I recently read the book “Dreamland” by Sam Quinones, an investigative reporter who tracked the roots of the opioid crisis in America. I was interested in the subject because I have unfortunately seen several of my clients develop devastating addictions due to pain caused by work injuries. The title of the book comes from the town of Portsmouth, Ohio, where residents flocked to a huge swimming pool named Dreamland, which served as the communal center of the once-vibrant town. The idyllic pool closed when industry left the town, but another type of dreamland took its place — in the form of a “pill mill.” The author researched the evolving attitudes of the medical community, which struggled to balance the need to alleviate patient pain against the risk of addiction.
Before the advent of prescription painkillers, patients often suffered horribly without medication, even post-surgery, due to the fear of addiction. In the 1980s, Dr. Hershel Jick studied hospital records to determine the percentage of hospital patients treated with narcotics who became dependent on the drugs. He advised the New England Journal of Medicine of his findings in a one-paragraph letter to the editor, writing that “despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.” For decades, this simple letter has been twisted, misquoted, and misrepresented by the pharmaceutical industry to persuade the medical community that their fear of narcotics was overblown. Purdue Pharma, the manufacturer of OxyContin, began to use the letter in their marketing plan to convince doctors that it was safe to prescribe such narcotics to people suffering from chronic pain on a long-term basis.
Physicians were lectured that it was cruel to turn away those who suffered from chronic pain when they could be treated with “non-addictive” miracle painkillers, such as OxyContin. The theory peddled by the pharmaceutical industry was that the patient’s pain would “soak up” the euphoric effects of the drug, reducing the likelihood of addiction. In his book, Quinones details the cycle of how patients with relatively minor injuries could become hooked on opioids after a short period of time. These patients found out the hard way that terrible withdrawal symptoms occurred when the medication was stopped. Pain clinics started popping up all over the Midwest to meet the growing demand, and an underground economy was born. To feed their addiction, patients often visited multiple clinics to stock up on opioids and sold the extra pills to support their habit.
Some patients, unable to get their prescriptions refilled and desperate to relieve the withdrawal symptoms, learned of a cheaper alternative which would provide them with a similar high: heroin. The illegal drug known as “black tar heroin” made its way into the heartland of America from Mexico around the same time that our country experienced a proliferation of pain clinics. In his book, Quinones explains how traffickers of black tar heroin soon found a new group of customers in chronic pain patients. This poison was marketed as the “Happy Meal of dope” — fast, cheap, and convenient. Dealers hung around pain clinics and offered special discounts for firsttime users, leaving their customers with phone numbers to call anytime they needed a refill.
I have unfortunately watched several of my own workers’ compensation clients go down this distructive path. Physicians must no doubt perform a difficult balancing act — to alleviate pain while avoiding addiction to medication. Sometimes the bureaucratic red tape of the workers’ compensation system makes this balancing act even more challenging. Some insurance carriers try to avoid surgery at all costs, at times unwittingly leading doctors to prescribe narcotics for patient pain instead of surgically addressing injuries that cannot be cured with conservative measures. It is not uncommon for a patient to wait months for surgery while attorneys are litigating the issue of whether a procedure is necessary and related to a work injury. During that time, patients are often sustained by pain medication. Of course, after surgery, the pain medication continues to address the acute pain caused by the surgical procedure. In short, the delays experienced by workers’ compensation claimants often result in unnecessarily extending the amount of time a patient is on narcotic medication, increasing the risk of addiction.
On the flip side, most carriers will not authorize alternative medical treatments, such as chiropractic care and acupuncture, which could at least temporarily ease the pain of a traumatic injury while the body is healed over time. How many injured workers could have avoided surgery and opioids altogether if such alternative treatments were available?
For example, one of my clients, whom I will call John, injured his lower back at work. He dutifully followed the recommendations of the workers’ compensation physician, who performed a lumbar fusion. The fusion failed, leading to several additional surgeries. It was obvious that John was addicted to pain medications and should have been referred to a detoxification program. He was not. Instead, his pain medication was abruptly deauthorized, which drove John to feed his addiction with illegal drugs. While his case was pending, he was found dead of an overdose on Christmas morning.
The case of another client who developed an addiction to prescription drugs thankfully ended on a more hopeful note. Bill suffered multiple injuries after he fell off of a roof at work. His case was settled with the understanding that he could return to active medical treatment through workers’ compensation upon request. He called the insurance carrier to request a return visit to the workers’ compensation physician since he was suffering from increased pain. His call was ignored. Unfortunately, he did not call my office. Instead, he scheduled an appointment with an unscrupulous doctor who began prescribing high doses of narcotics rather than investigating the source of his pain. Bill eventually lost his job. It was his wife who wrote to me pleading for help, tearfully explaining that she no longer recognized her husband. We fought with the workers’ compensation carrier to get Bill admitted to a rehabilitation hospital. After multiple motions, he was eventually assigned to a doctor who helped him overcome his addiction and reunite with his family. When his reopened case was finally resolved, I was thrilled to see him appear in Court with his wife and daughter, looking like a new man. He was back to work with a stable job and vowed never to return to drug use. Unfortunately, many people who have fallen into the trap of prescription drug abuse wear out the patience of families who love them, doctors who try to treat them, and lawyers who attempt to assist them. Once they enter the underworld of addiction, many can only find their way out with the help of a higher power.
How, then, do seriously injured patients with chronic pain lead normal lives without developing an addiction? Many states, including New Jersey, have significantly cracked down on physicians who overprescribe narcotic medications — perhaps going too far and preventing patients with agonizing pain from obtaining short-term pain relief. In my view, the opioid epidemic will not disappear just because the pendulum swings back to the era in which pain relief was reserved for terminal illnesses. Acute pain can and should be treated immediately. But we cannot forget that pain is also the body’s way of communicating with us about an injury, so masking pain with the fog of narcotics is not always the best course of action.
Perhaps insurance carriers should start considering authorizing treatment plans with an eye toward longer-term solutions. For example, back pain sufferers may benefit from a medically supervised weight loss program. Alternative medicine, such as acupuncture and chiropractic care, should also be offered to patients who would prefer to avoid surgery and its accompanying risks. At the same time, no amount of conservative care will fix certain injuries that require surgery without delay. The insurance industry, physicians, and patients should take a more holistic approach to medicine in order to encourage long-term health and avoid the use of narcotics for chronic pain.
Ask your doctor to discuss alternatives to narcotic pain medication, which should be used sparingly. Become an advocate for yourself, get those recommendations in writing, and call us if you need help getting insurance coverage.
Please also talk with a professional if you feel like you have become dependent upon medication. Call New Jersey’s addiction helpline at 1-844-ReachNJ (1-844-732-2465) to connect yourself or a loved one with organizations that provide substance abuse and support services to those struggling with addiction. There is help available, but you have to want it. Ultimately, we are all responsible for our own health and happiness.