Report — From the April 2018 issue

The Pain Refugees

The forgotten victims of America’s opioid crisis

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It began with a loud pop. Though Austin Sell had suffered from severe back pain since childhood, on a clear autumn morning in 2011, not long after his twenty-first birthday, the pain became something much more frightening. He was chasing his younger brother through their mother’s yard in Great Falls, Montana, and his left foot landed in a crevice. His upper body buckled backward; there was a sound like “a bungee cord being snapped in two.” He could tell that it was bad, a kind of bad he had not experienced before. A few hours later, having tried heat and ice and Tylenol, Sell was sobbing and incapacitated; a piercing ache in his lower spine made it impossible to walk. A trip to the emergency room resulted in several morphine injections, a CT scan showing a slight disk bulge, and the assurance that he would be feeling better within four to six weeks.

Illustrations by John Ritter

Later that night, when his wife, Kelsey, who was pregnant with their second child, brought him home from the hospital, they hoped the worst was behind them. But it was just getting started. Soon the most innocuous movements were sending a shrill, lacerating sensation from his lower back into his groin, hips, and legs. “I was beside myself,” he told me. “The pain was out of control. I kept thinking, ‘Isn’t there something that can be done for this?’ ” So he proceeded again — and then again and again and again — to the emergency room. Instead of eliciting concern or further action, however, the return visits were met with annoyed suspicion. “I’m a big black guy with tattoos,” he said. “They accused me of exhibiting drug-seeking behavior.” Six weeks came and went.

It was not the first time Sell’s pain had provoked a skeptical response. His mother, Kathy Sell Mitchell, who raised Sell and his four siblings mostly on her own, recalls her hunched-over son confined to bed by a mysterious condition that struck randomly but persistently. It was just debilitating enough to cut short outings and playdates, but not to persuade his Medicaid-reimbursed pediatricians to take it seriously. No MRIs, no referrals to a pain clinic. He’s too young, they’d say. He probably has a low pain threshold. “The doctors would sort of blow us off — and I would just let them,” Mitchell said. “I wish I’d had the strength to say, ‘No, you really need to look into this.’ ” Instead, Mitchell did what little she could: with money she didn’t have, she paid for visits to a local chiropractor, gave her son ibuprofen and nightly back rubs, and drew him baths filled with Epsom salts and surrounded by small tea candles.

Now with a family of his own, Sell convinced himself that he needed to push through. The commission checks that he collected from Colonial Life and Accident Insurance Company, where he was employed as an agent, made up the bulk of the family’s income. The work required him to visit clients throughout Montana; he knew that these grueling hours in his old Crown Victoria were only aggravating his condition, but he had grown up poor, believing he would never earn more than minimum wage — this job was the key to a different future. A month and a half later, though, he was forced to go on unpaid medical leave, from which he never returned.

The pain became a corrosive substance, eating away at his career and his marriage. Those closest to him were mystified. “I couldn’t figure out why he was hurting so much,” Mitchell told me. “I know he didn’t understand it either.” Sell’s primary care physician was no less perplexed. He referred him to a neurologist, who in turn referred him to another specialist. Desperate, Sell pursued an exhausting ensemble of treatments. There were epidural steroid injections and medial branch blocks; there was acupuncture and yoga and guided meditation. There were physical therapists, herbal remedies, and over-the-counter medicines. Some of the treatments were excruciating and offered not even temporary relief. Others proved more effective but, not covered by his insurance, were prohibitively expensive. He shuttled from one provider to the next, confused by the contradictory guidance he was receiving, and not sure how much longer he could remain in such a state.

In early 2013, Sell was referred to Rod Lutes, a physician assistant at Benefis Pain Management Center, one of the few pain clinics in the region. By then, Sell had grown somewhat leery of medical providers, but it was obvious right away that Lutes was different. A sixty-nine-year-old Air Force veteran with a warm, easygoing demeanor and a bushy horseshoe mustache (“a real Montana guy,” as one of his patients put it), Lutes began by asking a series of probing questions not only about Sell’s physical symptoms but about his family, his emotional stability, and how the pain was affecting him as a husband and father. “For the first time,” Sell told me, “I felt like I had a voice, like I was validated.”

