Fighting Opioid Dependency After Stomach Cancer
Ten years ago, Steve Melen was 37 years old, married with a 1-year-old daughter, and working a demanding job as a financial advisor. His world fell apart when he found out he had stage 3B stomach cancer. Doctors told him that he had a 14 percent chance to survive.
Melen had surgery at California's Stanford Medical Center to remove his entire stomach as well as part of his esophagus and pancreas. While recovering in the hospital he suffered major complications and had to have emergency surgery to repair an incision between what remained of his esophagus and his intestines.
He was in a medically induced coma for a week and remained in the hospital for a month, taking high doses of intravenous opiate pain medication. When he was finally discharged, he was sent home with “all the medication I wanted,” Melen told HealthCentral in a phone interview.
Looking back, he believes that when he left the hospital he was already on the path to becoming dependent on opioids.
Opioid pain meds: “You feel you need them to survive”
Melen, who lives in Northern California, said he had never really taken pills to cope with pain before the surgery, but he began to rely on them heavily afterward. Opioid pain medication also made life bearable as he underwent chemotherapy coupled with radiation, which left him feeling burned from the inside out.
After he had healed from his surgery, his pain became chronic, and his dependence on pain medication grew. For a time, he was using multiple sources of opioid pain medicine, including wearing an opioid pain relief patch, and taking a variety of opioid-based medications.
“They gave me energy and allowed me to function. I was so weak and tired and beaten up. Sometimes just getting out of bed and walking was very difficult,” said Melen, whose 6-foot frame had dropped to a skeletal 95 pounds following stomach surgery.
“You become convinced in your mind you need these pills and you get violently ill if you stop taking them,” Melen said. “You feel like you need them to survive. I felt like I couldn’t function without the pills.”
A year after his surgery, he was taking up to 20 OxyContin pills a day.
Recognizing opiate dependence in cancer patients
Cases like Melen’s are more common than many medical professionals may realize, Dr. Jay Lee said in a phone interview with HealthCentral. Lee is a general surgery resident at Michigan Medicine, the University of Michigan academic medical center. While opiates are an important part of managing pain for many cancer patients, it’s important to recognize that some cancer patients, including gastric cancer patients who undergo surgery, may be vulnerable to habitual opioid use, Lee said.
Lee was the lead author of a 2017 study that looked at 68,463 cancer patients nationwide who underwent surgery to cure their cancer between 2010 and 2014. The research found that 4,159 of those cancer patients, or about 6 percent, continued to take high daily doses of opiates three to six months after surgery—much longer than they needed to recover, Lee said. And for patients who underwent additional treatment, such as chemotherapy, the study found that the risk of habitual opiate use increased to between 15 and 21 percent.
The study looked at patients who were treated for melanoma, breast, colorectal, lung, esophageal, and hepato-pancreato-biliary/gastric cancer (or cancers of the liver, pancreas, biliary tract and stomach).
Gastric cancer patients showed an even higher risk of habitual opioid use. They had between 18 to 20 percent chance of persistent opioids use, Lee said.
“It’s hard to say why those patients are associated with higher rates,” Lee noted. “Those patients often need chemotherapy, which is associated with painful side effects and may require opioids to treat,” Lee said. “Another reason could be that those patients often have poorer prognoses and may have less long to live in general than patients with early stage skin cancer or breast cancer. That could factor into how those physicians prescribe to those patients, as well.”
Opiates to subdue the pain
Steve Melen eventually went on long-term disability while going through cancer treatment, but he still worked from home as much as possible. He was trying to keep his foot in the door with clients. He was a fairly new financial advisor and was worried about losing his job and all he had worked so hard for.
“I was running on a lot of fear. Fear of not supporting my family. Fear of dying,” Melen said. “I was so scared of losing it all, and that fueled more of the pain med problem.”
More than a year after his surgery he was taking higher and higher doses of opioids. He realized he had a serious problem. He talked with his doctor about slowly tapering off the drugs, but he struggled to follow through.
