Stress Cardiomyopathy Mortality From Opioid Cessation

Sudden cardiac death is still the leading cause of death in Westernized nations. These are most often due to cardiovascular disease, which can be structural, like atherosclerosis, which accounts for the majority (18%) of cases, or due to myocarditis (12%), arrhythmogenic cardiomyopathy (10%), hypertrophic cardiomyopathy (9%), valvular as in mitral valve prolapse (8%) or aortic stenosis (1%).

There are also inherited and developmental conditions, including some forms of dilated cardiomyopathy and conduction pathway problems, but also non-structural problems, like channelopathies, where inherited abnormalities of ion channels cause conditions like Brugada syndrome, CPVT, SQT, and LQT syndrome, all of which can lead to sudden cardiac death, particularly in the young.

Channelopathies have been implicated in some cases of sudden infant death syndrome.  That being said, cases of sudden cardiac death do not have an identifiable structural cause in many cases. This is the second most common category of sudden cardiac death (17%).  In these cases, autopsy and analysis find no clear physical reason for the death.  But there is a strong correlation with sudden, severe life stress.

Stress cardiomyopathy is what we call this condition, and it has several names, including broken heart syndrome and takotsubo cardiomyopathy. It was first described in the 1990s in Japan and is named after a traditional Japanese octopus trap called a takotsubo. The takotsubo has a similar shape to the left ventricle apical ballooning during systole, the heart’s squeezing phase, which is common in this disorder.

This form of cardiomyopathy involves a complex interplay of factors that we may not normally associate with heart problems.  Most heart problems are caused by the narrowing of the coronary arteries due to atherosclerosis and/or a sudden blockage of these vessels due to a blood clot forming or a fat embolism from a fracture blocking blood flow. These conditions are well known to restrict blood flow to the heart, a condition called ischemia,  which can result in heart failure.  Heart failure is when the heart cannot keep up with needed blood flow and falls behind, often ballooning from backflow, which worsens the problem.  A complete blockage can cause the sudden death of heart muscle, which we refer to as a myocardial infarction.

Takotsubo cardiomyopathy is different. In this condition, sudden emotional or physical stress releases a flood of catecholamines like epinephrine and norepinephrine, which, in high doses, can be toxic to cardiac muscle cells. This leads to impaired cardiac function, sometimes called “stunning.” The surging stress hormones also cause arteries to narrow, boosting blood pressure and increasing the workload.

The increased workload makes the heart work harder, further stressing the heart muscle and worsening the backflow problem.  These arterial constrictions can actually result in spasms of the coronary arteries, leading to reduced oxygen and nutrient flow and, again, causing heart failure.   85% of these cases are the result of extremely stressful emotional conflicts or a sudden physical insult.

Emotional stressors known to trigger this reaction are the death of a loved one, betrayal including marital infidelity, severe arguments, especially spousal, financial problems, and, surprisingly, public speaking.  Young men in societies where there is great social embarrassment related to criminal arrest have been found dead in their cells with no sign of physical injury or other identifiable cause. One other cause of stress cardiomyopathy has been identified as sudden cessation of opioid treatment. Something that is now being mandated by many state medical boards under threat of prosecution by the DEA.  While doctors are routinely prosecuted if a patient dies for any reason while on opioid therapy, I will wager that no doctor will be prosecuted for causing the death of a patient from any cause, suicide, electrolyte abnormality, or opioid withdrawal-induced cardiomyopathy after sudden opiate cessation.

The Georgetown Medical Review discusses two cases identified by Dr. Benjamin Hack et al. The first patient was a 68-year-old man who was initially treated for a non-ST elevation MI but worsened before opioid withdrawal-induced takotsubo cardiomyopathy was identified, and he was placed on pressors and fluid resuscitation in the ICU and recovered to baseline. The second was a 33-year-old woman who had been taking methadone with a lapse in her treatment.  She presented with edema, lower extremity weakness, and pain, at first being diagnosed with infective endocarditis.  Antibiotics did nothing, and she decompensated, going into respiratory failure, and ending up in the ICU.  Once TCM was identified and treated, she recovered, but not everyone is so lucky.

Jessica Fujimaki was a patient of Dr. David Bockoff, whose case I have written about before.  Jessica had lived with the severe pain of arachnoiditis and complications of Ehrlers-Danlos Syndrome before the DEA decided they didn’t like how Dr. Bockoff was practicing medicine.  Claiming he was putting some patients on “too much” medication.  How they felt qualified to make that determination is unknown.  Especially since the federal government is forbidden by law from trying to influence the practice of medicine (42USC1395).  The patients were left adrift, and she could not find another doctor, dying at her home after a complete loss of quality of life.  While medical records are being combed for patients who have died while on opiate medications, no one is tracking the deaths of patients forced off of them.

