This is the third of a three-part series on the nation’s struggle to address its crippling opioid crisis, and the unintended victims left in its wake. Read Part 2 here: Doctors caught between struggling opioid patients and crackdown on prescriptions

Many Americans today will attend several funerals before they get their first gray hair.

That’s in large part because of drug overdoses, now the leading cause of death among Americans aged 50 and younger. More than 70,000 people in the U.S. last year died from overdoses, most of which involved illegal opioids.

The overdose problem – and a rise in suicides, another byproduct of the drug epidemic — is so pervasive it’s being blamed for a drop in U.S. life expectancy.

The crisis has led to a rush of public health and law enforcement initiatives at all levels of government. The federal government has vowed to cut prescription opioids by a third. More than 30 states have passed some type of legislation aimed at attacking the opioid epidemic.

“Defeating this epidemic will require the commitment of every state, local, and federal agency,” President Donald Trump said in a March speech in New Hampshire. “Failure is not an option. Addiction is not our future. We will liberate our country from this crisis.”

We’re targeting the most vulnerable and sickest people who have been on opioids a long time.

— Dr. Stefan Kertesz, addiction specialist and professor at the University of Alabama at Birmingham School of Medicine.

The government response to the epidemic has many medical professionals, patients and their families welcoming the long overdue debate about the risks vs. benefits of opioid use. But it has also set off alarm bells for many of the millions of Americans with chronic pain who legally take opioids, under their doctor’s supervision, and are suffering a range of unintended consequences that have left them undertreated, ignored, and desperate for alternatives.

The root of the problem, according to dozens of pain patients, doctors, scholars, and others who spoke to Fox News for this story, are the Centers for Disease Control and Prevention (CDC) guidelines for opioid prescribing that were issued in 2016. While the guidelines are credited with focusing attention on prescribing practices, critics say they’ve been adopted by too many as hard and fast rules that must be enforced across the board, rather than serve their intended advisory purposes.

“We’re targeting the most vulnerable and sickest people who have been on opioids a long time,” said Dr. Stefan Kertesz, an addiction specialist and professor at the University of Alabama at Birmingham School of Medicine.

TOUGH NEW OPIOID POLICIES LEAVE SOME CANCER AND POST-SURGERY PATIENTS WITHOUT PAINKILLERS

Striking the right balance between getting control of the overdose epidemic and protecting access to treatment that brings relief to pain sufferers is a public health imperative.

The failure to do so threatens to exact a heavy price on the tens of millions of Americans whose pain is severe and disabling, and who are not driving the drug overdose epidemic.

Neglect of this large population of patients has the potential to prompt many to seek illegal opioids, or to become another statistic in the crisis of the rising U.S. suicide rate. Some have told Fox News that they have traveled, or plan to go to another country to obtain prescription opioids from doctors or pharmacies — a risky move for manifold reasons.

Video

So what’s the solution? Medical professionals, patients and others familiar with the opioid crisis and the fallout from the government crackdown have offered a variety of ideas.

RESETTING CDC GUIDELINES

Many believe the most urgent need is to address misunderstandings about the CDC guidelines. Clinicians and health experts say the CDC needs to make clear, in a high-profile way, what the guidelines were – and were not – meant to address. A letter signed by more than 300 health professionals, including former drug czars in the Clinton, Nixon and Obama administrations, calls on the CDC to examine the impact of the guidelines and publicly clarify them.

“Many doctors and regulators incorrectly believed that the CDC established a threshold of 90 MME as a de facto daily dose limit,” the letter said. “Soon, clinicians prescribing higher doses, pharmacists dispensing them, and patients taking them came under suspicion.”

The letter said that because the guidelines do not offer alternative pain care options, “patients have endured not only unnecessary suffering, but some have turned to suicide or illicit substance use. Others have experienced preventable hospitalizations or medical deterioration.”

The letter added: “We urge the CDC to issue a bold clarification…particularly on the matters of opioid taper and discontinuation.”

Richard A. Lawhern, a prominent advocate on behalf of chronic pain patients and co-founder of the Alliance for the Treatment of Intractable Pain, goes even further, suggesting the CDC should scrap its guidelines, and write new ones.

“The resulting document is fatally flawed,” Lawhern said, “and needs to be withdrawn for a major revision in an open public process by qualified experts in community practice for chronic pain treatment, assisted by representatives or advocates from chronic pain communities.”

CLARITY ON LEGAL PAINKILLERS

Many have acknowledged the need for better data about opioid use, on everything from the precise role that legal vs. illicit drugs have played in the national overdose crisis to more accurate information on the effect of dosage changes.

Over the summer, a U.S. Health and Human Services special task force on pain management formulated a draft report of recommendations for the guidelines and noted muddled data on deaths involving illegal opioids vs. prescribed drugs.