“I really wanted to quit. I was biting the pills in half and trying to cut back, but I just couldn’t,” Melen said.
After taking his entire months’ worth of medication — 300 pills — in two weeks, Melen decided he needed go off the pills cold turkey. It was a grueling experience. At one point he ended up in the emergency room. He spent several weeks at home going through withdrawal and detoxifying from opiates, he said.
“It felt like I fell off a cliff, I thought I was dying,” he said. “I couldn’t get off my floor for a week. Detoxing off heavy opioid use is the worst thing ever.”
Prevention starts with educated providers
“Steve has had a really remarkable odyssey. His surgery and therapies left him with a lot of pain,” said Dr. James Ford, a professor of oncology and genetics at Stanford University Medical Center who was one of the doctors who treated Melen for gastric cancer. “Not everybody struggles with pain in that same way, but some do.”
In a phone interview with HealthCentral, Ford said that the medical community is still struggling to figure out the best strategies for prescribing necessary pain medicine to cancer patients like Melen.
“We’re focused on treatment, and not where it leaves patients on the other end,” Ford said
It’s crucial that medical providers come up with better strategies to help prevent opiate dependence among cancer patients, Lee said. Part of the problem is that there isn’t any solid guidance on how much opiate-based medication a patient needs following surgery. Doctors often guess at how much to prescribe, without overdoing it, to keep patients comfortable while recuperating from surgery, Lee said.
Also, cancer patients often see multiple doctors who may not coordinate in terms of which doctor is writing prescriptions for what medications, making it easier for a patient to receive more than one prescription for opioids, Lee said.
But doctors may be able to use certain risk factors to help identify cancer patients who are more susceptible to persistent use of opiates, Lee said. This can include cancer patients who are under psychological distress, such as having feelings of depression and anxiety.
Rebounding after trying to regain his normal life
Shortly after detoxing from his opioid dependence, Melen decided to jump back into work.
He was cancer-free, but Melen still struggled to feel “normal.” He had lost so much weight he had to have all his suits taken in to fit his thin frame. He found it difficult to partake in many of the social engagements that came with work, such as working lunch meetings and after-work socializing, because eating regular-sized meals was impossible for him.
“I would walk around and just see people had these thoughts in their head, like I was being looked at differently,” he said. “Psychologically it was tough to feel part of society. There was some anxiety there.”
He was desperate to reclaim his old life, and before cancer had enjoyed being a wine connoisseur. He even had a large wine cellar in his house. He felt drinking a glass of wine would relax him and it seemed to lessen any physical pain he had.
“I felt like I could get back to normal socializing, because I didn’t want to isolate myself. I wanted to get out,” he said. “And whatever is was that was going on, people were drinking.”
Unfortunately, alcohol quickly became a substitute for opiates. He began using alcohol as a way to numb both the physical and mental pain he was in, including the fact that his marriage had turned rocky, he said.
Melen ultimately ended up going to rehab twice for alcoholism. During his second time in rehab, his wife divorced him. He spent six months living in a sober-living facility.
“Looking back, I was a real mess,” Melen said. “I’ve been given a second chance.”
Reconnected to life
Melen has been cancer-free for more than 10 years and sober for more than five years, he said. He has found a way to rebuild his life. He reconnected with his high school sweetheart, and the two are now married. He’s happier now than ever before, in part because he has the support he needs and feels reconnected to his life, he said.
Since his recovery, Melen has become a patient mentor with the non-profit organization Debbie’s Dream Foundation, which offers advocacy, support, and education to gastric patients and their families.
Melen said his goal is to offer support and guidance and, he hopes, help others avoid some of the issues he faced while going through treatment.
Stanford's Dr. Ford also encourages his gastric cancer patients to connect with other patients. He encourages them to open up and get the support they need. Ford recommends the non-profit organization, No Stomach for Cancer.
“For those patients who are cured, as Steve is a good example, some can be left very dependent on opioids,” Ford said. “It can be very difficult to get off. We in the medical community may be inadequate at recognizing that.”
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