Beginning in the 1980s but gathering steam in the mid-to-late 1990s, American doctors turned millions of their chronic pain-suffering patients into opiate dependents. There was nothing ill-intended or illegal about it; pain relief had become the patient’s right to relief from both acute and chronic pain. Doctors were simply riding the political winds─and obeying the laws─of the times. Those of us around in those years remember that even a stubbed toe could call out the prescription pad.
California legislation supported and eventually codified wholesale dispensing of chemical pain killers. In October of 2002, AB 487 was signed into law. Described as a professional conduct code, it mandates, in part, that standards be developed “for the investigation of complaints concerning the management, including, but not limited to, undertreatment, undermedication, and management of pain…” The law goes on to state that, “For the past 20 years medical journals have reported that physicians consistently fail to manage their patient’s pain appropriately.”
That was then and this is now. “There’s been a huge transition over the last 20-25 years,” says Mendocino County Public Health Officer Dr. Gary Pace. “Ten years ago doctors could get in trouble for underprescribing pain medication. And even though today we’re clearly facing a huge opiod problem and overprescribing is an issue, I think personally we may have swung too far.”
Back in that not-too-distant-past an avalanche of legally prescribed opiods, fast-tracked by multi-billion-dollar corporate pharmaceutical giants whose marketing reps were little more than legally sanctioned drug pushers, ironically unfolded as public concerns over drug addiction ramped up. A deep cultural stigma developed; if you were a law-abiding, gainfully employed patient with a doctor’s scrip you were managing your pain, but also drug dependent; if you were poor, unemployed, living on the street and buying your drugs illegally, you were a drug addict and subject to arrest.
The dual stigma persists. There is “opiate” and its synthetic equivalent “opioid. Whatever you call it, the numbers of people who use them keep on climbing. On the legally prescribed side a recent California state summary of opioid prescriptions by county puts Mendo in the second-highest tier: 1,148.81 prescriptions per 1,000 residents per year, only marginally fewer than in neighboring Lake County.
Kyree Klimist, Mendocino County Health & Human Services senior program manager, says that judgmental words matter and hurt the people they’re trying to help. [These judgements] “don’t take into consideration poverty, unemployment, lack of opportunity and trauma,” she said, “and it’s slow, hard work” to turn it around. Klimist says her group has pulled together a team of doctors, other hospital workers, social workers, community members, and representatives from the Sheriff’s office and other branches of public health to form a united front. “We’re just hitting our stride,” she said. She added that a primary focus is working with kids to keep them off drugs in the first place, to draw a kind of generational line against addiction. “Because we are in prevention, we can’t really do much about those who are already addicted,” she said. Their mantra is prevention. “We’re working real hard to not make new addicts,” ultimately the most effective path to less addiction.
Back on the treatment side, Dr. Pace emphasized that his medical group is all about treatment and harm reduction. “We’re public health people,” he said. “We respond.” He said that, medically speaking, there are three basic approaches to reducing opiate dependency: reducing the amounts of medication, expanding treatment availability, and using more life-saving treatments for overdoses like Narcan, a nasal spray that counteracts the effects of opiates. He recognizes that pain clinics that recommend treatments like acupuncture and meditation can be a tough sell for seriously addicted people. “It’s like throwing a cup of water in a hurricane,” he said. He said he’s been successfully prescribing Suboxone for 15 years. Suboxone is a prescription drug, still a narcotic, but blunts symptoms of withdrawal and does not require ever-higher doses like opioids. “It is used to treat a chronic disease, not to replace one drug with another,” Pace said, in response to critics who do not believe that one drug should be used to counter the use of another. He said he also questions whether total abstinence should always and inflexibly be the goal – heresy for abstinence-only programs like AA and NA. He says some can effectively live with it. About those for whom addiction has become a problem, he said, “These people are struggling and we don’t want to be puritanical. We want to help people get out of this morass” they’ve found themselves in.
Both prevention and treatment efforts are hindered by past practices. The 1970s War on Drugs failed, as did expanded international efforts to negotiate with opium-growing countries to compel growers to switch crops – a tall order in poor countries like Afghanistan where poppies are more profitable than other crops and where there is little to no local drug addiction.
So who can we blame for today’s opioid mess? It’s a crisis, there has to be somebody to blame! This time, in typical American blame-game style, doctors themselves have moved into the crosshairs, the same doctors who could have been sanctioned for underprescribing prescription narcotic pain killers a mere decade-and-a-half ago.
