How one man got off prescription opioids and got his life back
[Originally published on November 3, 2017]
By Dr. Brian Goldman
In 2016, opioid-related overdoses killed more than 2,800 Canadians and more than 59,000 Americans, and last fall,U.S. President Trump declared the opioid crisis a public health emergency.
With so much attention focused on the number of casualties, you might get the impression that death is the only exit. Except that it isn't. I learned that a long time ago, when I had an office practice in pain management. I saw a woman about 50 years of age. I started her on opioids, and slowly increased the dose, until one day, she stopped coming.
Six months later, she came back to say she had weaned herself off the opioids because she didn't like the way they made her feel.
At the time, I thought I knew a lot about opioids. I was one of the first doctors in Canada to prescribe them for chronic pain. I helped write prescribing guidelines. And, I taught lots of physicians in lectures and workshops that were sponsored by Purdue Pharma, the makers of OxyContin, OxyNeo and others.
I was wrong about the risk of opioids and chronic pain. As I have said and written before, I was wrong to accept money from a drug company to teach colleagues about the company's products. And I was wrong about my patient. I thought that taking her off opioids was removing her last, and best hope for pain relief. My patient thought differently, and, looking back, I'm glad for that.
Physicians spend a lot of time learning medicine by cracking open textbooks. But sometimes, the most effective lessons come from patients such as Kirk Foat. A few months ago, Kirk contacted our show with quite the tale of a serious injury that got him started on opioids, and an even more incredible story about how he managed to stop.
His story begins early in 2008, on the Dutch Caribbean island of Curaçao, where Kirk and his wife Anna were on vacation. Kirk accepted an invitation for a night out, but when he arrived, he believed he was being set up to be robbed, or worse. He badly injured his right hand while managing to escape.
"While running for my life, I pulled myself up a rusty fence and severely cut my right hand on security spikes as I flipped myself over to land on the other side," Kirk recalls. "The group was in pursuit and I had to think quickly to survive."
Kirk managed to hide out from his would-be captors. The next day, he returned to his home in London, Ontario, where doctors feared they might have to amputate his badly-damaged and infected hand.
"It took four surgeries to rebuild and save my right hand," says Kirk.
Kirk's injuries and the operations needed to rebuild his hand left him in a lot of pain. By May 2008, he was taking OxyContin and Pregabalin (Lyrica) for his pain.
When I had my office practice in chronic pain, I saw many patients just like Kirk. At the time, I saw opioid therapy as a way to improve a patient's quality of life, and in some cases, enable them to return to work. Kirk thought differently about opioids. While it was good to have some pain relief, he experienced many side effects that greatly affected his quality of life. The opioids took away his clear thinking.
I just kind of lost myself in this veil of opioids . - Kirk Foat
"It's just a cloud. You're numb. It was affecting my memory. It was affecting my being sharp and fast."
They made him feel depressed, and lowered the testosterone level in his blood stream, making it difficult for he and Anna to start a family. They now have two sons — Dylan and Jack.
Kirk says he made his first attempt to get off opioids in April 2011.
"I had been urged by my doctor," Kirk recalls. "But I was not given any information or support about what to expect or how to best accomplish this goal."
Kirk was taking 120 mg of OxyContin per day at the time. He reduced the dose by 30 mg a day, but his pain shot up, and he experienced withdrawal symptoms. He went back up to the dose he had been taking before trying to cut down.
He tried every non-opioid option he could to try and control his pain. A neurostimulator implanted in his spine didn't help. He tried methadone as a pain reliever, but stopped it after falling asleep behind the wheel of his car on two occasions.
"I felt my medication was increasing my pain," says Kirk. "I was at the end of the road. I had tried everything and nothing worked. I knew that the medication was becoming less and less effective and I knew it was having detrimental effects on my life."
Kudos to Kirk Foat for recognizing something that often takes physicians a long time to recognize. What he was experiencing is known as opioid-induced hyperalgesia. Basically, the opioid medication that is supposed to relieve pain has the opposite effect of increasing it. The problem is real, though the reasons for it are unclear.
The two greatest factors in Kirk's decision to quit opioids once and for all were his young sons, Dylan, 4, and Jack, 6.
