A new investigative report on opioids for Medicare recipients is the latest study to place Alabama at the top of the list when it comes to per capita prescriptions for powerful painkillers.

The U.S. Centers for Disease Control and Prevention and Blue Cross Blue Shield Association have also drawn attention to the high number of opioid prescriptions written in the state. Some states have responded to increases in overdose deaths by imposing limits on the amount of medication doctors can prescribe.

In Alabama, doctors are now required to check the prescription drug database for some patients before prescribing opioids. But the focus on prescriptions is hurting pain patients without reducing overdose deaths, said Dr. Stefan Kertesz, an addiction specialist at UAB and Birmingham VA.

The number of opioid overdose deaths nationwide hit 33,000 in 2015 - an average of 90 people per day, according to the CDC. That total includes deaths caused by heroin, fentanyl and prescription drugs. Alabama doesn't track overdose deaths caused by opioids.

While prescriptions dropped between 2010 and 2015 - overdose deaths rose sharply. Many were caused by heroin and fentanyl, which have overtaken prescription drugs as a cause of overdose death in Jefferson County, Alabama's most populous county. Between 2015 and 2016, the number of overdose deaths caused by fentanyl more than doubled, and the number of total overdose deaths rose from 221 to 248.

Doctors across the country, including Alabama, have moved or closed down in response to investigations into prescribing practices. Kertesz said he is concerned about patients who are stable on high doses of prescription painkillers, who may suffer withdrawal and even become suicidal if they lose access to opioid drugs.

"As a doctor, the choice might be to keep this patient stable as my patient, or stop opioids and potentially let them die," Kertesz said.

Alabama has long held the top spot for per capita opioid prescriptions. Doctors, nurse practitioners and physician assistants prescribe enough opioids to give each resident 1.2 prescriptions a year. Alabama has topped lists compiled by the CDC since 2014. The Centers for Medicare and Medicaid Services investigative report found that more patients on Medicare's drug program receive opioids in Alabama than any other state.

Kertesz said there are good explanations for the state's high rate. Alabama has one of the nation's largest populations of disabled residents - and disabled people often need opioids for pain. The state also lacks mental health and drug treatment resources, so patients might seek pain treatment for conditions that could be better addressed with medication for drug addiction.

"Alabama doctors are not dumb - they are not any dumber than doctors in Massachusetts, California or anywhere else," Kertesz said.

Although Kertesz has grave concerns about the welfare of chronic pain patients and others who receive high doses of opioids, he said he agrees with some efforts to reduce opioid prescriptions. Excessive prescriptions of opioids from 2000 to 2010 caused a sharp increase in substance abuse and overdose death, he said. Because many patients become addicted to heroin after exposure to prescription drugs, it makes sense to limit doses in patients who haven't been exposed to opioids to reduce the potential for abuse.

Patients on high doses of prescription opioids and those who receive prescriptions from several different sources have a higher risk of overdose. Seniors also face increased risk of falls. To protect patients on Medicare, the Office of the Inspector General for the agency has been tracking opioid prescriptions in a series of reports.

In addition to identifying Alabama as the state with the highest rate of opioid prescriptions, the report also found 90,000 patients covered by Medicare Part D at risk of overdose due to high dosages or multiple prescriptions.

Some of the patients received so many prescriptions, they couldn't possibly take all of them without dying, said Miriam Anderson, an investigator for the Centers for Medicare and Medicaid Services. She said there is a good reason to focus on prescription opioids, which still kill thousands of people every year.

"If Medicare pays for drugs that are medically unnecessary, they can feed this opioid epidemic," Anderson said.

Anderson said the 400 extreme prescribers in the report doled opioids out at rates much higher than the national average.

"They were far outside the norm," Anderson said.

U.S. Attorney General Jeff Sessions recently announced a crackdown on fraudulent prescriptions that could bar hundreds of doctors from participating in Medicare. The agency has also been moving forward with efforts to make it harder for patients to obtain high doses of opioids, which Kertesz opposes.

Reports that focus on the number of opioids prescribed miss the mark because they don't emphasize treatment, which has been shown to reduce death from drug overdose, Kertesz said. There's no evidence to show that forcing patients off prescription opioids reduces the risk of death, he added.

"I'm happy to see that prescriptions are going down, but I'm not happy to see patients suffering due to inadequate care," Kertesz said. "What we really need to do is provide comprehensive care that includes mental health and substance abuse treatment. In some cases, that may mean helping a patient switch from a more dangerous opioid to a less dangerous one and providing mental health care."