“The national crisis of illicit drug use along with overdose deaths are confused with the appropriate therapy of patients who are being treated for pain,” the draft report said. “This confusion has created a stigma that contributes to barriers to proper access to care.”

Federal data on overdose deaths generally do not offer specific statistics on how many involved patients who were prescribed opioids, though other data – such those compiled by states – indicate they account for a small minority.

AS DOCTORS TAPER OR END OPIOID PRESCRIPTIONS, MANY PATIENTS DRIVEN TO DESPAIR, SUICIDE

In November, a data and software company serving emergency medical services, fire departments and hospitals, released national opioid overdose data based on approximately 15,000 records collected between January and October of this year, and found that 94 percent of opioid overdoses involved illicit drugs, with only 4 percent being prescribed.

But that hasn’t stopped political leaders from developing policies and initiatives around cutting prescriptions as well as the supply of opioids. Trump vowed to cut opioid prescriptions by 30 percent over three years.

And many state and government officials are boasting about opioid prescription reductions, giving a misleading impression, Kertesz said, that progress is taking place in the drug overdose epidemic.

The [CDC opioid guideline] document is fatally flawed and needs to be withdrawn for a major revision in an open public process by qualified experts in community practice for chronic pain treatment, assisted by representatives or advocates from chronic pain communities.

— Richard Lawhern, co-founder of the Alliance for the Treatment of Intractable Pain

Many medical groups and health researchers also are calling for the CDC to address the fallout – such as reports of pain patients suffering withdrawals — from misguided implementation of its guidelines.

Kertesz, a lead author of the letter to the CDC, said that the many anecdotal reports of suicides and suicidal plans coming from pain patients who are being undertreated or cut off by doctors must be studied by the agency.

“It’s a large number of anecdotes,” he said, adding that if forcibly tapering or cutting off patients from opioids is leading to suicidal thoughts, “who will stand up to defend that policy, would we be ethically comfortable with that?”

The American Medical Association (AMA) recently released a resolution critical of the CDC guidelines that said: “We urge the CDC to follow through with its commitment to evaluate the impact by consulting directly with a wide range of patients and caregivers, and by engaging epidemiologic experts to investigate reported suicides, increases in illicit opioid use and, to the extent possible, expressions of suicidal ideation following involuntary opioid taper or discontinuation.”

In an interview with Fox News in 2017, Richard Baum, then-acting director of the Office of National Drug Control Policy, said the dialogue about the opioid epidemic has been misleading.

“This is framed as an opioid epidemic. But when you look under the hood at the report of people who overdose on fentanyl and heroin, they often have other drugs on board – cocaine, methamphetamine, other pharmaceuticals,” Baum said. “So we have a multi-drug threat that’s complicated. It means people often aren’t using [just] heroin, fentanyl, they’re also using cocaine.”

“Sometimes we inadvertently simplify it,” Baum said, “[saying] that it’s only one drug that’s causing the problem, but a lot of drug users use multiple drugs so we absolutely have to focus and are focusing on heroin and fentanyl and the opioids as the number one threat.”

LOOKING BEYOND DOSAGES

Health experts say the Drug Enforcement Administration (DEA) and state authorities must not be so narrowly focused on quantity and dosage when looking at prescribers who might require disciplinary action.

“No entity should use [morphine milligram equivalent] – thresholds as anything more than guidance, and physicians should not be subject to professional discipline, loss of board certification, loss of clinical privileges, criminal prosecution, civil liability, or other penalties or practice limitations solely for prescribing opioids at a quantitative level above the MME thresholds found in the CDC Guidelines for Prescribing Opioids,” according to the AMA.

The DEA and other authorities told Fox News they are judicious when taking action against prescribers, stressing the number who face punitive measures are just a small part of the more than 1 million registered with the agency to handle controlled substances.

Ronald Chapman II, a Michigan attorney who represents doctors accused of overprescribing, said sometimes a prescribing problem doesn’t rise to the level of a crime, and should be addressed administratively. Many prescribers trigger so-called “red flags” by errors or omissions in pain patients’ medical records, he said, and shouldn’t automatically be treated as sinister.

“We have a lot of hammers out there looking for a nail,” Chapman said.

Physicians should not be subject to professional discipline, loss of board certification, loss of clinical privileges, criminal prosecution, civil liability, or other penalties or practice limitations solely for prescribing opioids at a quantitative level above the MME thresholds found in the CDC Guidelines for Prescribing Opioids.

— American Medical Association

John Martin, the DEA’s administrator of the Diversion Control Division, said his agency has taken steps to reach out to pharmacists and clarify how investigators go about opening cases.

“I’m sure there are doctors … out there that are afraid” to prescribe opioids now, Martin said, “but that’s part of our responsibility in communication. We had that issue with pharmacists over the years.”

Martin said DEA officials have met with more than 15,000 pharmacists and pharmacy technicians “to educate them on proper prescribing on the regulations, diversion and so forth.”

