Journal of Addictive Behaviors and Therapy Open Access

Introduction

Opioid overdose is the leading cause of death in United States of America. There were 47,055 cases of lethal drug overdose in 2014, among them 18,893 were associated with prescribed pain relievers and 10,574 were related to heroin [1,2]. In a study of methadone patients with pain, participants stated that, they switched to heroin when they no longer could receive the prescribed opioids, and heroin was cheap and easier to access [3]. Over 5,000 deaths per year were attributed to the combination of opioids and benzodiazepines, and the growing number of illicit drugs (e.g. non-pharmaceutical fentanyl) was included in the statistics for prescription opioid death rates [4,5]. A recent national cohort study by Liang & Turner found that, both the daily morphine equivalent dose and amount of opioid prescribed from the initial prescription to the time of overdose were important indicators of the highest risk for overdosing [6]. When patients use high doses (>100 mg daily morphine equivalent dose), or have high risk related to substance use disorder, they are at higher risk of overdose [6]. This was further confirmed by another cohort study by Dasgupta et al. [7], yet little is known about the experiences of people at risk for opioid overdose. This article provides the perspective of a patient with chronic pain, who survived his intentional prescription opioid overdose.

T.W. was a participant recruited for a larger study in a large primary care clinic in the Midwest to tell his story in a 90 min audio-recorded interview [8]. Approval from two Institutional Review Boards from two institutions was obtained and all participants in this study provided written informed consent. An interview guide consisted of open-ended questions and was used to help identify the experiences of people with chronic pain receiving opioids from primary care.

In this interview, T.W. reflected his experiences receiving opioids for pain from his primary care provider, the events leading up to the overdose, his emergency situations, hospital experience, and discharge to his home from the hospital. The investigator in the primary care study, where T.W. participated [8], had over 30 years experience, as a nurse practitioner caring for people with chronic pain and substance use disorder, had no clinical relationship with the participant. However, the value of his narrative revealed significant gaps in knowledge and care. The purpose of his story was to (1) gain valuable clinical knowledge and insight on how his overdose occurred and how it could have been prevented, (2) raise awareness to the circumstances leading up to this overdose, and (3) to aid in developing better therapies for those receiving opioids for chronic pain.

T.W. is a Caucasian, middle aged male, who was suffering from pain in lower back and hip region, and had numerous surgeries resulting into acute and chronic pain. He was reported to have a previous history of alcoholism, and was unemployed at the time of the interview. Themes from his narrative revealed, (1) fear of losing access to prescription opioids for pain, (2) high doses of opioids prescribed for pain, (3) distracting his healthcare provider as a way to obtain more opioids, and (4) events leading up to his overdose. Recommendations from this individual for preventing prescription opioid overdose were offered.

Fear of losing access to prescription opioids for the pain

T.W. experienced fear of losing access to prescription opioids and commented on his desperation while he received opioids for pain.

“I was active in AA… I was just completely in denial of my use, and I didn’t know who to tell… and if I tell someone, what’s gonna happen? The repercussions are, I’m not gonna get any pain medication. Then what am I gonna do? How am I gonna deal with a broken back? How am I gonna work?”

His focus was, “… get me my drug and let me sleep.” He was focused on keeping his supply of opioids available. The fear of losing access to prescription opioids eventually steered him to overdose. He stated, “I was afraid of losing the drug … I wasn’t willing to go out on the street. I felt the walls were coming in on me with the doctors…. ”

High opioid doses were prescribed for pain

T.W. experienced adversity from being prescribed high dose opioids. His past medical history consisted of multiple back surgeries, and he felt he was “addicted to hydromorphone and fentanyl.” He tried to taper from hydromorphone, fentanyl, and methadone; however each time he required surgery, the process of dose increases repeated as he managed his acute postsurgical pain. At one point, he was prescribed 200 mg oral hydromorphone daily and applied prescribed fentanyl patches. He found that higher doses of opioids were not helping his pain and he described himself as “a prisoner of (his) own body….” Despite the large amount of medications, he stated, “nothing seemed to work.” He commented that he never used street drugs, however he would split, crush, and chew his long acting opioids, or place them under his tongue. He described his experience:

“Well that was pretty good. I’ll try that again.” Kinda duplicating what I had just discovered, and then I was off to the races doing that… that’s when I thought… “I’ll just cut the fentanyl patch open and try.” I’m glad I didn’t kill myself…

Despite his early efforts to taper from opioids following each surgery, his doses increased. He explained that, his “supply chain” stayed open because, he had a prescriber who tried to manage his pain without realizing the harm.

Distraction of the healthcare provider to receive more opioid

He knew his healthcare provider for a long time and felt that, his healthcare provider was well meaning and caring. He also commented on the healthcare provider that, he did not pick up on the signs of dangerous problems.

