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Part 2 of a two-part series.

CHESAPEAKE - Charles Grose held his cane in front of him and used it as leverage to pull himself out of the recliner where he'd spent most of the past five months.

It was a quarter to ten, and time for him and his wife, Debbie, to leave for the doctor's appointment that they hoped would give him the relief he'd been searching for ever since his pain management doctor had told him she would be tapering him off of the prescription fentanyl he'd been taking for six years.

“Don’t forget your wallet,” Debbie said. “And your files.”

Grose checked his pocket and Debbie doubled-checked the thick stack of paperwork to make sure they had everything. If they were missing anything, they might be sent away without seeing the doctor.

Grose had lost count of how many doctors he'd called, only to be told the same thing: no, they weren't taking new patients, and no, they wouldn't prescribe opioids.

After an influx of opioid prescribing led to a sharp increase in overdose deaths in recent years, creating a public health crisis, U.S. and state authorities have tried to rein in prescriptions for the drugs to stem the tide of fatalities.

But last month, the Centers for Disease Control and Prevention acknowledged that its guidelines have been misapplied in many cases - resulting in chronic pain patients being inappropriately tapered or cut off from the medicine.

Grose walked gingerly down his three front steps and headed slowly for the couple’s Dodge pickup truck. Debbie went to get the newspaper from the driveway so she’d have something to read in the waiting room.

Twenty minutes later, they’d parked in a handicap spot and made their way into the Eastern Virginia Medical School Physical Medicine and Rehabilitation office.

Charles walked up to the receptionist and greeted her cheerily. The two fentanyl patches that Debbie had applied to his left arm earlier that day had eased his pain enough for him to muster a good mood.

Since he'd been conserving medication, on most days his pain - a result of two serious car accidents 35 years earlier - made him irritable and barely able to get up from his recliner.

“Got this stuff here for ya, all filled out,” he said to the receptionist, handing her the lengthy acknowledgments that he’d had to sign, accepting that he’d have to submit to urine drug tests, random pill counts and a number of other measures to ensure he wasn’t abusing his prescriptions.

“My neurosurgeon is right across the street,” he told her, making conversation. “I’ve been operated on like five times at Norfolk General. Five or six, yeah.”

Charles and Debbie headed to the waiting area, where Debbie pulled out the newspaper. A headline on the front page declared that drug overdose deaths had gone down in 2018, though they still killed 1,484 people in Virginia. The drugs remain the leading cause of unnatural death in Virginia, but it was the first decline in six years.

Debbie shook her head.

She and Charles thought that all the attention on drug overdose deaths was what had prompted pain doctors to fear giving him the pain relief he needed.

Charles felt bad for the people suffering from opioid addiction, but he didn’t understand why it had to impact him.

He thought the rules meant to prevent overdoses were pressuring him to look elsewhere to get drugs, the kind that weren’t controlled by a doctor.

A staff member pushed open the swinging doors to the waiting room and called out a name.

“Did you say Charles? Yeah, that’s me.”

***

Opioid prescribing practices in the U.S. have fluctuated dramatically for centuries.

Doctors prescribed opioids and cocaine for common ailments like diarrhea and toothache until a sudden surge of heroin abuse and morphine dependence prompted federal regulations in 1914. After that, doctors moved away from prescribing the drugs, according to “A Brief History of the Opioid Epidemic and Strategies for Pain Medicine,” a scientific article published last year by several doctors from Harvard Medical School, Johns Hopkins Medical Center and Louisiana State University Health Science Center.

What followed were decades of what some call “opiophobia,” when prescribing of opioids was shirked and stigmatized, including for cancer patients.

But in the 1990s, there was a movement by physicians to combat what they saw as under-treatment of pain. In 1995, the American Pain Society launched a campaign calling pain “the fifth vital sign,” meaning doctors should ask patients about their pain at every visit, just like checking a pulse. But unlike other vital signs, pain can't be measured objectively. National standards for pain management led some health care providers to believe they might be penalized if they didn't prescribe enough pain medicine.

At the same time, pharmaceutical companies amped up marketing that often was misleading for opioid medications, paying physicians to vouch that the drugs were a safe and humane option. Medical students were taught to rely on opioids for treatment of pain, and prescribing increased rapidly.

Prescriptions for OxyContin, a brand of opioid pain pill, jumped from 670,000 in 1997 to 6.2 million in 2002, according to the article.

Around that time, the first wave of overdose deaths began.

In 1999, at the same time prescriptions were increasing, the number of people dying from overdosing on prescription opioids began to inch up. The second wave hit in 2010, when there was a sharp increase in heroin-related deaths as people turned to the illegal drug in the same family as painkillers. And the third wave came in 2013, when powerful synthetic opioids, particularly illegally manufactured fentanyl, drove an even more dramatic increase in deaths.

The epidemic reached a record year in 2017, when 47,600 people in the U.S. died of an opioid overdose, according to the CDC. Fentanyl, the drug Grose relies on, is 100 times stronger than morphine and since 2015 has been the deadliest drug in Virginia.

