Pain Free is Killing Us… Bechukotai 5776

by Leiby Burnham | June 3, 2016 1:46 pm

I could hear the screams from the other side of the door. A good friend of mine had just undergone back surgery a few days earlier, and I was trying to do the right thing by visiting him, but the yelps of pain were making me reconsider that decision. The door to his home was locked, and he wanted to come and open it to let me in, but that meant getting up out of bed, and getting out of bed came along with stabbing pain all over his back and legs.

Just four days earlier, I came to visit him at Beaumont Hospital a few hours after the surgery, and while he was as charming, sweet, and jovial as usual, I could see that he was in major pain. The hospital has a rating system for pain from one to ten, with one being “very mild, barely noticeable,” and ten being “unspeakable pain, bedridden and possibly delirious.” When the nurse asked him what his pain level was, he said it was eight and a half. Eight is described as: “Intense pain. Physical activity is severely limited (which it was), conversing requires great effort (I didn’t realize it!).” Nine is described as: “Excruciating pain. Unable to converse. Crying out and/or moaning uncontrollably.” So he was somewhere in the middle of those two unenviable positions. I’d rather be fishing.

No one wants anyone to be in that kind of pain, so the nurse asked him if would like another dosage of Oxycontin being that she only gave him half a dose two hours earlier. He politely declined, saying that he didn’t want to get addicted, so he’d rather just deal with the pain…

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Abdul Waleed Rahimi took a long sip of bracingly hot coffee as he surveyed his vast fields from the veranda of his villa. Tucked in the misty mountains of northern Afghanistan, his farm produced millions of poppy plants, from which raw opium gum was harvested and then converted into heroin in his labs. Normally, he found the endless fields of poppy softly waving in the morning breeze to be a soothing sight. But the news he received a few hours earlier took him far beyond soothed, he was downright jubilant! Sales were soaring through the roof, and the demand was there for much more. As much H as he could produce, he could sell, and at double the price he expected!

Growing up in abject poverty in the slums of Kabul, Abdul had never dreamed of this kind of success. But he worked his way up, finally buying a plot of land in the ignored hinterlands of Afghanistan. And then he did everything right. He paid off everybody, and in Afghanistan that meant a lot of people. He paid off the Taliban, Al Qaeda, the military, the police, politicians, and even the US Air Force base commander, because they occasionally napalmed local poppy fields.

He spent a fortune hiring a private army of mercenaries to protect his property. He maimed and killed a few locals to make sure everyone in the area knew not to mess with him. He kidnapped smart Indian scientists and forced them to work the labs, ensuring that his heroin was purer than fresh snow. And after all that investment, all that hard work, all that blood, sweat, and tears, everything was finally coming together. Sometimes it seems, life was fair!

Where was all this demand coming from? The US of course! That is where 90% of Abdul’s heroin went, smuggled back on US military planes going back stateside from Bagram Air Base. And the US is going through an absolute boom in heroin use! The Centers for Disease Control and Prevention recently reported that in the last decade, among males, heroin use has risen by 50% and among women, it has doubled! Overdose deaths quadrupled over the same period, but there were more new customers coming in, than old ones dying. Many groups that previously did not have a big heroin problem, now do. The best example would be white people and women, traditionally not big heroin users, but over the past decade 300,000 new people started using, many of them white and many of them female.

Abdul knew what was driving his suddenly skyrocketing fortune, he read all the CDC reports. It was the rapid proliferation of opioid painkillers. Millions of Americans were being prescribed high doses of Oxycontin, Vicodin, and Percocet. They are expensive and tightly controlled, and when sold on the street they are even more expensive. While a prescribed 80mg pill of Oxycontin costs $6-8 at the drug store, on the street it can cost anywhere from $50 to $100! When people’s prescriptions run out, they are often still hooked on the drug, and still experiencing pain. But they can’t afford the high price of street Oxycontin, which is when they start to buy Abdul’s product, which costs only $45 for a multi-dose supply.

