Tagged opioids

Must-Reads Of The Week From Brianna Labuskes

The next time I even hint that we’re drifting into a slow news period, feel free to remind me not to jinx things: This week was bursting with industry moves, health law attacks, midterm strategizing, and, oh yeah — an indictment.

A quick programming note before we dive into all that: The Breeze is going on hiatus as I breeze out of town for a bit. But I’ll be back Aug. 31, just as we really start heading into midterm season, so look for me again then.

Now for the news you may have missed:

This week’s swipe at the health law focused on accountable care organizations (shorthand explanation: a program that took a carrot-and-stick approach to getting hospitals, doctors and other providers to coordinate, with the end result of higher-quality, more efficient care). They were supposed to save the government billions of dollars, but data show they’ve failed to measure up to the promise, so the program is being overhauled.

The Washington Post: Trump Administration Proposes Further Dismantling of Affordable Care Act Through Medicare

Rep. Chris Collins (R-N.Y.) was charged with fraud in connection to alleged insider trading after an investigation into his ties with Innate Immunotherapeutics, an Australian biotech firm.

Politico: GOP Rep. Chris Collins Charged With Securities Fraud

If that all sounded vaguely familiar, it’s because back when then-HHS secretary nominee Tom Price was being vetted for any possible ethics violations, his connection to both Innate and Collins was put in the spotlight. And just a small plug: KHN did deep reporting on this, and you can read the stories here.

Medicare Advantage got some leverage to curb drug costs this week by way of “step therapy” (or, as it’s known to critics, “fail first”). Essentially, the private plans will be able to require that patients try cheaper versions of drugs before moving on to more expensive ones. To be clear: This is a pretty distant cry from campaign promises to let Medicare negotiate drug prices, and there’s no guarantee patients will actually see any savings from this move.

Stat: Private Medicare Plans Will Be Able to Use a New Tool to Lower Drug Costs

Would a Netflix model work for drugs? That’s what Louisiana wants to find out. Under the proposal, the state would pay a subscription-type fee to be able to cover all of its Medicaid patients who need hepatitis C treatment. Beyond the click-baity notion, though, experts warn that because drug prices are such a moving target (with some costs coming down quickly) the state may not actually save money.

Stat: Louisiana Explores a ‘Netflix’ Subscription Model for Buying Hepatitis C Drugs

For even some moderate Democrats, “Medicare-for-all” is a pipe dream involving all sorts of politically unpopular complications like trillions of dollars in government spending (the current point of contention). But on the trail, it’s a rallying cry. Gubernatorial candidates, especially, are embracing it, suggesting their states become early testing grounds for universal coverage plans that have been more rhetoric than action so far.

The Washington Post: Tossing Aside Skepticism, Democratic Candidates for Governor Push for State-Based Universal Health Care

The Hill: Ocasio-Cortez: ‘Medicare for All’ Is ‘Not a Pipe Dream’

Apart from “Medicare-for-all,” Democrats could have a winning health issue with drug prices. The problem? They can’t really coalesce behind a plan, all these “concessions” as of late are making it harder to attack the administration, and, uh, there may be a lack of interest in cutting off campaign cash this close to the elections.

Stat: Drug Prices Could Be a Winning Issue for Democrats — If Only They Had a Plan

The idea to penalize legal immigrants’ use of Medicaid has been rumbling around for a bit now, but it picked up some speed in recent days. Though it could be a winning issue for Republicans on the trail, the argument isn’t really backed up by the data. It turns out that legal immigrants are likely subsidizing native-born Americans’ health care.

The New York Times: Plan to Punish Immigrants for Using Welfare Could Boost G.O.P. Candidates

The Hill: Study: Immigrants Have Lower Health-Care Costs Than People Born in US

Buckle up, there were industry moves galore this week. I’ll try to keep it quick:  Billionaire Carl Icahn came out against Cigna’s attempts to acquire Express Scripts, saying it is (in my favorite vocab usage of the week) a “$60 billion folly”;  Rite Aid called off its (unpopular) merger with Albertsons; the American Medical Association came out against CVS’ deal with Aetna; and GM signed an exclusive deal with a health system to provide care for its workers.

