In Grips of Opioid Crisis, Doctors Struggle Finding Balance Between Treating Pain, Overprescribing
President Donald Trump has called the opioid crisis a national health emergency, ravaging Appalachian states like Kentucky, West Virginia, and Ohio. That’s helped put the spotlight on the role doctors play in prescribing powerful pain relievers that sometimes lead to addiction and overdose deaths.
A former Warren County physician will get a stinging reminder on Monday that his medical career is over, and that his freedom is being taken away. Fred Gott will be sentenced in federal court for overprescribing powerful painkillers, including fentanyl and methadone. The case against the 66-year-old heart doctor started to build in 2012.
“We received a call from the coroner’s office that they had noticed quite a few overdose deaths and that Dr. Gott was their prescribing physician," said Tommy Loving, director of the Bowling Green-Warren County Drug Task Force.
Gott was eventually charged with prescribing powerful painkillers, including fentanyl and methadone, without a legitimate medical purpose over a seven-year period starting in 2006. According to prosecutors, Gott transitioned his practice from cardiology to pain management, which he wasn’t qualified to do. His plea deal requires him to serve eight years in prison.
Similar cases have unfolded against other doctors who crossed a sometimes blurred line between treating pain and overprescribing. Simpson County physician Roy Reynolds was convicted two weeks ago in federal court for his illegal prescribing habits. He was acquitted on the more serious charge of causing the death of a patient. Reynolds’ attorney Alan Simpson says he believes the 69-year-old general practitioner simply fell behind the times.
“What Dr. Reynolds was doing as a general practitioner was pretty much accepted, but as opioids became more of an issue, the Medical Licensure Board for Kentucky, in prior years had said, ‘Make sure you treat pain. It’s really important.’ Now we get to 2012 when this really started happening and they said, ‘Now we’re seeing a problem from treating all the pain, be careful,'" explained Simpson. "Are there some bad physicians? Sure, there are bad physicians, but Dr. Reynolds is not one of them. Was he negligent? Sure. I’ll go to my grave thinking he did not set out to do this on purpose.”
Russell Coleman is the U.S. Attorney for the Western District of Kentucky. His office prosecuted the Gott and Rynolds’ cases.
“When I’m sitting in the courtroom watching a small town doctor be prosecuted for behavior that ultimately results in death, I understand how deeply important that practitioner is to the small town. A pillar of the community, becomes part of families," Coleman told WKU Public Radio. "So when I make the statement that these doctors are becoming drug dealers in white coats, I don’t make that lightly.”
According to the U.S. Attorney's Office, one of Reynolds' patients who overdosed and died had a history of illicit drug use and psychiatric issues. Prosecutors argued that Reynolds placed the patient on a regimen of chronic opiate therapy, failed to hold the man accountable by conducting urine screens and pill counts, and didn't attempt to wean the patient off of opiates.
Reynolds prescribed pain killers to other patients who weren't considered good candidates for opioids. The patients had histories of mental illness, doctor-shopping, and other risk factors for abuse and addiction.
In the last two years, the U.S. Attorney’s Office for the Western District of Kentucky has prosecuted nineteen medical professionals for illegally distributing controlled substances, with death resulting in some cases. These medical professionals include physicians, nurses, medical assistants, a chiropractor, pain clinic owners, and a pharmacy.
When doctors are prosecuted for over-prescribing, Coleman say it’s almost like dismantling cartels.
“Dr. Reynolds was prescribing around 132,000 Oxycodone pills in 2011. The next highest number was 9,000," explained Coleman. "So when you’re able to go after a physician that has abandoned the foundations of medical practice, it really is a force multiplier in these communities in getting opiates out the community and preventing addiction.”
Dr. Sherry Jones practices family medicine at a small, rural clinic in Munfordville. A year ago, she watched her friend and colleague Clella Hayes of Monroe County be sentenced to prison for over-prescribing.
“That is something that I think all doctors fear, that we are going to cross a line between trusting what the patient is saying and not recognizing the fact that illness drives what they say," Jones stated. "It really leaves us in a difficult situation where if you are believing the patient you can end up losing your license, your home, your freedom.”
Jones says doctors are taught that pain is a fifth vital sign, and if you’re not treating a patient’s pain, you’re not being a good doctor. However, there isn’t an objective test to determine how much pain someone is suffering.
“If someone has a cardiac blockage, you can look at that and say that’s 75 percent or 99 percent, but for pain, that involves a trusting relationship between the patient and physician, and often times, we have to take the patient at their word.”
While sworn to do no harm, Dr. Jones says she thinks most physicians have become more apprehensive about prescribing opioids. The state legislature passed measures in recent years aimed at curtailing and monitoring doctors’ prescribing habits. One of the laws requires doctors to use Kentucky's prescription drug monitoring system, KASPER, to view their patients' prescription history. Another law puts a three-day limit on prescription pain medicine, with some exceptions.
Jones thinks doctors need to move away from opioids for chronic pain control, but she says there aren’t a lot of alternatives. There are few clinics that specialize in pain management, especially in rural areas, and some don’t accept insurance.
For attorney Alan Simpson who represented Dr. Reynolds, it’s time to start holding pharmaceutical companies partly responsible for addiction and overdose deaths. He says, for years, the pharmaceutical industry has been under-selling the addictiveness of certain opioids.
“The pharmaceutical companies are making billions of dollars," commented Simpson. "They’re not on the frontline in the trenches with the patients who come in with all kinds of complaints of pain, panic disorders, post-traumatic stress disorders, so it’s tough to see just one group take the fall.”
Kentucky Attorney General Andy Beshear has so far filed five lawsuits against drug makers for fueling the state’s opioid epidemic.