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For patients in pain, opioid dependence may be a necessary evil

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Illustration by Jordan Sellergren

It had been about a year since my dad was diagnosed with cancer. He’d had a tumor removed from his heart and hadn’t returned to work. Sitting in an armchair in our living room, watching Wayne Brady on The Price Is Right, my dad seemed stuck in some sort of outpatient purgatory. When I walked into the room, I saw about 15 different prescription drug bottles of various sizes on the coffee table right in reach of where he sat.

Over a commercial break, he extracted from his array a white pill: oxycodone, an opioid painkiller. He put it in his mouth. That’s one. A few hours later, he asked me to bring him a glass of water with fresh ice. He took a sip and relaxed into his seat. He took another pill. It was not yet lunchtime, and he’d already taken two painkillers.

Watching this happen was terrifying. With stories of opioid overdoses coming to light in recent years, I couldn’t help but to think, This is how addiction happens. In 2017, there were 157 opioid-related deaths, with oxycodone and hydrocodone as the cause for the rise in drug poisoning deaths. An audit by the Iowa Board of Pharmacy revealed that 2,042,054 prescriptions for opioids were filled in the state last year. My dad, I learned, had been taking opioids regularly since 2016 and 20 mg of oxycodone daily since the start of this year.

One of the prevailing narratives surrounding the opioid epidemic is that addiction can happen to anyone. A literature review of chronic pain studies shows that as many as 8 percent of cancer patients who are given opioid pain relievers suffer from opioid addiction, though that probability changes when the patient has been on the medication long-term. Risk of overdosing increases sevenfold when the patient has mental health issues such as anxiety, PTSD or depression, all of which are part of my family’s history.

I was constantly worried about enabling my father in any way to develop a dependency on the drug. I began asking how many he took each day and counted the pills in the container if he didn’t tell me. I hesitated to hand him the bottle.

What I didn’t know was that, because my dad had been on oxycodone for so long, a dependence on the drug was likely already there.

Not only had my dad endured more than 20 cycles of radiation therapy, he had three substantial surgeries to remove several metastatic tumors, one that left a seven-inch scar down his chest and another six-inch scar in his abdomen, completing a line from his collarbone to just below the belly button. Over the years, I could tell he was most in pain when he closed his eyes, puffed out his cheeks and held his breath.

Lee Kral is a clinical pharmacy specialist in pain management at the University of Iowa Hospital, where my dad was a patient. She tells me when it comes to pain for those with cancer, opioids are often a requisite. With the nerve damage from radiation or chemotherapy and growing tumors pressing against the body, patients can experience a low baseline of chronic pain.

“We need them to be as comfortable as possible while they go through an incredibly uncomfortable process,” Kral told me. “So the addiction in the cancer patients is kind of a secondary concern. Even if someone had a history of addiction and they had cancer, we could not withhold a pain medication from them. That would just be awful.”

My dad needed the drug, but never had an addiction; the difference between a “physical dependence” and an “addiction” is that the latter is a condition that implies a person compulsively consumes opioids without regard to negative consequences. However, the American Academy of Addiction Medicine writes, public health information does not offer a definitive consensus about the difference.

Illustration by Jordan Sellergren

In 2016, the Centers for Disease Control and Prevention issued a set of widely circulated guidelines that raised the red flag about overprescription. Healthcare providers now concerned about patient reviews and lawsuits have stopped prescribing opioids or are dispensing lower doses, according to the Pain News Network. Lawmakers across the nation implemented policies to cap the duration of patients’ opioid use and the amount prescribed. Patients with chronic pain are already beginning to bear the costs.

At the same time, physicians excessively prescribing opioids have put more pills into unregulated circulation — the effects of which Sarah Ziegenhorn, director of the Iowa Harm Reduction Coalition, witnesses while working with clients who have overdosed on prescription opioids. Many of the clients Ziegenhorn sees have never been prescribed opioids and never had chronic pain, but rather have what she calls “emotional pain.”

Ziegenhorn says the narrative that addiction happens to anyone, like a flu or “viral infection that doesn’t discriminate,” isn’t really the case.

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“There has been this demonizing of the medical use of opioids in general and it piques a lot of fear in patients’ thinking,” she said. “I do talk to cancer patients sometimes who do have pain, or [patients with] sickle cell pain or something quite severe, and they say ‘I can’t take an opioid, I don’t want to become a drug addict.’ It’s important to have more of an understanding of what the process of becoming addicted to a drug looks like and who does that happen to.”