The Wall Street Journal: Carl Icahn Publicly Opposes $54 Billion Cigna-Express Scripts Deal

The Wall Street Journal: Rite Aid, Albertsons Call Off Merger Amid Investor Opposition

Reuters: American Medical Association Opposes Merger of CVS and Aetna

The Wall Street Journal: GM Cuts Different Type of Health-Care Deal

If that wasn’t enough news for you, here’s my miscellaneous file: A billionaire and his PTSD clinics have become entangled in the fierce debate over VA privatization; a look at how Zika babies are faring as they grow up is sobering in the breadth of damage the virus has done; an app can warn those recovering from addiction when they’re in neighborhoods or with acquaintances that could trigger a relapse; and a medical examiner is writing to doctors personally each time one of their patients dies from an overdose — and it’s working.

ProPublica: Steve Cohen Is Spending Millions to Help Veterans. Why Are People Angry?

The Washington Post: 1 In 7 Babies Exposed to Zika in U.S. Territories Have Birth Defects, Nervous System Problems

Stat: Can An App’s Warnings to Avoid Triggers Prevent Opioid Addiction Relapses?

Los Angeles Times: Coroner Sent Letters to Doctors Whose Patients Died of Opioid Overdoses. Doctors’ Habits Quickly Changed

 —

And don’t miss one of my favorite long reads of the week (which I got sucked into while on deadline, thank you very much) about an Appalachian odyssey and a hunt for ALS genes.

Stat: Appalachian Odyssey: Hunting for ALS Genes Along a Sprawling Family Tree

Have a great weekend, all!

Clinicians Who Learn Of A Patient’s Opioid Death Modestly Cut Back On Prescriptions

Physicians and other medical providers modestly reduced the volume of opioids they prescribed after being told one of their patients had died of an overdose, according to research published Thursday.

“You can hear a lot of statistics about the crisis,” said Jason Doctor, lead author of the study, published Thursday in the journal Science. “But it always feels like it is happening elsewhere if you are not aware of any deaths in your own practice.”

The research included more than 800 clinicians — doctors, nurse practitioners, physician assistants and dentists — comparing those who received a letter from the medical examiner about a patient’s death and those who didn’t. The ones who knew about the overdose death cut the overall volume of opioids they prescribed by almost 10 percent over three months, while those who didn’t know prescribed roughly the same amount as before.

The study shows that awareness and education can change prescribing behavior, said Doctor, lead author and associate professor at University of Southern California’s Price School of Public Policy. The modest size of the reduction among those who were notified of a death suggests “that clinicians exercised greater caution with opioids rather than abandoning use,” according to the study.

The providers in the study who were informed about patients’ deaths were also 7 percent less likely to start new patients on opioids.

The letter did not blame providers for the deaths but showed that authorities were paying attention, according to the study.

“We were providing them with important information and also giving them a way to make things better by changing prescribing,” Doctor said. “Anyone who got the letter could continue to prescribe as much as they wanted, but we found that they didn’t. They became more judicious prescribers.”

Over 19,000 people died from prescription opioids in 2016, roughly double the number 14 years earlier, according to the National Institute on Drug Abuse. Most of that increase occurred from 2002 to 2011, and the numbers have been relatively stable since then, according to the NIDA.

Meanwhile, prescriptions of opioids are declining, and health officials are seeking ways to accelerate the trend.

The study did not measure whether the letters from the medical examiner or the changes in prescribing patterns had any effect on patient deaths.

Across the country, physicians have been accused of overprescribing opioids and have even faced charges related to patient overdose deaths. In an effort to better track prescribing patterns, states have started prescription drug monitoring databases.

The CDC recommends that providers avoid opioids if possible, but if they are necessary, they should start with the lowest effective dose.


KHN’s coverage in California is supported in part by Blue Shield of California Foundation.

As Opioid Crisis Rages, Some Trade ‘Tough Love’ For Empathy

It was Bea Duncan who answered the phone at 2 a.m. on a January morning. Her son Jeff had been caught using drugs in a New Hampshire sober home and was being kicked out.

Bea and her husband, Doug, drove north that night nine years ago to pick him up. On the ride back home, to Natick, Mass., the parents delivered an ultimatum: Jeff had to go back to rehab, or leave home.

Jeff chose the latter, Bea said. She remembers a lot of yelling, cursing and tears as they stopped the car, in the dead of night, a few miles from the house.

“It was really, really difficult to actually just drop him off in a parking lot on our way home and say, you made the decision — no rehab — so we made the decision, no home,” Bea said. “It was exquisitely difficult.”

