April 10th, 2016 by Steve Johnson in Local Regional News Read Time: 7 mins.
I don't think what is happening with addicts should have anything to do with whether I'm getting my health care. Rich Oberg
JACKSON, Tenn. — Rich Oberg doesn't fit most people's image of a drug addict, although he has been called one. Sitting at a table in his spacious suburban home here, with nothing but woods visible beyond the two-story windows in the living room, he looks much more like the doctor he is, a 38-year-veteran pathologist at Jackson-Madison County General Hospital, and a former medical examiner in Bradley, Meigs and Polk counties.
Nor does his wife, Holly Clowers, seem like someone who would be conniving to score pills to resell to addict buddies, although she has been accused of that, as well. She's more believable as a graduate of the University of Alabama medical school and the Mayo Clinic who has spent the past decade treating patients with skin problems, including cancer, at the Jackson Clinic here.
But Oberg has psoriatic arthritis, a debilitating disease that leaves him in constant pain, while Clowers has been diagnosed with Ehlers-Danlos hypermobility syndrome, a rare condition that causes joint deformity and accompanying pain. Both believe they will need prescriptions for opioids, a class of drugs that are highly addictive, for the rest of their lives.
Getting those drugs was not a problem until recently, when a national focus on a rise in drug overdoses led the state and federal governments to crack down on doctors who prescribe opioids.
Now, Oberg said in an interview, he and his wife are being treated like drug addicts, forced to turn from doctor to doctor, clinic to clinic, to find any physician who will prescribe the medicine that lowers their chronic pain and allows them to function.
"I don't give a damn about addicts," Oberg said. "I don't think what is happening with addicts should have anything to do with whether I'm getting my health care."
But it does.
The news headlines are full of stories about the opioid "epidemic" in America, primarily caused by a surge of overdoses from heroin and from the abuse of prescription drugs based on opioids, such as Vicodin, OxyContin and Percocet. In February, President Barack Obama proposed a $1.1 billion program to deal with the issue.
No one, including Oberg and Clowers, argues that there are not problems with opioid abuse. But what concerns them is the state and federal crackdown on drug abuse is leaving those with a legitimate need for something to dull their perpetual pain with nowhere to turn.
And many of them say when they try to obtain a prescription, too many doctors and clinics seem to presume they are addicts attempting to obtain drugs illegally.
"I think just because abuse is so prevalent, it creates a cynicism among doctors," said Dr. David Castrilli, with CHI Memorial Internal Medicine Associates on Gunbarrel Road in Chattanooga. "It gives you that feeling that they are a little bit suspicious of anyone in pain."
Couple that with new rules on doctors prescribing painkillers, and the result is that many family physicians have decided to get out of the pain management business, according to Dr. Thomas Miller, a pain management specialist in Chattanooga and head of the Hamilton County Regional Health Council's committee on addiction.
And some pain specialists are following their lead. Just last week, Miller said, Tennova Healthcare in Knoxville changed the rules for its pain treatment clinics to ban the prescription of opioids.
Under the new rules, doctors prescribing painkillers are going to have to perform a urine test, check a prescription database to be certain the patient is not getting drugs elsewhere, enter their prescription into the database, count the number of pills a patient has left in his or her prescription, and make certain the pills have been correctly prescribed, Miller said.
"Absolutely, I see people turning away patients," Castrilli said.
Oberg was diagnosed with psoriatic arthritis 23 years ago, when he was 39.
"You feel like you have the flu 24/7," he said. "You ache everywhere, you get joint deformities, not unlike rheumatoid arthritis. I was running three miles a day, three times a week and then suddenly I couldn't walk. Overnight."
For decades, his treatment has tracked the history of pain medicine in the U.S.
First, there was methotrexate, which he could inject himself. But it didn't work.
"I was at the point of a real meltdown," he said.
Then came a new class of drugs called "biologics," made with biological processes using what is called recombinant DNA technology. At first, they were like magic, suppressing his pain and restoring his ability to live his life almost normally.
"It restored about 50 percent of my capacity," Oberg said. "But 50 percent is better than 5 percent."
But over the next 10 years, the drugs slowly seemed to lose their potency, although he worked his way through a dozen of them.
Another new drug was promising, but caused a nasty allergic reaction that almost killed him.
