Chronic-pain patients feel sting of Washington state’s opioid crackdown
As physicians tighten their prescribing practices for opiates, patients feel punished for the actions of doctors they’ve never seen, such as at the now-closed Seattle Pain Centers. Patients deserve more understanding, experts say.
Chris Hegge has been taking opioids almost 20 years for relief from seven back surgeries, including a spinal fusion.
The drugs have helped him walk his dog, practice tai chi and lead a relatively pain-free life, said Hegge, 57.
Hegge says he’s being punished for others’ misdeeds. “Why do innocent patients have to suffer because of doctors being investigated? Instead of fighting chronic pain,” Hegge said, “I’m fighting the system.”
After years of surging opioid prescriptions, leading to addiction and deaths, the pendulum swung back hard against abuse, culminating in the July shutdown of the Seattle Pain Centers (SPC), a chain of eight Washington clinics. That state action, amid allegations of improper oversight that may have contributed to patient deaths, sent 8,000 patients looking for new providers.
Pain-treatment experts express sympathy for “legacy” patients like Hegge, who were prescribed high doses of opioids before a new approach took hold with new state rules in 2012.
“It could take years to get these folks’ (doses) down because their bodies have been so transformed by exposures that create changes in the brain, spinal cord and elsewhere.”
Their problems are compounded by doctors who now fear sanctions for prescribing high doses — fears that may come from misunderstanding the state’s rules. Doctors don’t have to slash dosing for legacy patients, according to Tauben and others. It says so in state and federal guidelines.
That’s not much relief for Hegge.
“It’s like a primitive voice in my head keeps repeating, ‘have pain, stop the pain,’ ” he said, about a visit last month to an emergency room to seek help for pain, anxiety and symptoms of withdrawal.
“Never goes away”
Some doctors have long been reluctant to treat chronic non-cancer pain patients. With concerns about abuse and overdoses, and the complexity of diagnosing and treating pain, such patients tend to require more monitoring than a doctor’s schedule often allows.
“The amount of work to manage those patients safely and effectively is really high,” said Dr. Tom Schaaf, a member of an opioid-practices task force convened by the state medical and hospital associations.
No one knows what happened to all of the SPC patients and if any resorted to dangerous street drugs. Tauben, Schaaf and others believe the vast majority found new providers. Some were treated for withdrawal in emergency rooms.
“But from an ER perspective we’re not seeing large numbers of folks having difficulty accessing pain management at this point,” said Dr. Nathan Schlicher, an emergency physician in Tacoma, and member of the state opioid task force.
There was one suicide thought to be linked to the closure of SPC. Denny Peck, 58, of Thurston County, left a note in September saying he had run out of pills and couldn’t stand the pain caused by a commercial fishing accident 26 years earlier.
The SPC fallout appears to have fueled some doctors’ fears.
Robert Moran Jr., of Tumwater, said his doctor told him in July he was going to cut his dosage. “He just started saying, ‘We have to cut you back; I’m not going to lose my license,’ ” according to Moran, 60, who said his right arm, nerve-damaged in a motorcycle accident, aches more and is almost useless to him with a lower dose of painkillers.
He sleeps in a recliner because of the pain, he said, rarely showers and eats off disposable plates because he hasn’t been able to install the dishwasher he bought. “Imagine having a pain at the level of a bad toothache and it never goes away,” he said.
Moran’s doctor did not respond to requests for comment.
Under current state rules, Hegge and other patients sign a pain contract with their providers, agreeing to submit to random drug tests, pill-counting and other checks.
Hegge, now on disability, was a chemical-dependency counselor for 10 years. He weighs the costs and benefits of his morphine use, he said, including unpleasant side effects. He believes he’s a smart consumer.
But state officials suspended the license of his longtime doctor, Philip Roger Matthews, in December, saying he prescribed high doses with not enough care, endangering patients.
In his response, Matthews disputed that and called the suspension of his license “excessive and unwarranted.” He said he has not injured any patients and does not pose a risk to them.
His license remains suspended pending further action by the state. He did not respond to requests for an interview.
No upper limit
While legacy patients may deserve some flexibility, experts say the medical evidence is clear: there are more risks than benefits associated with daily doses above 120 milligrams of morphine, or the equivalent in other opioids.
Generally, doctors want to taper doses for patients like Hegge, who takes about 360 milligrams of morphine a day. But they should do it with care.
