For the past four years, San Antonio resident Joe Richie has taken daily opioid medication needed for a bad back that has been operated on five times. The Air Force veteran and former call center employee said Percocet gives him the ability to function and live a full life.

Wanting to be on the lowest amount possible, Richie, with the help of his health care provider, said he recently weaned himself down from six 10-milligram pills a day to five, a process that took about three months. Any faster, he said, would have sent him into physical withdrawals.

But in September, Richie, 56, learned from staff at his pain clinic that his daily pill regimen was about to be curtailed even more, and immediately.

He was told the clinic had to abide by 2016 Centers for Disease Control and Prevention guidelines, a part of which forced prescribers to limit their patients’ opioid dosage and strength to a certain level, lower than the amount Richie was taking for his pain. Not doing so put the physician’s license at risk, he was told.

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Overnight, Richie’s medication level was cut by almost half. He said his life went into a tailspin.

“I can barely function, said Richie, who receives federal disability payments and has insurance through Medicare. “I was given no warning. My productivity is down to zero, and I am never out of pain. I can’t sleep.”

A national epidemic of opioid misuse that is killing tens of thousands of people a year prompted more than two dozen states, but not Texas, to pass laws or add policies about how doctors prescribe opioids.

Some rules reduce the number of pills that can be given at any one time to a week or less. Others place a ceiling on the maximum allowable dose or tell doctors to do “forced tapering” with long-term chronic pain patients.

Many of these regulations cite the 2016 CDC guidelines, which were issued as a way to improve communication between doctors and patients on the benefits and risks of long-term opioid use for chronic pain and to make such use safer, among other concerns.

But some experts said the guidelines have been widely misinterpreted and that the collateral damage has been chronic pain patients who take their medication as prescribed and feel victims of an overreaction by the medical community. In some situations, the guidelines have created an adversarial relationship between doctor and patient.

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Some insurers have stopped covering certain opioids, such as OxyContin, and several big-box pharmacies are no longer filling certain prescriptions. About 18 million Americans take long-term prescription opioids for chronic pain, studies show.

The physician at the pain clinic where Richie is treated declined to be interviewed for this story, citing a busy schedule.

Misconstruing guidelines

Dr. Sherif Zaafran, president of the Texas Medical Board, said the guidelines were addressed only to primary-care physicians, not doctors who are pain specialists, who treat cancer patients and those in hospices, or who offer other end-of-life care.

“They’re absolutely being misconstrued,” he said. “They were not meant to hinder patients getting access to their needed medication, especially chronic pain patients.”

The guidelines recommend that when a patient’s opioid dosage reaches a certain level — the equivalent of a relatively high dose of morphine — a primary care physician should “strongly consider referring the patient to a specialist for chronic pain,” Zaafran said.

The particular dosage level is targeted by the CDC because it’s where over-sedation and other bad side effects can happen, he said. Patients who’ve been on opioids for a long time may require a far higher dose, which is why the guidelines aren’t meant to be a hard-and-fast rule, he said.

There are already parameters in place in Texas concerning the long-term prescribing of opioids, Zaafran said. They include written contracts between doctors and patients that require certain practices, such as frequent patient visits and routine urine screenings, to make sure patients are taking their medications properly.

“So long as those things are being done, doctors shouldn’t have to worry about” their prescribing practices, he said.

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One concern is that chronic pain patients — cut off from their medication or tapered too fast — may be driven by their desperation to street drugs such as heroin or illegally made fentanyl, the latter of which is driving the national opioid overdose numbers these days, far more than prescription medications. Some studies show pain patients cut off from their medication are at greater risk for suicide.

“We get calls at least two to three times a week from patients looking for someone else to take over prescribing their medications. It’s become so common we call them opioid refugees.” said Bob Twillman, executive director of the Academy of Integrative Pain Management in Kansas City, a physician-led organization that advocates for pain patients.

Twillman said some physicians are worried that the government, the Drug Enforcement Administration or their state medical boards are scrutinizing prescribing patterns, possibly putting their licenses at risk.

Shocking numbers are what’s powering the pendulum swing, from the early days when doctors freely prescribed opioids, assured by pharmaceutical companies that they weren’t addictive.

Last year, nearly 72,000 people in the U.S died of a drug overdose, according to the National Institute on Drug Abuse. Almost 50,000 overdosed on opioids, including prescription medications and illegal drugs such as heroin and illicit fentanyl, which is 50 times stronger than heroin. Almost 30,000 deaths were linked to fentanyl alone last year.

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According to NIDA, 8 percent to 12 percent of patients prescribed opioids for chronic pain eventually become addicted. The rate of opioid prescribing — almost half done by primary care physicians — has been on the decline, although the rate is still far higher than in the 1990s.

