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t was roughly halfway into a Saturday evening flight from Miami to Boston when I began to wonder if I was going to survive the night. What had started as a sharp pain on the right side of my abdomen now felt as if my gut was being hacked at with a phalanx of rusty chisels. The only explanation I could think of was that my appendix had burst and I was dying of sepsis.

After we landed, I was taken by ambulance to the emergency room at Massachusetts General Hospital. Over the next hour or so, I received five separate injections totaling the equivalent of 29 milligrams of morphine. Sometime around 4 a.m., I learned that my appendix was fine; the cause of my suffering was a pair of kidney stones lodged in my ureter.

One of the stones was roughly twice as long as the ureter is wide, which meant it would require surgery — and the soonest that could occur was at the very end of the following day. I’d need to be injected with a lot more painkillers before then — and I’d likely be sent home with a prescription for more. That was something I’d been dreading for years.

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A dangerous scenario

I have had much good fortune in my life: I’m happily married with two wonderful, healthy children, and I have a stable and satisfying job. But the luckiest thing that ever happened to me was surviving a three-year addiction to heroin that included shared needles, multiple overdoses, and more than a dozen attempts at treatment. I kicked the habit in 1997, after a stint in a long-term rehab in Delray Beach, Fla., but I can’t point to any one reason why that worked when so many previous efforts had failed.

That’s why I know there’s no guarantee that if I relapse, I’ll be able to get sober again.

And while everyone’s demons, secrets, and temptations are unique, I’ve seen enough friends stumble after years of sobriety to know there is one chain of events that is especially dangerous: a surgical procedure followed by a round of medically necessary pain pills.

That doesn’t mean people in recovery should shun all prescriptions. The scientific literature is full of studies and commentaries highlighting a paradox in treating ex-addicts: Appropriate use of prescribed opioids can put them at a significant risk of relapse, but so too can inadequate pain management.

That’s why, throughout the course of my 43-hour stay at MGH at the end of April and into early May, I told everyone I could — from the ER doctor who informed me that I’d need surgery, to the anesthesiologist who prepped me for the procedure — that I was in recovery from a substance use disorder.

And while my doctors all said they were aware of the issue, it still felt as if no one was listening.

An apparent oversight

At around 7 p.m. on Monday night, about 30 hours after I’d arrived at MGH, a surgeon threaded a scope into my bladder and used a laser to break up the larger of my stones. Before I awoke, a stent was inserted into my ureter to help me expel the stone fragments that remained. The entire procedure took less than an hour.

As I recuperated, the surgeon checked in with my wife.

“You know he has a history of addiction?” she asked the surgeon.

The reply surprised her: “No, I did not.” There wasn’t time for more discussion: I was waking up and the surgeon had already had a longer-than-expected day. (When I asked my surgeon about this later, she told me that she had, in fact, reviewed my history with her entire team before the operation. “When I’m seeing patients [and their families] afterward, I don’t have the records in front of me,” she said. “I’m just making sure they’re OK.”)

A few minutes later, still groggy from anesthesia, I was handed a stack of seven prescriptions. One was for 20 pills of oxycodone at 5-milligram strength.

When my wife and I talked about this later, we were nonplussed. On the very first page of the seven-page report generated before my operation, “substance abuse” was listed under “past medical history.” Three pages later, the first sentence of the “assessment/plan” for my care began, “Briefly, this is a 44 y.o. male with a history of … substance abuse (in remission).”

Despite that, I got no counseling before I checked out of the hospital that night. No one talked to me about the risk of relapse — or how to guard against it. No one offered to advise me as I began taking the powerful painkillers I would need to get through the next few days.

Fortunately, I had a robust support network and had come up with a plan I was confident would keep me safe from relapse: My wife would have possession of the pills and would never give me more than two within a six-hour period. This was going to be a breeze.

Matt Ganem, a former addict, explains the excruciating process of opioid withdrawal. Alex Hogan/STAT

A national epidemic

The Food and Drug Administration approved OxyContin, a time-release formulation of oxycodone made by Purdue Pharma, in 1995. Over the next five years, Purdue more than doubled its sales staff and aggressively marketed the drug as a “first-line defense” against everything from musculoskeletal pain to pain after surgery. The company assured doctors and patients that OxyContin was less addictive than other pills. It wasn’t.

