Nation & World

Opioid crackdown's unintended consequences

Pain patients try desperate means to get medication

Kenyon Stewart returns home after running errands in Colville, Wash. MUST CREDIT: Washington Post photo by Bonnie Jo Mount
Kenyon Stewart returns home after running errands in Colville, Wash. MUST CREDIT: Washington Post photo by Bonnie Jo Mount
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 COLVILLE, Wash. — The morning of the long drive, a drive he took every month now, Kenyon Stewart rose from the living room recliner and winced in pain.

He looked outside, at the valley stretching below his trailer, and again wondered whether it was getting time to end it. He believed living was a choice, and this was how he considered making his: a trip to the gun store. A purchase of a Glock 9mm. An answer to a problem that didn’t seem to have one.

Stewart is 49. He has long silver hair and an eighth-grade education. For the past four years, he has taken large amounts of prescription opioids, ever since a surgery to replace his left hip, ruined by decades of trucking, left him with nerve damage. In the time since, his life buckled. First he lost his job. Then his house, forcing a move across the state to this trailer park.

Then began a monthly drive of 367 miles, back to his old pain clinic, for an opioid prescription that no doctor nearby would write.

“It’s 10 after,” reminded Tyra Mauch, his partner of 27 years, watching him limp over to her.

 

“Got to go,” he said.

He hugged her for a long moment, outside the bathroom with the missing door. He knew what awaited him on the other side of the drive.

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Another impossibly difficult conversation with his provider, who, scared by the rising number of opioid prescribers facing prosecution, would soon close the pain clinic. Another cut in his dosage in preparation. More thoughts of the Glock.

The story of prescription opioids in America today is not only one of addiction, overdoses and the crimes they have wrought, but also the story of pain patients like Kenyon Stewart and their increasingly desperate struggles to secure the medication.

After decades of explosive growth, the annual volume of prescription opioids shrank 29 percent between 2011 and 2017, even as the number of overdose deaths has climbed ever higher, according to the IQVIA Institute for Human Data Science, which collects data for federal agencies.

The drop in prescriptions has been greater still for patients receiving high doses, most of whom have chronic pain.

The correction has been so rapid, and so excruciating for some patients, that a growing number of doctors, health experts and patient advocates are expressing alarm that the race to end one crisis may be inadvertently creating another.

“I am seeing many people who are being harmed by these sometimes draconian actions amid this headstrong rush into finding a simple solution to this incredibly complicated problem,” said Sean Mackey, the chief of Stanford University’s Division of Pain Medicine. “I do worry about the unintended consequences.”

Chronic pain patients, such as Stewart, are driving extraordinary distances to find or continue seeing doctors. They are flying across the country to fill prescriptions. Some have turned to unregulated alternatives such as kratom, which the Drug Enforcement Administration warns could cause dependence and psychotic symptoms.

And yet others are threatening suicide on social media, and have even followed through, as doctors taper pain medication in a massive undertaking that Stefan Kertesz, a professor at the University of Alabama at Birmingham who studies addiction and opioids, described as “having no precedent in the history of medicine.”

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The trend accelerated last year, in part as a result of guidelines the Centers for Disease Control and Prevention published in 2016. Noting that long-term opioid use among patients with chronic pain increased the likelihood of addiction and overdose, and had uncertain benefits, the CDC discouraged doses higher than the equivalent of 90 milligrams of morphine.

The guidelines, criticized as neither accounting for the differences in how quickly patients metabolize opioids nor addressing clearly enough what to do about patients who were receiving more than 90 morphine milligrams, helped open a new era of regulation.

Dozens of states, Medicare and large pharmacy chains such as CVS have since announced or imposed restrictions on opioid prescriptions. The Justice Department, in a continuing push to crack down on pill mills and reckless doctors, announced in January it would focus on providers writing “unusual or disproportionate” prescriptions. And some physicians, fearful of the financial and legal peril in prescribing opioids, and newly aware of their hazards, have stopped prescribing them.

“We have to be careful of using a blunt instrument where a fine scalpel is needed,” said former surgeon general Vivek Murthy, who prioritized the opioid crisis during his tenure, and wants to increase access to alternative treatments. “We already experienced a pendulum swing in one direction, and if we swing the pendulum in the other direction, we will hurt people.”

Stewart, who said he hurts more every day, let go of Tyra. “See you Friday night,” he whispered to her. “Like always.”

He went outside to his truck. He checked for the third time that his near-empty pain medication bottles were in his duffle bag. Zipping the bag, he sighed. What he had left — five pills — would never last until his next refill, two days from now. The pain, the withdrawal: All of it was only hours away. It would hit during the drive.

How much longer could he keep doing this? How much longer could he afford to blow $900 a month — on gas, food, two nights in a motel, and pills for which he had no insurance? How much longer could he drive so many miles for less and less?

He has once been a self-employed trucker with braided hair and so much energy it sometimes irritated those around him. Medical supplies, beef jerky, electronics — he’d load anything he could into his Roadrunner freightliner, then unload it across town. He lived in a big house in a Tacoma suburb and spent whatever came in, never considering that his hip would be shot from the heavy lifting by age 45, and that the surgery to replace it would go so wrong that he’d awaken screaming.

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The first thing had been the pain. After the surgery, he said, it had felt like a knife dragging down his leg from his hip. He initially wanted revenge, so he said he called malpractice lawyers, but was told his damage wasn’t severe enough to successfully sue. Then he just wanted the agony to go away, but it was 2014, and reports of an opioid epidemic were all over the news.

Stewart quickly noticed suspicion not just among doctors but among friends and relatives, too. Did he really hurt that badly? Had he tried exercise? What about Advil? Maybe he just needed more rest.