Martin said the agency is undertaking a similar effort aimed at doctors.

“We’re making them aware of what we’re actually looking for, so ways that they can reduce diversion and education so they understand the different regulations out there, what they can and can’t do,” he said.

But when prescribers are targeted by authorities, sometimes they lose access to their patients’ medical records, and either are forced to stop treating them because they lose their controlled substance prescribing rights or their medical license through suspension or revocation. Often, their patients are left to scramble, with nothing to fill the void of a doctor taken out of commission, and an abrupt loss of a medical treatment plan. Pain patient advocacy groups, and health care experts, say that authorities undertaking an investigation or disciplinary action  must have a plan in place for patients who are under the care of such health care providers.

Health professionals also argue that regulators and law enforcement authorities must stay in their lane, so to speak, and not interfere in the doctor-patient relationship in an effort to address the largely illegal opioid crisis.

“The key is to get the government out of medicine entirely,” said Dr. Kenneth W. Fogelberg, who specializes in obstetrics and gyneacology. “Let the politicians and lawyers do what they do and let us practice medicine. We have licenses and DEA certificates and most of us know what we’re doing.”

“In 2006, we were required to take a course in pain management. The thrust of the course was that we were underprescribing and our patients were in pain. If a patient said she had pain  I was expected, by the patient and the hospital nurse, to medicate. If I did not, I was written up. She might be sitting in bed reading a comic book but, if she said, ‘my pain is an 8’ (out of 10) she was to be medicated.”

“Now, MDs are blamed for overprescribing,” Fogelberg said. “Pain is subjective and I only can judge by what a patient tells me, but we are pretty good at separating legitimate pain from drug-seeking behavior. If the governments, both state and local, would let doctors doctor, we could handle this, but with their insatiable thirst for control of everything, the situation just keeps getting worse.”

MORE RESEARCH ON RISKS – AND BENEFITS

Most health experts agree more studies are needed on the effectiveness and dangers of opioid use.

“In medical school in the 1990s, it was taught that dosage does not matter if you go up slowly,” Dr. Deborah Dowell, lead author of the CDC guidelines, told Fox News. “Now we know there is an increased risk of opioid overdose.”

In an editorial in the “Annals of Internal Medicine,” Dowell noted “little evidence has been available to help weigh the benefits and harms of reducing or discontinuing opioids in patients already receiving long-term therapy or to guide clinicians in how to taper opioids safely and effectively.”

Other agencies, such as the Department of Health and Human Services (HHS) and the Food and Drug Administration (FDA), are moving ahead with their own guidelines on opioid prescribing and pain management. In August, FDA Commissioner Scott Gottlieb referred to the CDC guidelines as a commendable initial step, and said that his agency was working on developing evidence-based guidelines that would look at opioid prescribing.

In a rare acknowledgment of the depth of desperation among pain patients whose long-time opioid treatment had been abruptly cut down or cut off, Gottlieb expressed concern about suicides.

“In select patients and for certain medical conditions, opioids may be the only drugs that provide relief from devastating pain,” Gottlieb said in a statement on the agency’s website. “We’ve heard from some of these patients, and listened carefully to their concerns about having continued access to necessary pain medication. We’ve heard their fear of being stigmatized as a person with addiction, and the challenges they face in finding health care professionals willing to work with patients with chronic pain.”

“Tragically, we know that for some patients, loss of quality of life due to crushing pain has resulted in increased thoughts of or actual suicide,” Gottlieb said. “This is unacceptable.”

Little evidence has been available to help weigh the benefits and harms of reducing or discontinuing opioids in patients already receiving long-term therapy or to guide clinicians in how to taper opioids safely and effectively.

— Dr. Deborah Dowell, lead author of the 2016 CDC guidelines on opioid prescribing

And this fall, Trump signed into law a bipartisan measure that calls on the FDA to assess “existing opioid…guidelines, examine how these guidelines were developed and any potential gap” in data.

Some experts say more should be done in the classroom to help better educate health professionals on treating pain.

“We have to look at our culture and attitude toward people with pain – and people with addiction – but mostly with pain,” said Dr. Lynn Webster, former president of the American Academy of Pain Medicine and author of “The Painful Truth: What Chronic Pain Is Really Like and Why It Matters to Each of Us.” “In our medical schools, there are less than seven hours on average of education about pain. Even though it affects more people than any other problem, it is the number one public health problem. But we’ve spent little on research to try to find a solution to this. We need to make pain and addiction a core of our medical education curriculum.”

RESEARCH INTO NON-OPIOID ALTERNATIVES

Webster has called for major funding in alternative pain treatment, which could offer relief with fewer risks and side effects. There’s also a need for quicker treatments for patients in urgent need of relief.

Stricter pre-authorization policies for prescription and non-opioid treatments, such as physical therapy, many times mean delays that leave patients in pain.