In response to the escalating crisis, the CDC released opioid prescribing guidelines in March 2016 that advised primary care physicians to prescribe lower dosages, monitor patients closely and taper patients off the medication when possible.

The Virginia Board of Medicine relied on the guidelines when it developed its regulations in early 2017, which then went into effect in August 2018.

But even before the regulations went into effect, opioid prescribing began to drop.

Nationally, prescribing rates increased steadily starting in 2006, then peaked in 2012 with 255 million prescriptions before falling to the lowest rate in a decade in 2017.

In Virginia, there was a 30 percent decrease in the number of opioid doses dispensed between January 2017 and June 2018, from 29 million to 20 million, according to a report from the Prescription Monitoring Program, a state network designed to keep an eye on patients trying to score multiple prescriptions from different doctors and identify prescribers and dispensers giving out an inordinate amount of the drugs.

The Department of Medical Assistance Services, which runs the state's Medicaid program, lauds the fact that opioid prescriptions to Medicaid members were cut in half from 2012 to 2018. At the same time, the agency is working to increase access to alternative pain management, such as topical anti-inflammatory medication and physical therapy, said Dr. Jennifer Lee, the agency's director. But the agency doesn't have a system to track whether Medicaid patients feel that their pain is being adequately treated. The information, Lee said, may be reflected in patient surveys.

***

Before 2013, most fentanyl-related deaths in the state were caused by prescription forms of the drug. But by the end of that year, toxicology testing found an increase in illicitly produced forms of fentanyl, according to the Virginia Chief Medical Examiner’s fatal drug overdose report. By 2016, most of the 624 fentanyl deaths in Virginia - almost three times as many as the year before - were related to illicit forms of the drug. Heroin deaths also more than doubled from 2013 to 2016, from 213 to 448.

A research study published in the American Journal of Public Health last October concluded that policies to limit the supply of prescriptions opioids, such as prescribing guidelines, would likely result in an increase in overdose deaths over the next five years, as some people turn to illicit opioids and heroin in the absence of prescriptions.

But over ten years, the study predicted the number of overdose deaths would likely go down as fewer people are exposed to the substances through a prescription.

“Reduced opioid prescribing could simultaneously reduce opioid addiction incidence while decreasing the quality of pain management for patients with legitimate need,” the report stated.

It went on to say that policymakers "face difficult value judgments" when one policy intervention would avert some deaths but reduce quality of life for others or would increase quality of life for many and increase deaths for some.

On April 24, the CDC published a commentary in the New England Journal of Medicine warning practitioners not to misapply the guidelines that it had published in 2016.

The press release said the CDC is aiming to raise awareness of misapplications that could be putting patients like Grose at risk. Those missteps include reading the dosage recommendations as hard limits and abrupt tapering or sudden discontinuation of opioids.

In a letter to a citizen concerned about the tapering of chronic pain patients, the Virginia Board of Medicine explained that the state regulations do not limit dosages or require a reduction in opioid prescriptions. They do require the reasons for the treatment be documented in the patient’s medical record.

“In essence, the prescriber has great latitude in prescribing for any patient,” the letter read. “It just has to be done competently, safely, and be well-documented.”

The letter goes on to say that the board is aware that there are “ongoing misconceptions” about the regulations and that it is encouraging prescribers to read them rather than relying on word of mouth and media coverage of pain management practices being raided.

“Not understanding the regulations can be a disincentive to prescribe for chronic pain or maintain the treatment of patients in one’s practice that have been stable, functional, and without signs of abuse for years.”

***

Two hours after being called in to see the doctor, Grose and Debbie walked back through the swinging doors into the waiting room with muted smiles.

They walked straight to the receptionist's window to schedule Grose's next appointment.

It had almost been a dud.

Grose spent the first hour arguing with one of the doctors about prescribing guidelines. The doctor told him his doses were too high. Grose said he needed the relief.

"If you're in that bad pain, you're going to do something," Grose said. "Go out and buy drugs or get a gun and blow your brains out."

Scientific studies have shown a link between chronic pain and an increased risk of suicide.

Tired of doctors discounting his pain, Grose's temper rose and he nearly left the office in a huff.

But Debbie thought that if he calmed down, they could make their case.

After some time, Dr. Antonio Quidgley-Nevares, the chair of the Department of Physical Medicine and Rehabilitation at EVMS, came into the room and heard Grose out.

He said that they could give him withdrawal medication to ease the symptoms he'd been fighting for the past five months and that they would refer him to another doctor on the campus who specializes in pain management implants and devices.

Grose asked what would happen if that didn't work.

Quidgley-Nevares said they would address it at that point.

It was far from a guarantee, but it was more than he'd gotten from any of his other doctors.

Grose said that he wouldn’t mind if the solution to his pain relief didn’t involve opioids. All he wanted was to be able to live a life beyond his recliner.