MISHAWAKA, Ind. — Dr. Todd Graham wasn’t yet halfway through his workday at South Bend Orthopaedics when a new patient came into his office here complaining of chronic pain.
Heeding the many warnings of health officials, he told her opioids weren’t the appropriate treatment.
But she was accompanied by her husband, who insisted on a prescription. Graham held his ground. The husband grew irate. The argument escalated to the point that Graham pulled out his phone and started recording audio until the couple left.
Two hours later, the husband would return, armed.
Graham didn’t know that the shouting in his office wasn’t the end of the confrontation. It was frightening, he told his colleagues. But the incident two weeks ago wasn’t out of the ordinary — physicians here and across the country have grown increasingly accustomed to disputes over opioids. So Graham didn’t call the police. He didn’t file a report. He just kept seeing patients.
Many of his peers say they would’ve done the same thing. Many of them have.
Now, they’re not so sure.
That’s what they whispered to one another at the funeral five days later — the funeral for Dr. Graham.
Graham, 56, had worked in the community for decades. He was known for wearing a suit to most every appointment. For pushing patients to push themselves — to get out of bed even when it hurt. He and his wife had raised three children in the area, two daughters and a son, who was finishing his last year of residency and planning to return to town to practice medicine.
“He was really tough, but in a good way,” said Dustin Stacy, who credited Graham with helping him get out of a wheelchair and back on his feet when he didn’t think he ever would.
And now Graham was gone. Two hours after their verbal scuffle in the orthopedics office, Michael Jarvis — who had wanted that prescription so badly — had come after him again, this time in the parking lot. Again, Jarvis shouted. He ordered two people at a nearby picnic table to leave.
Then he pulled out a semiautomatic weapon and shot the doctor who wouldn’t give his wife pain pills.
Days after the July 26 murder, STAT interviewed doctors, law enforcement officials, and local residents to piece together the full story — and to understand how the shouts in the office and the gunshots in the parking lot have reverberated through this small Midwestern town.
Those reverberations echoed loudly at Graham’s funeral, when hundreds of mourners packed into the pews at Pius X Catholic Church. Among them were many of the area’s doctors — including Graham’s colleagues — who asked one another if they’d keep prescribing opioids.
“That fear was palpable, and this was among a group of orthopedists, who give tons of medicine because the things they do are painful,” said Dr. Mark Thompson, a local surgeon.
Dr. Brandon Zabukovic, a family medicine provider who also sees patients in treatment for opioid addiction, put it this way: “A lot of us right now are a little raw.”
In a modest town, opioids take hold
Mishawaka is home to 46,000 people, AM General’s Hummer plant, and plenty of cornfields. The median household income in this town — just a hop, a skip, and a jump from the University of Notre Dame — is $33,986. It is, by most measures, a modest Midwestern town.
It long thrived on the business of the Ball-Band rubber company, which made leather sneakers that were laced up on the feet of kids walking to school. Thousands of people here in the Princess City lined the streets and perched on the roofs of gas stations when 5,000 sticks of dynamite were tucked inside the factory’s five buildings on a summer day in 2000. A 9-year-old cancer survivor pressed the button to blow the buildings up into a massive cloud of milky-white dust at 8 a.m.
The opioid crisis is a quiet undercurrent in the area. There isn’t a “Methadone Mile” in Mishawaka — if there were, it’d stretch through a good part of town. More often, the overdoses take place in homes, whether in cookie-cutter subdivisions or subsidized apartments.
Across St. Joseph County, which includes Mishawaka, there were 59 overdose deaths last year, and 58 the year before. That’s more than the number of homicides and fatal car crashes — combined — in this quiet corner of northwest Indiana.
And the fatality numbers don’t begin to capture the depth of the problem: Last year, there were 384 overdoses so severe the victims required medical treatment.
“That fear was palpable, and this was among a group of orthopedists, who give tons of medicine because the things they do are painful.”
Dr. Mark Thompson, local physician
“This isn’t going away,” said Ken Cotter, the county prosecutor.
After shooting Graham in the parking lot, Jarvis, who was 48 and battling his own issues with addiction, sped off in his red Dodge Neon. He raced down Dragoon Trail, a road that parents tell their newly licensed teens to stay away from because the curves and the cars both come quick.
As police were swarming the murder scene in the parking lot, Jarvis called a friend and said he might not be around that much longer. Then he drove to his friend’s home and killed himself.
In the days since, Cotter’s phone in the prosecutor’s office has not stopped ringing. In the first few days after the murder, he fielded roughly 20 calls from doctors concerned about the safety of their patients, their staffs, and themselves.
Those calls are forcing him to rethink his own approach to the opioid crisis.
A clash over how to help
Cotter is a hard-hitting prosecutor when he needs to be. He chugs Diet Mountain Dew in the morning as he gets to work on the county’s criminal cases. But he’s also softened his office’s stance on addiction since being elected in 2014. He expanded the purview of the county’s drug court to allow individuals who commit crimes driven by drug use — not just drug crimes — to seek treatment instead of jail time.
“If you’re someone who is just profiting off another person’s addiction and misery, I have zero problems getting you in prison for as long as I can,” Cotter said. But the majority of individuals in the area who are arrested for selling opioids are themselves struggling with addiction, Cotter said.
