~When we hear about the opioid crisis, we think, “That has nothing to do with me.” Yet innocent people have become addicted, often through no fault of their own. Here’s a look at this uniquely American epidemic and a story of one frum woman who lived through it.
The nurse was at my door, but I couldn’t even answer. I had been crying all morning, and when the doorbell rang for the third time, I knew I had to let her in or she’d leave. Once inside, she checked my vitals, but even though I was now in the presence of another person, I couldn’t stop my tears. She then proceeded to help me do the exercises I was supposed to do daily to strengthen my knee, and though I followed her instructions, I bawled through it all.
“I’m sorry. I cry constantly, but I really can’t give you a reason for it,” I told her.
The nurse was concerned and called her supervisor, who recommended that I go to the hospital.
I didn’t want to go.
That was fine, she said; she would have people from the hospital come see me since I lived very close by.
The nurse left and returned a short while later. This time, when I answered the door, she was accompanied by a social worker with a yellow legal pad in her hand, and...a cop. I invited them in.
“Why is there a policeman with you?”
“When patients have symptoms like you have, it’s often because they are withdrawing from medication, and they become violent. We were afraid. That’s why we brought a policeman along.”
Afraid of me?
Esther’s Story
After a career as a biologist and science teacher, Esther had recently retired. She and her husband moved to Lakewood, where their three youngest children live.
“I have two degrees in biology,” she told me. “After college I worked in one of the city labs, where I tested water and air for impurities. After teaching in two colleges, I spent the rest of my career teaching in heimishe schools. Teaching was my best experience, and I didn’t want to leave.”
In May of 2015, Esther’s knee buckled under her.
“It just gave way. It was very painful to walk. I needed a full knee replacement, and the surgery was scheduled for August 13.”
The surgery was painful and Esther was given oxycodone in the hospital, which dulled the pain and helped her sleep. After her release, she went to a rehab center.
“The first night there was very difficult, so they gave me oxycodone every four hours. Just one pill. The next day, the doctor who deals with all the new patients came to meet me. I told him, ‘I still have a lot of pain, and it keeps me up at night.’ So he increased my dose of oxycodone.”
Knee-surgery patients need to use the new knee immediately. They’re put on their feet the day after surgery. In the rehab center, Esther had to learn to walk again. She had to move her leg in different positions, standing and sitting, and pedal on a bicycle. Another exercise involved putting weights on her ankles and lifting her legs.
“The further you are from surgery, the more exercises and bending you need to do, or you won’t regain flexibility. The rehab technician did all these exercises with me. He had the best intentions, but it was all so painful. No problem: I’d just take my oxycodone before going to my exercise sessions.”
At the end of ten days in the rehab center, Esther was taking two additional oxycodone pills every day in order to diminish the pain and get through the exercises.
When her pain still did not subside once she was home, Esther called her surgeon on more than one occasion. But no one ever came to the phone. Usually, after a day or two, one of the nurses or a physician’s assistant would call her back. And when Esther described how she was feeling, the PA would simply increase her dose of oxycodone.
At most, Esther’s bottle of oxycodone contained 120 pills. This was one month after surgery, when her dosage was up to four pills every six hours.
“When you take so much, you can’t eat,” she said. “You can’t sleep. You get nauseous. You have mood swings. It was at this point that I realized it was an addiction.”
Esther decided on her own to tolerate the pain and slow down the medication. The next day, she took three pills per dose, and the next day, two.
“I was dealing with a lot of pain, but it seemed I was able to tolerate it better,” she told me. “But then I experienced new symptoms. I had itching under the skin. I had hallucinations and felt like I was climbing the walls. I couldn’t sit still; I’d turn and turn. I couldn’t eat anything. One of my daughters had earned a master’s degree in family therapy and had taken classes on pharmacology. Even though I was a biologist, I didn’t know anything about medications. When I told my daughter what I was experiencing, she said, ‘Ma, you are having withdrawal symptoms.’”
Esther’s daughter called a psychiatrist she knew and left a message. Thirty minutes later, the psychiatrist called back. Esther gave her a brief rundown of her medication history over the last month, including the fact that she had been taking anti-anxiety and antidepressant medications at the time of her surgery.
“The amount of oxycodone that you were taking under the PA’s supervision is equivalent to very high doses of heroin,” the psychiatrist told Esther.
“Heroin?!”
“Yes. And to begin with, anyone taking antidepressants and other medications can’t go near codone,” she continued.
“At my age, when you go to a new doctor, you give them a list of your medications,” Esther explained. “When you go to the hospital, you give them the list again. I have them all listed on a piece of paper. This is because anything they prescribe can’t conflict with something you’re already taking.