Who does addiction and overdosing happen to? Research shows that while certain conditions do increase the vulnerability of an individual to addiction, opioid addiction is a brain disease that biologically can happen to anyone. Public health research regards social determinants such as poverty, class, racism and social isolation as influencing an individual’s ability to mitigate drug-related harm. Indeed, a survey of victims shows the same: Rates of overdoses and overdose deaths are fastest growing among Indigenous and African-American people. Compared to other patient populations, overdose deaths are more common among those who are Medicaid-eligible. In general, many overdoses are also suicide attempts.

In the end it was tumors that took my father’s life — not the opioids, not an overdose. In some ways, cancer is a foe to which people are much more empathetic, because it’s understood as an illogical, malicious force, not the cause of a human “failing,” as addiction is still too often seen.

The luxury of thinking long-term about the future and a return to health alludes so many. My father believed he would beat cancer and used painkillers to survive another day. Addiction wasn’t a concern to someone who could imagine a time when he might recover and return to a stable, happy life.

Ziegenhorn says anyone with a chronic condition — cancer and addiction alike — should receive treatment that follows a philosophy on which all long-term case healthcare providers agree, one that approaches treatment “day by day.”

For cancer patients, this might look like a reevaluation of daily priorities. Kral said questions assessing the need for painkillers might range from “Are the symptoms especially severe today?” to — for terminally-ill patients — “What medication will allow me to express my last sentiments?”

For those who do not suffer from chronic pain but repeatedly abuse opioids, Ziegenhorn suggests caregivers help victims rebuild a sense of agency in their lives, treating them with respect, providing them with buprenorphine, characterizing them beyond criminality and having conversations about hope.

Both approaches try to help sick people hold on.

Shirley Wang grew up in Iowa City and recently graduated from Tufts University. She now works as a freelance writer. She hopes you’ll tell someone you love them today. Follow her on Twitter at @shirleyshirlw.

Upcoming events by the Iowa Harm Reduction Coalition

Volte-Face

Gabe’s — Friday, Aug. 31 at 5 p.m.

Held in recognition of International Overdose Awareness Day, this IHRC fundraising event will feature a silent auction, collaborative memorial and free naloxone training (naloxone, also known as Narcan, blocks the effects of opioids and can prevent overdose). There will be performances by Sinnerfrenz, Zuul, Astrodome, Liv Carrow, Brooks Strause, DJ A to the K. Cost of entry is a suggested donation between $10-20. (Little Village is a co-sponsor of this event)

Harm Reduction Summit

Various locations in Iowa City — Monday-Friday, Sept. 24-28

In partnership with the University of Iowa Carver College of Medicine, the IHRC is hosting their third annual summit over five days, Sept. 24-28. Workshops feature speakers from Dr. Dan Ciccarone of the University of California San Francisco, currently studying heroin use and its roots in the opioid pill epidemic, to Iowa Sen. Joe Bolkcom.

Discussions held Monday-Thursday are free and open to the public:

  • Harm Reduction and Syringe Service Programs (12 p.m. Monday, MERF 1110)
  • Wound care and abscess clinic (6 p.m. Monday, MERF 2117)
  • Sex Worker Health (12 p.m. Tuesday, MERF 1110)
  • Advocacy Workshop (6 p.m. Tuesday, MERF 2117)
  • Safe Environments and Overdose Prevention (12 p.m. Wednesday, MERF 1110)
  • Distinguished Lecture: The Roots of the Opioid Crisis & the Solution of Safe Consumption Spaces (7 p.m. Wednesday, Old Brick)
  • Understanding the Structural Determinants of the Opioid Crisis (12 p.m. Thursday, MERF 1110)

Friday’s all-day conference requires pre-registration (cost: $40). You may choose one of three tracks: Syringe Exchange, Hepatitis C Treatment and Overdose Prevention.

Safe Shape
In conjunction with the summit, a traveling “pop-up” exhibit will be set up on the Ped Mall, across from FilmScene, from Wednesday to Friday, Sept. 26-28. Safe Shape models a 10-by-10-by-10-foot drug consumption room, also known as a supervised injecting facility — a safe space where users could inject drugs under medical supervision, with clean supplies and without fear of persecution. Studies from Europe have shown these types of facilities reduce overdose deaths and the spread of disease, but they are currently illegal in the U.S.

This article was originally published in Little Village issue 248.


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