That makes us wonder about patients like David Lackey Sr., who lived in Odessa, Texas. Mr. Lackey had married his wife in 1963 and opened a machine shop after serving in the US Navy.  He restored old cars and woodwork and enjoyed building and riding motorcycles.  The DEA raided the office of David’s physician, who was managing his chronic pain, leaving him without pain care.  He set about searching for another physician, but with the DEA targeting doctors who dare to help patients from a practice they have shut down, it was not easy.  He finally found one, but despite years of records documenting his history of spinal fractures and other medical problems, the new clinic wanted one more imaging study.  Old bones don’t miraculously heal old fractures, so why might the doctor want a new test?

The DEA has paid experts to argue in court that a thorough review of past medical records, including pain specialist examinations and multiple imaging studies, is not enough.  That if every new doctor does not order some imaging study, then they have failed to evaluate the patient’s medical condition objectively.  But don’t own part of the imaging facility, then they will say the extra imaging is unnecessary and, therefore fraud. Just like they do with drug screens. While finding a new physician and waiting for imaging, David ran out of medication and became deathly ill.  He developed the common opiate cessation symptoms of vomiting and diarrhea and was left shaking in his bed in agony. About a month after his doctor was forbidden to prescribe opiates, David dropped dead of a heart attack.

Back in April of 2019, the Food and Drug Administration had warned the DEA about reports of serious harm resulting from their targeting of pain management physicians. They mention withdrawal, uncontrolled pain, psychological distress, and suicide, going on to mention that these symptoms can cause patients to seek out other sources of medications, which may be confused with drug-seeking behavior.  They also talk about the threat of illicit opioids.  These are often fake medications, made to look like their regular pills,  poisoned with fentanyl.  This is the true cause of about 75% of America’s opioid “overdoses.”  These are not overdoses.  These are poisonings. What the warning does not mention, is the threat of stress cardiomyopathy.  How many people have we lost to this condition?

We will almost certainly never know.  Any new medical intervention is usually followed by a careful analysis of resultant patient outcomes, but not in this case.  The DEA is so convinced of their righteousness that something as mundane as an evidence-based evaluation is not necessary.  That simply stopping opiate medication therapy is THE solution to America’s opioid problems. They even prosecute physicians for continuing opioid treatment started by other physicians.  Ignoring the fact that not doing so could be deadly.  Indeed, I have seen statements from the DEA and its supporters that seem to indicate that they don’t really care if these patients die.  In the false belief that once they are gone, we won’t have all these “chronic opiate patients” and everything will be okay.

I disagree with that also.  Life is hard and unfair, and of the few ways that things can go right, there are thousands of other ways where things could go terribly wrong.  Just taking a motorcycle ride on a beautiful spring day can leave you with terrible spinal fractures and severe chronic pain when someone just doesn’t see you and pulls out in front of your bike. I’ve seen this happen.  I rode motorcycles regularly from when I was fifteen when it was my only transportation (farm roads), until I was 32.  I rode from my medical school in Minnesota to Scott Air Force Base on a motorcycle to study emergency medicine.  During this ride, a pickup pulled up to a stop sign, looked both ways, including directly at me, and pulled out.

I had slowed down, having learned that when the human brain is looking for cars, it often doesn’t see motorcycles, and was able to put the bike into a slide so I didn’t get hit from the side.  I impacted with my shoulder just above the fender but slowed to where the impact wasn’t severe enough to break anything.  It did put a big dent in his fender, which I have always hoped made him remember to look for bikes, too, and left me with a “bad” shoulder that flares up from time to time.  A few seconds difference, and I would have been hit by the front of the truck, and either ran over or thrown across the road.  Possibly dying and, if not, definitely left with severe injuries and broken bones.  I quit riding not long after that, realizing how lucky I had been.  David Lackey was not so lucky.

We always want to see a bigger meaning in life, that there is a great divine master plan controlling events like these, and that the disparity between David’s life of constant pain and suffering and mine of good health has a deeper meaning.  And maybe there is.  But I can assure you, the DEA agents that left a Navy veteran suffering horribly in his last days and may indeed have caused his death do not have a great master plan. They have no real plan at all that I can discern.  They have become convinced that the opioid crisis is the result of physicians coddling pain and addiction patients, speaking in dehumanizing ways about how those who suffer from chronic pain are “professional patients” faking their agony to get that sweet disability check. It is never a good sign when a government starts to demonize its citizens.

I am often uncomfortable when someone who knows that I am a Marine and Air Force veteran says thank you for your service.  Not because I am not proud of my choice to serve and defend, but because the honor, truly, was mine.  It was a privilege to wear the uniform, and the military was incredibly kind to me, giving me a home when I needed one, educating me when I could not afford it, and sending me to medical school when I was accepted but could not have afforded that either.  I will always cherish the opportunity to serve with the wonderful people I met on duty.  People like David,  who quietly serve their countries and go on to live a good life filled with love and family.  Thank you for your service, David, and wherever you are, I hope the road is clear and the wind is cool. You deserved better.