Donald Morehead was in pain. The Real Change vendor tore his rotator cuff in a car accident in 2001, a condition that is ostensibly temporary but which a doctor told him in May 2015 required a surgical fix. That’s difficult to arrange for the 50-year-old who lives alone with his blue nose pit bull, Optimus Prime, because he would need help caring for himself and his canine companion during his recovery.
In the meantime, a doctor prescribed Morehead a strong painkiller called Tramadol to help him deal with the pain. When that ran out, Morehead went to Neighborcare, a local clinic that caters primarily to low-income and homeless clients, to get more.
The physician said no. Instead, Morehead received a tri-fold pamphlet describing Neighborcare’s policy on prescribing opioid painkillers such as Tramadol, which are synthetic versions of opiates. The long and short of it: If a patient isn’t in hospice or diagnosed with cancer, they’re out of luck.
“We are very aware of the ripple effect this will have on the community,” the pamphlet reads.
That’s been Neighborcare’s policy for almost seven years, according to Medical Director Marcus Rempel, but it doesn’t end with them. In 2010, the Washington State Legislature passed House Bill 2876, restricting how doctors could treat patients with chronic pain.
Lawmakers were reacting to a steady rise in deaths related to prescription painkillers and increasing evidence from the medical community that opioids were not the best option when it comes to managing long-term pain.
That didn’t do much for Morehead, who waits in pain for his surgery, which he hopes to schedule for May, a year after his doctor told him he’d need it.
“Little Sue or John Junior ended up on drugs, and now they want everybody to not be able to get their prescription,” he said.
Morehead is not the only patient to feel left in the lurch.
After the law passed, stories began bubbling up in local news outlets about patients, usually on low-income medical plans, hitting a sequence of roadblocks in attempts to get the drugs that they had previously relied upon.
Reports from the time pointed to one big cause — a lack of qualified pain specialists.
The law and subsequent guidelines produced by the medical community required that doctors who prescribed more than 120 milligrams of an opioid pain medication to a patient get an outside consultation with a pain specialist. In a 2012 interview, Dr. Jeff Thompson, the medical director of Washington’s Medicaid program, told InvestigateWest that despite a large number of patients prescribed more than the daily 120 mg limit, only one or two could get evaluated by a specialist each month.
While the law does not prohibit doctors from prescribing pain medications, and allows them to use teleconference technology to access pain specialists to lower barriers for patients, other factors that reduce access may be at play, such as insurance restrictions or a desire to avoid taking on too many chronic pain patients.
If pain specialists don’t fall within a patient’s insurance network, primary physicians may have nowhere to send them. Neighborcare chose to stop taking patients with chronic pain that sought opioid medications, Rempel said.
“It was one of the most challenging things we’ve done,” he said of the decision.
Prescription drug abuse has been on the rise in the United States, and the bodies are piling up faster than those associated with heroin and cocaine combined, according to the 2015 National Drug Threat Assessment.
According to the Centers for Disease Control, deaths associated with prescription opiates nationwide rose from 4,685 in 2000 to 19,638 in 2014.
By the same metric, Washington mirrored the rest of the country until deaths peaked in 2009 and began falling steadily thereafter.
It’s possible that doctors and policy makers could have accepted the risk of opioids, but evidence began to mount that not only were the drugs dangerous, they might be ineffective at treating chronic pain.
One study in the Women’s Journal of Health that surveyed more than 2,000 men and women in group health plans in Washington state and Northern California found that only 20 percent of patients on long-term opioid therapy did well. But 52 percent had “unfavorable” results.
That realization happened in the medical community over the past five years, said Daniel Lessler, chief medical officer of the Washington State Health Care Authority. Since 2010 – 2011, research indicates that opioids are causing people harm.
“We know that for sure, that there’s a high risk of harm,” Lessler said. “On the other hand, there’s very little evidence that overall they help people with chronic pain.”
Patients have other options to manage their symptoms, although not all sound as satisfying as a pill that they know will make the pain go away. Doctors cited a number of alternatives to opioids, including physical therapy and less tangible options, such as a meditation practice known as mindfulness. Some suggest acupuncture, although that’s not of much use to Medicaid patients in Washington — it’s not covered under their medical plans.
“We have a lot of work to do on the Medicaid side and commercial insurance to find ways to make those alternatives known to work more available,” Lessler said.
That leads to another grey area, because the people who are prescribed opioid pain killers are not necessarily the people who abuse prescription pills. According to a study by the Substance Abuse and Mental Health Administration, about 70 percent of prescription drug abusers got the drugs through “diversion,” meaning that they took pills that had been prescribed for someone else.
Restricting the supply of opioids available to these people by clamping down on prescriptions to those in pain would help solve that problem, but it might have adverse consequences for those who choose not to think their way through the pain.
As prescription drug deaths have dropped in Washington, deaths associated with heroin, an illegal opiate, have risen from 61 in 2000 to 294 in 2014.
Scientists haven’t found a causal relationship between the two phenomena, but a 2015 study of prescription opioid programs in Denver found that as doctors began prescribing slow-release opioids, heroin use began to edge up.
“The role of switching from the abuse of a prescription opioid to the use of high-purity, low-cost heroin must also be considered,” the authors wrote.
Morehead didn’t need a study to tell him that.
“Everyone is scrambling around trying to find a doctor,” he said. “They’re forcing people to use drugs. They need to get information from people in the street before making decisions for people on the street.”
After Neighborcare turned him away, Morehead was given two separate referrals by hospitals for his pain, one to a pain center in Kent and another in Seattle. Both refused to help him, despite evidence from doctors at Swedish Medical Center that his rotator cuff injury was real.
Eventually, a psychiatrist was able to renew his prescription, but Morehead knows it’s a temporary fix. He is in the process of seeking an attorney and other people who feel that the 2010 law has created an untenable situation for low-income people who are trying to find an effective and legal way out of pain.
“This is simply denying people medical care,” he said.