Unintended consequences: Inside the fallout of America’s crackdown on opioids

COLVILLE, Wash. – The morning of the long drive, a drive he took every month now, Kenyon Stewart rose from the living room recliner and winced in pain. He looked outside, at the valley stretching below his trailer, and again wondered whether it was getting time to end it. He believed living was a choice, and this was how he considered making his: a trip to the gun store. A purchase of a Glock 9mm. An answer to a problem that didn't seem to have one.

Stewart is 49 years old. He has long silver hair and an eighth-grade education. For the past four years, he has taken large amounts of prescription opioids, ever since a surgery to replace his left hip, ruined by decades of trucking, left him with nerve damage. In the time since, his life buckled. First he lost his job. Then his house, forcing a move across the state to this trailer park. Then began a monthly drive of 367 miles, back to his old pain clinic, for an opioid prescription that no doctor nearby would write.

"It's 10 after," reminded Tyra Mauch, his partner of 27 years, watching him limp over to her.

"Got to go," he said, nodding.

He hugged her for a long moment, outside the bathroom with the missing door, head full of anxiety. He knew what awaited him on the other side of the drive. Another impossibly difficult conversation with his provider, who, scared by the rising number of opioid prescribers facing criminal prosecution, would soon close the pain clinic. Another cut in his dosage in preparation for that day. More thoughts of the Glock.

The story of prescription opioids in America today is not only one of addiction, overdoses and the crimes they have wrought, but also the story of pain patients like Kenyon Stewart and their increasingly desperate struggles to secure the medication. After decades of explosive growth, the annual volume of prescription opioids shrank 29 percent between 2011 and 2017, even as the number of overdose deaths has climbed ever higher, according to the IQVIA Institute for Human Data Science, which collects data for federal agencies. The drop in prescriptions has been greater still for patients receiving high doses, most of whom have chronic pain.

The correction has been so rapid, and so excruciating for some patients, that a growing number of doctors, health experts and patient advocates are expressing alarm that the race to end one crisis may be inadvertently creating another.

"I am seeing many people who are being harmed by these sometimes draconian actions amid this headstrong rush into finding a simple solution to this incredibly complicated problem," said Sean Mackey, the chief of Stanford University's Division of Pain Medicine. "I do worry about the unintended consequences."

Chronic pain patients, such as Stewart, are driving extraordinary distances to find or continue seeing doctors. They are flying across the country to fill prescriptions. Some have turned to unregulated alternatives such as kratom, which the Drug Enforcement Administration warns could cause dependence and psychotic symptoms. And yet others are threatening suicide on social media, and have even followed through, as doctors taper pain medication in a massive undertaking that Stefan Kertesz, a professor at the University of Alabama at Birmingham who studies addiction and opioids, described as "having no precedent in the history of medicine."

The trend accelerated last year, in part as a result of guidelines the Centers for Disease Control and Prevention (CDC) published in 2016. Noting that long-term opioid use among patients with chronic pain increased the likelihood of addiction and overdose, and had uncertain benefits, they discouraged doses higher than the equivalent of 90 milligrams of morphine.

The guidelines, criticized as neither accounting for the differences in how quickly patients metabolize opioids nor addressing clearly enough what to do about patients who were receiving more than 90 morphine milligrams, helped open a new era of regulation. Dozens of states, Medicare and large pharmacy chains such as CVS have since announced or imposed restrictions on opioid prescriptions. The Justice Department, in a continuing push to crack down on pill mills and reckless doctors, announced in January that it would focus on providers writing "unusual or disproportionate" prescriptions. And some physicians, fearful of the financial and legal peril in prescribing opioids, and newly aware of their hazards, have stopped prescribing them altogether.

"We have to be careful of using a blunt instrument where a fine scalpel is needed," said former surgeon general Vivek Murthy, who prioritized the opioid crisis during his tenure, and wants to increase access to alternative treatments. "We already experienced a pendulum swing in one direction, and if we swing the pendulum in the other direction, we will hurt people."

Stewart, who said he hurt more every day, let go of Tyra. "See you Friday night," he whispered to her. "Like always."