The current idea is that if fewer prescriptions are issued, drug dependency and, for some, full-scale addiction supported by illegal drugs, will go down, too. This belief has spread to insurers: MediCal has adopted tighter prescription guidelines and Medicare is midway into following suit. Also reflecting this latest belief, a statewide database known as The Controlled Substance Utilization Review and Evaluation System (CURES) will go into full operation October 2. CURES will theoretically reveal all statewide opioid prescriptions at the stroke of a key and eventually require all doctors with prescription rights to use it. Klimist says the system is meant to cut down on so-called “doctor” or “pharmacy shopping,” where someone can visit several doctors and/or pharmacies to purchase more of a narcotic than prescribed. It also means that, for the first time, pharmacists will join doctors on this last line of defense. Klimist explained that, “A pharmacist will be required to access the database and quickly determine, for example, ‘Hey she was just in here — I don’t think so!’”
The whole theory of electronic tracking is that cutting down the legal supply will in turn cut down on illegal supplies; every stat I’ve seen shows that the majority of illegal opioid users, in some cases four out of five, started down that road with legally prescribed pain meds. That’s the idea, anyway. Or not. In a classic case of unintended consequences, this time on supply and demand, Klimist had just that morning received an update on the cost of oxycontin versus heroin on Mendo’s streets. “Oxy is now up to $1 a milligram, or $80 for an 80-milligram pill,” while heroin is down to $100 for up to three grams,” a widening difference, she says, that is causing an equally unanticipated shift from now-expensive, now-harder-to-get pills to much cheaper heroin.
While Pace and Klimist work to broaden county coalitions to more effectively deal effectively and compassionately with current addicts and keep kids off drugs in the first place, another key group charged with enforcing ever-shifting drug laws faces the practical realities of dealing every day with illegal opioids and other drugs out on the street.
“Law enforcement should be the hammer,” said Mendocino County Sheriff Tom Allman, adding that law enforcement does not set policy. He said that his first priority is the safety of his officers, especially with the growing popularity of potent drugs like fentanyl, a narcotic many times stronger than heroin and often cut with heroin. He said two cops in Fresno touched some fentanyl during a traffic stop and, as non-users, had such violent reactions to that brief contact that they were off the job for a year. “I understand why officers don’t want to expose themselves,” Allman said, adding that that’s why the county is coming up with new ways to physically separate officers from questionable powders and other confiscated drugs. The county now owns one Tru-Narc, a $20,000 sophisticated piece of equipment that performs hands-off drug analysis without the hands-on involvement of law enforcement. Allman also said that another concern is well-intended privacy laws like the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), which provides data privacy and security provisions for safeguarding a patient’s medical information. The law not only prevents sharing medical information between counties and agencies without a patient’s permission, it also shields suspect prescribing doctors from scrutiny, like one Mendo doctor Allman described who writes thousands of opioid prescriptions a month. “We’ve talked to him, he knows he’s on our radar, but there’s nothing we can do about it,” Allman said.
In the end we arrive finally at chronic pain patients who have legally managed their pain with opiods for years and don’t want to follow what they see as arbitrary government regulations that interfere with their medicine.
Patients like Fort Bragg native Cindy Fayal. When I met Fayal in Ukiah she arrived armed with a well-organized file of her own voluminous paperwork. A gardener by trade but now disabled by worsening spinal disk deterioration, bone spurs, and scoliosis, Fayal says she doesn’t want surgery and its risks; she says she’s able to live a marginally normal life with the quick-release and extended release opioids she receives every month when she goes in person to Fort Bragg’s Mendocino Coast Clinic. That all changed a couple months ago when she says the clinic informed her that her dosages would be reduced immediately. She showed me the clinic’s paperwork, which stated in a nutshell that her prescriptions were being cut for her own good. “I’ve been taking this medicine for 10 years,” Fayal said, and “now they’re saying that everyone who takes it is addicted, that you have to just live with the pain.” She says she doesn’t want spine surgery, which she says is her only real option to pain management, and that the choice should be hers to make. “The DEA has to stop terrorizing doctors,” she said. “If they cut my medication much more I am not gonna be able to get out of bed.”
As the boom lowers on doctors, pharmacists, and patients alike, it is the hope of policy makers that this could finally roll back the so-called opioid epidemic, both legally prescribed and not. Its faith is in reducing legal supply, which is where most illegal users start out: with a doctor’s prescription. It’s a faith that skips over the poverty, unemployment, poor education, and crumbling social frameworks that contribute to the illegal side of the coin, focusing instead on the easy part: the drug alone.
Cultures are hard to change, including ours, but maybe it’s time to take a serious look at the more holistic approach espoused locally by professionals like Kyree Klimist instead of shaming and stigmatizing opioid-dependent people and putting the screws to pharmacists and doctors.
Sheriff Allman said this environment has threatened a valuable commodity – the trust that patients have in their doctors, doctors who have been legally whiplashed by opposing philosophies that have to be explained to their patients: those patients who may be taking an opioid for the first time, those who, under a doctor’s care, have taken prescription pain killers for years and become dependent upon them, and finally the seriously dependent now at greater risk of joining the ranks of illegal users once legal avenues close to them.