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Dreamland: RA & The Opiate Epidemic

I just finished a fascinating book about the “opioid epidemic” our country is currently embroiled in: “Dreamland: The True Tale of America’s Opiate Epidemic” by Sam Quinones. Quinones, a journalist and former reporter for the L.A. Times, has meticulously researched the origins of America’s addiction to opiates–from the explosion of “pill mills,” and legally prescribed painkillers (the introduction of OxyContin in particular) in the 1990s, to Mexican black tar heroin that’s infiltrating numerous U.S. cities today–to help others really understand why and how this problem began.

As a chronic pain patient who lives with serious pain on a daily basis, this issue affects me personally because I often need to rely on opiate painkillers for relief during RA flare-ups. During the last three years or so my RA has not been stable or well-controlled, which has basically forced me into going to a pain management clinic to help deal with the pain. The clinic requires all patients to actively participate in their multidisciplinary program: doctor check-ups, physical therapy, psychological counseling, and any other pain-related treatments (ex: trigger point injections).

My opiate prescriptions are strictly controlled and monitored through the pain clinic I go to once a month. I’ve also signed a pain contract, which basically lists several rules I need to abide by in order to continue going to the clinic and receiving my hydrocodone prescriptions. If I don’t follow them exactly, then I’m kicked out of the program and the clinic. I almost suffered that fate once when I was prescribed cough syrup with codeine when I had the flu and I forgot to report it to my doctor. Cough syrup? Yes, even that. I can remember only a few years ago when all my rheumatologist had to do to refill my pain medication was call it in to my pharmacy. Those days are long gone; now you need to have the paper prescription in your hand and jump through a bunch of hoops and red tape to get relief.

Tougher opioid prescription guidelines

I do realize why the medical profession has become much tougher on handing out opiate prescriptions to patients lately; way too much addiction and abuse of these drugs (Vicodin, Percocet, OxyContin) has happened and continues to happen. People are dying in record numbers from overdoses.

According to Quinones, “Overdose deaths involving opiates rose from ten a day in 1999 to one every half hour by 2012. Abuse of prescription painkillers was behind 488,000 emergency room visits in 2011, almost triple the number of seven years before.”

One overdose death every half hour?! Throughout the book, Quinones writes extensively about how addictive and dangerous opiate drugs are and just how widespread the addiction problem is. The statistics of use, abuse, and drug-related deaths are staggering. Especially disturbing is the prevalence of opiate users who become addicted to prescription painkiller medication and then begin abusing heroin. The more I read about these things, the more anxious and disturbed I felt.

“Dreamland” is a carefully researched and gripping, page-turner of a book, yet it’s freaking me out somewhat that I could be one Vicodin pill away from shooting up heroin under a bridge. I realize how ridiculous this sounds and I know I need to calm down, but in all seriousness, this nation-wide “crisis” is frightening. It’s scary how quickly people can become addicted to this powerful “morphine molecule,” as Quinones calls it. Mainstream media has also jumped on the story, spreading tales about all of the people who are supposedly dropping like flies from taking some form of opiates.

According to the Centers for Disease Control and Prevention (CDC)’s website:

“Past misuse of prescription opioids is the strongest risk factor for starting heroin use – especially among people who became dependent upon or abused prescription opioids in the past year. This indicates that the transition from prescription opioid non-medical use to heroin use may be part of the progression to addiction.

  • More than nine in 10 people who used heroin also used at least one other drug.
  • Among new heroin users, approximately three out of four report having abused prescription opioids prior to using heroin.”

Quinones provides similar troubling statistics in his book, so it’s no wonder I’m suddenly paranoid I’m going to end up an addicted, arthritic junkie. I brought up my concerns to my integrative doctor at my last appointment, and she is someone whom I really respect and trust, so I feel some relief after our conversation. She listened carefully to my fears after reading the book and then assured me that I was not an opiate addict or abuser. She also didn’t feel I was at risk for addiction based on my adherence to dosage and participation in the pain clinic. She also knows that I’m a huge worrier and helped bring me back to reality a bit.

However, even though prescription opiate pain medication is something that I currently take, off and on (more “on” lately), to help ease some of my RA pain, my goal is to completely stop taking it sometime in the near future. Long term use of opiate medication can pose threats to your health other than addiction: tolerance, physical dependence (not the same as addition!), withdrawal, breathing problems, constipation, hyperalgesia (heightened sensitivity to pain caused by opioids), depression, and others.

For more general information about opiate drugs and their side effects, check out the CDC’s website: “Prescription Opioids” and a Q & A on opioids from the Mayo Clinic: “Mayo Clinic Q and A: Opioids for Treatment of Pain.”

My goal, along with that of my rheumatologist and all of my specialists, is to find the right RA treatment to get my disease under control so that I don’t need to rely on prescription pain relief. We’re currently still waiting to see if my latest biologic, Rituxan, is going to do the job. Until then, I’m forced to cope with steroid medication (the evil prednisone) and the use of hydrocodone as-needed.

