Opioid limits test patients, doctors

States hope to stem epidemic, but many still seek pain relief.

Jan Hoffman MILFORD, NEB. — Susan Kubicka-Welander, a short-order cook, went to her pain checkup appointment straight from the lunch-rush shift.

“We were really busy,” she told Dr. Robert L. Wergin, trying to smile through deeply etched lines of exhaustion. “Thursdays, it’s Philly cheesesteaks.”

Her back ached from a compression fracture; a shattered elbow was still mending; her left-hip sciatica was screaming louder than usual. She takes a lot of medication for chronic pain, but today it was just not enough.

Yet rather than increasing her dose, Wergin was tapering her down.

“Susan, we’ve got to get you to five pills a day,” he said gently. She winced. Such conversations are becoming routine in doctors’ offices across the country. A growing number of states are enacting measures to limit prescription opioids, highly addictive medicines that alleviate severe pain but have contributed to a surging epidemic of overdoses and deaths. Last week the federal government issued the first national guidelines intended to reduce use of the drugs.

In Nebraska, Medicaid patients like Kubicka-Welander, 56, may face limits this year that have been recommended by a state drug review board.

“We don’t know what the final numbers will be,” Wergin told her, “but we have to get you ready.”

As politicians and policymakers decry the opioid crisis, the country’s success in confronting it may well depend on the ability of physicians like Wergin to reconcile their new role as enforcer with their mission of caring for patients. Collectively, primary care physicians write the greatest volume of opioid prescriptions — according to a recent study, 15.3 million prescriptions for Medicare patients alone in 2013.

The burden of monitoring patients for potential abuse, while still treating pain that is chronic and real, falls largely on these front-line gatekeepers.

“I have a patient with inoperable spinal stenosis who needs to be able to keep chopping wood to heat his home,” said Wergin, 61, the only physician in this rural town. “A onesize-fits-all prescription algorithm just doesn’t fit him. But I have to comply.”

In prescribing opioids, Wergin, who is also chairman of the board of the American Academy of Family Physicians, is taking professional and personal risks. He must go through an elaborate prescription checklist, with state and federal officials looking over his shoulder.

He has faced threats from addicts who show up at the hospital emergency room, desperate for pills. Following the recommendation of his malpractice insurance carrier, he now requires his patients to sign “pain management contracts,” in which they must agree to random drug tests before receiving an opioid prescription.

Though he has been enmeshed in his patients’ lives for decades, having gone to grade school with many of them and delivered their children and grandchildren, the new vigilance has injected an uncomfortable layer of suspicion in his relation- ships with them.

“I don’t want to stop prescribing opioids altogether,” Wergin said. “But I can see why some doctors have gotten to that point.”

Patients look at Wergin, stricken and indignant, when asked to sign a pain contract. “Do you think I’m an addict?” they say. Or, “I don’t need a contract for my heart medicine, so why this?”

Why? When a random drug test of one longtime patient showed no trace of prescribed opioids, Wergin had to “fire” him for breaking the contract. Instead of taking the pills, the patient had been selling them.

Wergin has learned to be even more wary during his emergency room shifts at the hospital 15 miles away. There, he has seen firsthand a growing number of overdoses and opioid-related deaths.

The scenario has become so familiar that now when a nurse reports that the patient in Room 3 is complaining of excruciating back pain and asking specifically for Percocet, Wergin will reply, “And is he about 31, single or divorced, and insisting he is allergic to nonsteroidals?”

These are “seekers n’ sellers,” he explained, who peel off I-80 and head for the hospital “thinking we’re just ignorant hayseeds.”

A few months ago, state troopers pulled guns on one such man, who had stormed into the hospital demanding pain medications and threatening Wergin and other staff members.

As Wergin recounted this, driving through the fog-shrouded back roads of winter-stubble prairie, where patients are rushed to the emergency room after being crushed by forklifts and tractor tipovers, he recoiled against his own cynicism.

“You don’t want to become so jaded that you assume everyone in the ER is a drug-seeker,” he said.

Still, he has made adjustments. He now rarely writes prescriptions for oxycodone, which is prized on the street. For other painkillers, he logs into an electronic pharmacy registry to view the patient’s other medications. Although every state but Missouri has such a system, Nebraska’s, like many, is not foolproof: Patients can opt out for privacy reasons and not all insurers, who supply the data, opt in.

And most state electronic systems are not compatible with one another.

Many medical associations now offer doctors training about opioids and chronic pain, urging them first to use other remedies: physical therapy, acupuncture, anti-inflammatories, antidepressants, counseling.

But alternatives are unrealistic for some. Physical therapy is too expensive for Kubicka-Welander: She can scarcely make the rent on her home in a trailer court. Patients with a compromised liver cannot take high doses of acetaminophen. Those on blood-thinners should not use ibuprofen.

Wergin is careful not to assure patients that they will be “pain-free.” Instead, he talks about setting realistic goals while living with pain. Can they work? Walk? Sleep?

His final patient of the day, a 55-year-old woman, had three rotated vertebrae in her lower back, migraines and a mastectomy for breast cancer this fall. She asked not to identified because she worried her opioid use might jeopardize her job.

Her fibromyalgia was flaring up, she told Wergin. Pain was aggravating her insomnia.

“And you have to cut my pills again?” she asked.

Wergin nodded. “It will be very difficult to get an override for your dose.” Instead, he increased her antidepressant.

“It’s people like my husband who screwed the rest of us over,” she said.

Her husband, she explained, used to sell methamphetamine and OxyContin. His doctor in Lincoln would readily write prescriptions. One night six years ago, she found her husband on the floor of their bedroom, dead, mostly likely from an overdose.

“It’s rough cutting back when I’m at a level that almost works,” she said to Wergin.

PHOTOS BY THE NEW YORK TIMES Larry TeSelle helps his wife, Beverly, who began to suffer vicious headaches that left her weeping and moaning after a second stroke and now takes a large amount of opioids for the pain, move into her wheelchair at their house in Milford, Neb. A...