Do no harm: Doctors struggle to treat pain while preventing addiction

Doctors on front lines in fighting painkiller abuse get little guidance on when and at what dosage to prescribe opioids

With little in the way of guidance, doctors have struggled to find the right balance between treating pain and avoiding prescription drug addiction among their patients.
Altrendo images / Getty Images

The stories often start the same way.

Something goes wrong — a bicycle accident, a bad fall, a back injury that never quite heals. See a doctor, get prescribed something for the pain, an opioid like Percocet or Vicodin. And then, as happens in many cases, develop a dependence or addiction that overwhelms your life and may even kill you.

Nearly 2 million Americans abused prescription painkillers in 2013, and every day 44 die from overdoses, according to the Centers for Disease Control and Prevention. The death rate now surpasses that from car crashes among 25-to-64-year-olds. For people 55 to 64, the rate of overdoses jumped sevenfold from 1999 to 2013.

Amid this deadly rise, a lot of attention has been paid to pill-mill doctors who profit from pushing addictive painkillers. But a more complicated problem has emerged, with a generation of doctors who prescribe opioids to treat patients’ pain but lack guidance about when and how much to prescribe and how to prevent opioid abuse. 

Marc LaRochelle, an assistant professor at the Boston University School of Medicine, is a co-author of a study published in January that found 91 percent of overdose survivors continue to get prescription opioids.

Pill-mill doctors are “an important minority to be looking at,” he said. “[But] the majority of these drugs are coming from community physicians who really have a good-faith effort trying to improve their patient’s lives.”

Opioids are a class of drugs naturally derived from the opium poppy or synthesized to have similar narcotic effects, like fentanyl, which is 50 to 100 times more potent than morphine. Common opioids include oxycodone and hydrocodone.

As recently as 25 years ago, doctors concerned about patients’ becoming addicted were generally cautious about prescribing opioids. The pendulum swung in the 1990s with the notion that doctors needed to take patients’ pain seriously and that opioids were a safe way to treat it.

In 1993, a young Dr. Malcolm Butler arrived in Wenatchee, Washington, a town of roughly 32,000 residents in the eastern foothills of the Cascade Mountains. “In the mid-’90s, there was sort of a pressure that we ought to be prescribing more opiates for pain … that if people were in pain and we could help them, we should,” said Butler, now 53. “If you were not taking adequate control of pain, you were not a high-quality practitioner.”

The standard of that time became that if patients said they were in terrible pain, even if nothing abnormal showed up on an X-ray or an MRI, doctors were expected treat them, he said.

Butler, a family-practice physician, and other doctors at the Columbia Valley Community Health practice, which serves mostly low-income patients, noticed as time went on that patients with chronic pain were not getting better. It seemed as if the more medication they took, the worse their pain became, he said.

Concerned, the doctors tried urine screenings for patients on opioids and having them bring in their pill bottles so that their pills could be counted.

Still, the patients’ demand for opioids increased, as did their outbursts in the clinic. The number of patients on opioids yelling and cursing at staffers grew to such a degree — up to five patients a month, Butler said — that the clinic developed a protocol for handling such incidents.

To avoid inappropriate opioid use, by 2007, Columbia Valley Community Health developed a sophisticated pain management program that included group sessions run by psychologists and limits to the total amount of opiates that doctors could prescribe. And yet in 2010, 23 percent of the practice’s patient deaths were due to accidental opioid overdose. 

“That really captured our attention, because as far as we could tell, we were doing better than anybody else around,” said Butler. “We really stood up at that point and said, ‘This is just not right.’”

“It was becoming clear to us that although we had been told that it was safe to prescribe opioids for chronic pain, it really wasn’t.” 

Percocet pills
Nathan Griffith / Corbis

In 2012 in the U.S., 259 million prescriptions were written for opioids — more than enough for each adult to have a bottle of pills, the CDC says.

Some states have worse problems than others. Tennessee, for example, had nearly 22 times as many prescriptions for oxymorphone as Minnesota in 2012.

Even as recognition of the opioid addiction crisis has grown, with the CDC calling it an epidemic, doctors are often on their own in deciding when to prescribe opioid painkillers or manage patients who are already on dangerously high doses.

