Paterson was once known as “Silk City.” After the war they built airplane engines here. Now, it’s struggling, a hard-bit city full of hardworking immigrants. It’s plight hasn’t gone unnoted. The town makes an appearance in the works of William Carlos Williams, Bob Dylan’s Hurricane and in Ginsberg’s Howl, you know the one that starts:
“I saw the best minds of my generation destroyed by madness, starving hysterical naked,
dragging themselves through the negro streets at dawn looking for an angry fix…”
That last bit smarts as Paterson’s latest claim to fame is as one of the cities hardest hit by the opioid epidemic in a state already demolished by them in a country held in their thrall. So viciously has the opioid epidemic slit the belly of the city that the city government recently made headlines for suing pharmaceutical companies for damages.
Some 1,900 New Jerseyites died on the streets or in their homes from opioid use last year and many of those tragic stories of addiction begin at hospitals like St. Joseph’s Regional Medical Center. This fact is not lost on the doctors pacing the hospital’s fluorescent-lit corridors or loitering with patients in the lobby, where a player piano cycles through an endless lonely performance, much to the confusion of the institution’s youngest patients.
“Opiates treat any and all pain,” explains Dr. Alexis LaPietra, the Medical Director of Pain Management in the St. Joseph’s Emergency Department, matter-of-factly. “They make you feel great and they’re predictable. Unfortunately, they’re exquisitely addictive and when we give too many of them, people stop breathing.”
So Dr. LaPietra is determined to hand out less codeine, fentanyl, morphine, oxycodone and hydrocodone pills in all their trademarked avatar names.That likely means more pain — a hard to measure metric if there ever was one — and definitely means trying some unconventional approaches with patients. Adults in this part of the world understand that, but it’s harder with kids and difficult with parents. Doctors understand that kids need to have a different relationship with pain management now so that adults can have a different relationship with pain management in the future. One way to solve the opioid epidemic is to undercut a clinical culture derived from decades of pressure exerted by pharmaceutical companies with bottom lines who rely on doctors like LaPietra to prescribe their product. But that’s no easy task.
Children rarely become opioid addicts. After all, they lack the skillset and circumstance necessary to score pills. But that doesn’t mean that they aren’t victims of the epidemic. Children rely on parents to take care of them, shelter them, feed them. Since those addicted to opioids often cannot fulfill those basic obligations for themselves, their wards are at tremendous risk. Opioid addiction has flooded the nation’s foster care system.
Protecting children from the ravages of addiction therefore requires short- and long-term strategy. In the short term, hospitals like St. Joseph’s are trying to prescribe fewer opioids to adults. To accomplish this, Dr. LaPietra and Dr. Mark Rosenberg, the hospital’s chair of emergency medicine, founded ALTO, a program designed to push alternatives pain management strategies. But ALTO also represents a long-term play because new techniques are employed to manage pain in children, fundamentally and permanently altering those young patients’ medical expectations. ALTO is working to minimize the damages of opioid addiction while addressing the conditions that facilitated the epidemic. And, yes, parents want this.
I meet Dr. Rosenberg, who looks like a wizened kindly version of Asterix, and Dr. LaPietra, in a hallway just outside the pediatric ward of the hospital. Like most things in this place, the pediatric ward, which sees about 40,000 patients a year, is highly regarded. The ward is full of bright colors and loud, the ambient noise of children’s shows playing on iPads. Dr. LaPietra explains how we have traditionally treated children for pain and how they do it now.
“Classically,” she tells me, “we do not treat pain in children the same way we treat pain in adults. We accept pain in children as though it won’t really affect them. They are, after all, resilient, easier to distract and would rather play than whine about pain. Adults whine and cry about it more.”
Dr. Rosenberg chimes in that perhaps one reason for the under-treatment of pain in children is that we’re so used to hearing them cry, it doesn’t register as an effective warning sign. But maybe letting them sweat it out unmedicated wasn’t such a bad thing after all. Under-treated children are accidentally inoculated against the expectation of painlessness that has fueled the rise of opioid abuse.
What’s more salient to Dr. LaPietra is their parents’ approach to pain and to opioids. Many families come from far afield to St. Joseph’s precisely because they’ve been touched already by the dread hand of the epidemic. “People are scared,” she tells me, “almost everyone knows someone or has someone in their family who has dealt with or is dealing with an opioid addiction.” Subway ads, like those from the Partnership for a Drug Free New Jersey that read, “Would you give your child HEROIN for a broken arm?” further worry parents. The fact is that, well, many of them would (albeit not if offered in those terms). And that’s not really their fault.