He went outside to his truck. He checked for the third time that his near-empty pain medication bottles were in his duffle bag. Zipping the bag, he sighed. What he had left – five pills – would never last him until his next refill, two days from now. The pain, the withdrawal: All of it was only hours away. It would hit during the drive. He knew it.

How much longer could he keep doing this? How much longer could he afford to blow $900 a month – on gas, food, two nights in a motel, and pills for which he had no insurance? How much longer could he drive so many miles for less and less?

Something had to change.

But for now he started the truck, pulled out onto the mountain road, and then one mile was down, and there were 366 to go.

He drove a gray Ford F-150 with a jacked-up cab, oversized tires and a custom grill. It felt good to be behind its wheel, remembering the man he had once been, the one who'd made the money to buy it. That guy had been a self-employed trucker with braided hair and so much energy it sometimes irritated those around him. Medical supplies, beef jerky, electronics – he'd load anything he could into his Roadrunner freightliner, then unload it across town. He lived in a big house in a Tacoma suburb and spent whatever came in, never considering that his hip would be shot from the heavy lifting by age 45, and that the surgery to replace it would go so wrong that he'd awaken screaming in pain, terrified that the life he had known was gone.

Twenty-eight miles down.

He pulled into a gas station, got a cheap cup of coffee. He filled his tank, then cursed. The gas tank door wouldn't close. He tried slamming it. And again.

"One more thing," he said, laughing caustically, and got back into the truck.

The first thing had been the pain. After the surgery, he said, it had felt like a knife dragging down his leg from his hip. He initially wanted revenge, so he said he called malpractice lawyers, but was told his damage wasn't severe enough to successfully sue. Then he just wanted the agony to go away, but it was 2014, and reports of an opioid epidemic were all over the news. Doctors who had once treated pain like a vital sign, basing opioid prescriptions on patients' subjective ratings of their suffering, were suddenly hesitating. Attempts to address a crisis of undertreated pain had created a new crisis, this one of addiction, and Stewart quickly noticed suspicion not just among doctors but among friends and relatives, too. Did he really hurt that badly? Had he tried exercise? What about Advil? Maybe he just needed more rest.

The first person who truly listened to him, besides his mother and Tyra, was Aileen Wedvik, a nurse practitioner in a small clinic near his house. "My savior," he called her. She still believed in treating patients according to the pain they said they felt, and he told her he felt a lot of it. She asked him to consider using marijuana and recommended physical therapy. But when the marijuana failed, and the co-pays from therapy became too expensive, she wrote prescriptions. She started him off on a daily dose of 30mg oxycodone and 12mg Dilaudid, equal to 93 morphine milligrams, then inched him up, month by month, until he told her he could function.

The first daily regimen that worked – 173 morphine milligrams – felt like creamer diluting bitter black coffee. He made his trucking routes, cared for Tyra, who has advanced multiple sclerosis, and his optimism returned. He didn't worry when his tolerance grew, and the pain resurged, and he was inched up to 436 morphine milligrams. Or when Tyra, who had always refused opioids herself, got angry at Wedvik for prescribing him so much. Or when, years after that first prescription, he was ultimately swallowing 584 morphine milligrams per day – more than six times the CDC recommended ceiling. He was still driving his truck, still making money. He wasn't a loser, not yet.

Outside the car window, the scenery went by, a wash of greens and blues then browns as he crossed into the state's arid center, where there was nothing but brush, giant silos of wheat, bundles of hay and windmills slowly turning in the sun.

Stewart had been making this monthly drive since last June, starting weeks after he said a medical examiner noted his extraordinary opioid use and declined to renew his commercial driver's license. He remembered the lost look on Tyra's face when he said they needed to sell the house, that they'd never make the final $33,000 in payments. They talked about getting off the pills, but what about the pain? So they sold the house for $290,000, immediately losing one-third of that – to closing costs, the bank, and their move to the trailer, where a relative lets them live for free, and where they'd soon be trapped, if he continued spending what little they had left on this drive.

One-hundred and 69 miles.