Last year, there were almost 3,000 drug overdoses in Texas, mostly from methamphetamine or cocaine use, although heroin and fentanyl overdoses are on the rise.

Doctors worried, too

It’s not just pain patients who are concerned about the CDC-fueled changes. Many in the medical field worry that a misreading of the 2016 guidelines is hurting patients.

“The wholesale reduction in access to opioids is based on the presumption there’s an equal risk of addiction for everyone,” said Jennifer Sharpe Potter, professor of psychiatry at UT Health San Antonio. “This approach is not based in science. And there’s no proof these kinds of reductions are effective.”

Potter said studies show opioids are not effective for certain types of pain, and some subgroups of chronic pain patients may be more prone to becoming addicted. There are also alternatives to opioid medication, such as non-opioid medication and options like exercise, acupuncture, physical therapy and cognitive behavioral therapy. But not all are effective, and many aren’t covered by health insurance companies, she said.

There are risks with many types of medication, she said. Above all, it’s the doctor, not the government, who should be having these conversations with patients.

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“The realistic concerns we have about opioids are in danger of becoming an irrational fear,” she said.

Dr. Debra Patt, executive vice president of Texas Oncology in Austin, said that in some states where strict opioid prescribing rules have been adopted, even some cancer patients have struggled with having access to their pain medication.

“These are state and federal policies that have the best of intentions but end in some really negative consequences,” she said.

One cancer patient in San Antonio who shares that concern is Jennifer Nelms, 45, who was treated for cervical cancer in 2004. Her treatment included multiple weeks of chemotherapy and intensive radiation treatments.

“It fried me,” Nelms said. “It caused all the problems I’m having today.”

In addition to extensive tissue damage, she has a bone infection that requires daily antibiotics and causes intense pain in her hip and spine.

Nelms, who had a recurrence of cancer in 2015 but is now in remission, is fully disabled and, like Richie, depends upon her opioid medication to function. She said she can’t stand for long periods and needs the drug Norco to do even simple things, such as laundry and cooking dinner for herself and her 19-year-old son.

“It scares me to death,” she said, regarding the idea that she may be forced to reduce her dosage. “I need this medication to have an even somewhat good quality of life. I need it to take my pain away, or else I’d go crazy.”

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Nelms compares the move to reduce access to opioid medication to the similar efforts to reduce access to food stamps — bad actors who commit food stamp fraud are hurting those who legitimately need assistance to survive, as she does.

“Do I worry about addiction?” she said. “I do have a slight concern. I know how powerful these drugs are. When I take mine on an empty stomach, I do get that buzz. So in the back of my mind, I’m always careful about that risk.”

Potter at UT Health agrees that opioids have been overprescribed in America.

“But is the only solution a dramatic reduction in access that hurts those with real pain?” she asks. “No. We must have a balanced approach and let science drive our policies.”

New federal report on way

The U.S. Department of Health and Human Services Task Force on Opioid Prescribing Guidelines, of which Zaafran is a member, will soon release its initial draft report on the proper management of acute and chronic pain, including opioid prescribing. The final report, due out in May, is expected to further clarify and give directions on the guidelines.

Zaafran said the initial draft will “strongly comment on the misinterpretation of the CDC guidelines and the unintentional consequences that it’s had.”

In a signed letter, hundreds of doctors across the nation have asked the CDC to clarify and amend its guidelines around opioid dose reductions.

Zaafran said the Texas Legislature in its last session passed a law that requires pain management clinics to be regularly audited to ensure they’re following appropriate prescribing practices. And legislators passed a second law that requires physicians, starting Sept. 1, to check a statewide prescription monitoring program before prescribing controlled substances such as opioids, to make sure patients aren’t “doctor shopping.” Those who treat cancer or hospice patients are exempt.

Richie, the pain patient, said that over the years he’s tried non-opioid medication to treat his spinal disc disease, along with acupuncture. Nothing relieved the excruciating back and leg pain that hobbled him.

“I wake up every day now, and all day long I’m thinking about medication,” he said “I wasn’t like this before. It’s insane.”

After his medication was reduced, he appealed to the clinic multiple times and was finally given some additional pills at a reduced dose, to help him taper over a two-week period. But it didn’t help much, and Richie continues to struggle with pain.

He said he plans to visit a homeopathic clinic to try to find something to help him sleep. He said he knows patients from his clinic who are looking into marijuana or cannabidiol oil to find some relief. Some are exploring ordering opioid drugs on the internet.

Richie said his wife, normally a conservative person, has suggested he try cannabis. Anything to help him return to the man he was before.

“This is driving legitimate pain patients who were never the problem into the category of those who are having the problem,” he said.