But it was not unexpected. Doug Duncan said many parents had told him to expect this moment. Your son, he remembered them saying, will have to “hit rock bottom; you’re going to have to kick him out of the house.”

Two torturous days later, Jeff Duncan came home. While he returned to rehab, the Duncans decided their approach wasn’t working. They sought help, eventually connecting with a program that stresses empathy: CRAFT or Community Reinforcement and Family Training.

“There was more compassion and ‘Wow, this is really difficult for you,’ more open questions to him instead of dictating what he should and should not behave like,” said Bea.

The Duncans said the training helped them shift from chaos to calm.

“I started to feel an immense sense of relief,” Bea said. “I stopped feeling like I had to be a private investigator and controlling mom. I could kind of walk side to side with him on this journey, instead of feeling like I had to take charge of it.”

For the Duncans, the approach meant they could switch from enforcing family consequences, like kicking Jeff out of the house, to supporting him as he faced others, like losing a job due to drug use. It worked well: Bea and Doug helped Jeff stick to his recovery. He’s 28 now and has been sober for nine years.

Many drug users say, in hindsight, they appreciated being forced into treatment. But studies show that a compassionate approach and voluntary treatment are the more effective ways to engage drug users in recovery and keep them alive. That’s a critical consideration for families in this era of fentanyl, which can shut down breathing in seconds.

“The concept of letting their children hit bottom is not the best strategy because in hitting bottom they may die,” said Nora Volkow, director of the National Institute on Drug Abuse.

But desperate parents often don’t know how to avoid hitting bottom with their children as the Duncans did on that dark, frigid January morning. They have found ways to help: Doug is a parent coach through the Partnership for Drug-Free Kids, which is now collaborating with the Grayken Center for Addiction at Boston Medical Center.

The collaboration will close a gap in services for families caught up in the opioid epidemic, said Grayken Center’s director, Michael Botticelli, who served as drug czar in the Obama administration.

“They don’t call this a family disease for no good reason,” Botticelli said. “The whole design of these services [is] to promote tools and information for families so they know how to approach a situation and can heal.”

There is no uniform path to healing for the drug user or parents, and no widespread agreement on the best approach for families.

Joanne Peterson, who founded the parent support network Learn to Cope, said there are reasons why some parents ask older children to leave the house — if there are younger children at home or if the parents don’t feel safe.

“So it depends on what tough love means; it can mean many different things,” Peterson said.

She applauds the Grayken Center for expanding access to parent coaches, but “we also need more professional help.” Peterson said she routinely hears from parents who can’t find counselors and doctors who understand their daily traumas.

Some critics suggest the CRAFT model is too soft, that it enables drug use.

“That’s a misconception,” said Fred Muench, president of the Partnership for Drug-Free Kids. “CRAFT is authoritative parenting, creating a sense of responsibility in the child and at the same time saying ‘I am here for you, I love you, I’m going to help you, but I can’t help you avoid negative consequences if you’re not looking to do that on your own.’”

The parent coaching extends beyond periods of crisis.

On a recent afternoon, Doug Duncan was on the phone with Doreen, a mom whose daughter is in recovery. (We’re using only Doreen’s first name to protect her daughter’s identity.) Doreen was upset about an angry text from her daughter that sounded like when the young woman was using drugs.

“It brings me back there. In two seconds, I am back on that scene thinking she’s on the heroin, she’s not going to live,” Doreen told Duncan, expressing a very common fear of relapse.

In a panic — her daughter had overdosed twice and been rescued — Doreen wanted to ask if she was using heroin again. But she ran it by Duncan first. He encouraged her to talk it through.

Doreen paused, then said she could ask her daughter about work, whether it’s been stressful, or about her grief after a friend’s recent death. There are many reasons, Doreen realized, that her daughter might be angry. Her tone doesn’t have to signal a relapse.

“You talk yourself off the cliff,” Duncan said.

“Oh yes, I know all about that cliff, I’ve visited a few times before,” Doreen laughed. “You know, that ties in with what you said before about focusing less on what your feelings are and the terror or fear that you’re going through and more on what they’re feeling and what they’re going through — turn the tables a bit. That’s an excellent point.”

“That’s true compassion,” said Duncan, “and oddly enough it’s very therapeutic for you, too.”

More compassion in the home fits the shift away from criminalizing addiction — toward accepting and treating it as a chronic medical condition.

If a child had cancer, parents “wouldn’t disengage with them or be angry with them,” said Botticelli. “So I do think it aligns our scientific understanding that addiction is a disease and not a moral failure.”