The marketing campaign worked: From 1997 to 2002, prescriptions of the drug for noncancer patients increased tenfold. Before long, Purdue was ringing up more than $1 billion in global sales each year. By that point, the United States was in the midst of a prescription opioid epidemic that continues to this day.

The result has been an eye-popping increase in more than just Purdue’s bottom line: In 1999, there were 4,000 deaths in the US attributed to prescription painkillers. By 2011, that figure was close to 14,000 — more than the number of overdose deaths from cocaine and heroin combined.

In 2014, the most recent year for which figures are available, the number of overdose deaths in the US had risen to 18,893.

That’s more than 50 people a day.

Over the past half decade, Massachusetts, like the rest of the country, has taken notice of the deadly toll of all forms of opioids, and for the past several years, MGH has been vocal about its work on “the front lines of the opioid epidemic.” That included creating Addiction Consult Teams, known as ACT, made up of internists, addiction specialists, social workers, and nurses to evaluate and recommend treatment.

Today, ACT is deployed in virtually every area of the hospital — except for the emergency department, where staffing constraints and a lack of certified addiction specialists present a challenge.

In any case, ACT wouldn’t have intervened in my case: It’s designed to help patients with active addictions — not those already in recovery.

Seth Mnookin
A self-portrait taken by the author during his recent hospital stay. Courtesy Seth Mnookin

The pill count grows

On Tuesday morning, my wife filled my sundry prescriptions. I took three oxycodones for each of the next three days. At that point, I called my surgeon’s office and said I was going to run out of painkillers before the appointment to have my stent removed the following week. Later that day, I picked up a prescription for 10 more pills.

From Friday, the first day I had to be back at work, through the following Monday, I took four pills a day. By the following Tuesday, 10 days after I’d arrived in the ER, I was up to five a day.

At an appointment that afternoon, I learned that the reason I was still in so much pain was that I’d developed a bladder infection. I was given a prescription for Cipro along with a prescription for 10 more oxycodone pills — the third one I’d received in a little over a week.

In one sense, the fact that I was given multiple prescriptions was evidence that my surgeon was being careful about giving me opioids: Instead of starting me off giving me a single, week-long prescription, as is standard practice, I’d only been receiving enough pills to cover a couple of days at a time. What’s more, those three prescriptions only totaled 200 milligrams of oxycodone, and my rough calculations put that as the equivalent of somewhere between eight and 15 bags of heroin. When I was using, it wasn’t unheard of for me to consume that much in a single day.

And since MGH knew about my history, surely someone would have let me know if there was cause to be concerned.

On Thursday, I received more bad news: My infection hadn’t cleared. My surgeon was still willing to take out my stent, but stressed that if I developed a fever, or felt aches or chills, I should go immediately to the nearest ER: It meant the infection had likely spread to my kidney.

The removal did not go smoothly. (Suffice to say that when a doctor is pulling something out through your urethra, the words “it has a kink in it” are not ones you want to hear.) When it was done, I was in more pain than at any point since my kidney stones were initially diagnosed 12 days earlier.

As I lay on a gurney with a hot water bottle pressed against my groin, I was told I should be feeling better within a day.

Even so, if I really thought I needed it, my surgeon told me, I could have one more prescription for several days worth of oxycodone.

This time, I declined.

Pain and panic

I spent that night writhing on the couch in our family room. The pain in my bladder and kidney was, I’d been told, due to the “trauma” of the stent removal — but that didn’t explain why my nerve endings felt as if they’d been electrified. At 4 a.m., still unable to sleep, I began to irrationally panic that I’d poisoned myself by taking too much of a powerful, prescription anti-inflammatory drug.

The following day was even worse. I was both deeply exhausted — more exhausted than I remembered feeling in years — and unable to sit still. Despite having just made it through two weeks of some the worst pain of my adult life, I was despondent about making it through the next 24 hours. Lights seemed brighter and harsher than usual. I didn’t have a fever but my skin seemed to hurt.