Several physicians told Fox News they’ve had to wait several days, or longer, for prescription pre-authorization. They also said there is much more paperwork required now in connection to pain management, leaving more room for error and, by extension, more potential for red flags that could lead to disciplinary action.

Most people interviewed by Fox News agreed there should be a concerted move toward a multi-faceted, more comprehensive way to treat pain. And, they stressed, because severe, unrelenting pain can lead to anxiety and depression, mental health must be an important part of treating the condition.

DOCTORS CAUGHT BETWEEN STRUGGLING OPIOID PATIENTS AND CRACKDOWN ON PRESCRIPTIONS

“There is a lack of multidisciplinary physicians and other health care providers who specialize in pain,” the AMA noted. “These physicians and other health care providers include pain specialists, addiction psychiatrists, psychologists, pharmacists, and others who are trained to be a part of the pain management team.”

Among the AMA recommendations was “Expand graduate medical residency positions to train in pain specialties including adult pain specialists, pediatric pain specialists, behavioral health providers, pain psychologists, and addiction psychiatrists,” and “expand availability of non-physician specialists including, but not limited to, physical therapists, psychologists, and behavioral health specialists.”

Some physicians and pain patients would like to see medical marijuana legalized in more states, and on the federal level. Military veterans who get their medical treatment from Veterans Administration health facilities say that even if they reside in states where cannabis is legal for health reasons, they cannot get a prescription because it is not legal on a federal level.

“My patients have benefitted by many opiate alternatives,” said Montana-based Dr. Mark Ibsen, who stopped prescribing opioids after running into trouble with state medical officials and the DEA over allegations, which he said were untrue, that he was unjustifiably giving high doses to pain patients. “Eighty percent of my patients on opiates got off with cannabis.”

Ibsen, whose license was reinstated, and who was never charged, said: “The key is to create a context for healing, which empowers the patient to interact with pain and their life in the most effective manner possible, and let go of what no longer works.”

Video

Dr. Daniel Alford, the associate dean at Boston University’s School of Medicine’s Office of Continuing Medical Education, is on a mission to ensure that the next generation of doctors are better equipped to make decisions about safe opioid prescribing.

“We’ve been over-reliant, too opioid-centric in terms of our prescribing for chronic pain,” Alford said. “Opioids shouldn’t be the first choice, they should really be the last choice. But if opioids are to be prescribed, how do you do it in a way that maximizes risk to that patient. We should try to minimize dose escalation.”

A prioirty, Alford said, is to improve the patient’s quality of life.

“It’s important to acknowledge and appreciate a person’s pain, for them it’s real,” Alford said. “Until we have some method to say ‘This is exactly where [the] pain is, our responsibility is to say ‘I believe you.'”

Most of the time, he said, there’s “zero percent risk” of being deceived by the patient.

“Based on their risk profile, to the best of your ability, you think about what treatment is best for them,” he said.

If tapering is necessary, “I’m going to taper over a long period of time, I’m going to try to keep the patient engaged and I’m going to try to do what’s really really hard, I’m going to try to get the patient into other forms of treatment,” Alford said, adding that multi-modal treatment plans, combining medication and other therapy, often are successful.

But the approach won’t go very far if insurers won’t cover non-opioid or multidisciplinary treatments, health experts said.

“Insurance won’t pay for many evidence-based treatments,” said Michael Schatman, a clinical psychologist who runs Boston Pain Care, which uses an array of programs – including exercise, psychotherapy as well as prescription painkillers—to treat pain. “My program loses money every year.”

“Some patients need to be tapered, some need to be taken off opioids, they’re not good for everyone, but there’s a void because of our health care system,” he said.

At Boston Pain Care, patients go through multiple treatments simultaneously. Shatman claims it is more effective than the status quo approach, which often involves trying one treatment, perhaps two, which may not work. Often, patients are pressed to try different therapies, one at a time, until one offers some improvement.

“Sequential pain management is an incredible failure,” Schatman said. “As long as we have a for-profit insurance agency, it’s not going to get much better. We’re seeing the devolution of the profession of pain medicine to the business of pain medicine.”

MORE DIVERSE VOICES IN DISCUSSIONS ABOUT SOLUTIONS

The debate over opioids and pain management has become emotional, with the overdose crisis and the dearth of reliable data fanning the flames.

Some of the leading voices on different sides of the debate are calling for unity toward working on finding solutions to both pain management and the overdose crisis.

Schatman said he would like to see health experts who are firmly opposed to opioids sit at a table with peers who are supportive of them as a beneficial treatment and bat around ideas.

Many pain experts and health researchers say that committees for agencies such as CDC should include specialists in pain and pain patients.

Dr. Stephen Gelfand, a rheumatology consultant from South Carolina, was quoted in OpioidInstitute.org saying that forced tapering is concerning. But, he added, “there is also a significant percentage of these patients who actually have the disease of addiction and need addiction treatment services including medication-assisted therapy.”