This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.

LISTEN: Inexpensive Nerve Drug Often Abused As Opioid Epidemic Grows

Kaiser Health News reporter Carmen Heredia Rodriguez joins the host of “On Point,” Anthony Brooks, to discuss public health officials’ concerns about the increasing use of the drug gabapentin by people addicted to opioids. Gabapentin is not an opioid, and it is approved to treat patients with nerve pain or epilepsy. However, some people are illicitly buying the drug and abusing it to enhance their opioid highs or stave off withdrawal from other drugs.

Heredia Rodriguez wrote about the problem in an earlier story on KHN.

The “On Point” discussion about the drug (cue it up at 39:22) follows a discussion on the show about proposals for a single-payer health system.

“On Point” is produced by WBUR in Boston and distributed by NPR.

How Rival Opioid Makers Sought To Cash In On Alarm Over OxyContin’s Dangers

As Purdue Pharma faced mounting criticism over deaths linked to OxyContin, rival drugmakers saw a chance to boost sales by stepping up marketing of similarly dangerous painkillers, such as fentanyl, morphine and methadone, Purdue internal documents reveal.

Purdue’s 1996-2002 marketing plans for OxyContin, which Kaiser Health News made public this year for the first time, offer an unprecedented look at how that company spent millions of dollars to push opioids for growing legions of pain sufferers. A wave of lawsuits demanding reimbursement and accountability for the opioid crisis now ravaging communities has heightened awareness about how and when drug makers realized the potential dangers of their products.

The Purdue documents lay out how the company and its biggest competitors were jockeying for market share. Some of those drugmakers’ sales promotions downplayed or ignored the risks of taking opioids, or made false claims about their safety, federal regulators have asserted in warning letters to the companies.

Purdue first offered OxyContin as a remedy for moderate to severe cancer pain in 1996. Within three years, the company viewed the cancer market as too limited, with $261 million in potential annual sales versus $1.3 billion for a broader range of chronic pain care, the company’s marketing reports said.

“That was a pretty good recipe for a blockbuster,” said Andrew Kolodny, who directs Physicians for Responsible Opioid Prescribing, an advocacy group critical of drug industry marketing.

Purdue has become the most high-profile drugmaker linked to the surging opioid crisis. But other opioid manufacturers didn’t sit by idly as sales of OxyContin skyrocketed, topping $1 billion in 2000, despite reports of overdose deaths and addiction.

Purdue’s marketing reports indicate the company was worried about losing business to fentanyl-laced patches called Duragesic, as well as morphine pills and, to a lesser degree, methadone — which some managed-care groups and Medicaid health plans preferred because it cost much less than OxyContin. Methadone and morphine are made by a variety of drug companies.

In its 1999 marketing report, Purdue noted that Janssen Pharmaceuticals, an arm of drug giant Johnson & Johnson, was making “slow but steady” progress in promoting its Duragesic patches. The patches, which users attach to their skin, deliver a dose of fentanyl, an opioid drug about 50 to 100 times more powerful than morphine, according to the Drug Enforcement Administration.

Purdue estimated that Janssen would spend about $4 million in 1999 on medical journal advertising to persuade doctors to prescribe the patches for “early treatment of non-cancer pain and pain in the more frail elderly.” That is more than triple what Janssen spent the year before, according to the 2000 Purdue marketing report. In a statement to KHN, a Janssen spokesman said the company quit “actively marketing” Duragesic in 2008.

Purdue also spent millions on medical journal ads — and like Janssen, it drew criticism from the Food and Drug Administration for minimizing the dangers of opioids, government records show.

In 2000, the Food and Drug Administration criticized Purdue for exaggerating the benefits of using OxyContin to treat arthritis, while in 2003 the agency found that some other ads had “grossly overstated” OxyContin’s safety.

Janssen also drew the ire of the FDA. In March 2000, the agency called some claims made for Duragesic “false or misleading,” including the suggestion that the drug “has less potential for abuse than other currently available opioids.”

In September 2004, the FDA told Janssen to “immediately cease” making “false or misleading” claims, including saying that Duragesic was “less abused than other opioid drugs.” In its statement to KHN, Janssen said its marketing actions were “appropriate and responsible,” adding that it “acted quickly to investigate and successfully resolve FDA’s inquiries.”

