This is the second of a three-part series on the nation’s struggle to address its crippling opioid crisis, and the unintended victims left in its wake. Read Part 1 here: As doctors taper or end opioid prescriptions, many patients driven to despair, suicide.
Dr. Stephen Nadeau received a warning from the Gainesville, Fla., hospital where he worked. Their policy on prescribing opioids was changing, to go beyond federal guidelines aimed at the national overdose crisis that has claimed hundreds of thousands of lives.
The hospital would stop treating pain with opioids.
That’s like a hospital deciding it would stop treating infections with antibiotics! Sure, not all people need them, but in some situations, it’s by far the best choice.
And every doctor, including Nadeau, had to stop prescribing them. Doctors otherwise risked losing hospital admitting privileges – and perhaps even their medical license.
In Helena, Mont., Dr. Mark Ibsen was feeling heat from the state medical board – and the U.S. Drug Enforcement Administration (DEA), for the high-dose opioids he was prescribing to patients in severe, chronic pain. An allegation made by what he described as a disgruntled employee charged Ibsen was overprescribing.
As a result, the state medical board suspended his license. The DEA visited five times, Ibsen said, suggesting he was risking his livelihood and could end up in jail if he kept prescribing.
Both doctors complied and stopped prescribing, affecting roughly 230 of their patients.
Tragically, among those were several who committed suicide, the doctors said, when they couldn’t find another health care provider to relieve the pain.
That’s a scenario playing out across the country, as government agencies respond to the staggering rate of drug overdose deaths, involving primarily illegal opioids like heroin and illicit fentanyl.
Doctors who maintain they are responsibly prescribing opioids are getting caught up in the crackdown
Some doctors like Ibsen and Nadeau are opting to simply stop prescribing legal opioids, as insurers, pharmacies, and authorities warn them about overstepping guidelines issued in 2016 by the Centers for Disease Control and Prevention (CDC).
“Not only is the government legislating the way we care for chronic pain patients,” said Nadeau, a professor of neurology at the University of Florida College of Medicine, “they are substantially taking away our ability to do it.”
Critics of the way the 2016 guidelines have been applied note they were not intended as law, but as a means to advise primary care physicians.
The CDC specifically cautioned against abruptly stopping or forcibly tapering opioid treatment for patients already taking them, because of the danger of withdrawals, or debilitation.
More than 300 health care professionals, including former drug czars in the Clinton, Nixon and Obama administrations, have signed an as-yet unpublished public letter to the CDC, warning of a brewing crisis among pain patients, despite the “laudable goals” of the guidelines.
Others argue many authorities have misunderstood, or outright ignored, the CDC’s disclaimer.
Health care providers who don’t drop opiate painkillers are setting strict limits on dosage limits, even for chronic pain sufferers who require more medicine because of serious conditions, or the way they hyper-metabolize opioids.
It’s so gratifying to finally see this mentioned in the mass media. Ms. Llorente (Author) is a rare example of a truly knowledgeable reporter when so, so many just blather on endless repeat some PROPaganda about “opioids are bad”.
Many who do so cite the CDC guidelines, saying they were told to follow them — or took them up as a kind of pre-emptive strike.
DEA TARGETING ‘WORST OF THE WORST’
Much of the opioid overdose epidemic in recent years stems from illegal drugs, not legitimate prescriptions.
Yes, it’s an epidemic and/or crisis of overdoses, not any particular drug. Overdoses are what’s killing people, not prescription opioids alone taken as directed.
Most prescribers say they recognize many health providers were not prudent enough when prescribing opioids. And many doctors noted they were previously criticized for undertreating pain.
John Martin, the DEA’s Administrator of the Diversion Control Division, said an overwhelming percentage of prescribers followed the rules. Of 1.6 million registrants, he said, less than one percent “operate outside the law.”
Martin said most prescribers have nothing to worry about.
He must be joking – and doesn’t even know it.
But that’s not what prescribers and patients see.
“Doctors around the country are terrified because of what happened to me and other doctors,” Ibsen said. “We don’t arrest car dealers if someone drives a car and gets into a fatal accident.”
Yes, that’s a good point.
Doctors cannot control what people do with the medications they’ve prescribed, so they shouldn’t be held responsible.
“Standards of care are being decided by a jury of people without medical training,” Ibsen added
THE CHALLENGE OF PAIN MANAGEMENT
For many medical professionals, treating pain patients has become a thankless task. The stakes are too high, they say, as even those who try to responsibly manage opioid treatment for their sickest pain patients find themselves hounded by authorities or pharmacists.
Many doctors say they view opioids as a last resort.
That’s how most pain patients feel as well. If anyone would ever ask us, they’d hear about how many other and “alternative” treatments we tried before starting opioid therapy.
They are very strong medicines, which often come with strong side effects, ranging from constipation, nausea, liver damage and respiratory problems. Many pain patients said in interviews they were reluctant to take them initially, and eventually did only after other treatments and surgeries failed.
“If we had a good alternative to opioids, every physician would be at the front line of it to prescribe that,” said Dr. Lynn Webster
Many pain patients told Fox News that after being forcibly tapered down or abandoned by their pain doctors, they have lost much of their ability to function. Many said they have made suicide plans.
“I have heard from — either through email or posts on my blogs — about 1,000 people over past two years who have been denied pain medicine or forced to dramatically reduce their dose who have expressed a desire to die or commit suicide,” Webster said.
WARNINGS, RAIDS AND ARRESTS
Health care providers who prescribe opioids, particularly to high-impact chronic pain patients, are finding themselves on the radar of any number of sources – pharmacists, state medical boards, insurers, and law enforcement.