And so, he said, “we also need to have victim advocates who have survived and overcome the scourges of addiction as the result of opioid overprescribing to sit on these patient advisory boards at every level of decision-making.”

Dr. Stephen Nadeau received a warning from the Gainesville, Fla., hospital where he worked.

Their policy on prescribing opioids was changing, to go beyond federal guidelines aimed at the national overdose crisis that has claimed hundreds of thousands of lives.

The hospital would stop treating pain with opioids. And every doctor, including Nadeau, had to stop prescribing them. Doctors otherwise risked losing hospital admitting privileges – and perhaps even their medical license.

In Helena, Mont., Dr. Mark Ibsen was feeling heat from the state medical board – and the U.S. Drug Enforcement Administration (DEA), for the high-dose opioids he was prescribing to patients in severe, chronic pain. An allegation made by what he described as a disgruntled employee charged Ibsen was overprescribing.

As a result, the state medical board suspended his license. The DEA visited five times, Ibsen said, suggesting he was risking his livelihood and could end up in jail if he kept prescribing.

Both doctors complied and stopped prescribing, affecting roughly 230 of their patients. Tragically, among those were several who committed suicide, the doctors said, when they couldn’t find another health care provider to relieve the pain.

That’s a scenario playing out across the country, as government agencies respond to the staggering rate of drug overdose deaths, involving primarily illegal opioids like heroin and illicit fentanyl. Doctors who maintain they are responsibly prescribing opioids are getting caught up in the crackdown, according to dozens of medical care providers interviewed by Fox News, leaving little room to both play by the rules and properly treat huge numbers of patients who legitimately suffer chronic and intense pain.

Some doctors like Ibsen and Nadeau are opting to simply stop prescribing legal opioids, as insurers, pharmacies, and authorities warn them about overstepping guidelines issued in 2016 by the Centers for Disease Control and Prevention (CDC).

Meanwhile, other doctors, nurses and medical associations accuse the federal government of interfering in the physician-patient relationship, and pursuing simplistic, politically expedient solutions that put tens of millions of Americans at risk.

“Not only is the government legislating the way we care for chronic pain patients,” said Nadeau, a professor of neurology at the University of Florida College of Medicine, “they are substantially taking away our ability to do it.”

CDC GUIDELINES CONTROVERSY

Critics of the way the 2016 guidelines have been applied note they were not intended as law, but as a means to advise primary care physicians. The CDC specifically cautioned against abruptly stopping or forcibly tapering opioid treatment for patients already taking them, because of the danger of withdrawals, or debilitation.

More than 300 health care professionals, including former drug czars in the Clinton, Nixon and Obama administrations, have signed an as-yet unpublished public letter to the CDC, warning of a brewing crisis among pain patients, despite the “laudable goals” of the guidelines.

“Within a year of (CDC) Guideline publication, there was evidence of widespread misapplication of some of the Guideline recommendations,” said the letter, written by three doctors and a pharmacist. “Soon, clinicians prescribing higher doses, pharmacists dispensing them, and patients taking them came under suspicion.”

“Patients with chronic pain, who are stable and, arguably, benefiting from long-term opioids, face draconian and often rapid involuntary dose reductions,” the letter continued. “Often, alternative pain care options are not offered, not covered by insurers, or not accessible … Consequently, patients have endured not only unnecessary suffering, but some have turned to suicide or illicit substance use. Others have experienced preventable hospitalizations or medical deterioration.”

Others argue many authorities have misunderstood, or outright ignored, the CDC’s disclaimer. Health care providers who don’t drop opiate painkillers are setting strict limits on dosage limits, even for chronic pain sufferers who require more medicine because of serious conditions, or the way they hyper-metabolize opioids. Many who do so cite the CDC guidelines, saying they were told to follow them — or took them up as a kind of pre-emptive strike.

Not only is the government legislating the way we care for chronic pain patients, they are substantially taking away our ability to do it.

— Dr. Steve Nadeau, a professor of neurology at the University of Florida College of Medicine

Dozens of pain patients have told Fox News they were dropped or forcibly tapered down by doctors who long treated them quite successfully, but who became fearful about losing their license after being formally admonished, or hearing about other doctors who ran afoul of the government.

Meredith Lawrence, who lived in Tennessee with her husband, Jay, while he suffered decades of pain following a tractor-trailer accident, recalled the helplessness she felt watching him suffer, while his dosage of opioids was being sharply reduced.

Lawrence said the doctor who had treated him successfully for years was very clear about his decision to taper down the dosage.

“He said ‘My patients’ quality of life is not worth risking my practice or my license over,'” she told Fox News. “I’ll never forget that.”

“Jay felt like they gave up on him,” she said, recalling what finally prompted her husband to kill himself. “That was the day Jay gave up. He felt the doctor gave up – and he gave up.”

