Jonathan Chen’s new patient knew exactly what drug she wanted. That was the first red flag.
According to Chen, she said she needed Norco, a name-brand opioid, for an ailing foot. She didn’t want physical therapy or the host of other medications the Stanford Health Care physician suggested after checking her prescription records, which fit the pattern of an addict “doctor shopping” for pills.
The 36-year-old doctor said he still might have prescribed her some temporary Norco to help her avoid withdrawal, hoping to build a relationship so he could wean her off the drug. But then he saw her prescription for Valium, a common sedative that, when taken with opioids, can turn deadly. Unable to prescribe even a handful of pills, he watched the patient walk out. She never came back.
That dilemma, from earlier this year, is just one example of the tough positions doctors navigate when prescribing opioids amid an addiction crisis that in 2015 left 1,414 dead from overdoses in California alone. Such alarming numbers have spurred the state’s medical board to scrutinize high prescribers more closely and inspired doctors to re-examine how they prescribe powerful painkillers.
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Seeking to treat pain differently, many health care providers have shifted toward alternative treatments or in some cases stopped prescribing opioids at all. Even if they prescribe with strict limits, doctors say they grapple with ambiguity about whether their patients are misusing medication and whether opioids are the best solution for their pain.
“By far, most if not all doctors are trying to do their best,” Chen said. “But this is a complex and hard situation that doesn’t have easy answers.”
Rural Northern California has been hit particularly hard by the opioid crisis, but the issue affects doctors all over. Last year, a cluster of overdoses from a highly potent opioid called fentanyl left a dozen dead in Sacramento.
The National Survey on Drug Use and Health found that 75 percent of opioid abuse cases begin when someone uses medication they didn’t get directly from a doctor, but rather through another person such as a dealer or a family member with a prescription. Still, efforts to turn back the wave of addictions have focused largely on regulating prescriptions more tightly.
The California Medical Board took action against 57 doctors for inappropriate prescribing in the 2015-2016 fiscal year, up from 30 five years ago. Under legislation passed early last year over the opposition of a major physicians association, doctors who weren’t already checking patient’s prescription records in a statewide database will have to do so before giving them controlled substances.
“We’re still seeing overprescribing. It takes a long time for the tide to change. But I think we’re on the right path in California,” said Carmen Balber, executive director of Consumer Watchdog, an advocacy group that has pushed for mandated database checking.
Balancing act for doctors
Doctors said determining when someone is abusing pills can be difficult, even when they are diligent about checking patients’ histories, examining X-rays and testing urine to make sure they aren’t on other drugs – or drug-free because they’ve given the medication to someone else.
Andrew Linn, director of pain management at Mercy Medical Group in Sacramento, estimated that about 10 to 20 percent of the patients who come to him are looking to use opioids inappropriately, either recreationally or to support an addiction.
He said he steers patients away from opioids when possible, not just because of addiction risks but also because he questions opioids’ long-term effectiveness: Continued use can lead patients down a “slippery slope” of needing higher dosages to get the same relief, he said.
When he does prescribe opioids, he takes a series of steps to verify pain complaints. But he admitted the process is not foolproof.
“A lot of it’s just, you sit with a patient and talk to him for a while, you try to get a sense of how much you trust them,” Linn said, echoing other pain specialists. “We basically do everything we can but still, sometimes … I’m not a detective.”
Another pain management doctor in Sacramento, who requested anonymity to protect his patients’ confidentiality and because he questions his practices, said he’s aware of only a couple of patients per year out of more than 100 who leave his care because they are abusing opioids. He attributed that low rate to being up-front about his “stingy” approach with pills.
The doctor said some cases give him a “funny feeling” when they involve patients who need opioids for improved quality of life and ability to function, the criteria he uses to justify long-term prescriptions. They pass their urine tests, he said, but still he questions whether he is helping them in the long run.
Each month, for example, he treats manual laborers who complain of back arthritis and say the only way they can keep working is with opioids. He said he believes them but is “doing a disservice to the patient basically” by letting them cover up the pain rather than address the root problem.
“I’m giving the patient medication so they can beat up their body,” he said.
However, the doctor said he doesn’t want to refuse people in dire need. On “an everyday basis,” he said, he deals with people who blame him for not showing them compassion by prescribing them the medication they seek.
“The patient will say, ‘I stop walking, I lose my housing, now me and my kids are homeless,’ ” he said.
Using alternatives to opioids
David Copenhaver, an expert in cancer pain management at UC Davis Health, said doctors prescribing opioids have to contend with two massive public health issues.
On the one hand, they’re aware of the opioid crisis. But they’re also mindful of the Institute of Medicine’s much-cited 2011 report that found that more than 100 million Americans suffer from chronic pain.
Copenhaver recalled that he began to suspect one of his patients was an addict as the person’s personal life unraveled with each visit to get more medication. First, the patient lost a job. Next came relationship troubles. Then, a car crash and other misfortunes. Copenhaver said he believed addiction hindered the patient’s cancer treatment as well, causing the person to miss chemotherapy appointments.
The patient ultimately died of cancer, Copenhaver said, but “felt much better” and was more equipped to fight the disease after moving from opioids to other pain treatments and starting drug therapy for addiction.
With more studies suggesting opioids aren’t the best way to combat chronic pain, some doctors are no longer willing to prescribe the class of drugs.
In Lake County, which in 2015 had the second-highest opioid overdose death rate in California, Sutter Health’s Lakeport hospital and clinics will only prescribe opioids for the occasional short-term need.
Andrew Schwartz, medical director at Sutter Lakeside Community Clinic, said physician’s assistants and nurse practitioners approached administrators about three years ago to report how uncomfortable they felt about prescribing opioids. According to Schwartz, prior to that request, the clinic had discharged about 30 patients in the space of a few months for abusing their medication or selling it rather than taking it.
“How about we don’t write (opioid prescriptions) at all?” administrators responded to the worried staff, according to Schwartz.
He estimated the clinic has lost about 10 percent of its opioid-seeking patients as a result of the shift. He said the medical team has convinced the majority to stay and try other treatments for chronic pain, such as physical therapy or surgery, that Schwartz believes address the source of his patients’ issues.
Some patients and medical professionals worry that reluctance to prescribe opioids — out of fear both for patients’ safety and doctors’ reputations — has gone too far, penalizing people who genuinely need chronic pain relief.
Linn said he sometimes even has to convince patients it’s OK for them to use opioids. Overall, he and Copenhaver said, they both believe the medical community is honing in on a better balance between pain relief and addiction prevention.
“I try to get people off opioids more than I'm trying to put them on opioids,” Linn said.