“They’re pinching off a little for themselves and selling it to support their habit. Those people I’m trying to get to treatment,” he said.
But until recently, Cotter hasn’t supported the full range of treatment.
He has long been opposed to the use of buprenorphine, a medication-assisted treatment to help individuals who are addicted to opioids wean off the drugs. It helps reduce cravings. But it is, in itself, an addictive substance. And Cotter saw it as simply swapping one opioid for another.
That changed after Graham’s death.
“I began talking to doctors who I respect very much, and they’ve shown me to reconsider that there might be a place for that,” Cotter said.
But Cotter and some area doctors still don’t see eye to eye on other ways to tackle the crisis. At a press conference after Graham’s murder, Zabukovic, the family medicine physician, said he’d like the town to discuss hosting a needle exchange. It’s an idea that many in this conservative community wouldn’t support — including Cotter, who stepped to the center of the stage to interrupt.
“I’m against drug safe zones. I’m not a fan of needle exchanges. I think all we’re doing is allowing people to die in a very nice place,” he explained in an interview.
They all do agree on one thing: There aren’t nearly enough resources to deal with the crisis. The closest medical detox is in Plymouth, Ind., 35 miles away. The nearest inpatient addiction center is in East Chicago, Ind., more than 80 miles west. Every homeless shelter in town is “dry,” meaning individuals who are still using drugs can’t come in and try to wean off opioids.
“Right now the best place for somebody to dry out is in jail. It’s not the best place, by far, but it’s the best place we have,” said Cotter.
Doctors, law enforcement officials, and mental health providers have tried to find ways to address the crisis. But up until now, those efforts have been largely been separate.
“[Doctors] have done a lot of good work, but they’ve been working in a silo. We’ve done a lot of good work, but we’ve been working in a silo,” said Cotter.
Now, Cotter and the rest of the law enforcement community are trying to figure out how to best support doctors who are afraid they can’t win either way — overprescribe opioids and they risk fueling the fire; refuse to prescribe and they risk losing a patient in need of help, or putting their staff and themselves in danger.
“The last thing we want doctors to worry about while prescribing is safety,” Cotter said. But doctors in the area say that’s something they’ve had to worry about for years.
“I have had knives pulled on me over narcotic prescriptions,” said Zabukovic. Six years ago, his practice stopped prescribing long-term opioids to anyone but cancer patients. Everyone else is referred to the pain specialist. Some patients left the practice over the decision, but it calmed things down in the clinic.
“Since then, it’s just how we do things, so there’s not a lot of argument,” said Zabukovic.
Some of the community’s doctors, for their part, said they want to focus on educating their peers about the proper way to prescribe opioids. They also want to double down on efforts to get their peers to use the state’s prescription drug monitoring program, dubbed INSPECT, which lets physicians look up a patient’s history of opioid prescriptions. Just 47 percent of Indiana’s health care providers were licensed to use the program in 2015.
Thompson, the surgeon, said he wanted to raise the idea at the state Legislature of requiring doctors use INSPECT, following the lead of New York and other states with aggressive prescription monitoring programs.
But he knows — everyone here knows — that that there isn’t one easy solution.
“I don’t think there’s a way to find the smallpox vaccine for this epidemic,” said Thompson.
Doctors caught in the middle
Jarvis’s wife, who was in to see Graham that morning for pain, was a new patient. First-time patients who are seeking painkillers present a tricky problem for doctors who say they often need considerable time to diagnose what’s wrong with the patient and figure out how best to help.
If a patient demands the quick fix of an opioid prescription instead, the situation can swiftly escalate. But doctors say they’re not sure what to do when that happens. They often don’t want to call the police on a patient. Yet they don’t want to give in and write an unnecessary prescription, either.
They are all too aware of the stakes. Health care workers face a disproportionate share of violence in the workplace: An average of 146 attacks for every 10,000 workers, compared to seven assaults per 10,000 workers across the entire U.S. labor force, according to Bureau of Labor Statistics data from 2015.
“If patients become belligerent, what is the plan in your office? Do you have a back-up of a social worker, a psychologist? Do you have a plan to help take care of these patients that are upset?” said Steven Stanos, the president of the American Academy of Pain Medicine.
“If patients become belligerent, what is the plan in your office? Do you have a back-up of a social worker, a psychologist? Do you have a plan to help take care of these patients that are upset?”
Steven Stanos, American Academy of Pain Medicine.
That’s a question the St. Joseph County community is coming together to try to answer now. It’s not just about whether doctors decide to call the police — it’s also what, if anything, the police can actually do to help.
Cotter said he’d tell doctors to contact the police any time they feel uncomfortable. But, he admitted, most police officers wouldn’t have known how to respond appropriately. He likened it to a fight in a bar over rival football teams.
“What can the police do? They say, ‘Knock it off, knuckleheads,’” he said. “People get mad at each other all the time, that’s human nature. When does it cross the line? You shouldn’t have to make that call as a medical provider.”
Cotter said even if the police did toss a report about a belligerent patient on his desk, he wouldn’t have paid much attention to it before Graham’s murder. He would’ve seen it as the patient just “letting off steam.”
He’s still not sure what he’d do with such a report now. But he knows he would pay close attention.
Casey Ross contributed reporting.