Dr. Kenneth Choquette knows the kind of chronic pain his patients endure every day. Without opioid pills, some cannot work, sleep or do simple chores like wash the dishes.
“If I take pain medication away from a patient who is properly taking it for the right reasons, it means they hurt more,” said Choquette, a Coordinated Health pain management specialist and a physician for three decades.
“So, are they dependent on the medication?” he said. “Absolutely.”
But are they addicted to opioids?
That’s the question facing many medical professionals practicing in the United States, a country grappling with an opioid epidemic with a death toll that outpaces car crashes. They are tasked with balancing patients’ needs with the possibility that opioids will be abused.
Decades ago, before the opioid crisis gathered steam, the pendulum swung toward overprescribing the drugs to quell patients’ pain. Now, some doctors say the pendulum has rocked too far in the other direction, leaving their patients with less access to the medicine they need to get through their days.
“We do see those who have a true medical need being treated like drug addicts where their problem and their ongoing medical condition is no longer taken seriously,” Choquette said.
Choquette and four other medical professionals — an OB-GYN, an oral surgeon, a pharmacist and a community nurse — recently gathered for The Morning Call’s second community roundtable on the opioid crisis. They said efforts to stem the epidemic fail to balance the legitimate use of opioids by patients and illegal use of them by addicts.
Political leaders, law enforcement and insurance companies have responded with broad, shallow strokes, the roundtable participants said. The result has made opioids harder to get for patients who need them, often causing those patients unnecessary pain and leaving them feeling like criminals.
Doctors’ concerns echoed those of the first responders who convened in February for The Morning Call’s first roundtable conversation.
First responders agreed that the nation’s reaction to the unrelenting opioid epidemic, which claimed more than 300 lives across the Lehigh Valley last year, is inadequate. Using an opioid-reversing drug called naloxone saves lives, but doesn’t fix addiction, they said. They want money for treatment, laws to force addicts into court-ordered treatment and education programs about the dangers of opioids.
Both roundtable groups want an overarching approach to the problem where everyone linked to the epidemic works together to break through the crisis.
“It’s not a one-size-fits-all solution,” said Melissa Miranda, a nurse and the director of Neighborhood Health Centers of the Lehigh Valley.
“Every conversation should be talking about collaborative partnerships across communities. Because this one definitely is more than one single conversation or solution.”
Some doctors are changing their practices
With no one-shot solution available, doctors have found their own ways to address the crisis. They are limiting the amount of opioids they prescribe, treating pain with other methods and talking to patients about the risks of opioid use.
Over-prescription of opioids can lead to so-called “diversion” of opioid drugs. When patients have more pills than they need, those medications are at risk for abuse and illegal sale.
OB-GYNs at Lehigh Valley Health Network now prescribe fewer pain pills, said Dr. Amanda Flicker. A mother recovering from a cesarean section gets about 20 pills. Before the epidemic became a public health emergency, moms would receive up to 60.
“We may not say ‘we’re not going to give you the opioid pain medication,’” Flicker said. “But we’re going to give you 20 tablets, which is what the average user will take after a certain procedure. It minimizes the rest of the bottle hanging out there in the medicine cabinet and potentially getting diverted into other hands.”
Many doctors rely on other ways to control pain, such as applying ice or heat to injured areas, physical therapy and using non-narcotic medicine to dull inflammation.
Dr. Robert Laski said he and his colleagues at Valley Oral Surgery no longer write prescriptions for pain medicine ahead of surgery, instead waiting until the day of a procedure to write them. That helps prevent the pills from getting diverted.
They also use a non-opioid numbing medicine. For patients with mild pain, such as toothaches, they prescribe heavy-duty Motrin instead of opioids, Laski said.
Those kinds of efforts have yielded results at the pharmacy counter, where independent pharmacist Pauline Vargo said she’s been filling fewer prescriptions for opioid drugs.
“I have definitely noticed a trend,” she said. “When I first went into practice they were given more freely. Now they are definitely used with more caution.”
Doctors’ new practices — alternative pain treatment, fewer pills — may mean that patients feel some pain. But that’s a good thing. The expectation that patients should feel no pain has contributed to a mass drug abuse problem, those at the roundtable said.
Laski, who trained as an oral surgeon in the early 2000s, said he was taught that to care for patients, a doctor must eliminate their pain.
“You’re also better off giving a little bit more than they may need just in case because if you’re not managing their pain, you’re not really taking care of the patients,” he said, describing the standards at the time. “Are you kind of leaving your patient, for lack of a better description, high and dry? And now they need to find care somehow?”
That’s one reason doctors are often saddled with the blame for the overprescriptions that fueled the opioid epidemic. But Laski and others gathered at the roundtable agreed it was unfair for them to shoulder all the responsibility, since they once were taught to eliminate pain and because data and marketing initially characterized opioids as safe and non-addictive.