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It all felt vaguely familiar — but given the warning I’d received the day before, I thought it just meant my infection had spread. I was girding myself for another trip to the ER and another bout of bad news.

Then I got a text from a sober friend of mine who was checking up on me. (He’d had a years-long relapse after being given a prescription of hydrocodone, better known as Vicodin, following a dental procedure.)

When I described how I was feeling, he didn’t hesitate in his reply: “You don’t have a kidney infection,” he told me. “You’re in mild withdrawal.”

He was right: While two weeks of continuous use is quick to develop a physical dependence, it’s not unheard of, even in what doctors refer to as “opioid naïve” patients — and dependence can occur even more quickly in people with a history with opioids.

Once I realized that, I was simultaneously relieved and scared: Relieved that I hadn’t filled that fourth oxycodone prescription and scared that I had been caught so unawares.

The hell of addiction isn’t that you’re compelled to take a drug to make you feel euphoric — it’s that eventually, you need the drug just to feel physically stable and emotionally sane. I’d convinced myself that the fact that I hadn’t been getting high meant that I wasn’t at any risk, somehow forgetting that my years of addiction hadn’t been years of doped-up bliss; they’d been a never-ending struggle to feel normal again.

If I had filled that fourth prescription, would I have convinced myself that it made sense to just keep on going for a few more days — and then a few more days after that?

I was also angry.

I’d been treated at a hospital that reminds patients at every opportunity that it’s regularly rated the best in the country. Both my wife and I had spoken up about my history. Despite this, no one had talked to me about the risks of relapse or how best to manage and track my prescriptions.

There’d been no discussion of the proper way to stop using opioids and no warning about how I might feel once I did stop. And no one had checked up on me to make sure I hadn’t encountered any difficulties along the way.

When I asked MGH about my case, they put me in touch with my surgeon. She shared my frustration. “At the moment, we’re not getting a lot of guidance,” she said. “And the addiction specialists are few and far between. I think people are moving in the right direction, but it’s like anything — it’s going to take time.”

At present, MGH doesn’t have a policy mandating discussions with patients about proper opioid use, although that is about to change: A task force is putting together best practices on prescribing pain medications, to be released later this month. Those will include hospital-wide guidelines that all patients be given information on the risks of opioids before receiving them.

There will also be guidelines on treating patients in recovery — something that Dr. Sarah Wakeman, one of the task force’s cochairs, acknowledges is needed.

“The person doing the prescribing really needs to screen for that,” she said, emphasizing that she had no knowledge of my specific case. “They should be very thoughtful, both in their own decision-making and also in the counseling they would offer that patient.”

A call for common sense

In March, Massachusetts Governor Charlie Baker fought back tears as he signed a law that put tighter restrictions on prescription opioids. Talking directly to families who have lost loved ones to overdoses, he said: “May today’s bill passage signal to you that the Commonwealth is listening and we will keep fighting for all of you.”

Some of the provisions will undoubtedly help; for instance, the law limits first-time opioid prescriptions to a seven-day supply and requires practitioners to check a database before prescribing certain drugs, to make sure the patients haven’t been going from doctor to doctor to stockpile opioids. Federal officials are working on prescription guidelines, too.

But as my case highlighted, other simple reforms are being ignored.

Why isn’t every patient who receives an opioid prescription given information on physical dependence, as the Massachusetts Medical Society recommended back in March? And why aren’t patients in recovery already receiving the same screening and evaluation as those in active addiction?

If recent history holds, around 150 Massachusetts residents will have fatally overdosed in the six weeks since I was admitted to the hospital — and countless others will have relapsed or become addicted for the first time. Hospital-wide initiatives and new laws are important. But let’s not ignore common sense protocols that could also save lives.

Seth Mnookin is the director of the MIT Graduate Program in Science Writing and the author of several books, including “The Panic Virus” and “Feeding the Monster.”

