It was 4 P.M., and Andrew
I met Andrew the next day in the emergency room, where he told me about the previous day's act of desperation. I admitted him to control his swelling legs and joint pain. He was also detoxing from opioids.
Andrew looked older than his 69 years. His face was wrinkled with exhaustion. A frayed, tangled mop of grizzled hair fell to his shoulders. Andrew had been a satellite network engineer, first for the military, more recently for a major telecommunications company. An articulate, soft-spoken fellow, he summed up his (rather impressive) career modestly: “Well, I'd just find where a problem was and then find a way to fix it.”
Yet there was one problem he couldn't fix. “Doctor, I'm always in the most terrible pain,” he said, with closed eyes. “I had no other options. I started using heroin, bought it from my neighbor to help with the pain. I'm scared stiff.”
For two decades Andrew had suffered serial joint failures from a combination of arthritis, obesity and other factors. Each began as an achy pain and ended in a joint replacement. His right shoulder was the first to go, followed by both hips, a knee and an ankle. Pain always ensued. The new joints kept getting infected: more surgery, more pain. To make things worse, a bathtub mishap broke his right femur. That led to an operation to insert a full-length titanium rod. A perfect storm of complications had left Andrew barely able to hobble around the small apartment he shared with his adult son. (Andrew's wife had left him shortly after he broke his femur, and his son took him in.) Pain became Andrew's all-consuming nemesis, devouring most of his waking hours.
Andrew was first prescribed an opioid after one of his many surgeries. This was in the late 1990s, around the time when prescriptions for these painkillers began to take off nationally. His doctor began him on Vicodin, a commonly used opioid that combines hydrocodone with acetaminophen (Tylenol).
Pain, like vision, touch or taste, is a sensory signal. The brain has an elaborate network of receptors, neurons and centers dedicated to pain. Opioids exert their effects by binding to mu-opioid receptors, which are densely concentrated in brain regions that regulate pain perception and reward. Activating mu receptors blocks pain signals in the spinal cord and the response to this signal in the brain. Mu receptors also cause the release of dopamine in reward pathways, which is why opioids cause both analgesia and euphoria.
Surgery after surgery, opioids became Andrew's vitamins, as vital to his pain control as blood pressure drugs are for hypertension. Yet in 2005 Andrew noticed he was feeling anxious about his pill supply. “You start out with a bottle of 30 pills, then there's only 20, then only 10. It's scary when you run out.”
Months after his surgeries, after his scars were healed, he still struggled with deep, biting pain. It had spread throughout his body and required more pills to tame. Andrew had transitioned from what is called acute pain (pain from his surgical wounds) to chronic pain (pain in the absence of an obvious cause). He had also developed a tolerance to the opioids. On a cellular level, this means that his neurons expressed fewer mu receptors, so he needed to flood his system with higher doses to get the same effect as before. (Andrew, ever the engineer, appreciated the irony of wrangling yet another network, this time with drugs.)
Possibly, the opioids had contributed to Andrew's spreading pain. Some patients on these drugs have been known to develop increased pain sensitivity known as opioid-induced hyperalgesia.
From Prescription Meds to Street Drugs
As his tolerance for opioids grew, Andrew found that even 15 milligrams of oxycodone no longer worked for him. After he relocated to his son's apartment, he no longer had a primary care provider familiar with his history and could not refill his medications.
With nowhere to turn, Andrew mentioned his situation to his neighbor, who sold him diverted opioids—prescription medications hawked on the street. When these ran out, his neighbor sold him heroin. Andrew's dependence on heroin terrified him, and at $100 a day, it threatened to bankrupt him as well.
This trajectory is by no means unusual, according to Andrew's lead doctor, William Becker, an addiction medicine specialist and assistant professor at the Yale School of Medicine: “Chronic pain is the new initiation to heroin. We're finding that it's older and older patients, who start on the path to chronic pain, then on to opioids, then on to heroin.” Andrew's case is a “classic example,” he said. “The numbers are controversial, but as tens of millions of people taking opioids for pain age, we think 10 percent and maybe more will develop at least a mild opioid use disorder. And their pain isn't going away. We have to become more fluent in managing the co-occurrence of chronic pain and addiction.”
His words and recent warnings from U.S. surgeon general Vivek H. Murthy about the “urgent health crisis” caused by our lax approach to opioids now come to mind every time I consider writing a prescription for one of these painkillers. I also think of Andrew standing at his kitchen counter, hands trembling as he forms a line of heroin.
Relief and Release
Luckily for Andrew, Becker runs the Opioid Reassessment Clinic, which is pioneering strategies to taper patients with chronic pain from high-dose opioid use to Suboxone, a clever sublingual tablet that combines buprenorphine and naloxone. Buprenorphine activates the mu-opioid receptor. When taken under the tongue, it provides pain relief and prevents withdrawal. Naloxone is added as a safeguard to keep abusers from injecting the drug. When taken sublingually, naloxone has no effect. When injected, it blocks the mu receptor and causes acute withdrawal, a physiological inducement to use Suboxone in the prescribed manner.
At a dollar a day, Suboxone is affordable. In combination with intensive psychosocial therapy, it is a safe and highly efficacious treatment for opioid use disorders. And, as Andrew attested, it actually controls pain better than heroin. Instead of being strung out on heroin, Suboxone allowed Andrew to meaningfully interact with our medical team. He undertook a program of proved therapies for chronic pain that included physical therapy, mindfulness training and psychosocial therapy. Andrew left the hospital after nearly three weeks with a clear plan: weekly check-ins at Becker's Suboxone clinic and continued physical and psychosocial therapy tailored for pain. The last time I saw him in his hospital room, he was excited at the prospects: “The plan is to continue with Suboxone and to stay with it. And hopefully I won't have any more surgeries. It's been a rough decade, a long haul, but I'm making slow progress.”
Andrew will be managing pain and addiction for the rest of his life, but now he has a variety of tools for doing so that are safe, legal and effective.