In the midst of an opioid epidemic, doctors are caught in a
fierce debate over whether to stop medications for patients
with chronic pain. Here’s what happened to one man when his
painkillers were taken away.
Posted on November 30, 2017, 15:47 GMT
After the six-hour drive to the Lake Erie beach, Paul
stood in the water and began walking into the waves.
The 53-year-old had been in intense pain for seven years,
ever since a failed hernia surgery. That morning it had been
so bad he couldn’t put on his underwear, only shorts and a
A passerby on the beach asked him if he was okay. And he
remembered he hadn’t said goodbye to his wife.
So he went home to tell her that he didn’t want to live
Paul is one of some 2 to 6 million chronic pain patients in
the United States who are prescribed extremely high doses of
opioid painkillers like Vicodin, Percocet, and OxyContin. In
the midst of a growing opioid epidemic, medical authorities
say that’s far too many.
Last year, the CDC issued
sweeping new guidelines encouraging doctors to stop using
opioids for chronic pain. Now the FDA is weighing a
petition asking the agency to outlaw “ultra–high” dose
pills such as OxyContin 80 milligrams. The experts behind
these changes argue that the benefits of these medications
for chronic pain are
unclear, and the risks of overdose very real: These
painkillers, whether bought legally or on the black market,
more than 14,000 fatal overdoses last year.
But people like Paul, and a vocal minority of doctors,
reject the idea that prescription opioids are driving
the wider crisis, and say the new policies are doing
more harm than good. “Those CDC guidelines ignited a
wildfire,” geriatric medicine specialist Thomas Kline of
Raleigh, North Carolina, told BuzzFeed News.
Kline says it’s not chronic pain patients who are
dying of pill overdoses, but rather “a group of heroin
addicts” who take the
pills illicitly to get high. Specialists in this camp argue
that, although high-dose painkillers are linked to overdoses,
no studies have yet shown that tapering medications reduces
that risk. They also suggest that the lack of evidence for
the pills’ effectiveness just means that no one has done a
study to show something obvious — that painkillers dull pain.
The guidelines have had swift impact: Some doctors are
abruptly ending prescriptions even when patients have been
stable on high doses for years, throwing them into withdrawal
— a soul-rending mix of nausea, agony, depression, and
sometimes worse. Kline maintains
a list of chronic pain patient suicides — now up to 23
names — that he attributes to having prescriptions cut off.
As opioid overdoses have officially become a
public health emergency, the chronic pain debate has
turned nasty, complete with insults and insinuations. Kline
calls one well-known proponent of the new guidelines, Andrew
Kolodny of Brandeis University, “kind of a comic book demon.”
In October, a group of pain patients and doctors
tried to have Kolodny fired,
inaccurately claiming he wanted to force unwilling
patients off opioid prescriptions. Some patients
post inaccurate allegations that he has lost a child to
an overdose or is profiting off rehabilitation centers.
Kolodny, meanwhile, told BuzzFeed News that he actually
agrees that stable patients who are physically dependent on
opioids shouldn’t have their medication stopped abruptly. But
he says it’s “not a coincidence” that pharmaceutical
support the patient organizations in an uproar over the
But underneath the animus, almost everyone agrees, is not so
much a clash between the doctors and patients. It’s a medical
system, built on 15-minute doctor visits that end with a
prescription, that doesn’t effectively treat pain.
Eric Ogden for BuzzFeed News
Paul, photographed in New York City on Nov. 22.
Although he had lived with a bad back for decades,
Paul’s experience with high-dose opioids began in 2010, when
he got a hernia after moving a desk. His body rejected the
plastic mesh implanted for the hernia, which led to more
surgeries, which led to more back pain. He put a lot of extra
weight on his 6-foot frame, reaching a high of 221 pounds and
adding even more stress on his back.
All of that led to high-dose prescriptions for Tramadol — an
opioid strong enough that the FDA bars
its use in children — plus up to 30 oxycodone pills a month,
if he needed them. He also took Valium, an anti-anxiety drug
increases the risk of an
The country was only just waking up to the opioid problem.
