Every day, Dr. Rohit Mahajan watches his patients leave, knowing he tried to ease their pain.
What he doesn’t know is if he turned them into addicts instead.
Every decision he makes — every patient he sees, every procedure he performs, every prescription he writes — is colored with this question. He’s an interventional pain specialist, and while he tries to help people without offering opioids, not every patient is open to that.
There’s no good answer.
He’s exhausted. It’s the end of his workday, and he’s telling a story about when he was a resident, studying internal medicine and then anesthesiology. He was reviewing the chart of a woman who was using a patch with fentanyl – an opioid medication – to deal with the pain of her chronic pancreatitis.
The story unfolding in the medical notes from previous appointments worried him. Her husband had taken to storing the patches in a locked box, doling them out as needed.
Then he read something even more disturbing.
“She was chewing on her fentanyl patches,” he says. He waits a beat, lets it sink in. “She had become addicted, and she was chewing on her patches to extract the medication.”
The word addict hadn’t surfaced with their doctor, at their home, in their minds.
That day in the hospital, Mahajan didn’t know what to say. He had been taught that most doctors were undertreating pain. He had no training for a patient who had become addicted. Still, he believed he had to bring it up with the patient, and, heart racing, he did, and then didn’t renew the prescription.
“I left the hospital feeling like I did something,” Mahajan says.
It didn’t last long – the next day, the attending physician was angry and restarted the medications.
“There’s a longstanding culture of treating pain,” Mahajan says now from the Sanford Health Pain Clinic in Fargo, North Dakota. “And I think it’s compassionate to do that, but once you realize you’re creating harm, you have to take that into consideration.”
Changing attitudes on opioids
That experience was a decade ago, and nobody was talking about what happens – what will almost always happen – when you rely long-term on opioids to manage pain. Most patients will become physically dependent on the pills, and some of those will become addicted.
A report from the Centers for Disease Control and Prevention ties the misuse of prescription drugs to high levels of prescribing. It also says most people who use heroin have a history of misusing prescription opioids first.
In the six years since Mahajan began practicing, attitudes have shifted wildly. He likens it to how doctors didn’t know how to talk about death and dying, and now palliative care is a household word. The same is becoming true with opioid addiction. News stories are full of accounts of communities buckling under the weight of it, social services and black markets, where deadly synthetic drugs now cost more than heroin.
In October, President Donald Trump declared the opioid crisis a public health emergency.
Like any trend, good or bad, it hasn’t hit the Dakotas, where Sanford Health is based, as hard as other areas of the country. But human nature being what it is, and opioid medications being what they are, it’s only a matter of time.
“I know without a doubt, you are going to get tolerant,” Mahajan says of people using opioids. “That’s not up to you or me. That’s up to your liver, your brain. I know you’re going to get dependent. So now we’re just waiting to see if it helps you, or you become addicted. Those are the two options.”
He stops again. The literature doesn’t show the medications help that much in the long-term, he says. If you ask a patient about their pain when they’re on four pills, they’ll tell you it’s not much different as when they were on three pills.
Pain is insidious like that – one kind creeps in when another leaves and makes room for it. People can’t always separate it – their memories shift. A story is only as accurate as the storyteller, and over time and distance and the haze of medications, the real stress of chronic pain can alter the details.
“So, really, we’re just hoping you won’t become addicted,” he says.
Mahajan is one man, in one clinic, trying to stop it.
‘I was a basket case’
On a random Wednesday afternoon, Mahajan sees a different patient every half hour, each with some kind of chronic pain. They talk to him about their grandkids. They ask about his daughter, Adriana, who just turned 1. He shows them photos on his phone, leans in close when they take out theirs.
A man from Detroit Lakes, Minnesota, tells him that his young grandson can make every car noise, animating the matchbox cars he pushes around on their carpet when he comes over to play. “He even makes the ‘beep beep’ when they back up,” he tells him.
“Unbelievable what they learn, and how fast,” Mahajan laughs. He’s a doctor, he knows how the brain works, how it absorbs everything around it, turns it into action and emotion. But he’s still a new dad, filled with the wonder of watching it happen in his own house, and can appreciate it when someone sees it anew in the next generation.
The man, Fred, is here with his wife, Linda, who has fibromyalgia and degenerative disease in her back. She has eight grandchildren, and she can’t pick them up. But before that, she had a migraine for more than a year.