The Purdue marketing reports are part of a cache of documents the company provided to the Florida attorney general’s office in 2002. The Florida attorney general released them to two Florida newspapers in 2003 after Purdue lost a court battle to keep them under wraps.

More than 1,500 groups, mostly cities, counties and states, are suing Purdue Pharma, Janssen and several competitors and drug distributers in federal court in Cleveland demanding reimbursement for treatment costs and other compensation. In a statement to KHN, Purdue said: “We vigorously deny these allegations and look forward to the opportunity to present our defense.”

The growing cluster of lawsuits argue that drugmakers set out to deceive doctors and the public by claiming their products presented little risk.

For its part, Purdue accused Janssen of trying to exploit public alarm over OxyContin-linked deaths to spark new sales of Duragesic.

“It has been reported that Janssen sales representatives are using improper techniques to capitalize on the negative press surrounding OxyContin Tablets and the issue of abuse and diversion,” reads the 2002 Purdue marketing plan.

In fact, opioids made by Purdue’s rivals also contributed to overdose deaths in those years and have continued to do so. In 2016, more than 42,000 people died nationwide from opioid-related causes, according to the Department of Health and Human Services.

Florida was one of the early states to see a rise in overdose deaths tied to prescription drugs. Florida medical examiner’s toxicology reports in 2002 detected oxycodone, the active ingredient in OxyContin, in hundreds of overdose fatalities. Abusers realized they could crush the pills and inject or snort the powder to get high. Many others died after mixing the pills with sedatives also prescribed by their doctors.

Florida medical examiner files also showed that abuse of fentanyl pain patches, methadone and morphine took many lives. Some abusers had figured out how to drain the Duragesic patch of its liquid fentanyl and inject it like heroin, or otherwise ingest it.

In July 2005, the FDA warned health care professionals about abuse of fentanyl patches. In December 2007, FDA cited reports of deaths and “life-threatening adverse events” when the fentanyl patch “was used to treat pain in opioid-naïve patients and when opioid-tolerant patients have applied more patches than prescribed, changed the patch too frequently and exposed the patch to a heat source.”

Purdue also kept an eye on methadone, noting in a 1999 marketing plan that “market research as well as reports from the sales force indicates that methadone use is increasing in both the management of cancer pain and non-malignant pain due to its low cost.” But as methadone won acceptance for treating pain, it also began to kill with alarming frequency.

The FDA in November 2006 warned of deaths and dangerous side effects among patients “newly starting methadone for pain control and in patients who have switched to methadone after being treated for pain with other strong narcotic pain relievers.”


KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Patients With Chronic Pain Feel Caught In An Opioid-Prescribing Debate

It started with a rolled ankle during a routine Army training exercise. Shannon Hubbard never imagined it was the prologue to one of the most debilitating pain conditions known to exist, called ­­­­­­­complex regional pain syndrome.

The condition causes the nervous system to go haywire, creating pain disproportionate to the actual injury. It can also affect how the body regulates temperature and blood flow.

For Hubbard, it manifested years ago following surgery on her foot — a common way for it to take hold.

“My leg feels like it’s on fire pretty much all the time. It spreads to different parts of your body,” the 47-year-old veteran said.

Hubbard props up her leg, careful not to graze it against the kitchen table in her home east of Phoenix. It’s red and swollen, still scarred from an ulcer that landed her in the hospital a few months ago.

“That started as a little blister and four days later it was like the size of a baseball,” she said. “They had to cut it open and then it got infected, and because I have blood flow issues, it doesn’t heal.”

She knows it’s likely to happen again.

“Over the past three years, I’ve been prescribed over 60 different medications and combinations; none have even touched the pain,” she said.

Hubbard said she’s had injections and even traveled across the country for infusions of ketamine, an anesthetic that can be used for pain in extreme cases. Her doctors have discussed amputating her leg because of the frequency of the infections.

“All I can do is manage the pain,” she said. “Opioids have become the best solution.”

For about nine months, Hubbard was on a combination of short- and long-acting opioids. She said it gave her enough relief to start leaving the house again and do physical therapy.

But in April that changed. At her monthly appointment, her pain doctor informed her the dose was being lowered. “They had to take one of the pills away,” she said.

Hubbard knew the rules were part of Arizona’s new opioid law, which places restrictions on prescribing and limits the maximum dose for most patients. She also knew the law wasn’t supposed to affect her — an existing patient with chronic pain.

