Hegge has been taking opioids almost 20 years for relief from
seven back surgeries, including a spinal fusion.
drugs have helped him walk his dog, practice tai chi and lead
a relatively pain-free life, said Hegge, 57.
the doctor he has relied on for relief is in trouble. His
medical license was suspended in December for what state
officials called "unprofessional" prescribing
scrambled to find a new doctor before his pills ran out and
pain and withdrawal kicked in. His current doctor wants to cut
his dose by 10 percent a month.
says he’s being punished for others’ misdeeds. "Why
do innocent patients have to suffer because of doctors being
investigated? Instead of fighting chronic pain," Hegge
said, "I’m fighting the system."
years of surging opioid prescriptions, leading to addiction
and deaths, the pendulum swung back hard against abuse,
culminating in the July shutdown of the Seattle Pain Centers (SPC),
a chain of eight Washington clinics. That state action, amid
allegations of improper oversight that may have contributed to
patient deaths, sent 8,000 patients looking for new providers.
experts express sympathy for "legacy" patients like
Hegge, who were prescribed high doses of opioids before a new
approach took hold with new state rules in 2012.
have reason to be upset because frankly they were caught up in
a medical experiment that high-dose opiates were the way to
go," said Dr. David Tauben, chief of pain medicine at the
University of Washington.
could take years to get these folks’ (doses) down because
their bodies have been so transformed by exposures that create
changes in the brain, spinal cord and elsewhere."
problems are compounded by doctors who now fear sanctions for
prescribing high doses — fears that may come from
misunderstanding the state’s rules. Doctors don’t have to
slash dosing for legacy patients, according to Tauben and
others. It says so in state and federal guidelines.
not much relief for Hegge.
like a primitive voice in my head keeps repeating, ‘have
pain, stop the pain,’ " he said, about a visit last
month to an emergency room to seek help for pain, anxiety and
symptoms of withdrawal.
doctors have long been reluctant to treat chronic non-cancer
pain patients. With concerns about abuse and overdoses, and
the complexity of diagnosing and treating pain, such patients
tend to require more monitoring than a doctor’s schedule
amount of work to manage those patients safely and effectively
is really high," said Dr. Tom Schaaf, a member of an
opioid-practices task force convened by the state medical and
knows what happened to all of the SPC patients and if any
resorted to dangerous street drugs. Tauben, Schaaf and others
believe the vast majority found new providers. Some were
treated for withdrawal in emergency rooms.
from an ER perspective we’re not seeing large numbers of
folks having difficulty accessing pain management at this
point," said Dr. Nathan Schlicher, an emergency physician
in Tacoma, Wash., and member of the state opioid task force.
was one suicide thought to be linked to the closure of SPC.
Denny Peck, 58, left a note in September saying he had run out
of pills and couldn’t stand the pain caused by a commercial
fishing accident 26 years earlier.
fallout appears to have fueled some doctors’ fears.
Moran Jr., said his doctor told him in July he was going to
cut his dosage. "He just started saying, ‘We have to
cut you back; I’m not going to lose my license,’ "
according to Moran, 60, who said his right arm, nerve-damaged
in a motorcycle accident, aches more and is almost useless to
him with a lower dose of painkillers.
sleeps in a recliner because of the pain, he said, rarely
showers and eats off disposable plates because he hasn’t
been able to install the dishwasher he bought. "Imagine
having a pain at the level of a bad toothache and it never
goes away," he said.
doctor did not respond to requests for comment.
current state rules, Hegge and other patients sign a pain
contract with their providers, agreeing to submit to random
drug tests, pill-counting and other checks.
now on disability, was a chemical-dependency counselor for 10
years. He weighs the costs and benefits of his morphine use,
he said, including unpleasant side effects. He believes he’s
a smart consumer.
state officials suspended the license of his longtime doctor,
Philip Roger Matthews, in December, saying he prescribed high
doses with not enough care, endangering patients.
response, Matthews disputed that and called the suspension of
his license "excessive and unwarranted." He said he
has not injured any patients and does not pose a risk to them.
license remains suspended pending further action by the state.
He did not respond to requests for an interview.
legacy patients may deserve some flexibility, experts say the
medical evidence is clear: there are more risks than benefits
associated with daily doses above 120 milligrams of morphine,
or the equivalent in other opioids.
doctors want to taper doses for patients like Hegge, who takes
about 360 milligrams of morphine a day. But they should do it
a tiny reduction will be experienced by the patient’s
central nervous system as increasing pain," Tauben said.
"It is a slow journey that involves an empathic response
to these individuals caught in this shifting pendulum."
will not lose their licenses just for prescribing above the
state-recommended daily threshold of 120 milligrams of
morphine, according to Tauben and others.
may prescribe above that limit, the rules state. If they do,
they should consult with a pain specialist.
even need to do that if the patient meets criteria such as
being on a tapering schedule, or the patient’s function is
improved without apparent risk, or the prescribing physician
has a certain amount of training in pain management.
rules "got distorted" by some, Tauben said.
state Department of Health put out a reminder late last year
— a month after Peck’s suicide.
fact, there is no upper limit for opioids in the Washington
state pain rules," wrote Melanie de Leon, executive
director of the Medical Quality Assurance Commission, which
the opioid epidemic is a public health crisis, we must not
forget the crisis that is the patient without relief from
debilitating pain or functional improvement," de Leon
issued last year by the Centers for Disease Control and
Prevention called for "very slow opioid tapers as well as
pauses in the taper to allow gradual accommodation to lower
the ER doctor, said he thinks providers understand the rules.
But they also have to safeguard against patients who don’t
want to do what the doctor deems necessary and "bounce
between providers," he said, rather than building a
relationship with a doctor that might evolve to allow higher
have sympathy for both sides, patients and doctors,"
Matthews, deputy director for the medical quality commission,
said state officials tried to educate doctors about the new
rules. They even went on a yearlong road show. "We gave
presentations to some 5,000 practitioners around the
state," Matthews said.
patient thinks the state is interfering in his treatment,
Matthews said "that’s an educational opportunity we’re
willing to take on with the physician."
patients should give his email to their doctors so they can
ask Matthews or state medical consultants about appropriate
practices under the rules.
advises patients to give de Leon’s "technical
assistance" memo to their doctors or clinic
administrators. Patients should also encourage their doctors
to visit a weekly teleconference the UW hosts to discuss
complex chronic pain cases, he said.
all, Schaaf said, patients shouldn’t give up their
"search for finding a doctor who will listen and be
honest with you about your condition but is willing to
compromise with you toward a goal of least medication with
best functional status."