T.W. said “… all the signs were on the wall.” He received a 2 weeks supply of opioids and would ask for a refill on the 10^th day and a couple of times it was on the 8^th day. He described using a great deal of energy to figure out how to convince the healthcare provider to prescribe his next medication prescription. He recalled, one time, using distraction by talking to his healthcare provider about a newspaper article regarding prescription opioid abuse:

I solely brought in a (newspaper article) to minimize my issue. I didn’t bring it in for any other reason, but to down play the issue that I had. (I) was “Hey look. People have problems with this. I don’t. But here’s a good article that you may wanna read.”

One time he spoke with a different healthcare provider, his surgeon, about how he used his opioids. He related his conversation with this physician:

(He said) ‘I’ve tried to break ‘em in half. And, you know, use half of it.’ (Doctor said) “Oh, you can’t do that… don’t ever break the pills in half,” and when she said that, then I thought, “Oh. That must mean I will get a better high, so I’ll try.” It was just my behavior. It was just stupid, crazy behavior …’

He tried to indicate that, he was attempting to reduce his opioids on his own by splitting them but, in reality he had split his long-acting opioids and put them under his tongue to get high. Moreover, he inadvertently discovered, from the surgeon, that splitting pills was a known phenomenon that was dangerous, pushing the limits. He described his deceptions as, “… some subtle things I was doing to try to block the noise of, ‘Hey you got a problem’.

Leading up to the overdose

The participant recalled lying in bed for 20 h/day and not wanting to get out. He told of his experience prior to his overdose:

‘… I’ve only used pain medication to help with the pain, but the crossover to using more than I needed it was because at some point it wasn’t (for pain)… The traditional stuff, the dilaudid or the oxycodone, or the oxycontin wasn’t working (so) we just kept moving (the dose) up … I started to see the writing on the wall … when I crossed that line of the fentanyl. … I was afraid of losing the drug … I wasn’t willing to go out on the street. I could feel my doctor … starting to question. I was running out of ways to approach … making the refill (frequency) smaller…’

T.W. knew when he opened the fentanyl patch and placed it under his tongue that he was abusing prescription opioids. He did not want to tell his family, his doctor, nor revealed this to his weekly AA group. Additionally, he never obtained the drugs from the street because he received prescription opioid from his doctor for his pain. While he knew about Narcotics Anonymous, he did not feel he could relate to the group. He stated, “… it’s frustrating trying to figure how to get out… of this. You’re in it. … Where is the safest place to go (that’s) non-judgmental?” He wrote his family a note on his cell phone, took a lot of pain medications and went to sleep, not expecting to wake up.

The next morning he woke up. The trajectory of events that followed his overdose revealed that, his healthcare providers did not know how to care for someone with coexisting substance use disorder and pain. He eventually sought help from an addiction expert, who helped him with his previous alcohol use disorder. See Table 1 for his trajectory following his overdose.

Physician admitted him to the emergency room in hospital #1

In the emergency room, a hydromorphone infusion was initiated

Hydromorphone infusion continued for 4 days.  He stated, “They just kept me completely, as much as I wanted, they gave it to me”

While hospitalized, he used higher doses than he used before the overdose, not sure if he was using the PCA device for back pain or something else

He saw psychiatrist in the hospital, and antidepressant was initiated

Discharged to free-standing pain clinic over a holiday weekend

Pain clinic switched him to oral opioids per their protocol

First week of outpatient care, he went through withdrawal.  He stated, “I’ve never felt like that in my whole life”

He went to hospital #2 for one night

Discharged from hospital #2.  On his own, went to hospital  #3 where he recalled his life was saved when he was admitted for alcohol use disorder years ago

Hospital #3 initiated methadone for a “couple of days” to taper off opioids

Methadone was then stopped and he was prescribed suboxone.  He stated, “…suboxone immediately helped… it was profound”

At the time of this study, his goal was to taper from suboxone eventually

Table 1: Health Care Trajectory of T.W. Following Overdose.

T.W. tried to take his own life, not feeling there was anywhere he could turn to get help neither for his pain nor for his abuse of prescription opioids. When asked what he thought saved his life, he answered, “My family, my God, ‘cuz I took enough that day to die.” Furthermore, his family knew there was a problem but, they were unaware about where to turn to get him help because he was getting the prescription opioid from his healthcare provider, in whom they had confidence, and did not believe he would be harmed or harm himself. He stated, “When I woke up (from the overdose), my will … I really wanted to live.” He commented about his prescription opioid experience.

‘Why would it rob me of my soul like that? It took very little (to take) the will to live away….I believe.. I’ve only used pain medication to help with the pain, but the cross over to using more than I needed, it was because at some point it wasn’t, --- I don’t know... then we just kept moving it up (on the dose).’