Hubbard argued with the doctor, without success. “They didn’t indicate there was any medical reason for cutting me back. It was simply because of the pressure of the opioid rules.”

Her dose was lowered from 100 morphine milligram equivalents daily (MME) to 90, the highest dose allowed for many new patients in Arizona. She said her pain has been “terrible” ever since.

“It just hurts,” she said. “I don’t want to walk, I pretty much don’t want to do anything.”

Hubbard’s condition may be extreme, but her situation isn’t unique. Faced with skyrocketing drug overdoses, states are cracking down on opioid prescribing. Increasingly, some patients with chronic pain like Hubbard say they are becoming collateral damage.

New Limits On Prescribing

More than two dozen states have implemented laws or policies limiting opioid prescriptions in some way. The most common is to restrict a patient’s first prescription to a number of pills that should last a week or less. But some states like Arizona have gone further by placing a ceiling on the maximum dose for most patients.

The Arizona Opioid Epidemic Act, the culmination of months of outreach and planning by state health officials, was passed earlier this year with unanimous support.

It started in June 2017, when Arizona Gov. Doug Ducey, a Republican, declared a public health emergency, citing new data, showing that two people were dying every day in the state from opioid overdoses.

He has pledged to come after those responsible for the rising death toll.

Arizona Gov. Doug Ducey’s moves against opioid over-prescribing initially faced resistance from the state’s medical associations.(Will Stone/KJZZ)

“All bad actors will be held accountable — whether they are doctors, manufacturers or just plain drug dealers,” Ducey said in his annual State of the State address, in January 2018.

The governor cited statistics from one rural county where four doctors prescribed 6 million pills in a single year, concluding “something has gone terribly, terribly wrong.”

Later in January, Ducey called a special session of the Arizona legislature and in less than a week he signed the Arizona Opioid Epidemic Act into law. He called it the “most comprehensive and thoughtful package any state has passed to address this issue and crisis to date.”

The law expands access to addiction treatment, ramps up oversight of prescribing and protects drug users who call 911 to report an overdose from prosecution, among other things.

Initially, Arizona’s major medical associations cautioned against what they saw as too much interference in clinical practice, especially since opioid prescriptions were already on the decline.

Gov. Ducey’s administration offered assurances that the law would “maintain access for chronic pain sufferers and others who rely on these drugs.” Restrictions would apply only to new patients. Cancer, trauma, end-of-life and other serious cases were exempt. Ultimately, the medical establishment came out in favor of the law.

Pressure On Doctors

Since the law’s passage, some doctors in Arizona report feeling pressure to lower patient doses, even for patients who have been on stable regimens of opioids for years without trouble.

Dr. Julian Grove knows the nuances of Arizona’s new law better than most physicians. A pain doctor, Grove worked with the state on the prescribing rules.

“We moved the needle to a degree so that many patients wouldn’t be as severely affected,” said Grove, president of the Arizona Pain Society. “But I’ll be the first to say this has certainly caused a lot of patients problems [and] anxiety.”

“Many people who are prescribing medications have moved to a much more conservative stance and, unfortunately, pain patients are being negatively affected.”

Dr. Julian Grove, a pain specialist, says that doctors were already facing pressure on many fronts to reduce treatment by opioids in Arizona.(Will Stone/KJZZ)

Like many states, Arizona has looked to its prescription-monitoring program as a key tool for tracking overprescribing. State law requires prescribers to check the online database. Report cards are sent out comparing each prescriber to the rest of their cohort. Clinicians consider their scores when deciding how to manage patients’ care, Grove said.

“A lot of practitioners are reducing opioid medications, not from a clinical perspective, but more from a legal and regulatory perspective for fear of investigation,” Grove said. “No practitioner wants to be the highest prescriber.”

Arizona’s new prescribing rules don’t apply to board-certified pain specialists like Grove, who are trained to care for patients with complex chronic pain. But, said Grove, the reality is that doctors — even pain specialists — were already facing pressure on many fronts to curtail opioids — from the Drug Enforcement Agency to health insurers down to state medical boards.

The new state law has only made the reduction of opioids “more fast and furious,” he said.

Grove traces the hypervigilance back to guidelines put out by the Centers for Disease Control and Prevention in 2016. The CDC spelled out the risks associated with higher doses of opioids and advised clinicians when starting a patient on opioids to prescribe the lowest effective dosage.

