How one group of doctors drastically decreased opioid prescriptions

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JUDY WOODRUFF: But, first, we continue with our America Addicted series, looking at the opioid epidemic.

Roughly 100 million Americans suffer from chronic pain. And most health officials agree that legal painkillers, prescribed by doctors and filled by pharmacies, triggered a tidal wave of addiction throughout the U.S.

Recent guidelines from the Centers for Disease Control and Prevention urge doctors to avoid or dramatically limit these prescriptions in most cases. But where does that leave the chronic pain sufferers?

Special correspondent Cat Wise has our report from Orange County.

AMY CRAIN, Kaiser Permanente Patient: Let’s go to the park.

CAT WISE: In many ways, Amy Crain’s story has followed the same path as hundreds of thousands of other chronic pain sufferers caught up in the opioid epidemic.

There was the accident, in her case, getting slammed in the family car… the hospitalization and surgeries that saved her from paralysis…

AMY CRAIN: Ready? One, two, three, jump.

CAT WISE: And a resulting dependency on prescription painkillers — OxyContin, methadone, and Norco, that had left her foggy and barely functional.

AMY CRAIN: I couldn’t lift my daughter, couldn’t care for her.

CAT WISE: But then Crain’s story took a dramatic turn that has led her on a very different path, thanks to this doctor and a new effort by one of the country’s largest health care providers to tackle this national emergency.

Dr. Anh Quan Nguyen is a Kaiser Permanente pain specialist who has been prescribing Crain and other patients alternative therapies, all covered by Kaiser’s insurance plan. The treatments include needles in the back, carefully placed by an acupuncturist; mindfulness at the clinic; yoga training, which she often practices in a local park.

And, perhaps most importantly, she’s been prescribed fewer and fewer pain pills. In fact, Crain is now taking just a small percentage of the meds she was once on … a result at first she didn’t think was possible.

AMY CRAIN: How am I going to do this? How am I going to, you know, get to clean my house? How am I going to, you know, get up in the mornings? And it was terrifying. But it wasn’t as hard as I thought it was, with the other tools.

CAT WISE: Crain knew the stakes were high; 33,000 people died in the United States in 2015 from opioid overdoses, and early estimates from last year indicate that the numbers are up significantly.

As communities and health care providers around the country seek solutions, some are turning here, to Southern California, where Kaiser Permanente’s program has led to a big drop-off in opioid prescriptions.

DR. ED ELLISON, Southern California Executive Medical Director, Kaiser Permanente: We have seen between 2010 and 2015 a reduction of more than 80 percent in the use of OxyContin, the long-acting opioid.

CAT WISE: Eighty percent?

DR. ED ELLISON: Eighty percent.

CAT WISE: Dr. Ed Ellison is the executive medical director for the Southern California Permanente Medical Group.

DR. ED ELLISON: Across the program, we have seen more than a 30 percent reduction in opioid prescribing. So, we’re seeing significant movements being made.

CAT WISE: Ellison says getting those reductions wasn’t easy — a sign that far too many of the drugs were being prescribed in the first place. In fact, in 2009, when a small group of Kaiser leaders gathered in Pasadena to look at recent prescription numbers, they were stunned. They expected to see diabetes and hypertension medications top the list.

DR. STEVEN STEINBERG, Southern California Family Medicine Chief, Kaiser Permanente: And instead, we saw hydrocodone, oxycodone, OxyContin, fentanyl, methadone.

CAT WISE: Dr. Steven Steinberg is the lead physician for the medical group’s controlled substance task force.

DR. STEVEN STEINBERG: And we saw these just massive numbers of prescriptions, massive numbers of refills. And not just that, huge numbers at one time. People were getting 800 or 1,000 pills at a time.

CAT WISE: Kaiser Permanente may have been among the first to spot the problem, but its numbers reflected a deep national trend.

Billions of pills have been prescribed over the past two decades. Addictions and overdoses have surged, both for prescription painkillers and a growing number of people turning to illegal opioids like heroin.

So, in 2010, Kaiser decided the new approach for patients like Crain, and their doctors, was needed. They called it the Safe and Appropriate Opioid Prescribing Program.

DR. ED ELLISON: Pain is very subjective. And I can’t sit here and tell you you’re not in pain. My job is to help alleviate that pain. The key is to understanding that all roads don’t lead to an opioid.

CAT WISE: It started with data assembled from the organization’s nearly 12 million members and 21,000 physicians. Doctors were given reports of their prescription habits and their patients’ histories with pain killers.

And Kaiser Permanente’s computer system was reprogrammed to make it harder for physicians to prescribe certain high-risk opioids or dangerous combinations.