Still, LaPietra says, younger parents, those in their twenties especially, grew up with the expectation of being pain-free. “These younger generations,” she tells me, “have grown up with a lot of pharmaceutical advertising. They’ve grown up with social media. They’ve grown up with instant gratification. They believe everything can be solved.” A big part of Dr. LaPietra’s job is convincing both the parents of young children and adolescents that it’s okay to feel pain. “Pain is a stimulus for survival,” she says, “our bodies are not meant to go through life without ever feeling pain.”
It’s a tough sell to a scared parent of a suffering kid. As a father of two rough-and-tumble boys myself, I am no stranger to the ER. The asphyxiating feeling of helplessness when your kid is in pain is like an instant game of emotional Mercy. You just want it to stop and if the deadening sledgehammer of opioids makes the pain go away, the attraction is ineluctable. How much of this is societally conditioned and how much is hard-wired is hard to say but, as Dr. LaPietra tells me, my experience is common and derivative of social conditioning.
“Over the last decade,” LaPietra says, “our tolerance for pain as a society has decreased.” Both she and Dr. Rosenberg kinda roll their eyes and say, in chorus, “Pain is the fifth vital sign.” I later learn that this is shorthand for, “The pharmaceutical backed approach to pain management produced the opioid epidemic was deeply flawed from the outset.”
“It all started with the Veterans Administration,”Dr. Rosenberg explains. In 2003, he says, “a study came out that claimed opioids are for acute pain, are safe and non-addictive and the medical profession should use them without delay in patients who presented acute pain. The VA, whose guidelines were written by Purdue, maker of Oxycontin, mandated that, for all beneficiaries of the VA, if they had pain, the physician should not delay giving them opioids.” Rosenberg describes a trickle-down effect whereby what worked for the governmental goose spread to the private sector gander. The result has been catastrophic. Less pain has lead to much more suffering. More Americans died of drug overdoses in 2016 than died in the entire Vietnam War.
At the pediatric ward, Dr. LaPietra divides children into two categories: those under eight who do not represent a risk for addiction and early adolescents, who do. For the really young kids, the medical team relies on a combination of distraction and rather innovative use of existing modalities. A perky nineteen year named Ariana who introduced herself as a child-life specialist and who was lovingly sanitizing an action figure from a cart laden with iPads was an example of the latter. When a child is in pain or about to receive a shot or an IV drip, a child-life specialist swoops in with screens and games and bright shiny things. So much of a child’s pain, Dr. Rosenberg tells me, is tied up in anxiety that if you can allay that, you’re doing pretty well.
But screen-time isn’t a panacea. ALTO’s success at lowering the opioid prescription by 57 percent at St. Joseph’s has much to do with its use of alternative treatments. Much of this is a shift in mindset. If opioids are sledgehammers, Drs. LaPietra and Rosenberg are searching for scalpels. One of the most effective treatments they tell me is ketamine, the completely non-addictive downer we all knew in college as K.
“Ketamine works differently in the brain than opioids,” Dr. LaPietra explains to me, “it antagonizes a different receptor in the brain.” Though the drug has long been used as a sedation, its use as an analgesic is a rather more recent development. It has been quite successful. (One doctor recently wrote on a medical message board that, “To know ketamine is to love ketamine.”) At St. Joseph’s, the drug is prescribed in small sub-dissociative doses, often in an intranasal spray, which dulls pain but otherwise doesn’t affect overall cognition. The kids don’t trip — not hard anyway — and they also don’t realize they’re in pain. There’s little anxiety, which is the argument for dissociation from pain over pain blockage.
Because they are terrifying to children and to adults and to adults watching terrified children, many of the non-opioid pain management techniques employed in the pediatric ward at St. Joseph’s don’t feature needles. Besides ketamine, the doctors often use Lidocaine, an anesthetic, in either patch or gel form and nitrous oxide, which is better known as laughing gas and has been a dental staple for decades. When a needle is needed, doctors prefer trigger-point injections of anesthetic into muscle knots. None of these treatments, Drs. LaPietra and Rosenberg quickly admit, are quite as effective as opioids at dulling pain. That does not make them worse solutions. In fact, that might be the best case for them.
As I walk out from the pediatric ward, a lady plucking a harp held in a special holster waddles by. She’s another part of ALTO, a volunteer at the hospital offering distraction and healing to the patients here. She’s like Carol Kane in The Princess Bride mixed with an angel. Is she as effective as Oxycontin? Probably not and her celestial notes can’t drown out the cries of babes emanating from the ward behind me. But, thanks to the work of ALTO, the parents of the patients there no longer hear those cries as something to silence, but something to live with.
If pain is the fifth vital sign, moaning is reassurance and whining is hope.