He could feel it now. The pain had begun as a tingle, then needle pricks, then a throb coursing through his left leg, as he pulled off I-90 and stared at the worst part of the drive. Route 18 was frozen with traffic. His heart was going fast. He was thinking about his last pills – three 8mg Dilaudid and two 30mg oxycodone – but knew he had to ration.

He tried to let in a blue SUV with its blinker on, but it didn't change lanes.

"Dumbass," he said, speeding up.

Then came a thought. He could drink a beer. A little alcohol helps. All he had to do was find a gas station. But he knew what could happen. He could fail his urine test. The pain clinic could then kick him out for violating an agreement he'd signed promising that he wouldn't mix the medication with alcohol, would submit to pill counts, and would treat opioids like "a loaded gun," storing them where only he could get them.

He called the clinic, listened to the message saying, "We are no longer accepting any pain management referrals," and the receptionist picked up.

"How do I put this?" he said. "Am I going to get pee-tested tomorrow?"

He gripped the wheel so tightly that his knuckles turned white.

"I want to have a beer," he said. "I need something."

He heard her saying, "I'm sorry." She couldn't answer his question.

"You know me," he pleaded, laughing nervously. "If I had a beer . . ."

"Have you found another pain clinic yet?" the receptionist, Jennifer Perkins, asked.

He hadn't. A year of searching, and he hadn't.

"Because, you know, in July she's not going to be doing this anymore," she said.

"I know," he said, looking at the traffic, cars pressing in from every direction. "Believe me, I know."

He hung up the phone, finished his bottle of water in one gulp and crushed it between his hands.

Twenty-one miles away, the receptionist walked over to Aileen Wedvik's office and told her that Kenyon Stewart had just called. He was thinking about drinking a beer. It sounded as if he was coming apart.

It was a call that had become more familiar, as Wedvik tapered 325 pain patients, some by 50 percent, others by 90, to bring them within the CDC guidelines. When she'd first told Stewart and the others that she was leaving pain management, they had seemed to understand. Providers had gone to prison, lost their licenses, faced lawsuits. She already had received two complaints of excessive prescribing, both from insurance providers. The state had substantiated neither, but she couldn't deal with the stress of it anymore, so come June, she'd explained, she'd write the patients three final prescriptions, and then they would be on their own.

It was months later now, and the effects of the taper had set in, and not a single patient had found another doctor to take over their opioid regimens, Wedvik said, and they no longer seemed to understand. Stewart's prescription already had been cut by 276 morphine milligrams, and others were struggling to walk, including one woman hobbling into her office, shoulders hunched.

Maggie Reygers, 57, sat down, grimacing in pain from a work injury that had herniated five discs in her spine. She said, "I've had a really bad month." She said, "I'm just so angry." She said, "You want to talk about pain? Please kill me."

Wedvik handed her a nearly empty box of tissues. This isn't what she got into medicine to do, she had been thinking. She wanted to help people, and her job had once felt like that. Many patients had been desperate when they found her. No one, they had said, would adequately treat them. So she tried to, and even though the dosages sometimes became very high, she trusted the patients, and the clinic's rules to expose drug seekers, and that she was in fact helping, although these days she wasn't sure.

"What did I do to have this happen to me?" next pleaded E.J., a 43-year-old paraplegic shooting victim who allowed a reporter to attend his appointment on the condition that he be identified only by his initials. "I've had a great increase in my lifestyle by using [opioids], and without them, I'm just a loser on the couch."

"It's just a matter of time before I have to be going through a bottle or two of Excedrin in a day," later said Kevin Johnson, 56, a trucker whose lower back was injured in a traffic accident.

"I'm not sniffing it up my nose or shooting it in my arm," Rose Kidd, 54, who has nerve damage from back surgery, now begged. "It's monitored."

Which one was addicted? Which one was dependent? Whose pain was real? Whose pain wasn't?