The opiate epidemic or opioid crisis or whatever you want to call it is indeed a real and major problem in this country right now. I agree that safety measures need to be taken to help prevent even more people from becoming addicted, abusing, and overdosing on these drugs. However, I do not agree with chronic pain patients, such as myself, being stigmatized and criminalized when we genuinely need pain relief. The main and complex challenge right now seems to be: How can we stop the over-prescribing and abuse of prescription opiates yet not deny the patients who truly need these drugs for relief? I hope someone figures out this balance soon, because I’m getting tired of feeling like a criminal and addict whenever I just need extra help easing my pain.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

  1. Quinones, Sam. Dreamland: The True Tale of America's Opiate Epidemic. Bloomsbury, 2015.


  • ldpnn8
    2 years ago

    I am not a person who believes in “fake news”. I don’t see a conspiracy around every corner. However, I do have doubts about this so-called “opiod crisis”. Opiods have been available for years and now we suddenly have a crisis? Frankly, I am sick of druggies and their pusher docs making it so difficult for real patients. No one in my circle has fallen into the addiction trap, so my opinion might be different under different circumstances. I feel bad for the children of druggies, but have ZERO concern for the druggies and/or the money hungry pusher docs. Now, if they steal my car to buy drugs, it will get my attention and a few days cold turkey in jail sounds good to me. Once again in the USA, the bad apples are poisoning the whole basket of mostly honest people and making life more difficult for legit patients and docs. My opinion, and it is okay with me if you disagree.

  • sharoncookie57
    2 years ago

    You can thank the kids for the lack of being not able to get help with pain.

  • Tich
    2 years ago

    Thank you Angela for diving deep into this subject even though it is one filled with fears and anxieties. I too have cycled through most all of the biologics (those approved for my Ankylosing Spondylitis) and have developed nasty reactions to them such that I am off treatment now except for (you guessed it!) prednisone. I recently restarted methotrexate and I am currently awaiting approvals to start Rituximab. I have daily pain from all the damage done by AS which is considerable. The eye pain is highest and responds to high levels of NSAIDs. But since I have impaired kidney function and elevated liver enzymes I was sent to pain mgmt where I was immediately put on opioids. I’ve tolerated them well and actually use less than when I started. I attribute that progress to radon therapy. My goals now are to use even less pain medication and to achieve remission in the eyes. Hopefully one or two doses of Rituxan will do that. I don’t want the side effects I had from other long term use of biologics.

  • Richard Faust moderator
    2 years ago

    Hi Tich. Hoping right there with you that the Rituxan helps. Many people don’t realize that Rituxan operates differently than the anti-TNF function of most of the other biologics. Rituxan, instead seeks to halt inflammation by stopping the body’s B cells. This additional article from Angela goes into more detail on Rituxan: Please keep us posted on how things go. Best, Richard ( Team)

  • Nitrobunny
    2 years ago

    Well done Angela! You have beautifully articulated many of the same concerns I have had for sometime now as the “Opiate Crisis” response has gained increasing momentum and is now at a fever pitch, blasting across social media and the nightly news. I completely get how we got here and the fact that opiates have been abused to a degree that is beyond dangerous. But what about us? Like you, I have chronic pain. I have what I call the royal flush of autoimmune diseases and a history of battling ALL leukemia since 1997. I’ve been through the biologics, ALL of them. I have serious drug allergies to things like MTX that are often a cornerstone in treating autoimmune issues as well as cancer. I am literally down to prednisone and all the nastiness that dual edged sword brings and pain medication. I do meditate. I do exercise. I do absolutely everything in my power to try and control my pain aside from reaching for a pill. It was nothing but pure luck that I found my pain management doctor. I first started seeing him five years ago and from the first moment I met with him, his care and concern have been life changing. He is an anesthesiologist, very well trained with an impressive resume. He feels the amount of opiates I am currently taking are actually relatively low considering my physical condition but he has helped me achieve a level of pain management that works for me. I understand some people want to be completely snowed, laying on the couch, staring at the ceiling, with drool running down their face. That’s not me and I am pretty sure that’s not you either. In fact most people I know with chronic pain just want to be able to function a little better. There’s no such thing as waking up pain free. That’s not a realistic expectation for me. In fact a pain level lower than a four or a five isn’t possible for me but I can deal with it. I’ve learned to deal with it and how to function with and around the pain. I’ve learned what time of day I function best both mentally and physically. I know when to schedule appointments and when I need a nap.