Their outlooks have changed. The drugs’ addictive qualities are obvious, and the days of prescribing enough Vicodin to eliminate pain after surgery are over.
Those are things patients need to know, Laski said.
“A lot of patients believe that post surgery, they should have no pain,” he said. “That’s unrealistic.”
Patients should be open to having difficult conversations with their providers about opioid use, Flicker said. That’s especially important for pregnant patients, for whom the stakes are higher because “you’ve got two lives at stake.”
Some of Flicker’s patients use opioids throughout their pregnancies. Others transition off, but all of them know the risks.
“It’s a frank and candid conversation with the patient about what’s going on with her health care and what alternatives she may have and what risk she’s placing her fetus and her newborn at by continuing that medication,” she said.
Conversations have worked for Vargo, too. She and other Lehigh Valley pharmacists now distribute one-page pamphlets about opioid addiction treatment resources.
“We would distribute those with their prescription and have a little conversation,” she said. “Not saying any blame, that they need this, but (saying) if they ever felt that this was something (they needed), here’s where you can get some help to look into it.”
At least two of Vargo’s patients have sought treatment because of those conversations, she said.
One helpful tool
While doctors have taken steps to limit them, opioid prescriptions are still written for patients dealing with serious pain. But measuring pain is a challenge for doctors. It’s subjective, Flicker said.
That’s one reason the doctors applauded Pennsylvania’s prescription drug monitoring program, which they said helps them make sure patients aren’t secretly collecting prescriptions for controlled substances from multiple providers. The program, enacted in 2014, monitors patients’ prescription histories.
It’s helped — opioid prescriptions in the state dropped by 12 percent in the last quarter of 2017 compared to the previous year, though the opioid overdose death toll continues to rise.
Outside of monitoring, insurance companies have moved to limit prescriptions. In February, Lehigh Valley insurer Highmark announced it would limit patients who are starting opioids to a seven-day supply and required approval from the insurance provider before filling prescriptions. Capital Blue Cross, another local insurer that already had such a limit in place, in March said the number of patients that used opioids decreased by 12 percent in mid-2017.
But the medical professionals at the roundtable were short on praise for the insurers. They said the companies were controlling how they were allowed to care for patients with a top-down approach that limited their ability to practice medicine. It threw off the balance between caring for patients’ pain and avoiding opioid abuse.
“We need to look at a better way to deal with the crisis other than labeling people who need their medication as addicts,” Laski said.
Limits can make it harder for people with chronic pain to fill prescriptions they need, sometimes making those patients feel anxiety or guilt for their opioid use, doctors said. Sometimes it leaves patients in a bind if they can’t get to a pharmacy on the day their shortened prescriptions run out.
“It puts … me as a pharmacist in a bad situation, you know, doing what is right or legal or using my heart, saying, ‘I want to give this patient what they actually need,’” Vargo said.
“That’s getting a little bit ridiculous.”
Even though data show there are fewer opioid pills prescribed since those restrictions were set, there’s insufficient evidence that prove those restrictions are driving down addiction, the medical professionals said. People who abuse substances likely won’t stop because they get fewer opioid pills from a doctor.
“They’ll find it on the streets,” said Miranda, the community nurse. “They’ll find some substitute. They’ll find something.”
Choquette put it simply: “Pills don’t make the addict.” People vulnerable to addiction are at risk to abuse pills, drugs or alcohol, not just opioids.
“It’s like nobody knows what else to do so let’s just stop making pills,” he said.
The doctors, just like the first responders before them, agreed that treatment is paramount to reversing the epidemic. They can encourage their patients to get help, but that’s only effective if help is available — and sometimes it’s not.
“We’re looking to the government to provide more resources toward these facilities so we can help manage our pregnant and non-pregnant patients who have addiction problems,” Flicker said.
That leaves doctors at the center of the nation’s opioid crisis, with no end or simple solution in sight.
But they hope they won’t be left there alone. Choquette, the pain specialist at Coordinated Health said others — lawmakers, patients, insurers, the media — are finally recognizing the need to balance pain treatment with opioid abuse.
“We’ve been having decades and decades of people who misuse medications because they’re trying to deal with some issues … like psychological, advanced depression. They have an addictive personality,” he said. “This is not new. What’s new and great is everyone is getting a little more aware that this is going on and we’re really opening our eyes as to the severe complications that can occur as to when this is happening.”
Perhaps that will bring the pendulum to rest.
State of Emergency
Editor’s Note: The opioid epidemic affects every part of our society. From families to health care providers to the first responders who rush to the scene of overdoses, it’s truly a community crisis. As part of a yearlong, multimedia series on the opioid epidemic, The Morning Call is hosting a series of roundtable discussions with community members who are directly impacted.