But the red line triggering disciplinary action often is inconsistent, and murky.
The CDC considers an opioid’s benefits to outweigh risks if it improves pain and function by at least 30 percent. But, doctors say, those factors rarely are considered when authorities scrutinize prescribing patterns.
More often, it’s large amounts of opioids and high doses – statistics on a spreadsheet or chart, without the context of a patient’s medical condition — that can bring disciplinary action.
U.S. Attorney B. Jay Pak called those doctors “outliers,” adding the warning letters were meant to point out “atypical practices.”
Significantly, Pak said the doctors may not have done anything wrong.
Yet they don’t think this should shelter them from law enforcement raids and prosecution?
The U.S. Attorney’s Office in Atlanta announced in October that some 30 doctors were put on notice there for prescribing opioids in larger quantities and higher doses than others. Prosecutors enclosed the CDC guidelines with the warning letters.
“When we are investigating something like a doctor that may be overprescribing, you know because we’re not doctors, in the course of our investigation we are going to solicit medical experts,” Martin said
So these investigations are decided by whatever doctor that supports their approach, so I’m sure they are getting advice from doctors like Kolodny.
Roughly 800 prescribers each year surrender their DEA registration – a kind of license – when the agency opens an investigation. DEA investigations can involve having assets and medical records seized. In some cases that can lead to bankruptcy, doctors said, prompting many to surrender their opioid prescribing rights, rather than fight a battle against a behemoth government.
Ibsen said he became a target of the state board of medical examiners after an employee he fired filed a complaint, saying he over-prescribed. His license was suspended but eventually reinstated – after four years.
But he decided to stop prescribing opioids after five visits from the DEA.
They have time to visit this doctor 5 times, instead of visiting the drug dealers that are poisoning people with fentanyl.
“They were very vague,” he said of the DEA agents. “They said ‘You’re risking your freedom by prescribing to patients like these.’ I said ‘Patients like what?’ They said, ‘Patients who might sell the pills.’”
This sounds like how the Mafia worked, strong-arming people to go against their principles (like believing people in pain should have access to opioids).
“Doctors are taking plea deals because they don’t want to go to prison,” said Ibsen, who was not charged. “Once they arrest a doctor, they seize all their medical records. A doctor can’t make any more income. They seize your assets, and can’t afford an attorney.”
Ibsen referred patients to a prominent pain doctor in California, Dr. Forrest Tennant, who became known for taking people cut off by other doctors. Tennant for years had been researching non-opioid alternatives.
Then the DEA raided Tennant’s office. The agency never charged him, but he, too, gave up prescribing opioids.
“It’s immoral and unsafe to forcibly taper down or abandon a patient,” said Tennant, whose patients included those with terminal illnesses.
“Some doctors don’t give these patients any withdrawal medication. Who is the worst offender, then? The CDC, the DEA, the U.S. attorneys who are shutting down doctors, or the doctors who abandon patients?”
One Tennant patient, Jennifer Adams, a former Montana police officer who had been treated by Ibsen, died from a self-inflicted gunshot in April, after the California doctor’s office was raided by the DEA.
Dr. Lesly Pompy was one of a few pain physicians in a rural part of Michigan, serving as many as 1,500, the majority of them referrals from other doctors who could not treat their chronic conditions.
A pain specialist since 1995, he kept long hours, sometimes going to hospital emergency rooms when he was summoned to help a patient in severe pain. Sometimes he would try nerve blocks, many other times opioids.
On Sept. 26, 2016, roughly 25 law enforcement officers raided Pompy’s office at the ProMedica Monroe Regional Hospital.
“There were DEA agents, county and local police, they had everybody in my waiting room and who worked in my office put their hands up. Children were crying. There was a helicopter over the building. It was like a scene from a Jason Bourne movie,” he said.
The DEA enjoys using their “battle gear” and raiding doctors’ offices fully armed with automatic weapons drawn, threatening everyone with being shot dead.
Pompy’s former patients and some former employees have stood by him, saying he is being scapegoated. Former patients have held rallies and started a Facebook group in support of him.
Janet Zureki, a former patient of Pompy, said that — as often happens after a prescriber’s arrest — patients were left in limbo, having to scramble to find another pain doctor.
“After the raid and he could no longer prescribe, everyone was dangerously cut off of their medicines, including me,” she said. “It took me three months to find another pain doctor and they put me on a lower dose of medicine. During that three month period, I had to go without medicine and go through withdrawal.”
DOCTORS LAMENT WALKING AWAY
Nadeau is bewildered over having to stop treating his pain patients, at least one of whom died by suicide. And he said his hospital’s decision to stop working with opioids is by no means unique.
Hospitals increasingly see opioids as a liability; an overdose can land them in a lawsuit, he said. But he wrestles with the fact there are people he can no longer help.
“It’s been extremely difficult to find physicians to provide comprehensive pain therapy,” he said. “I don’t blame physicians for being scared to death and for prescribing to CDC guidelines, but I do blame [some of] them for treating patients badly.”
For his part, Ibsen is treating patients with medical marijuana. Ibsen said he always strived to get patients on opioids to agree to taper down, and about 80 percent did, often using medical cannabis. For the others, opioids were the best treatment, Ibsen said. He understands the threat of the overdose epidemic all too well.
“My nephew died of a heroin overdose” in the summer, he said. “But incarcerating doctors is not going to solve the addiction crisis.”
Wow, I’m very impressed that he doesn’t see his nephew’s death as a reason not to prescribe opioids for pain patients.
“There are two things doctors do –
- we save lives and
- we relieve suffering.
If we’re not willing now to relieve suffering, then what are we about?”