While high-profile cases against doctors have brought yet another spotlight to the nation’s ongoing opioid epidemic, experts say this is rare and overlooks the bigger picture.
Once a wonder drug
“In the late ’80s, early ’90s, we were all told that we were too cautious and we were not appropriately treating patients’ pain,” said Sur, a professor of family medicine at the University of California, Los Angeles.
“That was a quote I heard regularly,” said Sur, who has testified in cases in which doctors are accused of recklessly prescribing opioids.
More and more, Sur sees other doctors referring risky patients to pain specialists who might be better equipped to offer alternative treatments, screen for addiction and, when necessary, prescribe opioids safely.
The fear, she said, “is not just strictly about being sued; it’s about harming somebody.”
“Personally, it’s very frightening … when you’re working with medications that are receiving this type of scrutiny,” Curseen said.
But she said it’s a risk that many doctors accept to help patients in need.
“This is the profession that we chose,” she said.
Scope of the problem
But some researchers have pushed back against the idea that a small number of doctors are responsible for the opioid epidemic.
But looking more broadly, a greater number of opioid prescriptions were written by general practitioners, such as family doctors, who see far more patients overall.
“There’s just not that many pain medicine specialists. They can’t drive national prescribing patterns,” said Humphreys, also a former White House drug policy adviser under Presidents Bush and Obama.
Humphreys described criminal cases against doctors as “rare.” Many doctors see these cases as outliers, which may also involve allegations of fraud, poor record-keeping and other misconduct.
The investigation lasted several years, but no charges were ever brought against him.
“It’s kind of like a scarlet letter that I will always carry with me,” Webster said. “An investigation can be life-altering, but it can be career-ending.”
Patterson, who has investigated opioid cases involving doctors, said the DEA has made the drug epidemic a priority in recent years. He said it is much easier to push these investigations forward than before.
“There was a reluctance to really prosecute doctors” early in his career, he said. “That’s being prosecuted all over the country right now. That’s how far we’ve come.”
But Patterson said that doctors shouldn’t fear prescribing opioids if they’re checking all the boxes. These investigations, widespread as they might be, represent a “small percentage” of doctors, he said.
“When a doctor is acting responsibly … opioids are one of the best things they could have to treat pain,” he said. “But when it’s irresponsible — in other words, a doctor hasn’t even examined the patients, and they’re prescribing them — that’s what’s killing people.”
Webster, who has spoken in defense of other doctors in criminal cases, said that colleagues were “stunned” that this could happen to him.
Beyond legal concerns, Stanos said, doctors are acutely aware of a rising opioid death toll and powerful synthetic drugs hitting the streets, like fentanyl. Stanos said doctors are becoming “more worried” about prescribing opioids — but that worry, he said, is not necessarily a bad thing.
“They should be careful, and opioids aren’t for every patient,” Stanos said. “Opioids are just a small part of (pain) management.”
Many doctors even have formal “agreements” with their patients, Stanos said. This may involve taking occasional urine samples to check for other drugs.
But experts like Stanos have had to solve another looming question: What about all the patients who were put on high-dose opioids in the past?
In the aftermath of cases involving doctors, some patients might be drug-dependent and have nowhere to go. Many face severe withdrawal symptoms and a heightened sensitivity to pain, a condition called hyperalgesia, Kolodny said. If those patients get their hands on opioids later on, they are more likely to overdose, having lost their tolerance.
Stanos, who is also the medical director of Swedish Pain Services in Seattle, has absorbed patients when nearby clinics have closed.
“We took over a number of patients that were in clinics where … I don’t agree with what was done with them,” Stanos said. “Those patients are at high risk.”
“You could call it a U-turn,” Kolodny said.
“The (VA) had one of the earliest and worst guidelines on opioid prescribing that I’ve ever seen,” he added. “And in 2017, they put out the most conservative guideline that’s ever been made to date — which is, I think, a very good guideline.”
But many veterans on high-dose painkillers suddenly had to cut down medications that their bodies were dependent on.
“If you are getting a patient who’s been put on chronic opioids, even though they never should’ve been started on it, that doesn’t mean you should force them to come off rapidly,” Kolodny said.
Stanos said that the VA’s interdisciplinary approach to pain has changed the field but that many unaffiliated doctors aren’t able to offer the same array of alternative treatments and programs.
The VA “had to deal with this even sooner than the commercial payors, Medicare and Medicaid.” Stanos said. “Now, they have some of the strongest treatment centers.”
But many physicians and advocates want to focus on the doctor’s office in order to protect patients at risk.
“If we’re ever going to bring (the opioid epidemic) to an end … we need these folks to prescribe much more cautiously,” Kolodny said. “If you can get your patients off of opiates, that should be the goal.”