The American Northeast, once only mildly affected by heroin, is now in a full blown epidemic, the Midwest is following suit, and the West is also experiencing a surge. It is no longer a poor man’s drug; in many states the zip codes with the worst heroin problems are among the zip codes with the highest median incomes. Those places are the exact places where people would have started their habit with legally prescribed opioids.

Abdul’s dad, who died when he was twelve, had always told him, “Do the right thing, keep working hard, take pride in what you make, and eventually you’ll get lucky.” Baba sure was right about that!

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Rarely does a lawyer walk out of a courtroom where his client was just slapped with a $634.5 million fine, and feel elated. But that is exactly how Howard R. Udell, chief counsel for Purdue Pharma, felt as he walked out of court on a sunny day in May of 2007. That is because the case he just settled was one that should have totally bankrupted Purdue Pharma, being that it was attached to a dead body count that numbered in the tens of thousands. $635 million was peanuts in comparison, especially because the drug causing the lawsuit, Oxycontin, made the company over $32 billion, and $635 million was just 2% of the Oxycontin profits.

How did this whole Oxycontin problem start? It started in the late eighties, when Purdue was facing a crisis. The main source of their revenue, a morphine pill for cancer patients called MC Contin was about to lose its patent protection. When that happened generic companies would start selling it for pennies on the dollar, and Purdue would lose the bulk of its revenue. Even worse, they didn’t have anything promising in their drug pipeline to replace it. In a memo written by Robert Kaiko, vice president of clinical research, the warning was clear, either come up with a new painkiller drug or face financial implosion.  

The solution they came up with was relatively pathetic, but ended up being a bonanza beyond belief. Purdue simply took a cheap, generic, opioid painkiller that had been on the market for decades, oxycodone, and added a slow release mechanism to it, and renamed it as a new drug, Oxycontin. The entire value add of this new drug was that it was supposed to last twelve hours, so that a patient would only need to take two pills a day, and be pain free all day.

In the very first clinical study, done on women who were recovering from abdominal surgery in Puerto Rico, about one third of the patients began complaining of pain within the first eight hours, and half of them needed a second dose before twelve hours had elapsed. In dozens of successive studies, the results were consistent. But numbers and hard data were not going to get in the way of Purdue’s success. They lied, falsified the data and got their patent approved, on the basis that it was supposed to work for twelve hours.

The problem is that it didn’t and patients kept complaining of pain after six to eight hours. But if the solution was to give the drug more frequently than they would lose everything that their patent stood on. Instead, Purdue decided to recommend to doctors to keep the frequency the same and increase the dosage.

While this was going on, Purdue aggressively marketed their “wonder drug” spending $207 million in marketing in the first few years. Purdue doubled its sales force to 600 eager young sales reps, crossing the nation, and taking out entire doctors’ offices to expensive dinners where they presented their new wonder drug. Five years later, Purdue was making $1 billion a year in Oxycontin sales, and this continued to climb until its peak in 2010 of $3 billion a year. All the while, they knew that Oxycontin didn’t really work for 12 hours, as discovered from multiple company memos brought to light in the lawsuits.

For the patients, Oxycontin was a disaster. It pumped them up with a powerful opiate like high, especially with the higher doses recommended by Purdue, but then left them in agony after six to eight hours. If they used another pill, they would run out of their prescription early, because it was tightly kept to a twelve hour window. If they didn’t they would be in agony. Prescription abuse began to skyrocket. Illegal sales of Oxycontin soared. Overdoses started becoming common. Finally, people began turning to heroin.

Oxycontin abuse, has cost this nation untold billions. Every day there are 87 opioid related deaths. Every day there are thousands of emergency room visits due to overdoses, or due to people taking tainted street opioids. And as the CDC reports: “From 2000 to 2014 nearly half a million people died from drug overdoses. We now know that overdoses from prescription opioid pain relievers are a driving factor in the 15-year increase in opioid overdose deaths. Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupled, yet there has not been an overall change in the amount of pain that Americans report.”