“After I was released from the hospital, I went to the rehab center and gave them the list again, complete with the phone numbers of all the doctors and surgeons. That means that no one – not the surgeon, not his staff, not the doctor who saw me in rehab – not one of them looked at my list of medications.”
Esther’s psychiatrist was furious about her doctors’ recklessness. “She was afraid I might die because I was on such high levels of oxycodone,” Esther said.
Once someone is addicted to oxycodone, it’s a long and difficult process to overcome the addiction, and it can only be done under a doctor’s supervision. Withdrawing too fast is as dangerous as the drug itself.
“She put me back on the full four pills so that she could wean me off slowly,” Esther continued. “I took four pills for each dose for three days. Then, for a week, I took one less of the 20 daily pills. Each week she had me take one less pill.”
Rosh Hashanah came a week later. “I went to shul and came home an hour later, crying. I couldn’t sit at any of the seudas. But after two or three weeks of diminishing the dosage, I started feeling a little better. On Yom Kippur, I was able to stay in shul for the entire Mussaf. I switched from using a walker to using only a stick. I was mentally in a better place.”
After four months, Esther was down to one pill a day, then half a pill. Finally, she was done. She still had some withdrawal symptoms during this time, but they were not as intense.
“Were you in touch with your surgeon after discovering this?” I asked.
“The only time I was able to speak to him was at the one-year checkup. I told him the story, and he didn’t comment; he ignored me completely. Besides the mindless prescriptions, it also upset me that my medication list was ignored. Even my dentist knows I can’t take codone. I had oral surgery and stuck to Tylenol.”
Esther still experienced pain for a year and a half after her surgery, but she was able to manage it with Tylenol or Motrin.
“How long does it usually take to recover from knee surgery?”
“Every individual is different. A friend of ours had surgery right after Yom Tov the same year, and he was walking without help six weeks later.”
A Different Kind of Drug Abuser
Oxycodone is one of the drugs contributing to America’s current opioid crisis. When I had previously heard about this crisis, I had imagined it to be a problem happening far away, at a dark, smoky party in a college dorm room perhaps, or on an urban street corner or in an abandoned row house with boarded up windows and graffiti. And while there are non-prescription opioid abusers, and there are opioids coming illegally over the Southern border, studies have shown that 75 to 80 percent of opioid addicts begin taking the drug by prescription.
That’s what makes battling this epidemic so different from the “War on Drugs” of the 1980s. The problem doesn’t discriminate. Opioid addiction affects a much more diverse spectrum of the population than do other drugs. It’s not linked to character flaws or risky behavior. Seniors actually have double the number of opioid hospitalizations than the 15-to-24 age group (although cases of youth addiction are growing at the fastest rate).
To make matters worse, nine out of ten prescription opioid users had no idea that the pill in their medicine cabinets could become addictive. Prescription opioid addicts like Esther begin taking the medication to diminish pain.
“We as a nation have not done a good job at managing pain,” adds Dr. Benjamin Miller, chief policy officer at Well Being Trust. “In many cases, as seen with opioids, we have added a problem on top of a problem without really giving people the help they need.”
Once patients become dependent on an opioid medication, it affects them both psychologically and physiologically. They crave the drug even though they know it has negative consequences, and their bodies react strongly to the absence of the drug. Over time, the body also becomes less responsive to the drug, and a person needs higher doses to achieve the same effect.
Rats in Pain
And that’s not all. “There is another dark side to opiates that many people don’t suspect,” says Dr. Linda Watkins. “It shows that trauma, including surgery, in combination with opiates, can lead to chronic pain.” Opioids don’t only relieve acute pain. They actually prolong pain, turning postoperative acute pain into a chronic issue.
It may not be a coincidence that Esther’s neighbor recovered from a knee replacement in six weeks, while her pain persisted for 18 months.
Professor Watkins, of the Department of Psychology and Neuroscience at the University of Colorado-Boulder, has given opioids (in the form of morphine injections) to animals in her lab to quell pain after stomach surgery. She’s found that when animals take the medication for more than three weeks, their immune cells actually become more reactive to pain. The less medication each group of animals received, the quicker their pain diminished. The opioids actually caused inflammation and tissue damage.
If the same is true for people, it could have far-reaching implications for pain management.
Dr. Peter M. Grace, who co-authored Dr. Watkins’ study, doesn’t deny that opioids are effective. “For acute pain, there is nothing better,” he says. “But very little research has been done to look at what it is doing in the weeks to months after it’s withdrawn.”