High doses of these drugs had been reserved for cancer and
hospice patients until the mid-1990s, when doctors began
prescribing them for chronic pain. By 2010, high doses were
standard care, at more
than 10% of all opioid prescriptions for chronic pain,
and the pendulum started
to swing the other way.
Whether delivered by pill, patch, or syringe, opioids can
bring both pain relief and euphoria.
The Department of Veterans Affairs and the American Pain
called for cutting the highest dose prescriptions in new
triggering a slow decline. Ohio and Kentucky, among the
states with the highest overdose rates, started monitoring
prescriptions to prevent patients from “doctor shopping” for
providers who would give them pills. Florida and other states
started cracking down on “pill mill” pain clinics that handed
out painkillers like candy. And over the next few years,
reports linked high-dose prescriptions with addiction and
Whether delivered by pill, patch, or syringe, opioids can
bring both pain relief and euphoria. Over time, the high may
fade, but opioids still trigger a chemical dependence, as the
brain stops making its own natural opioids and comes to rely
on the drug instead. Nearly half of people
taking opioids for a month will still be taking them a
Paul’s opioid prescriptions made his pain bearable, but did
not eliminate it, leaving him distracted at work by the
stabbing pain along his spine. He tried many alternative
treatments, from “biofeedback” (which uses electrical sensors
to monitor physical changes in the body) to cognitive
behavioral therapy. Nothing worked.
In the fall of 2015, stable on 300 milligrams a day of
Tramadol, as well as oxycodone and Valium, Paul’s longtime
doctor went on permanent leave. His new doctors presented him
with a “pain contract” to sign. Its 12 stipulations included
promises to undergo urine testing, alternative treatments,
and detoxification treatment, if ordered. They cut off his
oxycodone and Valium, but increased his Tramadol to 400
milligrams, and started giving pain shots of steroids to his
Without the high-dose oxycodone, Paul could no longer
tolerate the days when his back pain flared up, locking him
down in agony.
The CDC guidelines released in March 2016
called for avoiding opioid painkillers for chronic pain
patients. For those who are already dependent, the guidelines
recommend limiting prescriptions to less
than the equivalent of 90 milligrams of morphine a day.
Paul’s old prescriptions of Tramadol and oxycodone were above
this threshold, but his new prescriptions, even with the
higher dose of Tramadol, were below it.
In some cases, people do manage to cut down on their opioid
use, reduce their pain, and lead more functional lives,
psychiatrist and pain medicine expert Mark Sullivan of the
University of Washington told BuzzFeed News. A recent
study of 35 patients who wanted to cut down their
painkiller doses, for example, found their lives improved and
their pain wasn’t any worse after they switched to moderate
“My pain got better after I got off opiates,” Ken Start, 54,
of Muskegon, Michigan, told BuzzFeed News. He has written a
book, Prescription For Addiction, about his 15-year
Start’s dependence culminated with a pain pump, a machine
that delivered doses of pain medicine straight into his
spine, that he flew down to Florida every three months to
have refilled. “I thought I needed it for the pain, but I
also needed it for the high,” he said. “The pain was severe,
but the addiction took over and ran everything in my life.”
But not everyone has such a strong dependence. Paul dealt
with oxycodone withdrawal a few times over the years, and
each was a few days of flu-like misery. (It had been far more
difficult to wean himself off of Cymbalta, a non-opioid
antidepressant sometimes used to treat back pain.)
Eric Ogden for BuzzFeed News
In 2016, shortly after the CDC guidelines were released,
Paul’s doctors sent a memo to all their patients saying they
were “going to start to slowly lower the opioid doses we
prescribe,” in accordance with the recommendations.
With more bad days, sometimes unable to walk, Paul
downshifted from working at a hedge fund to a less stressful
job as a consultant, and relied heavily on relaxation
techniques he learned in therapy to manage his pain.