DR. STEVEN STEINBERG: Type in OxyContin. You cannot proceed without answering various questions. Are there any other drugs that you tried first that are safer? Are you aware this is a dangerous drug?

And what we found is, people do change their behavior. It’s one thing when you know it, and one thing when you have to commit it to print.

CAT WISE: Pharmacists have been trained to spot high-risk activity, duplicate prescriptions, excessive quantities or early refills, and to contact the prescriber or a supervisor to discuss their concerns.

DR. ANU SINGH, ER Chief Physician, Kaiser Permanente: And on a scale of 10 to zero, where would you put your pain right now? It was eight?

CAT WISE: In emergency departments, where it was once the norm for patients to be handed scripts for 30 to 50 pain pills, patients have been put on notice that the rules have changed.

DR. ANU SINGH: We have posters in every room. We have handouts we give out to our patients where we don’t give out prescriptions for more than a three days’ supply. We don’t refill lost or stolen prescriptions. So, all those guidelines are made clear to every patient when they walk in.

CAT WISE: Dr. Nguyen and his colleagues have regular training sessions on opioids and meetings to discuss difficult cases. But they still worry about creating “opioid refugees,” pain patients who turn to street drugs like heroin when their medications are yanked away quickly.

That’s a sensitive subject for Crain and many other patients.

AMY CRAIN: I resent it when doctors treat us like we’re some kind of drug addicts, because I didn’t put myself in this situation.

CAT WISE: Dr. Nguyen says one of the first steps, with all his patients, is to build trust. And so he’s developed what he calls the difficult pain conversation.

DR. ANH QUAN NGUYEN, Pain specialist, Kaiser Permanente: The first thing I will tell patients is, ‘I know you have pain. I believe you. I’m going to examine you today, and figure out what I can do for you.’

After the examination, I say, ‘Look, I happen to notice that you’re on these medications, and I really want to have an open conversation with you about the dangers of these medications. Can we have this conversation?’

CAT WISE: George Teter has had that difficult pain conversation with Dr. Nguyen. Teter found himself on high levels of prescription fentanyl and other opioids after two surgeries on his elbow.

GEORGE TETER, Kaiser Permanente Patient: I would have to kind of schedule around, like, make sure I wasn’t doing any driving or anything like that.

CAT WISE: Dr. Nguyen’s slow and steady regimen of reducing his opioid intake made him feel more like his old self. Teter’s off fentanyl completely now and has cut his other opioid pain med by about 75 percent.

These days, when his pain surges at work, he finds relief by meditating at a fountain near his office. He says the process wasn’t always easy, but he credits Dr. Nguyen’s careful approach with saving his life.

GEORGE TETER: He told me one thing that really stuck in my head, that the pain will never kill you.

DR. ANH QUAN NGUYEN: But if you keep these medications up, it will kill you. These medications tell you to go to bed at night, ‘Stop breathing. Stop breathing.’ And eventually your brain listens to it, and then you don’t wake up in the morning.

So it’s not a painful way to die. It’s just very sad.

CAT WISE: But some doctors say the nationwide crackdown on pain pills has gone much too far.

In West Covina, California, just outside L.A., pain specialist Dr. Forest Tennant says patients are now flying in to see him from all over the country, like Gary Snook of Montana.

Tennant says a small fraction of pain patients, about 3 to 5 percent, have rare chronic conditions, like Snook, and need high doses of opioids to function, but can’t get them elsewhere.

DR. FOREST TENNANT, Pain Specialist: There’s no question about it. The pendulum has swung too far.

CAT WISE: After reviewing details on Kaiser Permanente’s program, Tennant had some praise for its depth and general approach. But he said there’s still a very good chance that the type of patients he sees most frequently would be left behind.

DR. FOREST TENNANT: It takes a lot of work to treat these people. It takes a special clinic, special time. And I hate to say it, but I’m afraid a lot of parties just don’t want to treat these folks.

CAT WISE: But, for chronic pain patient Amy Crain, Kaiser’s program, she says, was exactly what she needed, when others might have written her off. And it’s helped her learn to cope.

AMY CRAIN: You just kind of acknowledge the pain. You know, ‘OK, you’re there. I’m working with you today.’

CAT WISE: She now marks progress in the simple things, rides on the swing, trips down the slide, and in the laughter that makes her feel like she’s gotten her life back.

For the PBS NewsHour, I’m Cat Wise in Anaheim, California.

JUDY WOODRUFF: Online, you can find all of the stories in our America Addicted series. Just go to PBS.org/NewsHour.

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