"I didn't want my children exposed to a random pill that they pick up off the ground and swallow," says Kirk.
I didn't want my children to remember me as a dad who was in bed every weekend.- Kirk Foat
Decision made, Kirk needed a plan. He went to his family doctor, who suggested he take Suboxone. It's a combination pill containing buprenorphine and naloxone. Like methadone, the drug reduces the withdrawal effects of opioids. Doctors say it is safer and less likely to be abused than methadone, but Kirk didn't want to try it.
"Throughout all the medications I had taken over the years," he says, "I became a good researcher and read that getting off Suboxone was close to impossible. I didn't want to trade one medication for another."
Here's the thing: when he told his doctors and nurses of his plan to get off all pain relievers, their responses ranged from doubt to tepid support that he would be able to pull it off. Kirk could have taken the hint, and kept taking his prescribed medications. Instead, he learned from his failed attempt to get off opioids in 2011. He figured the withdrawal symptoms — sweats, muscle aches, tremors and diarrhea — would be milder and more manageable if he tapered his medication as slowly as possible.
At the time, he was taking four tablets of long-acting oxycodone three times a day — 12 pills per day. For the first dosage reduction, he went down to 11 pills per day, and gave himself three weeks to get over the withdrawal effects.
"It's exactly what you think of when you see people in the movies detoxing," says Kirk's partner, Anna. "Every three weeks for seven months, he would have this weekend of vomiting and sweating and a week of not feeling well. Then, he'd have a week of feeling kind of sort of normal, and then a week of gearing himself back up to do it again."
Kirk did that while never missing a day of work as a consultant to Ontario Lottery and Gaming Corporation. In September of 2016, seven months after beginning his self-imposed tapering regimen, Kirk was off all of his opioid and non-opioid pain relievers.
After that, Kirk came across a book and an app called My Opioid Manager. Both have information he says he could have used when he weaned himself. Both are written by Dr. Andrea Furlan, a pain expert who led the team that wrote the 2017 Canadian Guideline for Opioid Therapy.
At the pain clinic where she works, Dr. Furlan says she is spending most of her time these days taking patients with chronic pain off opioid pain relievers. She calls it "opioid de-prescribing."
"Every patient on long-term opioids deserves a trial of tapering," says Dr. Furlan. The pain doctor uses a number of techniques, including Kirk's method of slow tapering. She also switches patients to a different opioid to control pain while tapering. Suboxone is also an option. But the slow taper is the most important technique.
"I tell my patients that for every year that you have been on opioids, let's give one month to do the taper," she says. Five years on opioids means a five-month taper. The longer the time on opioids, the longer the taper.
"I've had patients who were on opioids for 15 years, and I told them the tapering is going to take 15 months," she says.
Hard to believe, but Dr. Furlan says she's had patients who have quit opioids after taking them that long — 15 years.
The trouble is, doctors have gotten good at prescribing opioids and raising the dose, but they aren't being taught how to de-prescribe.
"It's almost like they learned how to drive pressing the gas pedal," she says. "But nobody ever showed me where the brake pedal is."
When he tapered off opioids, Kirk's pain did not go away. But he says his regular "standing pain" is better. When he's doing physical activity, like shovelling a driveway or playing with his kids, it can be worse than when he was on opioids. The difference is, now he has tools — such as meditation and exercise to help him through. For the inevitable spikes in pain, Dr. Furlan also recommends similar techniques: hypnosis, meditation and stretching.
Today, Kirk doesn't take anything stronger than Tylenol or Ibuprofen to combat his pain.
When Dr. Furlan heard Kirk's story, she figured she could learn from him. I agree. All doctors who prescribe opioids for chronic pain have much to learn from Kirk. So do patients who take opioids, and who might fear tapering.
I'm not saying that doctors should never prescribe opioids to patients with chronic pain. I am saying they don't work for everyone, and they aren't nearly as effective as we had hoped they would be.
Doctors who want to prescribe opioids need to take a course in de-prescribing. And Kirk is the perfect patient to tell them that there's empowerment in a slow taper, and life after opioids.