These were the questions, the nuances and ambiguities, that Wedvik navigated every day at a time when opioids were increasingly cast in absolutes: that to use them at all was to become addicted. But experts increasingly recognize this as a conflation of two separate things. It is true that opioids cause physical dependence, and that higher doses are needed to achieve the same effect as tolerance grows, and that, when the dose falls, withdrawal symptoms may include pain that is difficult to differentiate from the underlying condition. But not everyone develops addiction, which Nora Volkow, director of the National Institute on Drug Abuse, described as a brain disease that weakens self-control, incites intense cravings beyond physical dependence and occurs "only in a small percentage of people." It is the "continued use of opioids despite harmful consequences in someone's life," Scott Gottlieb, commissioner of the Food and Drug Administration, said in a statement last year.

Wedvik worried about the consequences of taking them away, too. Telling her staff that she was closing the pain clinic, she had said, "I will be shocked if we make it through this without anyone dying." She knew chronic-pain patients were a particularly vulnerable group. Scientists have shown they're twice as likely to commit suicide, and what little research has been done on forcibly tapering opioid regimens has been troubling. One study, published last year in the journal General Hospital Psychiatry, tracked 509 military veterans involuntarily taken off opioids. It reported that 12 percent had suicidal ideation or violent suicidal behavior, nearly three times the rate of veterans at large.

She also knew about the hysteria in online chronic-pain forums. People were threatening to kill themselves because they couldn't get medication. News articles about pain patients who had done it were being passed around on the Internet. "My wife committed suicide in October as a direct result of this," said Wes Haddix, a retired dentist in Charlottesville. One doctor, Thomas Kline of Raleigh, North Carolina, recently came out of retirement and is reaching out to suicidal pain patients. "They write me, 'Help me, I'm going to kill myself. What can I do?' " he said, echoing conversations that were ongoing in Wedvik's office, too.

Some discussed it overtly: "I'll be here for six months," one man had said, "and then I'll commit suicide."

Others subtly: "I don't want to kill myself," said Karla Friend, a slight woman of 54 years. "But . . ."

Then there were patients such as Kenyon Stewart. Wedvik didn't know about the Glock. But when he came into her office later that day, and was looking at her from across the desk, eyes red, hair disheveled, leg shaking, she knew something was very wrong.

"Can we have a talk?" Stewart said.

The evening before that appointment, Stewart limped into a cheap motel room. He downed a pill, then drove to a gas station, coming out with a six-pack of Natural Ice beer. He quickly drank one, felt better, and went to his old house, a brown two-story with big picture windows. In the falling light, he watched it for a long while from a church parking lot.

Hours later, he couldn't sleep. This was it, he worried. He'd screwed up. They were going to drug-test him, then cut him off.

He texted Tyra, but didn't tell her he was having a panic attack.

He chopped an oxycodone and a Dilaudid in half and took them.

He got up at 6:30 a.m., having slept for less than an hour, swallowed the other halves, and elevated his bad leg on a malfunctioning heater.

How much longer could he keep doing this?

His appointment with Wedvik was at 1:20 p.m., but he came in half an hour early. He crouched over the patient form in his hands, wondering whether to answer the questions honestly. "Over the last 2 weeks," it asked, how often had he felt "hopeless . . . bad . . . that [he was] a failure?" His pen went from "nearly every day" to "several days." He next read, "Thoughts that you would be better off dead." He marked "not at all," and handed the document to Perkins, the receptionist he'd spoken to on the phone.

He joked with her, asking her about her 13 tattoos, before coming out with the question, as casually as he could:

"Do I get to pee today?"

She said he wouldn't have to, and he breathed in sharply, deeply.

He walked unsteadily toward Wedvik's office, where she was seeing off a short-haired woman, who looked as though she'd been crying and who would attempt suicide a week later. He sat down and stretched out his bad leg. Holding his glasses in one hand, he leaned forward.

Wedvik folded her hands and leaned forward herself, her face just a few feet from his.

"Do you remember what I was getting a long time ago?" he said of his prescription before the taper, voice thickening. "Is there any way you can do that one more time? Then cancel me off the program?"

He told her he couldn't do this anymore. The drive. The money. The anxiety. He'd like his final prescriptions, and have that be that.

She looked at him for a long time. She'd known him for four years, longer than most of her patients. She'd been with him through it all: the pain, the failed attempts at other treatments, his partner's descent into illness, his unemployment and his move across the state. She'd never seen him so broken.