The first person who truly listened to him, besides his mother and Tyra, was Aileen Wedvik, a nurse practitioner in a small clinic near his house. “My savior,” he called her.

She believed in treating patients according to the pain they said they felt, and he told her he felt a lot of it. She asked him to consider using marijuana and recommended physical therapy. But when the marijuana failed and the copays from therapy became too expensive, she wrote prescriptions. She started him on a daily dose of 30mg oxycodone and 12mg Dilaudid, equal to 93 morphine milligrams, then inched him up so he could function.

But years later, after that first prescription, he was swallowing 584 morphine milligrams per day — more than six times the CDC recommended ceiling. But he was still driving his truck, still making money.

Stewart had been making this monthly drive since last June, starting weeks after he said a medical examiner noted his extraordinary opioid use and declined to renew his commercial driver’s license.

He remembered the lost look on Tyra’s face when he said they needed to sell the house, that they’d never make the final $33,000 in payments. They talked about getting off the pills, but what about the pain? So they sold the house for $290,000, immediately losing one-third of that — to closing costs, the bank and their move to the trailer, where a relative lets them live for free.

 

When Wedvik, at the clinic Stewart was heading to, first told him and others that she was leaving pain management, they had seemed to understand. Providers had gone to prison, lost their licenses, faced lawsuits.

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She already had received two complaints of excessive prescribing, both from insurance providers. The state had substantiated neither, but she couldn’t deal with the stress of it anymore, so come June, she’d explained, she’d write the patients three final prescriptions, and then they would be on their own.

It was months later now, and the effects of the taper had set in, and not a single patient had found another doctor to take over their opioid regimens, Wedvik said, and they no longer seemed to understand.

Stewart’s prescription already had been cut by 276 morphine milligrams, and others were struggling to walk, including one woman hobbling into her office, shoulders hunched.

It is true that opioids cause physical dependence, and that higher doses are needed to achieve the same effect as tolerance grows, and that, when the dose falls, withdrawal symptoms may include pain difficult to differentiate from the underlying condition.

But not everyone develops addiction, which Nora Volkow, director of the National Institute on Drug Abuse, described as a brain disease that weakens self-control, incites intense cravings beyond physical dependence and occurs “only in a small percentage of people.”

Wedvik worried about the consequences of taking them away, too. Telling her staff that she was closing the pain clinic, she had said, “I will be shocked if we make it through this without anyone dying.” She knew chronic-pain patients were a particularly vulnerable group.

Scientists have shown they’re twice as likely to commit suicide, and what little research has been done on forcibly tapering opioid regimens has been troubling. One study, published last year in the journal General Hospital Psychiatry, tracked 509 military veterans involuntarily taken off opioids. It reported that 12 percent had suicidal ideation or violent suicidal behavior, nearly three times the rate of veterans at large.

She also knew about the hysteria in online chronic-pain forums. People were threatening to kill themselves because they couldn’t get medication. News articles about pain patients who had done it were being passed around on the internet.

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Then there were patients such as Kenyon Stewart. His appointment with Wedvik was at 1:20 p.m., but he came in half an hour early.

He sat down and stretched out his bad leg. Holding his glasses, he leaned forward.

Wedvik folded her hands and leaned forward herself, her face just a few feet from his.

“Do you remember what I was getting a long time ago?” he said of his prescription before the taper. “Is there any way you can do that one more time? Then cancel me off the program?”

He told her he couldn’t do this anymore. The drive. The money. The anxiety. He’d like his final prescriptions, and have that be that.

She looked at him for a long time. She’d known him for four years, longer than most of her patients. She’d been with him through it all: the pain, the failed attempts at other treatments, his unemployment and his move across the state. She’d never seen him so broken. Doing what he asked, however, would go against her patient plan. Six months of aggressive tapering, with office visits ending June. Then three final months of prescriptions.

What was the humane thing to do? Cut him loose? Or force him to drive back to see her again? She sighed and said, “Oh, God.”

 

She turned to her computer. The sound of keys clacking filled the room.

Stewart was breathing louder and louder. His face was getting red. He was sniffling. Then he suddenly he stood, opened the door and hurried into the bathroom across the hall.

Looking down at her scuffed and worn desk, she listened to the sobs and heaves coming from the bathroom.

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“Twenty percent per month,” she told him when he returned, explaining how to taper himself. She handed him three monthly prescriptions of his opioid regimen at its height of 584 morphine milligrams, which could be filled only one at a time, hoping it would last long enough for him to taper himself off high-dose opioids. “Five percent per week. Just be careful.”

He tried to say something but couldn’t.

“You’re not thinking of doing anything, are you?” she asked.

He shook his head.

“Promise?” she said.

He did. Then he picked up what they both believed would be the last prescriptions for opioids he’d ever receive.

IOWA ANGLE

  • Iowa saw 146 opioid-related deaths in 2016, according to the Iowa Department of Public Health, but no clear answer on how many of those related to prescription pills.
  • According to the National Institute on Drug Abuse, Iowa health care providers wrote 2.3 million opioid pain reliever prescriptions in 2013, or about 73.8 prescriptions per 100 people.
  • However, the number of these prescriptions in the state has declined leading up to 2015, which saw 2.1 million opioid prescriptions, or 68 per 100 people.
  • In Iowa, lawmakers enhanced the prescription monitoring program in an effort to curb the number of prescription opioids available in the state. A law recently signed by Gov. Kim Reynolds not only requires prescribers — like doctors, dentists, veterinarians — to register for the program, but they also must check the program before writing an opioid prescription to determine if the patient may be doctor shopping.

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