Opioids present a unique medical problem, Lewis Nelson told me last week. “Nobody is for diabetes or cancer,” continued Nelson, the director of medical toxicology at Rutgers New Jersey Medical School, but with opioids, “there are parties on both sides, pulling in opposite directions.” He’s referring to the fact that the chronic pain patients want easy access to opioids, while those combating addiction want limited access. “It’s pain versus addiction, and they’re both real problems.”
The perspective of pain patients was spotlighted this week, as the Washington Post carried a feature story focusing on the plight of what have become known as pain refugees. The story takes aim at the CDC’s 2016 Guidelines, and though that target seems misguided—they don’t require any of the misery we see depicted—the culpable parties are harder to pinpoint. We’ll take a closer look.
Other key stories this week include the DEA’s inexplicable raids on the offices of two of the nation’s most highly credentialed addiction medicine specialists; a JAMA study showing that, in 2016, 20 percent of deaths among young Americans were from opioid overdose; and an in-depth look at private insurer’s failure to pay for medication-assisted treatment.
The Post story, called Unintended Consequences, tells the story of a trucker in Washington State named Kenyon Stewart. Stewart, 49, is weighing buying a Glock 9 mm pistol in order to kill himself.
About four years ago, he had hip replacement surgery that left excruciating nerve damage in his leg. After unsatisfactory results with other pain treatments, he is prescribed opioids. A nurse practitioner, whom Stewart calls his “savior,” puts him on oxycodone and Dilaudid. Those finally help, but only at levels equivalent to 173 milligrams of morphine (173 MME), or nearly twice the 90 MME level that the 2016 CDC Guidelines now urge great caution in exceeding. (Though the article doesn’t say it, the guidelines were motivated by evidence that high-dose opioid therapy can lead to accidental overdose death, addiction, depression, cognitive decline, hormone imbalance, cardiac problems, breathing problems, and, indeed, increased pain—known as hyperalgesia.)
The relief doesn’t last long, though, as Stewart grows tolerant to the opioids. So the nurse keeps ratcheting up the dose, all the way to 584 MME—more than six times the CDC’s line-in-the-sand. A “medical examiner” finds out how much Stewart is taking, the article says, and cancels Stewart’s commercial driver’s license, depriving him of his job and insurance.
By then Stewart has moved 367 miles away from the pain clinic, but he keeps driving back because, also by then, no other provider will prescribe him doses at those levels. Then the nurse decides to shutter her practice because she’s “afraid of going to prison for exceeding the CDC guidelines,” the story tells us. (That’s not literally possible.) In addition, two insurers have filed complaints against the nurse with a state authority, the article says, and though there’s been no finding against her, the nurse can’t take the stress.
So she’s begun tapering down the doses she’s giving to Stewart and to 325 other patients. She cuts Stewart’s dose by about 5 percent per week and, so far as the story indicates, she does so without prescribing any substitute treatment or therapy. She tells Stewart she’ll give him his three final prescriptions, and then wish him the best.
The reporter accompanies Stewart on his last journey to the clinic, during which Stewart stops to buy some beer because, in combination with the opioids, it helps him kill the pain. Stewart keeps thinking about the Glock.
I asked Anna Lembke, a Stanford addiction psychiatrist and a member of the board of Physicians for Responsible Opioid Prescribing, how she reacted to this article. (We recently published an interview with Lembke, in which she advocates that most high-dose patients should be tapered down—involuntarily, if necessary—while being given alternative pain treatment and therapy.)
“First I’m distressed by the way the author, in highly dramatized language, created an inevitability between continuing to get opioids, or suicide,” says Lembke. “The article should have included a description of the many chronic pain patients who have successfully tapered off of opioids and are not merely doing okay, but are in fact doing much better than when they were on opioids.
“Second, the man in the story appears to meet criteria for opioid addiction. … He should be directed to an opioid addiction treatment clinic, where he could continue to receive opioids in the form of methadone maintenance or buprenorphine, not to mention psychosocial interventions.
“Third, the nurse practitioner who was willing to be so liberal with opioids for so long, but is now essentially abandoning these patients, represents the all or nothing kind of care that we need to fight against. … She should help him get a methadone or buprenorphine clinic. She should get her buprenorphine license and prescribe for him. Or she should taper him down more slowly.”
Before we leave this topic, a Vermont paper this week covered a talk by Stefan Kertesz, MD, a leading advocate of the view conveyed by the Post article—that we are pushing chronic pain patients toward suicide by making it too hard for them to get opioids. Kertesz is quoted there saying that “forced opioid reductions … violate ethical and evidentiary norms of medical practice.” In an email I asked Kertesz if he meant that all tapers against the patient’s preferences—which Lembke, for instance, has advocated—are unethical. He responded: “There is room for serious debate among well intentioned individuals, including experts who are able to conduct tapers that work out well for a good number of patients.” He also referred me to a TEDx talk he gave in which he recounts an involuntary taper that he himself conducted on a patient—with positive results.
For six years Blue Cross Blue Shield of Illinois had no problem paying for a woman’s Vicodin prescriptions, according to Vox’s German Lopez. But now it won’t pay for the buprenorphine she’s been prescribed to treat her Vicodin addiction. (It will run her close to $2900 a year, even with discounts.) Harvard Medical School health economist Richard Frank (who is on Opioid Watch’s advisory board) tells Lopez that such a situation may violate federal parity laws. BCBS-Illinois tells Lopez that it “takes the opioid epidemic — and our role in addressing it — seriously,” but can’t comment on the individual’s case.
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