Moreover, following his opioid overdose, his family transported him to an emergency room resulting in hospitalization. He stated, “they didn’t put me in the suicide watch area when I went in that week; they just felt I was honest with them, and they felt I was fine”.

Despite his attempted suicide and clear communication about his attempt, the hospital provided no watch, no hold, no addiction specialist consult, and the psychiatrist he was referred to, placed him on an antidepressant medication without a suicide contract nor other follow up interventions. Additionally, the healthcare team at the hospital, following his suicide attempt with prescription opioids, provided this patient with an opioid infusion plus patient controlled analgesia (PCA) for his pain management and he was told to take “…as much as I wanted….”.

For T.W., the risk factors for suicide were his unemployed status because of his pain, his feeling of isolation from his family and his AA group, his change from being a successful contributor to family finances, high doses of prescribed opioids, and a past history of alcohol abuse even though he had been successful in abstaining from alcohol. The depression was not identified and he felt an inability to communicate his emotional status with his healthcare providers, which is similar to an earlier report [9]. However, when he was hospitalized for this overdose, he received medication for depression from a psychiatrist but not before this major event.

Recommendations from T.W. to prevent overdose

The recommendations from T.W. included opioid contracts or agreements, participating in group therapy when receiving prescription opioids beyond the first prescription, creating a regimen for taking opioid. He felt healthcare providers should address the fears of losing access to prescription opioids. Healthcare providers also need to allow more time for patients to share their stories of prescription opioid difficulties.

Opioid contracts are common between the healthcare provider and the patient receiving prescription opioids. The purpose of these opioid contracts is to provide information on the behavioral expectations of the patient while taking prescription opioids, and the actions taken if the behavioral expectations are not met. He had to review and sign opioid contracts with the insurance company, the pharmacy, and the healthcare providers so that “… every time I got something, three parties knew everything.” Since the amount of opioids he received was high, his insurance company required he “talk to a nurse… every time I received a refill.” However no action was taken by these three healthcare systems when the doses and frequency increased. The opioid contracts did not help him while he spiraled out of control.

T.W. recommended that, patients receiving opioids for pain attend mandatory group therapy every 3 weeks to share their concerns or successes about pain management and opioids. “… You miss it, you don’t get a prescription refilled.” T.W. felt these group sessions would offer hope and less isolation because “… someone else has experienced it … lived through it” and would provide an avenue for help when needed. He felt Alcoholics Anonymous (AA) helped his alcohol use disorder but no one at AA would understand a prescription opioid use disorder. Therefore, this group would only focus on prescription opioids.

He recommended during the healthcare encounter, that the fear of losing access to prescription opioids be addressed. He stated his fear of losing access to opioids to treat his pain and not knowing where to get help, led to his overdose. When asked, what the healthcare provider could do to reduce the fear of losing prescription opioids, he stated:

‘I guess for me it would … be a case of just saying,’ “Do you have chemical dependency issues? My goal in asking this question is not to take … the drugs away.” If someone asked me in that way ‘cuz like, again, the fear is having them taken away.

T.W. wanted to share his story of his desperation and the overdose. At the time of this interview, he was stabilized by his addiction specialist and felt this was going well. He commented, “Just share my story, and if there’s one person that I can help then… the pain’s been all worth it.” He had nothing to hide.

Discussion

In his book, The Wounded Storyteller, Arthur Frank [10] referred to listening as a fundamental moral act; yet listening to those, who suffer is one of the most difficult duties for human beings. Illness and treatment take away the voices of the suffering. However, as Frank suggested, stories can create bonds and can heal. As people express their stories, there are two things occurring: (a) the speaker presents how they want to be known in the interaction, and (b) the speaker is self-reflective, independent of the social interaction [11]. From the transcribed text of this interview, there emerged opportunities to take the lessons learned and consider carefully how this may change what needs to be changed. T.W. had lived in a world of chronic pain, sustained multiple surgeries, had been escalated to very high doses of opioids to treat chronic pain, felt fear of losing his opioid and not able to envision the world of being without, and felt such a level of desperation that death was a welcome relief.

Key findings from this case revealed significant gaps in healthcare that led to his overdose. In his narrative, the fear of losing access to prescribed opioids was an important event leading up to the overdoses. In the larger primary care study [8] participants experienced loss of prescription opioids and blamed the media for creating pressure felt by healthcare providers to not prescribe. This finding was confirmed in a recent study, finding media coverage of prescription opioid misuse was slanted towards criminal issues rather than a public health problem [12]. The media has also revealed stories of other individuals, who fear the loss of opioids for pain treatment due to state regulations that limit the number of days a healthcare provider can prescribe opioids for pain [13,14].