The daylight hurt her head too much, and eventually she was confined to her darkened house, the television so dimmed her husband couldn’t make out the picture. “Emotionally, I was a basket case,” Linda says.
She began taking opioids, but they just made her feel foggy. Now Fred worried – would she fall when he was at work? But it was worse than that. He tells of one weekend where he came home after a 12-hour shift. They talked. She doesn’t remember it. She doesn’t even remember that day. Or the next one. Her next moment of clarity is that Sunday afternoon.
That’s when they realized something was wrong.
They came to Mahajan, and he helped them find other medications and solutions, weaned her off some of her pills.
“Our life has gotten better,” Fred says.
She’s not pain-free, and maybe she never will be. To live without pain is unrealistic, Mahajan says. Believing that’s possible – and then medicating people to that point – is part of how we got here, he says.
Mahajan tries to peel back the onion, get to the root of what’s hurting his patients. Treat the depression and anxiety, the sleep disorders, figure out if it’s nerves or muscles, joints or all of it causing the pain. He tries various anti-inflammatories, procedures that block nerves or implanted devices that release medications or deliver electricity to the spine.
He recommends physical therapy, massage, acupuncture.
“What about cupping?” one patient asks him.
He recommends finding someone licensed, talks frankly about the medical data behind alternative therapies, asks his patients sincerely if they’re finding relief.
“Patients say, ‘I feel like a guinea pig,’ but that is part of the process to treat pain in the most conservative way,” Mahajan says.
Living with chronic pain is terrible. He knows that. “It can make people feel like life is not worth living,” he says. “It makes you feel like you might do things you wouldn’t otherwise do. Pain feels so bad. It literally feels so bad.”
But he knows the risks of overtreating it, of even treating it like he was told to in med school. It’s not the same world. “In 10 years, maybe we’ll think the pendulum has swung too far,” he allows. But it has to, right now, to move the needle.
Asks good questions, then listens
He high-fives one patient when she says she was able to stop taking prescription sleep aids. He repeats everything his patients tell him back to them, they go through their charts together. He asks about their life, listens sincerely when one woman says her shoulder hurts too badly for her to style her hair.
“I have to style my hair,” she laughs.
He laughs with her, in a way that recognizes the importance of daily living, doesn’t diminish her desire to feel good about herself, her desire to feel good.
Patients talk about how to maintain their walking routines in the winter. Exercise can help keep the pain at bay. But every action has an equal and opposite reaction, and so he asks how expensive it is to use the community center where they can walk. He asks about insurance costs and work and disability payments.
He understands when one woman says she just can’t add another appointment to her week. She’s already down to barely part-time work. He tells her to pick one thing, just one, to control. They decide it’s smoking. He tells her she can do it, reminds her how it worsens chronic pain. She knows that. But right now everything feels insurmountable. Her dad died this fall. Everything hurts.
“I think it’s hit my husband and my boys that this isn’t going away. If your socks are on the floor, pick them up,” she says. “You’re just going to have to buck up … forever.”
Roadblocks in the system
Next he sees Anna. She’s a newer patient. She just switched insurance, and she hopes to retire in June. She works in food service at a school in West Fargo. She’s been there just shy of a decade. Before that, she was a waitress, but her husband got laid off, and she needed work that had insurance.
She’s been managing her pain with muscle relaxers that don’t make her groggy. But her new insurance won’t pay for it.
Mahajan is frustrated. He has a general idea of what the different treatments cost, counseling patients every day about not only what’s effective but what they can afford. Sometimes it means making what feels in the moment like a terrible decision.
“Opioids are so cheap,” Mahajan says. “It became a solution of convenience. The problem is what happens in the long haul.”
He orders a non-opioid muscle relaxer and tells her it might make her a little groggy. She understands.
‘Not be part of that problem’
At the end of the day, Mahajan looks tired. He’s ready to go home to his wife, Sonya, and their daughter. He’s ready for decisions that don’t feel like incremental progress, like standing still. It isn’t the tough conversations he has every day that scare him, or navigating bureaucracy or struggling with insurance companies.
“I’m most worried this person might not find the help they need, and they are going to wind up dead,” he says.
It’s happened to him. A woman came in who wanted an implantable pain-relieving device, but she had a history of opioid abuse and addiction. He counseled her to get treatment first. She was angry and stormed out.
Later, she died from an overdose.
“I can’t force someone to help themselves. I can give someone information, but I can’t force them,” Mahajan says. “What I can do is not be part of that problem.”