In April of this year, a mishandled injection to his back
sent Paul to the emergency room. His doctors took that
opportunity to cut his Tramadol prescription, with the
goal of getting him off opioids completely. During this
tapering, one of his doctors called him an “addict” in front
of his wife.
Pain patients often contend that they’re wrongfully lumped in
with people addicted to heroin and fentanyl. “The assumption
is that people in pain are drug seekers. It’s widespread,”
fibromyalgia patient Audrey Liebl, 44, of Springfield,
Massachusetts, told BuzzFeed News.
The definitions of a “stable” patient on opioids versus one
who “misuses” painkillers vary wildly.
Liebl recalled a recent trip to the emergency room for a skin
infection when a nurse began interrogating her about the
dosage of the opioid patch she wears for pain. “Obviously
nobody starts off on a high dose,” she said. “I’ve been in
pain for 20 years.”
Some doctors, too, put opioid-dependent patients into
different categories. The hallmark of addiction is
out-of-control drug-seeking behavior, which affects roughly
12% of chronic pain patients, according to one review.
But those are the patients doctors see most often, perhaps
explaining why many believe the numbers are far higher.
Adding to the confusion, the definitions of a “stable”
patient on opioids versus one who “misuses” painkillers
wildly in studies, with the latter averaging around
one-quarter of patients. Few people fully adhere to their
prescribed treatment plan, with many taking a pill ahead of
schedule when pain flares. Smoking a joint might constitute
misuse, as might drinking a beer, or even taking fewer pills
The opioid epidemic appears to be splitting into
two epidemics, one of young people taking illegal drugs,
and one of older people who, by and large, don’t. “People
have to learn to inject heroin from people they know and
trust,” medical epidemiologist Jay Unick of the University of
Maryland, Baltimore County,
told BuzzFeed News in April. It might be that older
people just don’t want to do that as much.”
“There is a group of people who are addicted, compulsively
using, despite ongoing harm to themselves,” addiction
specialist Stefan Kertesz of the University of Alabama,
Birmingham, told BuzzFeed News. “But there are other patients
who are stable on high doses and are very worried” about the
crackdown on their prescriptions, he said. The opioid
pendulum is swinging too
far, he added, if those patients are suddenly forced into
withdrawal by doctors scared of losing their license to
Earlier this year, Kertesz said, a younger doctor asked for
his advice on pain patients who constantly wheedle, threaten,
or demand higher doses of opioids. Kertesz replied by email:
“If I have a guy who is working, taking care of his wife,
attending Bible study, then I look at the case in a very
different way than someone who is volatile and
The US medical system is ill-suited to treat pain
patients with the kind of individual attention they need.
There’s too little training on pain, too little time to treat
people, perverse incentives to keep prescribing painkillers,
and too few resources devoted to alternatives by insurers,
said David Tauben, a pain medicine expert at the University
of Washington, Seattle. “The problem is enormous.”
For example, until recently, doctors measured pain by asking
patients to grade it on a scale of 1 to 10. “For a decade or
more, many entertained the delusional idea that complex forms
of human suffering could be resolved by reducing pain to a
single number,” Kertesz said.
More than a dozen states and 100 counties have sued drug
companies for deceptive marketing of painkillers to pain
Handing out pills was a substitute for the real medical care
— dedicated pain centers staffed with teams of psychologists,
doctors, and social workers — that insurers, politicians, and
taxpayers have been reluctant to pay for. And pharmaceutical
firms have relentlessly flogged
painkillers for the last two decades, despite a $600
million judgment against Purdue Pharma for its marketing of
OxyContin in 2007. Just this year alone, more than a dozen
states and 100 counties have
sued drug companies for
deceptive marketing of painkillers to pain patients,
downplaying the risks.
No X-ray, no stethoscope, only the patient can measure pain.
Modern medicine, driven by blood tests and insurance rates,
falters at this impasse, while chronic pain is extremely
common, affecting as many as 1 in 3 US
The causes of chronic pain are wide ranging and often
mysterious. In theory, it results from a lowered threshold
for perceiving pain signals in the brain, following an injury
or illness. The patients are in real pain. And they are
frequently also dealing with depression, anxiety, or genetic
conditions that might worsen pain.