Dr. Stephen Nadeau

DEA TARGETING ‘WORST OF THE WORST’

Much of the opioid overdose epidemic in recent years stems from illegal drugs, not legitimate prescriptions. But more than a decade of overprescribing – out of ignorance for some, and for others the chance to rake in big profits – played a significant part, according to federal authorities and others who have studied the issue.

Assured by what some charged were deliberately deceptive pharmaceutical companies insisting opioids weren’t very addictive, some health care providers prescribed liberally, even for minor procedures such as a pulled tooth, or non-serious orthopedic injuries. Overprescribing led to greater daily dosages or easy-to-get refills – more than were needed. That, along with the theft and resale of opioids from people who had prescriptions, laid the groundwork for the crisis.

Most prescribers say they recognize many health providers were not prudent enough when prescribing opioids. And many doctors noted they were previously criticized for undertreating pain. Medical schools devoted little time to the study of pain and to opioids, they also say.

“Physicians and particularly medical school residency programs should have been taking more responsibility. Pain is the most common condition, and it’s one of the most difficult to treat,” said Nadeau. “And there [have been] pill mills that have relied on physicians to prescribe and many have done so very irresponsibly. But I think many are compassionate physicians … it’s a reflection of the inadequacy of their training that they basically had to learn the ropes on their own.”

John Martin, the DEA’s Administrator of the Diversion Control Division, said an overwhelming percentage of prescribers followed the rules. Of 1.6 million registrants, he said, less than one percent “operate outside the law.”

But there are still unscrupulous prescribers.

“Remember, with the opioid epidemic, just one practitioner that’s operating outside the law can really have a lot of serious consequences. In a small community, it can wreak havoc,” Martin said. “They’re really going after the worst of the worst of the criminal violators.”

Martin said most prescribers have nothing to worry about.

“Doctors are writing less prescriptions. And that goes down to education with the CDC guidelines,” he said. “There’s a new and different way of looking at using opioids for chronic pain.”

But that’s not what prescribers and patients see.

“Doctors around the country are terrified because of what happened to me and other doctors,” Ibsen said. “We don’t arrest car dealers if someone drives a car and gets into a fatal accident.”

“Standards of care are being decided by a jury of people without medical training,” Ibsen added. “It’s a very bad situation. We’re playing Whack-a-mole with the wrong mallet.”

Remember, with the opioid epidemic, just one practitioner that’s operating outside the law can really have a lot of serious consequences. In a small community, it can wreak havoc…[the DEA agents] are really going after the worst of the worst of the criminal violators.

— John Martin, DEA Administrator of the Diversion Control Division

THE CHALLENGE OF PAIN MANAGEMENT

For many medical professionals, treating pain patients has become a thankless task. The stakes are too high, they say, as even those who try to responsibly manage opioid treatment for their sickest pain patients find themselves hounded by authorities or pharmacists.

Many doctors say they view opioids as a last resort. They are very strong medicines, which often come with strong side effects, ranging from constipation, nausea, liver damage and respiratory problems. Many pain patients said in interviews they were reluctant to take them initially, and eventually did only after other treatments and surgeries failed.

“If we had a good alternative to opioids, every physician would be at the front line of it to prescribe that,” said Dr. Lynn Webster, vice president of PRA Health Sciences, and the past president of the American Academy of Pain Medicine.

In a recent survey by the North Carolina Medical Board of its licensees, 43 percent of 2,661 respondents said they had stopped prescribing opioids. They attributed their decision to concern about getting into trouble.

Patients complained to the board doctors had cut them off, pointing to the CDC guidelines or an initiative by the board aimed at cracking down on health care providers who prescribed high doses of opioids, or who had two or more patients die of overdoses in a year.

And of 3,000 doctors responding to a recent nationwide survey by the SERMO physician network for BuzzFeed News, 70 percent said they had dramatically cut down or altogether stopped prescribing opioids. The main reasons were “too many hassles and risks involved,” “improved understanding of the risks of opioids,” and fear of “getting into trouble,” according to BuzzFeed.

Yet another survey, commissioned by The Physicians Foundation, showed about 70 percent of nearly 9,000 physicians nationwide were prescribing fewer opioids.

In Nevada, where so many doctors stopped taking pain patients after the state implemented strict opioid prescription rules – which increased required record-keeping – physicians like Dan Laird now have a six-month waiting list.

“We turn patients away every day,” said Laird, who last year could fit in patients soon after they called for an appointment. “It’s heartbreaking, but many can’t find doctors.”

Many pain patients told Fox News that after being forcibly tapered down or abandoned by their pain doctors, they have lost much of their ability to function. Many said they have made suicide plans.

“I have heard from — either through email or posts on my blogs — about 1,000 people over past two years who have been denied pain medicine or forced to dramatically reduce their dose who have expressed a desire to die or commit suicide,” Webster said.

