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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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  • Having been the medical director of a methadone clinic and in house detox facility in Michigan, and having ran thousands thru, I have never met a drug addict….. Seems strange?? I have met many patients with health care problems, mental health issues and they go to “COP DOCs”, Doctors that make the patient pass a moral turpitude test before being treated. I have met patients that get street drugs because it is easier than to deal with the cop docs.

    A patient with a health/mental health issue, IS NOT A CRIMINAL.

    On discovery, with thorough interviewing, the people involved with manufacturing, sales and distribution, were always people in authority, cops, sheriffs, mayors, city council, senators, congress and higher. The ones that get up on their platform and say “WE NEED TO KEEP THESE DRUGS ILLEGAL, WE NEED A WAR ON DRUG ADDICTS.”

    Again, patients with health care issues are not criminals.

    The issue and the problem is BLACK MARKET. If one legalizes all drugs, then the problem goes away. YES IT DOEs. It allows the patient with a health care issue to be honest. It allows doctors to stop looking at patients as criminals,
    and it allows patients to admit their health care issue and find the best and most appropriate therapy.

    The AUTHORITIES that pushed the Prescription Monitoring Program are all involved with the Manufacturing, Sales and Distribution of street drugs. And what better place to be than right there making the laws.

    These authorities are the criminals. And what we really need is a Politician / Authority Monitoring Program. Any person that pushes programs to keep track of patients and their drug use, these people need to be watched and
    put in jail for their treasonous and black market activity.

  • Im confused. The author did stay that he was already an addict prior, right? if so, thats a predisposition to addiction, right? so are we going to use this as a measuring stick against ALL other patients whom the majority have no predisposition to addiction, no prior history? because wouldnt that then skewer the data we need? if you compare the experience of addicts, with the experience of non addicts with these medications, we’re going to have different results. If we seek to ignore them, and then use hysteria, and misinterpretations, we’re going to push a certain agenda not really based on real, scientific data..because it’s all biased. Im confused. Non addicts do not have a higher rate of addiction with these medicines, but we’re judging EVERYBODY the same, as having the SAME RISK. And that’s simply not good science, or medicine.

  • Being a doctor doesn’t make you a genius or a good person. I can’t tell you how many people are prescribed powerful opiates with no warnings about their addictive properties or the fact that they will experience withdrawals. This is how many, if not most, addictions begin. Most doctors simply don’t care, they are in it to make money or feel important. Don’t ever trust someone to do right by you because of what degree they have.

    • Why are you so negative about doctors? It makes it hard to trust your judgment about the issue.

  • Are you implying the Mass General Doctors here are C- students because they didn’t “counsel” this poor whiney ex-addict when they properly treated his peri and post-operative pain? Highly doubtful on the other hand gist because you are in “recovery you asshats think you know everything don’t you- ? The displacement of blame is sickening and precisely why so many of you know it-all “addiction addicts” don’t make it. You take no responsibility at all and can’t think for yourselves. Poor me…oh

    • Sure am, Ben. Just as when my husband’s ICU nurse after he had quadruple by-pass surgery neglected to re-start one of his daily medications that you must never quit “cold turkey” was a C-student. She also couldn’t seem to remember that because of being deaf she needed to look at him to ask him any questions. And also lied about what she offered him for pain medication even tho I had witnessed the episode. So, ya, there are LOTS of C students out there.
      No matter what you think of this author, pain management is fraught with danger for drug addicts. Why else would he have been questioned about it in the first place, and notes been put into the author’s medical record if it didn’t matter? I think I was being kind in calling her a C student.

  • I commend your recovery and your alerting medical staff. I have suffered addiction my whole life. Pot, alcohol, speed, herion and cocaine. Many times a mixture of the above in some fashion, but it always started with alcohol and progressed to herion. I have 6 years clean now, and have had two surgeries during this time, one I was given percocet the other Ibuprofen only. recently I spent a couple days in the hospital and they gave me dilaudid IV while there, vicodin when I left. I am fine. the reason I am fine is my support system. Im an active member of AA, currently sponsored and will remain thus my entire life. the disease of addiction is one of perception and if you are an addict of my type the thinking that makes you use never completely goes away. left untreated I’ve made it 4 months without working my program and was absolutely nuts. My thinking so distorted I was very likely close to relapse. I wasnt obsessing over using but a hardcore life event could at those times push me over the edge. I have yet to meet someone stay clean without a similar program. been to many funerals from people who were ‘cured’. just my 2 cents.

  • Bravo, great article I worked at the MGH as a recovery coach for a year and still think the ER and active recovery patient population is totally underserved. Thanks for the article.

  • They see, but do not think —
    When my elderly mother was in the hospital, upon discharge the attending physician had given her a sulfa drug prescription, even though in INCH HIGH LETTERS ON HER MEDICAL BINDER COVER, it stated “Allegies — Sulfa”.
    Luckily, she had not finished her shift, I ran after her & pointed out the problem… & stated that I would not rest until it was fixed, since the nursing home where she was going for followup care, would not admit her with a clouded prescription history…
    What do patients who have no on the spot advocate supposed to do???

  • Recently I went to the dr for constant shoulder and neck pain and spasms along with a weird radiating pain in my left arm and hand. I was honest about my level of pain, which was maybe a 5 on a 1 to 10 scale. I wasn’t interested in pain medication, as I had been taking 800mg Ibuprofen and it knocked the pain, I wanted to know WHAT was causing the pain and spasms. My dr walked in the room, looked at my arm, poked around my shoulder and without hesitation said ” ok well lets try Lortab for the pain and flexeril for muscle spasms ” I was a bit shocked and frustrated, I told her that I didn’t want Lortab, and before I could finish she said “ok I’ll write for percocet ” again I was not only shocked but more so angry, I don’t want pain meds or any meds for that matter, until the CAUSE of the pain is addressed, also pain medication makes me vomit and gives me migraines, which I had informed my dr of, many times. After a few tests it turned out to be an exposed nerve in my elbow and what I consider muscle tension managed with a little physical therapy and lidocaine patches. Given the current crisis of opiate abuse and addiction, why would a dr jump straight to prescribing such medication without first tests for cause and trying non opiate medication first?

  • All you needed to say was “I would like to speak with someone about taking these medications because I have a history of problematic substance use”. Why didn’t you tell them you had reservations about using this medication? If you already told them once and they didn’t appear to be taking it seriously it’s your duty to tell them again and continue to tell them until they take it seriously. You have a shared responsibility when it comes to your health. If a doctor overlooks something and you notice it’s your duty to bloody well remind them. Doctors aren’t Gods. I have worked in hospitals for over a decade and I am already sick to death of patients like you who refuse to engage in their own health care.

    • You are so smug and arrogant looking down your nose like that is shameful. Clearly you are as ill-informed about addiction as the doctors pushing legal dope.

    • Right on! I just spent 7 weeks in rehab following surgery. I received excellent care AND had to ask questions and make decisions. Patients or their advocates must participate in the process.

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