Psychiatrist Sally Satel, a fellow at the American Enterprise Institute, said those guidelines stipulated the decision to lower a patient’s dose should be decided on a case-by-case basis, not by means of a blanket policy.

“[The guidelines] have been grossly misinterpreted,” Satel said.

The guidelines were not intended for pain specialists, but rather for primary care physicians, a group that accounted for nearly half of all opioids dispensed from 2007 to 2012.

“There is no mandate to reduce doses on people who have been doing well,” Satel said.

In the rush to address the nation’s opioid overdose crisis, she said, the CDC’s guidelines have become the model for many regulators and state legislatures. “It’s a very, very unhealthy, deeply chilled environment in which doctors and patients who have chronic pain can no longer work together,” she said.

Satel called the notion that new prescribing laws will reverse the tide of drug overdose deaths “misguided.”

The rate of opioid prescribing nationally has declined in recent years, though it still soars above the levels of the 1990s. Meanwhile, more people are dying from illicit drugs like heroin and fentanyl than prescription opioids.

In Arizona, more than 1,300 people have died from opioid-related overdoses since June 2017, according to preliminary state numbers. Only a third of those deaths involved just a prescription painkiller.

Heroin is now almost as common as oxycodone in overdose cases in Arizona.

A Range Of Views

Some physicians support the new rules, said Pete Wertheim, executive director of the Arizona Osteopathic Medical Association.

“For some, it has been a welcome relief,” he said. “They feel like it has given them an avenue, a means to confront patients.” Some doctors tell him it’s an opportunity to have a tough conversation with patients they believe to be at risk for addiction or overdose because of the medication.

The organization is striving to educate its members about Arizona’s prescribing rules and the exemptions. But, he said, most doctors now feel the message is clear: “We don’t want you prescribing opioids.”

Long before the law passed, Wertheim said, physicians were already telling him that they had stopped prescribing, because they “didn’t want the liability.”

He worries the current climate around prescribing will drive doctors out of pain management, especially in rural areas. There’s also a fear that some patients who can’t get prescription pills will try stronger street drugs, said Dr. Gerald Harris II, an addiction treatment specialist in Glendale, Ariz.

Harris said he has seen an increase in referrals from doctors concerned that their patients with chronic pain are addicted to opioids. He receives new patients — almost daily, he said — whose doctors have stopped prescribing altogether.

Dr. Gerald Harris II, an osteopathic physician, specializes in treating addiction in Glendale, Ariz. He says he’s seen an increase in referrals from doctors concerned that their patients with chronic pain are addicted to opioids.(Will Stone/KJZZ)

“Their doctor is afraid and he’s cut them off,” Harris said. “Unfortunately, a great many patients turn to street heroin and other drugs to self-medicate because they couldn’t get the medications they need.”

Arizona’s Department of Health Services is working to reassure providers and dispel the myths, said Dr. Cara Christ, who heads the agency and helped design the state’s opioid response. She pointed to the recently launched Opioid Assistance and Referral Line, created to help health care providers with complex cases. The state has also released a set of detailed prescribing guidelines for doctors.

Christ characterizes this as an “adjustment period” while doctors learn the new rules.

“The intent was never to stop prescribers from utilizing opioids,” she said. “It’s really meant to prevent a future generation from developing opioid use disorder, while not impacting current chronic pain patients.”

Christ said she just hasn’t heard of many patients losing access to medicine.

It’s still too early to gauge the law’s success, she said, but opioid prescriptions continue to decline in Arizona.

Arizona saw a 33 percent reduction in the number of opioid prescriptions in April, compared with the same period last year, state data show. Christ’s agency reports that more people are getting help for addiction: There has been about a 40 percent increase in hospitals referring patients for behavioral health treatment following an overdose.

Shannon Hubbard, the woman living with complex regional pain syndrome, considers herself fortunate that her doctors didn’t cut back her painkiller dose even more.

“I’m actually kind of lucky that I have such a severe case because at least they can’t say I’m crazy or it’s in my head,” she said.

Hubbard is well aware that people are dying every day from opioids. One of her family members struggles with heroin addiction and she’s helping raise his daughter. But she’s adamant that there’s a better way to address the crisis.

“What they are doing is not working. They are having no effect on the guy who is on the street shooting heroin and is really in danger of overdosing.” she said. “Instead they are hurting people that are actually helped by the drugs.”

This story is part of a partnership that includes KJZZ, NPR and Kaiser Health News.