    I’ve recently had an experience with a pharmacy, a nationwide chain I’ve been using for over a decade, call and start a fight with my pain doctor because the new pharmacist didn’t like the protocol I was on. The same protocol I’ve been on for years. I could not believe it when I went to pick up the Rx and it wasn’t ready all because a new pharmacist in the exact same store didn’t like something. In the end the doctor and I both action against the pharmacist, all the way up to the corporate level. There was a three day delay in getting the prescription filled. Fortunately I wasn’t out of the medication but had I been I could have been in great pain and very sick. My doctor has assured my that I am in no way psychologically dependent or likely to abuse drugs but that doesn’t mean I’m not physically dependent on opiates and again, even though it’s a very small dose, it’s a dose my body expects to be there. The pharmacist at the corporate level explained the local pharmacists reaction was due to some recent training that had been put in place but upon reviewing my account it was obvious to her that the local pharmacist made a big mistake and was in her words “over zealous” in his actions. I still was left feeling judged, stigmatized, and criticized all because I have decades of medical issues that cause chronic pain. I was literally thinking “Oh my goodness, what if I cannot get this filled?” “Did my doctor do something wrong?” “Is there some new law we don’t know about?”. With every new news article on the “Opiate Epidemic” I find myself poring over the latest information. Trying to discern any new changes to the laws and if they impact me. I look at new legislation. I look at laws in nearby states. My doctor and I often ask about these things too. It has definitely affected him and his practice as well. He warns all of his patients to never put any of their medication in anything but the original containers especially if they are traveling and if we are traveling to be sure to have the pharmacy generated receipt that matches the prescription bottle because more than once he has had patients hassled over such things. I am concerned that with all the effort to control the abuse of pain control drugs, the people who need them the most will be deprived of them.

  • kathbj
    2 years ago

    This is my first time to join a community of online support and information. I am 56 and I suffer from severe RA, officially diagnosed about 3.5 years ago. My doctor said I had had it for a long time and asked how I had lived with the pain. I didn’t have a good answer. Maybe it was the sparing times I had been prescribed a narcotic mixed with NSAID drugs which caused gastritis and a blood clot in my stomach, which I cannot take now. Bottom line, I just dealt with it, but it was SO difficult for me. I was already on an antidepressant, but I became more depressed, started missing work, had a hand-joint replaced, other orthapedic procedures done, etc. I was about to have a full knee replacement, but my orthapedist told me he wanted me to go to a rheumatologist first to see if I had RA and to see if there was anything that could be done to prevent a full knee replacement. He was right about me having RA, but I had to have the knee replaced, anyway.

    I loved Angela’s article and I read lots of posts that have my sentiments, exactly. But when you mentioned the trouble you had with a nationwide chain pharmacy, I totally related. I had been using a particular nationwide chain pharmacy for about 12 years, ever since it opened. It was convenient. Once the new law went into effect that requires a patient to have a handwritten and signed by the doctor prescription in hand to fill an opiate drug, the pharmacist started cautioning me about how easy it can be to become dependent on this drug. I listened politely, even though I already knew what I was being told, thanked the pharmacist and went home with my pain medication. Soon after that, the pharmacy began giving me a really hard time every time I needed an opiate prescription filled. After we exchanged a few words about the pharmacist’s qualification (or lack thereof) to determine which medications I should take, I asked the pharmacist what the real problem was and i was told that they had been audited and they were filling too many narcotic prescriptions. I quit going to that pharmacy and I have never had another issue anywhere else.

    Anyway, I also got a letter in the mail from my insurance company with all narcotics posted for the past several months that I had filled. They even offered to come escort me to my next doctor’s appointment. So, I took the letter to my doctor (part of the letter said they were sending one to my doctor as well) and she read it in my presence. She was as outraged as I was with the idea that people who never met me and who were not medical doctors thought they knew what was better for me than my doctor of 17 years did. That situation makes it even more difficult on those of us who truly need an opiate on an as-needed basis, and especially difficult for those who have tried every RA drug there is without relief for one reason of another. Perhaps we need laws to protect people from senseless use of drugs, but not to the extent that it affects those of us who need those drugs to deal with pain that is so awful sometimes that all I can do is moan.

    I’ve been on methotrexate twice, Humira, Enbrel, Orencia and hydroxychloroquine. I am currently taking only hydroxychloroquine. I’ve been hospitalized 3 times in the past 7 months, and a total of 4 times in about the past year. I had RSV, c. diff. twice, and most recently a terrible infection in the knee joint that sent me to the hospital for a week. At the hospital, the orthapedist operated on my knee, completely washing out the infection (hopefully) and only replacing the plastic parts. I had IV antibiotics that I was on and administered at home for several weeks and just recently finished. I truly believe that infection and some of the horrible GI issues were the result of me trying methotrexate a second time. I will never try it again. I say all of that to say that I don’t know what I would do without a way to legally get and take a narcotic that helps relieve me of some pain.

    I’ve said enough……I don’t know what can be done to get the law so that it eases up on people with a real need for opiates. Thank you all for your comments and for reading mine.

  • Vicki Laine
    2 years ago

    I too have a pain management doctor and am afraid of the crisis they are calling it stopping me from being able to get the medications I need for flare ups and in between steroid injections because of the heroin addicts. They need to differentiate between the street drugs and those under pain contracts with good doctors! My two cents worth!!

  • Lawrence 'rick' Phillips
    2 years ago

    Angela, As you know I love this book. It is such good information and I had no idea of the second part of the opioid issue, the rise of the heroin epidemic. It is an amazing examination.

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