Karen Nicholson, a former federal prosecutor who credits her opioid treatment with allowing her to function after years of being bedridden, said: “We’re looking only at the supply, and cutting off people who are not abusing the medication. It made all the difference in the world, I couldn’t sit or stand or walk because of nerve damage. I went from being bed-ridden and completely non-functional to doing my work as a prosecutor.”

WARNINGS, RAIDS AND ARRESTS

Health care providers who prescribe opioids, particularly to high-impact chronic pain patients, are finding themselves on the radar of any number of sources – pharmacists, state medical boards, insurers, and law enforcement.

In a speech about the national overdose deaths epidemic in March, President Trump said: “Whether you are a dealer or doctor or trafficker or a manufacturer, if you break the law and illegally peddle these deadly poisons, we will find you, we will arrest you, and we will hold you accountable.”

But the red line triggering disciplinary action often is inconsistent, and murky. The CDC considers an opioid’s benefits to outweigh risks if it improves pain and function by at least 30 percent. But, doctors say, those factors rarely are considered when authorities scrutinize prescribing patterns.

More often, it’s large amounts of opioids and high doses – statistics on a spreadsheet or chart, without the context of a patient’s medical condition — that can bring disciplinary action.

On Nov. 2, Dr. J. Julian Grove posted to Twitter a letter his Phoenix office had received from Walgreens. Grove said he wanted to provide chronic pain patients “an insight to the veiled threats” that health care providers treating pain are getting these days.

The letter said: “Walgreens has determined that you may have issued prescriptions for opioids that exceed the CDC guidelines.”

It said Walgreens had the right to refuse to fill a prescription that falls outside the guidelines, and added: “Walgreens pharmacists may notify appropriate regulatory agencies when prescriptions are refused.”

Grove blasted the letter.

“I am a double board-certified anesthesiologist and pain specialist, treating complex pain and cancer pain always w/comprehensive approach,” he said. “Insulting.”

Asked about Walgreen’s pressure on prescribers to follow the CDC guidelines, company spokesman Phil Caruso told Fox News in a statement: “As a key patient touchpoint in the nation’s healthcare delivery system, we regularly communicate with prescribers to help ensure the safe and effective dispensing of medications in the best interest of our customers … Fighting the opioid epidemic requires all parties, including leaders in the community, physicians, pharmaceutical manufacturers, distributors, pharmacies, insurance companies, PBMs (pharmacy benefit managers) and regulators to play a role and coordinate efforts.”

The U.S. Attorney’s Office in Atlanta announced in October that some 30 doctors were put on notice there for prescribing opioids in larger quantities and higher doses than others. Prosecutors enclosed the CDC guidelines with the warning letters.

U.S. Attorney B. Jay Pak called those doctors “outliers,” adding the warning letters were meant to point out “atypical practices.” Significantly, Pak said the doctors may not have done anything wrong.

“It is our plan to strategically reduce the impact of this crisis within our community by notifying outlier prescribers that their opioid prescribing habits are not in conformity with accepted standards, or the prescribing habits of their peers,” the agency said in a statement. “Through this initiative and others, it is the goal of the Department of Justice to reduce opioid prescriptions by one-third over the next three years.”

Prescribers particularly dread getting in the crosshairs of the DEA, which can revoke permission to manufacture, distribute and dispense controlled substances. The agency opens about 1,500 new opioid cases per year and makes more than 2,000 arrests. The arrests include DEA registrants, doctor-shopping patients, and prescription forgery rings.

Martin, the DEA administrator, said that actions against prescribers are not undertaken arbitrarily.

“When we are investigating something like a doctor that may be overprescribing, you know because we’re not doctors, in the course of our investigation we are going to solicit medical experts,” Martin said. “We’ll try to get what’s called prescription drug monitoring program information and that’s information that the states have at their level that shows how many prescriptions are being written by a doctor for a patient and being filled at a certain pharmacy.”

“So we’ll try to look at that stuff and then maybe go out to that pharmacy and do an inspection and look at their records and just see if there’s anything more there and then we’ll follow up with that,” he said.

Roughly 800 prescribers each year surrender their DEA registration – a kind of license – when the agency opens an investigation. DEA investigations can involve having assets and medical records seized. In some cases that can lead to bankruptcy, doctors said, prompting many to surrender their opioid prescribing rights, rather than fight a battle against a behemoth government.

Ibsen was an emergency room doctor in Montana when he became – as he puts it, an “accidental pain doctor,” taking “pain refugees” whose doctors had been arrested. Many patients were very ill and suffered severe chronic pain, said Ibsen, who added he was able to wean many patients down to lower doses.

Ibsen said he became a target of the state board of medical examiners after an employee he fired filed a complaint, saying he over-prescribed. His license was suspended but eventually reinstated – after four years. But he decided to stop prescribing opioids after five visits from the DEA.

“They were very vague,” he said of the DEA agents. “They said ‘You’re risking your freedom by prescribing to patients like these.’ I said ‘Patients like what?’ They said, ‘Patients who might sell the pills.’”