So when Howard R. Udell settled the massive lawsuit brought against Purdue for a middling $635 million, he walked out of court feeling like a winner. We the people, we are the losers…

For more on this unbelievable case read this powerful LA times story.[1]

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This all brings me back to my good friend. I salute his refusal to use as much opioids as the hospital is willing to give him. And I salute him for staying the course despite the fact that his pain is immense. Sometimes life is going to throw us a bunch of pain. There is no way to erase all pain, not physical, and not emotional. In the US, we try so hard to erase every bit of pain; for physical pain we have opioids, for emotional pain we have SSRI’s and for anxiety we have benzodiazepines. The prescription rates of these three classes of drugs have all soared in the last two decades. Yet we are not a happier nation, a more pain free nation, or a less anxious one.We can’t make pain just disappear, sometimes we need to live through it, and live through it with grace.

We are now in the period called Sefiras Ha’Omer, the time between Pesach and Shavuos, the time when we prepare ourselves for Shavuos, when each year we re-receive the Torah, just like we did at Mt. Sinai on the first Shavuos. The Torah is not simply a body of knowledge, but a G-dly way of life, and because of that, the things we need to acquire it are varied and many.

The Mishna in Ethics of Our Fathers (6:6) details “48 Virtues With Which the Torah is Acquired.” They include humility, engaging friends in dialectic dialogue, being slow to anger, loving charity, empathy with other’s pain, not talking a lot, knowing our place, and being happy with our lot. As you can tell, this is not the prescription for just any body of knowledge, but rather for becoming a receptacle for G-d’s wisdom and way of life.

One of the 48 Virtues is kabbalos hayesurim, acceptance of suffering. Part of becoming a fully developed human being is the ability to withstand pain, and forge on through it. Pain is a part of life, and one that helps us become stronger, much like tempered steel is improved when it is heated to extraordinary high temperatures. Being able to accept that suffering with grace is the mark of someone who is seeking the refining that suffering does to our souls.

In the past, when people learned the 48 Virtues, and learned that one of them was acceptance of suffering, they probably focused on the acceptance part. In those days, suffering was inevitable, the challenge was to accept it with humility and grace. Today, we almost need to focus on the suffering part. We are being told we can live a life without any suffering, all we need to do is find the right medication cocktail. But the 48 Virtues are telling us that it is important for us to go through the experience of pain.

This is obviously a controversial topic, and I’m not in any way saying that we should not take any painkillers, anti-anxiety or anti-depression drugs. There are clearly cases where it is necessary and good, and I have advocated strongly for them in those cases. But there is a fine line, one that we need to be prepared to walk. The goal of strong medications should be to remove extraordinary pain and suffering, not to quash out the smaller suffering that we can and should experience as part of life. When we try to even out every mountain or valley, somehow fate forces them back into our life. Accepting some level of pain is a good thing.

Ask any therapist, and they will tell you that if a couple is not experiencing any struggles or challenges whatsoever, they are probably not fully engaged in their relationship, and have detached from it to a degree. Relationships done right will entail suffering, the growing pains of becoming a bigger person through the relationship.

In the same way, life done right will entail suffering, and when we are willing to accept that suffering, we become bigger and stronger people. It’s not about increasing the dosage of the medication, but about increasing our capacity to forge forward through the pain. That is where real triumph lies.

 

Parsha Dvar Torah

In this week’s parsha, Bechukosai, we find the Torah outlining the cause and effect relationship of the world. When the Jewish people as a nation are Jewishly involved, world affairs will be favorable for them. When the Jews lose focus of their mission, and attempt to melt into the background as just another nation, the nations of the world will violently remind them that they are different. In one of the Torah’s descriptions of the Jews’ exile from their homeland it says,vi’avaditembagoyim” (Lev. 26:38) which translates as “and you will get lost amongst the nations.” This seems like a strange verb to use to describe our exile. Interestingly, there is a special mitzvah that uses the same root word, “hashavat aveida” returning lost objects. What is the connection?