When Dr. Jay Shukla began practicing in New York, he received patients on high doses of opioids. Some had prescriptions for 240 pills a month of the highest-strength Percocet, which led him to suspect these patients were selling pills.

He explained to each patient how concerned he was about the high doses of opioids — that he needed to slowly bring them down, that they needed to start seeing a pain specialist or a physical therapist on a regular basis and that he would offer them different combinations of pain medicine.

Not all doctors show the same sensitivity. Some, apparently skittish when they spot the possibility of addiction or overdose, may pull patients off high doses of opioids with no plan to replace them.

One recovering hydrocodone user, who asked that her name be withheld to protect her privacy, was working as a secretary in New York City when she got a terrible pain in her neck. About six years ago, she went to a doctor, who said it seemed to be arthritis. She was prescribed hydrocodone.

Eventually, she was taking up to eight pills a day.

“I was taking more than I was supposed to,” she said. “They made me feel good, and I suffer from depression … I did realize that there was something more than just the pain that I was taking these pills for.”

Then suddenly her doctor cut her off. “I said, ‘Taper me off. Don’t just stop giving them to me,’” she said. The doctor “refused and refused and refused, and I went through about four months of pure agony.”

She said she was jittery and depressed and could sleep only about two hours a night. Finally, she saw a TV commercial that eventually led her to getting opioid addiction treatment involving the drug Suboxone.

There is a growing movement among states to offer more guidance to doctors and other medical professionals about opioid use.

Forty-nine states have prescription drug monitoring programs, using electronic databases that allow doctors to track how many opioids a patient has received, even if they received them from a different physician, to help cut down on instances of opioid-seeking patients going doctor shopping.

However, not all those states make it mandatory for doctors to participate in the monitoring program.

The American Medical Association holds the position that drug-monitoring programs should be voluntary because there is no one-size-fits-all formula for different states and medical practices.

“There’s no magic or silver bullet here,” said Dr. Patrice Harris, a psychiatrist in Georgia who heads an association task force on the opioid crisis. “Each state needs to decide what works best for that state, and that’s another theme of our work, in that we want the states to come up with state-specific solutions.”

She said those affected by the epidemic — doctors, patients, regulators, pharmacists — need to come up with ways to prevent opioid abuse while continuing to treat pain.

In this search for solutions, many physicians say one big problem is that some health insurers do not cover a more holistic approach to pain management that could reduce the need for pills, such as through physical therapy, counseling, massage and acupuncture.

Washington state, where unintentional overdose deaths related to prescription opioids skyrocketed from 24 in 1995 to 512 in 2008, was one of the first to address the epidemic.

The state in 2007 implemented its first opioid dosing guidelines, which, along with other efforts, are credited with a 29 percent decrease in the rate of prescription-opioid-related deaths from 2008 to 2013, according to the state Department of Health.

“Surveys showed that the primary care doctors realized there’s a serious problem and they’re even stopping taking care of these patients because it’s too hard,” said Dr. Gary Franklin, a medical director at the state Department of Labor and Industries and the lead architect of the guidelines. “They’re using our tools and our guidelines. They welcome the threshold. They want the help.”

The state passed laws in 2010 that set a threshold dose — equivalent to 120 milligrams of morphine per day — above which a medical practitioner should consult a pain specialist. There were some complaints. The Seattle Times in 2011 published a critical story about how the new laws could result in patients’ not getting the pain treatment they need.

By 2010, Butler’s practice in Wenatchee had independently decided to significantly lower its opioid dosages: 98 percent of the practice's patients are now limited to a dosage equivalent to 100 milligrams of morphine per day.

The state guidelines were helpful in backing up the practice’s approach, he said, and he helped spread the word among other medical practitioners in the town “that opioids are not safe in chronic pain, that we were hurting people and that we had to be very, very careful. A lot of people, it turns out, were looking for that same support.”

Now, instead of Butler’s clinic having five disruptive patients a month, it gets about four a year.

He said, “Patients come back and say, ‘I cannot believe how far gone I was. I cannot believe I used to take that much medication.’”

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