Finally, in desperation, he turned to a fellow doctor at a nearby clinic, who recommended opiates. At first, he resisted, uncertain whether they would leave him too woozy to work.
But they didn't. Instead, the pain was again under control, and he was able to continue putting in 12-hour days in the hospital lab.
"I was amazed at how much better I felt," Oberg said.
Clowers' experience was similar. She has had all sorts of medical problems from an early age. Joints would pop apart unexpectedly and her jaw dislocates regularly. Because her joints are loose, "I can do circus tricks, like those people you see bent up in old photos," she said. "My fingers all go backward when I try to type."
When she was hired at the clinic, everyone knew of her disability, she said. But they didn't see all of the ways it affected her.
"I had so much back pain, half the time I couldn't stand up straight," she said. "I was lying down between patients, throwing up between patients, getting migraines every day."
She eventually ended up on painkillers, just like her husband, and her pain seemed under control.
Life seemed to be returning to normal, until June 2014.
That's when Clowers returned from what normally was a routine visit to the clinic to get their prescriptions filled with a piece of paper in her hand.
The note was succinct: "The Medical Clinic of Jackson will no longer prescribe long-term narcotics," it read.
Without stating a reason, the hospital had decided that it no longer wanted to be in the painkiller business and ordered clinic doctors to stop prescribing.
"We got thrown out into the street," Oberg said. "And this is the same system I've worked for, for 24 years."
They turned to another local clinic specializing in treating pain. But on a second visit, the doctor in charge accused them both of being addicts. A second pain clinic was no better, and now their medical record was making them look like addicts, shopping for a doctor who would prescribe them pills.
Fortunately for Oberg and Clowers, they found a doctor who understood that they legitimately need painkillers and who has been willing to comply with state and federal rules, even as they have gotten progressively tougher.
"Now I'm on about half [the medication] I was on before, which is unfortunate because the pain gets worse," he said. "But my greatest fear is that soon I'll get none."
Medical experts on all sides of the issue agree the painkiller problem is complex.
Central to the discussion is the fact that pain is hard to see and difficult to measure. There are no thermometers or glucose monitors or blood pressure cuffs to measure it. No one denies that it exists, but no one can be certain just looking at a patient that his claim of pain is sincere.
One, imprecise, way to measure is to look at whether a patient is able to function normally, but that is difficult to ascertain in a short visit to a doctor's office.
Similarly, while no one argues that opioids are highly addictive and can be abused, the data also indicate that only a small percentage of those using them, less than one in 20, become addicted. Some become dependent, Clowers concedes, but that is not the same as addicted.
"As a pain patient, you take opioids to participate in life," she said. "As an addict, you take them to escape life."
Figuring out the difference between legitimate patient and addict can be hard. Family doctors, who may know a lot about a patient, are not trained in treating pain and, particularly with new regulations, increasingly refer patients with long-term pain problems to pain treatment specialists.
Some of those specialists are thoughtful, caring doctors who work to resolve patients' issues.
Others offer alternative treatments with questionable efficacy.
And still others are what law enforcement officials refer to as "pill mills," places where anyone who claims to be in pain can get a prescription for painkillers with few questions asked, said Miller, who has testified for the U.S. Department of Justice in "pill mill" cases.
But because of the actions of a few, all pain treatment centers are getting increased scrutiny. A new state law taking effect July 1 will require the medical director of every pain treatment clinic in the state have an advanced degree and extra training.
Some pain specialists believe that could be the final push too far. Miller said the bill could put nearly half of Tennessee's 300-odd clinics out of business. That's more than 100,000 people, he estimates, who will be looking for another place to get their prescriptions filled.
"Where are those patients going to go?" he asked. "A lot of people are really in need."
And even if some of them are taking too many pills, that doesn't mean they are not in pain.
"Unfortunately, a lot of people in legitimate pain are also abusing the drugs," said CHI Memorial's Castrilli. "But if you take away the pills, you don't take away the problem."
Contact staff writer Steve Johnson at sjohnson@times freepress.com, 423-757-6673, on Twitter @stevejohnsonTFP, and on Facebook, www.facebook.com/noogahealth.
http://www.timesfreepress.com/news/local/story/2016/apr/10/prescriptidrug-crackdown-making-it-hard-some/359417/
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