the United States, and the climate has many doctors, including Dr. Sackstein, think twice about accepting new patients. He runs a clean practice, and works diligently to do everything right, but still he acknowledges that he can’t prevent drug seeking behavior, or truly separate those in legitimate pain from would-be patients who have fictitious symptoms.
“Do I get fooled? I get fooled,” he said. “I’m sure there are people in my practice right now who are receiving medications who are faking it.”
He works to eliminate the ‘fakers’ from his patient ranks through techniques that are now standard throughout the pain management field – regular drug screenings, urine tests, and a good relationship with emergency room doctors. It’s a completely normal occurrence for some of Dr. Sackstein’s patients to walk into the ER claiming the doc is on vacation.
With millions of dollars pumped into political lobbying groups and campaigns, ousting the influence of pharmaceutical companies is going to take a concerted effort. Photo Credit: Flickr
“The ER docs will call me and tell one of my patients is in the waiting room,” he said. “I’ll ask them where did they say I am this week? The savvier ER doctors know how to spot it.” Still, all the defensive strategies in the world don’t stop the gnawing fear that his practice, or a colleague’s, could attract the career-ending attention of a government agency.
“If you ask physicians their biggest concern about prescribing opioids is, number one, the DEA or the DOJ showing up,” he said. “Even if you turn out to be not doing the wrong things, if you end up on the front page of the local paper that you’re being investigated by the federal government for narcotics, you’re finished. Even if you win, you’re finished.”
A Better Detox: Stopping the Pill Ritual
Is there a way out of this pharmacological bramble? Are those locked in a continual pill spiral of stronger poppy-fueled doses doomed to take the drugs until one day it finally shuts their last viable organ down?
For Stephanie, today she’s actually functioning better on lower doses of pain medications, and has (in cooperation with her doctors) cut her daily regimen down to just four pills. After being on high doses for multiple years, physicians treating her noted that her pain might be, in reality, a symptom of the painkillers. The treatment for this condition, known as opioid hyperalgesia, is simple, but terrifying for a narcotic-dependent patient: wean them off slowly, but steadily. It sounds like a made-up disorder, but it’s a real thing. Patients on long-term opioids, including hydrocodone, morphine, or methadone, can develop increasing sensitivity to painful stimuli, even to the point where sensations that aren’t normally painful – like cloth touching their skin – generates excruciating agony. Stephanie is not off all the drugs yet, but remains hopeful that there’s an end in sight.
Hugh Laurie notwithstanding, opioid use is dangerous and not at all glamorous. More than 15,000 people die every year from opioid overdoses in the United States, says the CDC. Photo Credit: Flickr
“I got off the Norco and I feel this [better],” she said. “So, I’m going off the Methadone…I’ll go on to one pill a day next week, and a couple weeks later I’ll go down to none and we’ll see what happens…I’ve lost the weight so I feel good there…I think it was all the painkillers.”
Dr. Sackstein looks to the future, and better pharmaceutical solutions, to help stem the tide of rampant opioid addiction caused in part by the massive number of prescriptions written over the past two decades. “The Holy Grail is an opioid that produces pain relief, but does not create euphoria,” he said. “That drug is the drug of all drugs. That will put to shame whatever the biggest selling medication ever is because everyone will prescribe it.”