“Even a tiny reduction will be experienced by the patient’s central nervous system as increasing pain,” Tauben said. “It is a slow journey that involves an empathic response to these individuals caught in this shifting pendulum.”
Doctors will not lose their licenses just for prescribing above the state-recommended daily threshold of 120 milligrams of morphine, according to Tauben and others.
Doctors may prescribe above that limit, the rules state. If they do, they should consult with a pain specialist.
They don’t even need to do that if the patient meets criteria such as being on a tapering schedule, or the patient’s function is improved without apparent risk, or the prescribing physician has a certain amount of training in pain management.
But the rules “got distorted” by some, Tauben said.
The state Department of Health put out a reminder late last year — a month after Peck’s suicide.
“In fact, there is no upper limit for opioids in the Washington state pain rules,” wrote Melanie de Leon, executive director of the Medical Quality Assurance Commission, which disciplines doctors.
“While the opioid epidemic is a public health crisis, we must not forget the crisis that is the patient without relief from debilitating pain or functional improvement,” de Leon said.
Guidelines issued last year by the Centers for Disease Control and Prevention called for “very slow opioid tapers as well as pauses in the taper to allow gradual accommodation to lower opioid dosages.”
Schlicher, the ER doctor, said he thinks providers understand the rules. But they also have to safeguard against patients who don’t want to do what the doctor deems necessary and “bounce between providers,” he said, rather than building a relationship with a doctor that might evolve to allow higher dosing.
“I have sympathy for both sides, patients and doctors,” Schaaf said.
Educating doctors
Micah Matthews, deputy director for the medical quality commission, said state officials tried to educate doctors about the new rules. They even went on a yearlong road show. “We gave presentations to some 5,000 practitioners around the state,” Matthews said.
If a patient thinks the state is interfering in his treatment, Matthews said “that’s an educational opportunity we’re willing to take on with the physician.”
He said patients should give his email to their doctors so they can ask Matthews or state medical consultants about appropriate practices under the rules.
Tauben advises patients to give de Leon’s “technical assistance” memo to their doctors or clinic administrators. Patients should also encourage their doctors to visit a weekly teleconference the UW hosts to discuss complex chronic pain cases, he said.
Above all, Schaaf said, patients shouldn’t give up their “search for finding a doctor who will listen and be honest with you about your condition but is willing to compromise with you toward a goal of least medication with best functional status.”
If the state/federal laws are not being observed by prescribers… causing chronic pain pts to have needless pain and suffering. Why is the Medical Licensing Board not taking action against those prescribers… since the primary function of all medical licensing boards is to protect the public’s health and safety… Apparently in the state of Washington… they seem to only interested in what they perceive as over-prescribing of opiates and little/nothing about pt’s unnecessary and needless suffering from untreated pain.
Filed under: General Problems
I had surgery and they would give me nothing afterwards because I was already taking pain meds for chronic conditions. It was not enough and I suffered. I had emergency surgery for a rare condition (the hospital never had a case before) and had to wait for six hours for the surgeon to get there. The nurse said she was not going to give me any “narcotics like I was use to” and would only give me a muscle relaxer while I waited! Afraid to ever go to the hospital again. It was horrible.
I guess we all better not hurt ourselves more than we already are or have surgery. Cause we arent even going to get pain control for that. I need a knee replacement badly but I wont do it because they said I dont need any more pain medicine because I have surgery. Im like , No way am I gonna go through that without extra pain medicine for after surgery. That is cruel. But it shouldnt surprise anyone these days.
Also, It doesnt seem that anyone is concerned that people may be killing themselves because they have been cut down or taken off pain medicine. I guess then it falls to the patients instead of the Dr. As long as the Dr.s have their butts covered. The lack of compassion in this country is sickening.
All anyone seems to care about are standard dosages and people who choose recreational drug use! If I hear my doctor tell me one more time how good I am doing reducing my pain meds I am going to scream! The only one doing well is my doctor in covering her own butt with both hands cuz I am suffering but for now am able to follow the rules. I don’t know how much longer I can keep it up! As for emergency rooms not seeing more people looking for pain relief it’s probably because we already know that we won’t get any and will be treated worse than the proverbial red headed step child! When you become a chronic pain patient you soon learn that the best your going to get I total disrespect and the brush off! “WE DON’T TREAT CHRONIC PAIN PATIENTS HERE!” Sadly even if the pain your in is a broken leg!