Doing what he asked, however, would go against her patient plan. Six months of aggressive tapering, with office visits ending June. Then three final months of prescriptions. This was far ahead of schedule.

"You're going to knock me down anyway," he pleaded.

What was the humane thing to do? Cut him loose? Or force him to drive back to see her again?

She sighed and said, "Oh, God."

She turned to her computer. The sound of keys clacking filled the room.

Stewart was breathing louder and louder. His face was getting red. He was sniffling. Then he suddenly he stood, opened the door and hurried into the bathroom across the hall.

Looking down at her scuffed and worn desk, she listened to the sobs and heaves coming from the bathroom.

"Twenty percent per month," she told him when he returned, explaining how to taper himself. She handed him three monthly prescriptions of his opioid regimen at its height of 584 morphine milligrams, which could be filled only one at a time, hoping it would last long enough for him to taper himself off high-dose opioids. "Five percent per week. Just be careful."

He tried to say something but couldn't.

"You're not thinking of doing anything, are you?" she asked.

He shook his head.

"Promise?" she said.

He did. Then he picked up what they both believed would be the last prescriptions for opioids he'd ever receive, and Wedvik watched him go, before bringing in the next patient on her list.

He sat outside the grocery store pharmacy, the only one that he knew would fill his prescriptions, and tried to get himself under control. He closed his eyes. He thought of the gas-tank door he'd have to replace. He thought of the truck bed he had to clean. Anything except what had just happened. He splashed water on his face and looked in the mirror. Bloodshot eyes looked back. Taking one more deep breath, he dropped off his prescription, and the next morning, when it was time to pick up the medication, he was 14 minutes early.

He told the pharmacist this would be his last time. His pain clinic was closing, and he was on the other side of the state.

"So are you finding a different doctor, or is that hard?" the pharmacist asked.

"It's not hard," Stewart said. "Just impossible."

After a suspicious look, and a call to Wedvik's office, out came medication for one month: two pill bottles, one containing 240 oxycodone 30mg, the other 210 Dilaudid 8mg. The register said $478.74, and he paid in cash. One minute and 38 seconds later, he was in his truck, swallowing two of each.

The truck came alive, and he steered for the mountains. The green and clouds were soon behind him, and only brown and sun lay ahead. He drove hour after hour, rest stop after rest stop, through a country that, on this same day, was undergoing another set of reckonings over prescription opioids.

In Florida, a jury was finding a doctor guilty of five federal drug charges, including conspiring to possess and distribute prescription opioids.

In Pennsylvania, the governor was absorbing criticism that he wasn't combating the opioid crisis after he vetoed a bill that would have regulated drug prescriptions for injured workers.

In Montana, U.S. Attorney General Jeff Sessions was telling an audience in Billings that doctors prescribed too many opioids, and that "we're going to target those doctors."

And meanwhile, in Washington state, on the side of a mountain 48 miles south of the Canadian border, Stewart was putting two bottles stuffed with opioids into his pocket and heading into his trailer.

"I missed you," he said, hugging Tyra. "I missed you so much this time."

He let her go and went into his bedroom, overrun with things that fit in their old house but not here. He reached up into the closet and placed the pills in an alcove at the top of his closet, where he thought nobody would think to look. He changed into shorts, grunting in pain, then went outside to look at the trailers along the dirt road.

Tomorrow, he would wake early and divide his medication, placing the week's tapered ration into a plastic baggie. He would get on the computer and unsuccessfully try to buy kratom, which Wedvik had recommended. He would consider the Glock, then push the thought out of his head. "It's going to be hard," he would tell Tyra of what awaited, and she would respond, "We've been through worse."

But in this moment, he kept looking out into the valley, the mountain casting a long shadow across half of it.

An elderly neighbor came out and saw him.

"Did you just get back?" she asked, and he nodded.

"Got to go back again?" she asked.

"No more," he said, turning to head back inside. "I'm done."

He limped for the stairs and closed the door behind him, as the shadow outside began to move across the rest of the valley.