People in chronic pain have a higher incidence of depression and suicidal ideation than people without pain [15]. Relevant to the rising rates of prescription opioid overdose, a study by Smith et al. [16] showed that of 153 people with chronic nonmalignant pain, 13% had active thoughts of suicide, 5% had previous attempts, 5% had a plan where most individuals reported drug overdose in their plan. In a retrospective chart review of patients referred to a behavioral therapy pain management program, 25.8% chronic pain patients’ revealed passive suicidal ideation and 2.3% stated active suicidal ideation [15]. T.W. did not reveal his suicidal ideation or his suicide plan and as a result did not receive help for his depression and desperation.

Embedded in his narrative of overdose, was the revelation that high doses of prescription opioids were available for him from his healthcare provider. This is consistent with a landmark study by Dunn et al. [17], which indicated that persons with over 100 mg daily morphine equivalents had a nine-fold increase in overdose risk. Additionally, Liang and Turner [6] showed that both the daily morphine equivalent dose (MED) and the total MED should be carefully evaluated and individualized. Doses greater than or equal to 100 mg MED are dangerous regardless of the overall total dose. However, if the daily MED is 50-90 mg, then a lower overall total dose of <1,830 mg mitigates risk. Despite these studies across large populations showing increased risk for overdose in a dose-response manner, the risk for individuals or sub-populations may vary and requires further research.

T.W described his use of sociable and partially revealing discussions of his opioid use in ways that distracted his healthcare provider away from his problem with prescription opioid misuse. This was consistent with another study of methadone clinic patients who described their use of common distraction and deception in the healthcare encounter when their substance use disorder was out of control [18]. T.W. was frustrated that, the health care providers could not identify his behaviors as signs of problematic use of opioids.

T.W. described a mandatory group meeting for patients who are prescribed opioids for chronic pain, as a means to provide support and identify venues for seeking help if the patient loses control of the opioids prescribed. This is consistent with existing clinical guidelines, which recommended more support for those with coexisting substance use disorder and pain [19-21].

More recommendations by T.W. were about the need for education of the healthcare providers. Healthcare providers are ill-prepared in assessment and intervention of pain and risks for opioid misuse [3,22-29]. The current practice challenges are lack of education of clinicians, and a lack of access to non-medicine modalities for pain management either because of geography or because of insurance coverage. These issues must be addressed in order to balance these two competing mandates of pain and risk for substance use disorder.

Concerns of chronic pain and issues of opioid misuse have resulted in a number of Federal initiatives to try to address the problems of opioid misuse while at the same time promoting high quality effective pain management [30-34]. These initiatives have culminated into guidelines produced by the Centers for Disease Control and Prevention [35] entitled CDC Guideline for Prescribing Opioids for Chronic Pain. The CDC guidelines have influenced local and state regulations in limiting both length of time and doses of prescribed opioids for pain [36-38]. In further efforts to protect the public, the Food and Drug Administration (FDA) has improved access to naloxone. Policy is now rapidly developing to increase accessibility to naloxone, and to have this more readily available to first responders, patients, family members, and community members. The healthcare providers who prescribe opioids would be responsible to additionally provide education to patients and significant support people on the administration of naloxone if overdose occurs [35].

Providing healthcare providers with education on the safe use of opioids has been initiated through Risk Evaluation and Mitigation Strategy (REMS). The purpose of REMS education is to reduce adverse outcomes resulting from inappropriate prescribing while maintaining patient access to pain medications [39]. Thus far, training in REMS has been voluntary, however, federal policy changes have been proposed by the Food and Drug Administration to make this training mandatory for healthcare providers [40]. REMS provides an educational vehicle for reducing inappropriate and unsafe opioid prescribing.

Medication Assisted Treatment (MAT) is an underutilized yet safe and effective way of treating opioid use disorder; reducing fatal overdoses, infectious-disease transmission, and criminal activities; and improving social function [41]. Efforts are underway to expand the availability of MAT to high-risk patients by encouraging public and private insurance coverage of this intervention. Additionally, through the Comprehensive Addiction and Recovery ACT (CARA), prescriptive authority of buprenorphine is now extended to nurse practitioners and physician assistants [42]. These initiatives will increase the number of specifically trained healthcare providers and improve availability of MAT to patients with opioid use disorder to further decrease the harm caused by this misuse or abuse.

In summary, T.W.’s experience of overdose confirmed the importance of educating clinicians on appropriate opioid prescribing to manage pain while minimizing risk for overdose. Monitoring opioid doses to keep patients safe and minimizing risk requires knowledge of evidenced based guidelines including dosing parameters [35,43]. There needs to be an ongoing treatment accountability with a plan to discuss safety and potential for overdose with the patients and their support people identified by the patient. Healthcare providers must be able to identify behaviors that indicate risk for substance use disorder or risk for overdose and be ready to continue to support their patient and refer them for help when needed.

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