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The patient had a good reason for wanting painkillers: She’d fallen off a horse about a month before, and she’d just had shoulder surgery. But Dr. Jonathan Chen, an internist at the Stanford School of Medicine, was suspicious.

The woman’s chart showed that she had recently asked her family doctor for an early refill on an opioid called Norco, supposedly because her first pill bottle had been stolen from her car. Now, she was coming to see Chen at a same-day primary care clinic where most patients had little more than a sprained ankle or a cold.


Chen looked up the patient in California’s prescription drug database, and his suspicions were confirmed. “I found that over the past two months, she had gotten 12 different prescriptions for Norco from 10 different doctors,” said Chen.

For Chen, this case was more than just a clinical challenge. It was also representative of a national problem.

In a study published Monday in the journal JAMA Internal Medicine, Chen and three colleagues found that the majority of opioid painkillers aren’t being prescribed by a small group of bad doctors. Rather, they discovered that a huge number of those drugs are coming from run-of-the-mill family doctors and general practitioners.


In a time when opioid addiction has become an epidemic, these kinds of numbers could prove important for health care professionals to understand their role in the crisis. “You can’t just blame a handful of pain doctors,” said Chen. “All of us are part of this problem whether we want to admit it or not.”

On Monday, the US Centers for Disease Control and Prevention issued new guidelines calling on primary-care physicians to closely monitor their patients’ use of opioids and to limit prescriptions to help mitigate drug abuse.

Chen’s study looked at prescriptions written by 808,020 American doctors in 2013. Because the prescribing doctor is identified by number every time a pharmacist submits a claim to be reimbursed by Medicare, the researchers could tell what specialties were prescribing the largest number of opioids.

On a doctor-by-doctor level, pain management specialists and anesthesiologists handed out the most prescriptions for opioids. On average, individual pain doctors wrote around 900 to 1,100 prescriptions for painkillers in 2013, and anesthesiologists wrote nearly 500. By comparison, each family physician only wrote about 160 prescriptions.

But because there are so many more family doctors than specialists, as a group, their number of painkiller prescriptions was higher than for any other category of health care worker, with over 15 million prescriptions collectively, followed by internal medicine physicians at just under 13 million. Together, these two groups wrote more than half of all opioid prescriptions in the country.

The next specialty on the list was nurse practitioners at about 4 million. Pain specialists, including those involved in the more invasive sub-specialty of interventional pain management, were responsible for only about 3.3 million prescriptions.

To Dr. Neil Capretto, medical director of the Gateway Rehabilitation Center in western Pennsylvania and eastern Ohio, this study confirms what he’s seen in the clinic. “At least 95 percent of the heroin users I’ve seen over the past few years started on prescription painkillers, and a lot of those people are getting it from primary care,” he said.

But Dr. Richard Dart, director of the Rocky Mountain Poison and Drug Center in Denver, worries that, by looking at Medicare numbers, the paper considers only a slice of the American population, mainly the elderly and patients with disabilities — hardly representative of the country as a whole.

What these numbers can’t show are the wrenching clinical decisions related to opioid addiction — decisions like the one that Chen faced with the woman who was going from doctor to doctor looking both to relieve her pain and to satisfy her need for Norco.

Even though he’d been gearing up to publish a paper on the topic, Chen didn’t know what to do. He told her he was worried she had become dependent on this medication, and reported his concerns to her other doctors. But he wasn’t her primary care physician, and as an internist in a same-day clinic, he couldn’t personally help her overcome her addiction. A month later, she was back at her own doctor’s office, getting more Norco.

“As a doctor, this is exactly where you get twisted insides,” Chen said. “You don’t want to see a person in pain and there’s no easy answer, which is why the discussion needs to be had at an individual level as well as a national one.”

  • Based upon my experience and what I’ve read studies from pain clinics that show only about 1% of pain patients resort to buying illegal street drugs.

    One of my main complaints is pain doctors who refuse or severely curtail access to medications that will treat the source of the pain and when I insisted on getting that help, the doctor ordered serval injections that were simply needle pricks or injections in the wrong places, that were definitely NOT the source of the pain. (Are all pain doctors dishonest?)

    I’m fed-up with pain clinic doctors who automatically assuming you aren’t in pain even after they see the proof of the cause of the pain. My most recent experience, the clinic purposely twisted and rearranged my words so they could put that I’m a liar in the file.

    I’m outraged at this kind of treatment and yet, apparently, this country’s laws put the medical providers words as true over what the patient says.

    The article fails to blame the “Persons” who choose to buy illegal street drugs because when all is said and done using illegal street drugs is a “personal choice.” This failure to blame an individual for his/her choice to use illegal drugs is part of the overall drug culture in our country.

  • I found this article doing my own research looking for a new pcp. I have been with my pcp 8yrs now and the day before my monthly appt he was hospitalized with cancer. They don’t know when he will be back. I have been on my medication for 7 years now and saw a pain management doctor for the last 2yrs until the 3 rounds of epidural injections did nothing even leaving me hospitalized after the last round put me in the hospital a week. I lost my insurance almost a year ago and have been self paying with my doctor because he understands and I always do everything am supposed to. I am now faced with hurrying on no notice to find a new pcp willing to help me because of people who have abused things and the DEA scaring doctors to not be allowed to help there patients who are truly in need…makes me so upset and mad at the system it’s not the doctors fault!

  • Doctors under pressure to cut opioid prescriptions are harming the lives of many. Where I had been on the same combo (it took 2 years to find) for 15 years enabling me to successfully fight my Primary Progressive MS. I was not expected to live long yet the combo I was on let me fight. I could excercise, use imagery because I could again think clearly, I halted the progression of this disease & actually reduced scaring in the brain at times. My pain specialist looked at me the last visit I had,prior to his license being suspended , & said he was under pressure to cut everyone. He had seen him how previous cuts hurt my speech & walking, he said “I just can’t do that to you, I’ve seen what it does to you. I had been on the same dosage ( no increase) for about 15 years. Now I cannot find another pain specialist. My speech now slurs, & is halting, my walking now again requires wrist crutches, & my thinking & memory are not as good. My deteriation is continuing & I fear going backwards so very much. My MS unlike most is pure pain! The DEA & lack of knowledge in governing bodies has/is degrading quality of my life & I believe even killing me. I have several advanced degrees & taking a disability retirement hurt so much. Now I ,again, cannot even clean my home, go grocery shopping, or even care for my family . This is so incredibly wrong! Doctors more & more practice only in fear. The oath to do no harm is no longer in practice.

    • You are absolutely right. I have the same problem. I was seeing a pain specialist for 8 years. He tried morphine, Mscotton that didn’t help. I have had cancer 4 times and almost every bone broke, also ra,osteoporosis ,&osteoarthritis. The only thing that helped was Lortab 10.I also tried fentanyl patshes&Lyrica witch were 2 of the worst drugs I ever tried. I went 2 10lortabs every 6 hrs which made my life as good as I can remember. Now with new laws I get 1 Lortab every 6 hrs and I can barely function.I have never abused my med or ran out early or gotten pain med from more than same dr. Y r we being treated like drug addicts.I just want my life back.

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