A small case study with human subjects has confirmed the same results, showing that those who use opioids actually experience prolonged chronic pain as compared to those who don’t. “We think we are treating the pain with these drugs, and we may actually be prolonging it,” Dr. Watkins says. “It is a great irony.”
Drug Dealing in the Exam Room
So what’s the solution? Politicians have so far focused on stopping the flow of drugs across the US-Mexico border. Certainly that will be helpful as many addicts turn to illegal forms of opioids once they can no longer obtain a prescription. But it most likely won’t stop the majority of new cases.
Ohio, where 11 people die every day from an opioid overdose, is the national center of the epidemic, the reasons for which include over-prescribing physicians (9.5 percent of patients get a prescription, as opposed to 2.5 percent of patients in Connecticut).
Ohio doctors Glenn Waters, an oral surgeon, and Tim McConnell, an orthopedic surgeon, say that combating the epidemic starts with opioid-prescribing physicians. They compare the flow of opioids into the hands of patients to the flow of tap water into a clogged sink. The water is flowing out of the sink and onto the floor, and the only items used for cleanup are some sponges.
Two years ago, the two doctors decided that the only way to prevent the mess was to reduce the flow of the faucet, meaning reducing the prescribing of opioids. They introduced a new pain management protocol in their practices that relied on ibuprofen (Advil, Motrin), acetaminophen (Tylenol), and low doses of oxycodone only in extreme cases. By the end of 2016, they crunched the numbers and discovered that the total number of oxycodone pills prescribed in both offices combined was down 74 percent; 41,850 fewer pills than in the previous year for the same number of procedures. They won acclaim for their efforts, and the new protocol was so successful that seven Cincinnati-area ERs adopted their pain management system.
American trauma surgeon and father of seven, Dr. Corydon Siffring, remembers sitting in the back of the room at a conference and rolling his eyes as he listened to colleague Dr. Don Teater talk about treating patients with Tylenol and ibuprofen. He remembers making some rude, sarcastic comments during that lecture. “That might be fine for chronic back pain, but I’m treating people with real pain,” he told Dr. Teater.
Dr. Siffring was on the U.S. Army Reserves surgical team for 22 years, treating soldiers during three tours of Afghanistan. He also provided medical care to people living in poverty there, which prompted him to make medical outreach trips to Uganda in order to help develop and staff clinics.
During one of these trips, he saw a 16-year-old boy who had been stabbed and had undergone a seven-hour surgery, during which his spleen was removed, damage to the orbital mechanism of his eye was repaired, and six tendons in his left hand were reconnected. When Dr. Siffring walked in, the boy was hooked up to a ventilator and IV drip containing opioids to treat his pain – normal procedure. But then he saw something he had never seen in the U.S. The boy was weaned off the opioids quickly, and the medication in the IV was changed to Tylenol, with some ibuprofen added later. And the patient felt all right. Dr. Siffring couldn’t believe it. He had never before seen a postoperative trauma patient treated with Tylenol.
Dr. Siffring apologized to Dr. Teater the next time he saw him. Today he works with the National Safety Council to help change physicians’ prescribing habits, and he is working to make liquid acetaminophen readily available in post-op care.
Kick the Blame Down the Road
The opioid crisis is a North American problem; Americans alone consume 80 percent of the worldwide opioid supply. The structure of the U.S. healthcare system lends power to insurance companies, which favor cheap prescription drugs over more expensive drugs or therapies. Japanese and European insurers are much more hesitant to prescribe the drugs.
Though doctors have received much of the blame for the opioid crisis, most often their hands are tied by insurance companies that won’t pay for more expensive pain-relieving alternatives. They’ve been forced to turn patients to cheap, addictive opioids.
Twenty-eight-year-old Alisa Erkes suffers from chronic abdominal pain. It was previously managed successfully by a drug called Butrans, which had cost her insurer $342 a month. Then the insurance company stopped covering the drug. The New York Times reported that Alisa and her doctor scrambled to find a replacement, settling on low-acting morphine, which her insurer approved with no question. It only costs $29 a month. For most insurers, morphine is on the lowest tier of drugs and requires no prior permission before prescribing. For expensive drugs like Butrans and Lyrica, a non-opioid drug that treats nerve pain, patients are required to try other, cheaper drugs first and need special approval for higher-tier drugs. Erkes’ appeals to her insurance company were turned down. Since she is unable to pay for Butrans out of pocket, she’s forced to take the opioids. And she’s terrified of becoming addicted.
The Department of Health and Human Services is currently studying the role of the insurance companies in the epidemic. HHS senior policy official Christopher M. Jones stated that early findings have confirmed Erkes’ experience: Insurance companies are placing few restrictions on opioids but are keeping less addictive, non-opioid medications and non-drug options, like physical therapy, out of reach.