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  • My 22 yo son just OD after being clean a year and a half. He lived and worked hard in Florida. Trying to be normal and independent. Broke his hand. I am going to guess he thought he could handle the Oxy and he was in pain. He never told me he received the pain med. A month and a half later he was found dead in his apartment. My guess is was something laced with Fentanyl. Toxicology is not back. I know it was up to him to tell the doctor but at 22 you can take on the world. I cry everyday and wish there was a list (like the sex offender list) that doctors can see if a person has gone through rehab and just offer and alternative. RIP JTS Forever 22

    • Allison — I am so sorry for your loss. I can’t imagine how painful it must be to lose a son.
      Seth

    • I am so sorry to read this. My nephew will be 21 and been addicted to heroin after using pain pills. I miss him before he was sick. They regally are innocent and these drugs that they don’t under stand let it get the best of them. They deep down are such good kids that were given a bad break. I will pray for you.

  • Thank you for writing. I had ankle surgery and told the surgeon beforehand that I had a history of substance abuse, and had abused opioids after a previous surgery. I asked to be sent home with only 2 days worth. I usually have a very high pain tolerance and with the nerve block performed for the surgery any pain was 100% controlled by Tylenol. Still I was given an Rx for 25 oxycodone. Less than the 60 I had before, but still a dangerous amount I think. It is upsetting that I can specifically tell a doctor *I have abused prescription opioids* and not to send me home with more than 1 or 2 day’s worth of opioids, and not have that be listened to.

    • What is really upsetting is drug ABUSERS complaining publicly online about being given a typically appropriate amount of pain relief medication after a surgical procedure – rather than just asking the doctor to rewrite the prescription for less OR ask the pharmacy to only give you two days worth if you fear you can’t control yourself. (That is possible, you know. I see people do that with prescriptions they can’t afford to fill in full often at my pharmacy.)

      It’s people like you, drug ABUSERS, complaining about being given a prescription for too many pills after surgery, that is helping feed the myth and cause the restriction of prescriptions for all of the rest of us (the majority of patients) who exercise self-control – who now face legislation requiring that we get sent home from serious surgical procedures with just two days worth of pain relief and THEN be required to get out of bed, get dressed and go to the pharmacy – in person – two days later in order to get a refill. Many people will simply not be physically able to do that. And it is because you people whine – because you refuse to exercise self-control – or because you are tempted by being given too many pills.

      Before I became a chronic pain patient about 10 years ago, I was regularly prescribed 5 – 10 days worth of 7.5 mg Lortabs for broken bones in the ER and for painful dental procedures such as molar extractions and root canals. I only took them when needed and for only as long as I needed them for pain. And then I threw the rest of them away.

      Now…because of drug ABUSERS, my neurologist is so afraid of the DEA that last year he tried to cut down the already small amount of pain prescription he gives me each month. He finally stopped weaning me down after I developed Angina and Tachycardia due to the increased pain. So I now have to see a cardiologist regularly too and carry nitroglycerin and live in such constant pain that I am housebound…chairbound for the most part actually. Thanks to people like you – and that whiny attention whore who wrote the original article a year ago – and who is probably still capitalizing on his “disease” of lack of self-control. Your contributions to the discussion are literally killing chronic pain patients.

  • I want to thank-you for sharing your story. I had almost 8 years of recovery from 2002-2009 and had to have minor back surgery. Spiritually for me I was ready for a relapse and had non-physically relapsed months prior. When I went to the hospital I withheld the fact that I was and addict and sure enough I was treated with fentanyl and morphine before given a ten day prescription to Percocet. That sent me on a relapse that bottom after bottom continued to deepen until finally I section 35’ed myself and made sure I went to Bridgewater to be as uncomfortable as possible. I had been in and out of programs on Methadone maintenance and stayed active until June 4, 20015. I was finally ready to have my life back. It has taken me that time to finally begin to get my life back. I now before any medical treatment tell my doctors that I am an addict and do not want any opiates. I almost did not make it back but now am going back to school to get my degree and to start a non-profit focused on prevention first and then treatment.
    I previously worked with at-risk youth and had a lot of successes. The bottom line is that no matter what anyone says to an active addict they will not recover until they want regardless of past recovery. The other thing I remind myself daily is that I can dig deep and if not constantly vigilante I can easily dig another deeper bottom thank-you for your experience, I wish I was spiritual fit that first time I got that medical treatment but I have learned many tough lessons being active that I will apply to my work in the future…Thanks again.

    Sincerely,
    Michael W.

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