People with chronic pain typically have complicated medical
histories, said Sullivan of the University of Washington. On
top of everything else, they’re often dealing with family or
work problems, and the aftereffects of past trauma, he said.
They also often distrust doctors, buffeted by multiple
diagnoses and treatments through years of pain. Where the
patients might see themselves as only hanging on thanks to
the painkillers, physicians can see people cut off from
everyone else, sleepwalking through life, still in pain, and
letting their other health problems slide.
“We don’t need more opioids. We need more realism about
living with pain.”
“I say to people, it doesn’t seem like this medication is
actually helping, maybe it is time to try something else,”
pain medicine specialist Michael Hooten of the Mayo Clinic in
Rochester, Minnesota, told BuzzFeed News.
“Let’s face it, these are psychologically tough patients to
deal with for physicians,” he added. “You don’t get a lot of
warm fuzzy feelings from people you are trying to get to do
stuff they don’t want to do.”
Doctors and patients should stop expecting to eliminate all
pain, said Hooten, the Mayo Clinic pain expert. Given how
often both physical and mental health problems plague chronic
pain patients, he said, pain facilities should treat every
aspect of their lives.
“There’s a kind of false empathy when you are providing
opioids instead of really treating people, offering them
false hope,” Hooten said. “We don’t need more opioids. We
need more realism about living with pain.”
Eric Ogden for BuzzFeed News
Paul came home from the beach and tried to explain to
his wife. “My life is nothing but pain anymore,” he recalled
telling her. “Please let me go so we are all in a better
place.” The next morning she took him to the crisis unit of
an emergency room, where he was voluntarily committed to a
mental health ward.
Most of the beds there were filled with chronic pain
patients, he recalled, with those considering suicide
receiving treatment for two to four days, while people who
attempted suicide were treated longer. Paul was released in a
week, diagnosed with depression due to chronic pain.
The possible link between stopping opioid treatment and
suicide has become the bedrock disagreement in the fight over
the CDC guidelines. Critics like Kline warn that patients
forced off opioids will
kill themselves in the face of withdrawal. But many of
those same patients are also diagnosed with depression, a
major risk factor for suicide that needs more than a
painkiller to treat. Suicide rates have
skyrocketed in the last two decades, particularly the
rural parts of the country where opioids were prescribed in
the highest doses.
In July, back at work, Paul’s doctors cut his remaining
opioid prescription in half, to 150 milligrams, and took away
the Valium entirely. They took him completely off opioids in
September. Now he’s on a high dose of a non-opioid
painkiller, Aleve, which comes with its own side effects.
“It’s crazy from the standpoint that the fear of ‘addiction’
that I haven’t shown signs of in 25 years suddenly outweighs
the risk of heart attacks and ulcers,” Paul said in an email.
He has trouble sleeping most nights. He drinks (“the
aftereffects are terrible”), “borrows” medication from
friends and family, and has tried Kratom,
an unapproved botanical drug that upsets his stomach and this
month garnered a
health warning from FDA commissioner Scott Gottlieb. At
the end of his two-year tapering from opioids, Paul says his
pain is the same as when he started seven years ago.
Paul’s big hope is that New Jersey will legalize medical
marijuana. To deal with flare-ups, he has even considered
buying pain pills on the black market, the very threat that
inspired the drive to cut down on opioid prescriptions in the
first place. That’s especially dangerous with
dangerously potent opioid, now tainting the illegal drug
market and increasingly
turning up in counterfeit pain pills like the ones blamed
for the 2016 death of
“I am not close to the black market yet,” Paul said, “but I
feel that everyone is pushing me in that direction.” ●
Dan Vergano is a science reporter for BuzzFeed News and is
based in Washington, DC.
Contact Dan Vergano at email@example.com.
Got a confidential tip? Submit it here.