“Doctors are taking plea deals because they don’t want to go to prison,” said Ibsen, who was not charged. “Once they arrest a doctor, they seize all their medical records. A doctor can’t make any more income. They seize your assets, and can’t afford an attorney.”

Ibsen referred patients to a prominent pain doctor in California, Dr. Forrest Tennant, who became known for taking people cut off by other doctors. Tennant for years had been researching non-opioid alternatives.

Then the DEA raided Tennant’s office. The agency never charged him, but he, too, gave up prescribing opioids.

“It’s immoral and unsafe to forcibly taper down or abandon a patient,” said Tennant, whose patients included those with terminal illnesses. “Some doctors don’t give these patients any withdrawal medication. Who is the worst offender, then? The CDC, the DEA, the U.S. attorneys who are shutting down doctors, or the doctors who abandon patients?”

One Tennant patient, Jennifer Adams, a former Montana police officer who had been treated by Ibsen, died from a self-inflicted gunshot in April, after the California doctor’s office was raided by the DEA.

Tennant said he respects the idea “the DEA has a right and responsibility to investigate.”

“But since I used high doses, they said my patients were going to overdose and die,” Tennant said. “I’ve been practicing a long time, I’ve not had a single overdose. I’ve given patients thousands of opioid equivalents. I know how patients should be monitored.”

Dr. Lesly Pompy was one of a few pain physicians in a rural part of Michigan, serving as many as 1,500, the majority of them referrals from other doctors who could not treat their chronic conditions. A pain specialist since 1995, he kept long hours, sometimes going to hospital emergency rooms when he was summoned to help a patient in severe pain. Sometimes he would try nerve blocks, many other times opioids.

On Sept. 26, 2016, roughly 25 law enforcement officers raised Pompy’s office at the ProMedica Monroe Regional Hospital.

“There were DEA agents, county and local police, they had everybody in my waiting room and who worked in my office put their hands up. Children were crying. There was a helicopter over the building. It was like a scene from a Jason Bourne movie,” he said.

Pompy was charged with unlawful distribution of prescription drugs and health care fraud from 2012 to 2016. A federal jury indicted him this summer on 37 counts. The indictment maintained Pompy illegally prescribed some 10 million dosage units of controlled substances that fell outside the realm of standard practice. He was also accused of inappropriately filing claims to insurers.

Pompy denies the charges and claims that because he prescribed large quantities of opioids, some to severe pain patients who require high doses, he became a target.

“The damage that the proliferation of opioid distribution has done to our community, like many across the United States has been devastating,” U.S. Attorney Matthew Schneider said, according to published reports. “It’s particularly disturbing when the distributor is a medical professional.”

Pompy’s former patients and some former employees have stood by him, saying he is being scapegoated. Former patients have held rallies and started a Facebook group in support of him.

Janet Zureki, a former patient of Pompy, said that — as often happens after a prescriber’s arrest — patients were left in limbo, having to scramble to find another pain doctor. “After the raid and he could no longer prescribe, everyone was dangerously cut off of their medicines, including me,” she said. “It took me three months to find another pain doctor and they put me on a lower dose of medicine. During that three month period, I had to go without medicine and go through withdrawal.”

Zureki defends Pompy.

“As a doctor, I found him to be very compassionate and he also ran a tight ship,” she said. “I have been in his office and have heard him address someone who wasn’t taking their medicine properly, so I know he didn’t stand for that. He worked tirelessly to help the people in our community,” she said.

DOCTORS LAMENT WALKING AWAY

Nadeau is bewildered over having to stop treating his pain patients, at least one of whom died by suicide. And he said his hospital’s decision to stop working with opioids is by no means unique.

Hospitals increasingly see opioids as a liability; an overdose can land them in a lawsuit, he said. But he wrestles with the fact there are people he can no longer help.

“I can’t provide comprehensive care for my patients, meaning treatment of pain, depression, sleep problems, anxiety, and other problems,” Nadeau said. “In patients with chronic pain, there nearly always are a lot of problems.”

Nadeau reached out to fellow physicians to see if they would take his pain patients.

“It’s been extremely difficult to find physicians to provide comprehensive pain therapy,” he said. “I don’t blame physicians for being scared to death and for prescribing to CDC guidelines, but I do blame [some of] them for treating patients badly.”

For his part, Ibsen is treating patients with medical marijuana. Ibsen said he always strived to get patients on opioids to agree to taper down, and about 80 percent did, often using medical cannabis. For the others, opioids were the best treatment, Ibsen said. He understands the threat of the overdose epidemic all too well.

“My nephew died of a heroin overdose” in the summer, he said. “But incarcerating doctors is not going to solve the addiction crisis.”

“There are two things doctors do – we save lives and we relieve suffering. If we’re not willing now to relieve suffering, then what are we about?”