As the nation faces an epidemic of opioid drug abuse after a decade of aggressively prescribing narcotics , Montana doctors are becoming more cautious about giving painkillers to chronic pain patients.
It’s changing some patients ability to get treatment and what is considered compassionate care for chronic pain.
Last spring, the federal Centers for Disease Control and Prevention issued new opioid prescribing guidelines for doctors, designed to address the national epidemic.
In response, Butte Doctor Shawna Yates, the Medical Director of Southwest Montana Community Health Center, sent a letter to pain patients saying the clinic would no longer prescribe high doses of opioid painkillers.
“For me, personally, I really do try to stress that I believe in their pain," Yates says, "that I understand where the concern that they’re having is coming from."
But Yates says, her clinic’s new policies for the highly addictive drugs have caused a lot of patients to seek care elsewhere.
"I’ve said it more often in the last six months than ever before. I’m not leaving them. If they decide to leave, they’re leaving me.”
The CDC guidelines encourage primary care doctors to become less dependent on opioid medications for treating chronic pain because of the drugs’ serious side effects, including addiction.
The Butte clinic started tightening its prescribing policies back when it had about 700 pain patients coming in for treatment, years before the CDC released its guidelines.
It did things the CDC guidelines would eventually call for, like random drug tests, to make sure patients weren’t abusing their medication, or taking additional drugs. The clinic also required patients to only fill their prescriptions at one pharmacy.
“And many of those patients left" Yates' clinic, she says. "There are many patients that aren’t willing to follow those recommendations.”
After the clinic put in the additional rules for pain treatment, and sent out a letter telling patients the clinic was adopting the federal guidelines, implementing a cap on how many pills it prescribed, about 400 patients left the clinic.
Doctor Andrew Kolodny, with the national advocacy group Physicians for Responsible Opioid Prescribing, says lowering the limit on prescription painkillers is a good policy and it’ll help patients who are harmed by high doses.
“For patients who are being required to taper down who are on high doses, that’s appropriate,” Kolodny says.
Kolodny is also the co-director of the opioids policy research collaborative at Brandeis University in Boston.
“As Doctors start to figure out that we shouldn’t have been prescribing in this way, these patients are at risk of being cut off from a legal supply of opioids," Kolodny says. "And that’s why we really do need a compassionate response for that population.”
Kolodny says the problem isn’t people using opioids because it makes them feel good, snagging a few pills to get a quick high. The issue, he says, is the millions of Americans who were legally supplied, and hooked, on these drugs during an era of medicine where opioids were believed to be a good option to treat pain.
Now, Kolodny says the most compassionate thing doctors can do is slowly, and safely, begin to take away the painkillers and start treating these patients for narcotic addiction. Because he, and some doctors around Montana, say regular use of opioids can actually make pain worse.
But pain patients like Dalaine Propp don’t like being told they drug abusers.
“We either do what they say we do or we get kicked to the curb," Propp says.
Propp is a member a pain patient support group in Great Falls. They got together because they feel they’re being treated unfairly. There’s about 100 members in the group’s Facebook page, and this spring, a couple dozen people showed up to the group's first meeting.
Propp says she's tried alternatives to opioids.
“I did the physical therapy, we looked at the surgery option, we’ve done injections, and unfortunately the only thing that has kept me working and kept me going was the opiate medication," she says. "I think this whole thing with the CDC has scared even regular practitioners to even start people on any kind of pain regime.”
“I have no doubt that there are patients who are telling you that they feel agonizing pain," Kolodny says,"and then they take their opioid and they’re able to get out of bed and function and brush their teeth and have some type of life, and that without the opioid they wouldn’t be able to get out of bed and they’d feel like they want to commit suicide.
"I can tell you that’s exactly how people who are heroin users who are opiate addicted feel until you use your first dose of heroin in the morning you’re feeling agonizing pain and discomfort," he says.
Kolodny says too few doctors who prescribe opioids also prescribe drugs that can help patients wean off the painkillers. If doctors want to help chronic pain patients move past opioids, he says, more doctors need that addiction medication training.
There are patients who say that once they got off opioids, it became easier to deal with their underlying pain issue, some describe it like a fog being cleared.
At the clinic where Doctor Shawna Yates works, in Butte, patients are required to go to mental health specialists and encouraged to keep up a good diet and get enough sleep.
“I think the biggest thing we need to do moving forward as a culture is find better ways to treat pain," Yates says.
"The hardest part is to know that there are people out there that are not getting good pain relief, and with a culture that is getting older and that are suffering, that’s the part that bothers me," she says. "We can take stuff away, and we can know that there is harm related to this. I don't think the biggest challenge is taking these away. I think the biggest challenge is finding out what we are going to do in place of it.”
Yates says as she, and other doctors learn more about how to treat pain, she wants patients to know she’s not abandoning their care, even if that’s exactly how some patients see it.