Leo Beletsky, a professor of law and health sciences at Northeastern University, told Pro Publica, an independent investigative organization, that the insurance system is “one of the major causes of the crisis.”
A Nation Addicted
Opioids became the pill of choice for prescribers in the 1990s, when they went from being used exclusively to treat acute cancer-related pain to being prescribed liberally for chronic pain. The number of opioid pills prescribed since that time has tripled, from 76 million in 1991 to 207 million. The rise in prescriptions is directly correlated to the rise in addiction and accidental overdoses. And after a prescription has run out, abusers can turn to the streets or to “pill mills,” where drugs are prescribed by doctors without a proper examination or medical purpose.
In October, Pennsylvania physician Andrzej Zielke was arrested for over-prescribing pain medication. He operated a cash-only business and prescribed without a medical examination. Then, in December, another Pennsylvania doctor, Dr. Raymond Kraynak, was arrested for running the state’s biggest pill mill, prescribing six million oxycodone pills over a five-year period. Five more doctors were arrested last month in the state’s crackdown. After shutting down 250 pill mills in 2015, Florida law no longer allows clinics to dispense painkillers directly, and the state has shown a significant reduction in opioid use.
The federal government is addressing the issue from all angles. [See President Trump’s statements in sidebar.] And while more sponges might help clean up the mess, unless the faucet flow is turned down and surgeons like Esther’s stop dispensing opioids like candy, the water will keep overflowing.
Reprinted with permission from Ami Magazine: www.amimagazine.org.
Side Bar:
How to Avoid an Opioid Addiction after Surgery
You’ve just come home from the hospital and there are 30 opioid pills in your prescription bottle. So you think it must be fine to use them; after all, a doctor prescribed them, right?
No. A person can become addicted even after taking a few pills.
“Nobody needs a prescription for 30 or 50 opioids, and even those who are in major pain and may benefit should only take them for a day or two,” says Dr. James Grant.
• Use sparingly: Only take a pill when you are in extreme pain. Otherwise, use ibuprofen (Advil, Motrin), acetaminophen (Tylenol), or naproxen (Aleve). These drugs come in prescription strength, and they’re much less addictive.
• If you do need a prescription, tell your doctor to limit the number of pills in the bottle to five. Take them for only one, two, or maximum three days after surgery (some recommend up to seven). Never exceed your doctor’s instructions. You’ll feel better soon without the pills.
• Understand that using pills for just a few weeks can lead to dependence and withdrawal symptoms, and may even prolong the pain.
• In the days after surgery, don’t wait until your pain is unbearable to take the pills. This may cause you to take more than you need, prompting you to want them even more.
• Those in continued severe pain should talk to an anesthesiologist about other pain-management options. There are often therapies or other drugs that aren’t readily dispensed. If you can afford the more expensive drugs, it’s worthwhile to pay out of pocket rather than resort to continued opioid use.
• Have extra pills? Throw out the bottle!
Side Bar 2:
President Donald Trump on the Opioid Crisis
• Every day, 116 Americans die from an opioid-related overdose.
• On our most recent National Prescription Drug Take-Back Day, people across the country turned in more than 900,000 pounds of unused or expired prescription drugs – more than the weight of three Boeing 757s.
• Last year, the Department of Justice prosecuted more than 3,000 defendants in cases involving opioids, all of the trafficking, and the related crimes – 3,000 cases – including a pharmacist, a physician’s assistant, and an opioid trafficker, each charged with committing serious drug crimes in New Hampshire.
• First, we’re taking action to reduce drug demand by preventing Americans from becoming addicted in the first place. That includes increasing federal funding for the development of non-addictive painkillers. And we have to come up with a painkiller that’s not so addictive. And we can do it. We’re not that far off. These things are incredibly addictive. So we’re going to find that answer also.
• We’re also taking action to prevent addiction by addressing the problem of over-prescribing. And our Department of Justice is looking very seriously into bringing major litigation against some of these drug companies. We’ll bring it at a federal level. Some states are already bringing it, but we’re thinking about bringing it at a very high federal level. And we’ll do a job.
• Drug traffickers kill so many thousands of our citizens every year. And that’s why my Department of Justice will be seeking so many much tougher penalties than we’ve ever had, and we will be focusing on the penalty that I talked about previously for the big pushers, the ones that are really killing so many people. And that penalty is going to be the death penalty.
• The third part of our initiative is to get lifesaving help to those who need it. We’re going to make sure our first responders have access to lifesaving overdose-reversing drugs