Let us look at one of the key laws of the mitzvah, and through that we will be able to understand the connection. When is one required by Torah law to return a lost object, and when can he rely on the age-old adage, “Finders keepers, losers weepers?” The Mishna teaches us that when there are identifying marks on the object that indicate that it belongs to a specific owner, we are required to try to locate the owner and return it. When there are none, one can keep it (of course, one who returns it even in these cases is laudable, but he is not required to do so by Torah law).

For example, if one finds loose change in the mall, there is no way for the owner to identify it as his, and the finder can keep it. However, if one finds a bracelet on the street, he must try to return it. The way to do so is by putting up signs saying, “I found a bracelet on this date, in this area. Whoever lost it please contact me at this number…” When people call, you can ask them what does it look like? What color stones are in it? How big is it? If the person properly identifies the bracelet through these identifying marks, you return it to them, and pat yourself on your back for the mitzvah you just earned. In this way, finders get heavenly reward, losers get their object, and there are no weepers!

This is possibly what G-d is telling us in the statement, “you will be lost amongst the nations.” We will be like a lost object. If there are identifying marks on us that indicate that we have an owner – G-d – then we will be deserving of being returned to our rightful owner and rightful place. But if, G-d forbid, we will be so lost amongst the nations that there is nothing that says “this nation has a master,” then we won’t be worthy of redemption.

We see this idea reflected in the statement of the Sages. They tell us that the Jews were redeemed from Egypt because they did not change their language, dress, or names. Those were the identifying marks that made them into a nation deserving to be returned to its land and Owner.

We live in a world fraught with peril for the Jewish people. Most Europeans believe that the biggest obstacle to world peace is Israel. The president of a powerful and wealthy Middle Eastern country with a budding nuclear program has promised to wipe Israel off the map. People all around us believe that Israel is an apartheid state, and the Jews are bloodthirsty maniacs with aims for world domination. We often feel that there is nothing we can do to change this sorry state. The Torah here comforts us by telling us that when we show ourselves to be different and unique, when we put marks on ourselves that say “this nation belongs to an owner, G-d,” then we can bring ourselves closer to being returned to our home, and to our Owner!

 

Parsha Summary

The major theme of this week’s parsha, Bechukosai, is the concept that the deeds we do have a direct result on our world.  The world is like a finely tuned violin, and our actions like a bow being stretched across the strings. If we play it properly, the most beautiful and harmonious sounds emanate. However, if we play it improperly, the result is jarring and disturbing. It is not so much a punishment as a cause-and-effect relationship with our actions.

In line with that idea, the parsha starts off by saying that if we follow G-d’s Torah properly then our land will produce incredible yields, we will live in peace, (and the Pistons will win the Finals). However, if we refuse to follow G-d’s Torah and instead chose to ignore the role He plays in our world, then He will remove Himself from the picture, and the world will begin to crumble around us. Throughout this difficult period, G-d will wait for us to turn back to Him. If we continue to deny His reality, the devastation will become more and more severe. Ultimately, G-d promises that even during the most trying times our people will endure, He will not totally abandon us, rather He will be with us in our exile. In the end we will return to Him, He will remember the covenant He has with our Fathers and bring us back to our land in peace.

The Parsha then moves on to the subject of the different items that one can consecrate to the Temple, such as property, one’s own value, or his animals. The Torah discusses how a person pays for each, and if and when one can redeem them back for himself. The final verses of Leviticus deal with the second tithe a person gives on his crops, and the tithe on animals.

As we say in Shul (synagogue), when completing one of the Five Books of the Chumash: Be strong! Be strong! And may we be strengthened!!!

 Quote of the Week: Snow endures but for a season, and joy comes with the morning. – Marcus Aurelius

Random Fact of the Week: Napoleon designed Italy’s national flag.

Funny Line of the Week: Scientists today announces that they have found the cure for apathy. Unfortunately no one seems to care.

 

Have an Engaging Shabbos,

R’ Leiby Burnham

Endnotes:
  1. this powerful LA times story.: http://static.latimes.com/oxycontin-part1/

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