From Lutes, Sell also gained insight into the nature of chronic pain. He learned that, contrary to popular belief, chronic pain is not merely ordinary pain that persists longer than usual but a disease unto itself. He learned that it can be perplexing and unpredictable — that the pain can grow incapacitating long after a wound has healed or, most bafflingly, arise without any initial wound or tissue damage at all. He learned that many chronic pain cases can never be cured entirely; that he might be living with this condition for the rest of his life. And he learned, finally, that all this was more than just expertise gleaned from thirty-two years of practice: Lutes himself, it turned out, suffered from persistent pain resulting from an old pelvic injury. So he knew how isolating, how overpowering it could be, and he saw the task of alleviating pain as an almost sacred calling.

When the conversation turned to treatment options, Lutes proposed another round of physical therapy, discussed the pros and cons of additional epidural injections, and urged Sell to consider lifestyle changes such as getting more exercise, improving his diet, and quitting smoking. He also thought that an opioid analgesic could be worthwhile.

Sell was reluctant to go that route. Like most people, he had heard horror stories about prescription painkillers, and although the term “epidemic” wasn’t being widely used yet, he knew that opioids had surpassed methamphetamine as Montana’s leading cause of addiction. Besides, the narcotic medication he had already tried had left him feeling unpleasantly foggy and remote. But Lutes believed that a drug regimen, carefully overseen, could provide an affordable, relatively dependable source of relief. In the end, they settled on a daily dose of Effexor, an antidepressant used to treat neuropathic pain, and the opioid Opana, in both its short-acting and extended-release forms. As an added precaution, Lutes had Sell sign the clinic’s “pain contract,” a document stipulating that, among other things, he would submit to random urine and blood tests, bring his pill bottles to each appointment, and lock his medication in a secure location to keep it from being stolen.

Soon after he started on the regimen, Sell’s functionality improved dramatically, and he got a new job as a sales clerk at JCPenney. Kelsey gave birth to Malayeh, their third child, in the summer of 2014, and he was finally able to take an active role in his children’s lives again: playing on the floor with them, taking them to the park. In his spare time, with Lutes’s encouragement, he pursued his love of hip-hop, installing a home recording studio and performing in area clubs. And later, when his relationship with Kelsey deteriorated and he found himself in trouble with the law — there was an altercation with a man he claimed had threatened him — Lutes helped walk him through it. So inspired was he by Lutes that he enrolled in classes at Great Falls College: he wanted to offer care to other chronic pain sufferers by becoming a physician assistant himself.

Sell had been seeing Lutes for four years when, one morning in March of last year, he arrived at Benefis for a regular visit. After a long wait, he was joined in the examination room by a nurse practitioner whom he had never met. She informed him that Lutes was no longer with them. Sell’s initial thought, he told me, was that he had passed away. But in fact, Lutes had been fired. (Benefis would not discuss his case, citing employee confidentiality, and would not permit its current providers to comment on the care of individual patients.)

The nurse practitioner, Vilma Herrera, would now be overseeing Sell’s treatment. She said the first order of business was to reduce his medication — by 80 percent. The decrease was radically out of sync with standard practice: a gradual taper is recommended to avoid the agonizing, sometimes dangerous withdrawal symptoms that can result from sudden discontinuation of opioids. Herrera, however, did not acknowledge these risks. She asked no questions about Sell’s quality of life; there was no discussion of how he had been doing on the medication. It seemed, Sell told me later, that she had arrived with a prepared speech, one she had delivered to other patients, and that the details of his circumstances were unimportant.

Sell pleaded with her, explaining that with his wife having left the family and moved to Minnesota months earlier, he needed the medication in order to care for their three children on his own. But it was useless: the federal government, Herrera said, had imposed an upper “speed limit” on what clinics could prescribe.

And that was it. The appointment lasted about ten minutes.

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’s most recent article for Harper’s Magazine, “A Prayer’s Chance,” appeared in the May 2017 issue.

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