Doctors were part of the reason that more than 119 million highly addictive opioid pills flowed into Vermont between 2006 and 2012, including more than 5 million at Lamoille County pharmacies.
Now, doctors play a role in righting the wrong, says Dr. Katie Marvin, a physician at Stowe Family Practice.
Marvin has been practicing medicine for 11 years, and remembers what it was like to go from her residency to an actual practice and her new responsibilities.
“You become a doctor, and then on day one you’re given an enormous amount of power to write those prescriptions,” she said.
The Washington Post compiled a mammoth database that tracked every single oxycodone and hydrocodone pill in America, from mega-manufacturers to local pharmacies, between 2006 and 2012. The total number for the whole country: 76 billion.
The Post also broke the data down to the county level, and urged people to use it to look at their own backyards.
What the data doesn’t show, however, is the connection between doctors and the pills, nor does it show the connection between pills and the heroin and fentanyl that has followed in their wake. According the last month’s “opioid update” from the Vermont Department of Health, 80 percent of heroin users “had previously misused prescription opioids.”
As Lamoille County Sheriff Roger Marcoux, a former DEA agent, said last month when showed the numbers, “At the end of the day, you can’t blame the pharmacies. They can’t do anything without a script.”
Marvin works closely with Marcoux in trying to push back against the prevalence of opioids, which includes participating in the annual Lamoille County opioid summits. The most recent one, in June, drew hundreds of people.
It can be tough, being the only physician on the panel.
“Every single year, someone stands up and looks directly at me, and says, ‘It’s your fault,’” Marvin said. “And I think the best way to meet that statement is to own some of it. There is some truth in that. But we’re not shying away from that. We are part of the solution.”
But Marvin bristles at the suggestion that doctors are somehow completely at fault. She said there are plenty of societal problems at play: poverty, other substance abuse, domestic violence, subpar “role modeling.” And a doctor’s first instinct is to provide relief from injury.
“There wasn’t any malintent, maybe this naïve altruism,” she said. “There was never an intention to get people hooked.”
The Washington Post data runs only through 2012, although the newspaper is still fighting to get the DEA to release pill counts from 2013 and 2014, which might be the peak years for opioid prescriptions.
It was, after all, in early 2014 that Vermont Gov. Peter Shumlin dedicated his entire State of the State address to the brewing opioid crisis.
According to the Vermont Department of Health, doctors are prescribing fewer opioids. The July “opiate report” on the department’s website shows that the number of opioids prescribed from the beginning of 2016 through the first quarter of this year has decreased 39 percent.
When Marvin sees data showing that Kinney Drugs in Morrisville received nearly 2.7 million pills during the seven-year span of 2006 to 2012, she is not as surprised as some.
She said back in the day — and it’s perhaps indicative of how swiftly the trend against over-prescribing came that “back in the day” can mean just a handful of years ago — it was standard for doctors to prescribe pills using large, round numbers.
“It was pretty standard, and you gave everyone, like, 40,” Marvin said. “It was, like, pick a number, write the script, and move on to the next patient.”
The numbers also don’t surprise Marvin because she knows how many pills some patients go through, especially those with chronic pain or terminal illnesses, including cancer cases.
In a quick, back-of-the-envelope calculation, Marvin guessed that roughly 300 people in Lamoille County are prescribed opioids for chronic pain. If oxycodone lasts only six hours before the effects wear off, those patients could be taking three or four pills a day, and have been for years.
So, those three pills a day equals 84 pills a month, or 1,008 a year. Multiply that by seven years, the time span contained in the Washington Post data, and those patients took more than 7,000 pills. If, as Marvin estimates, there are roughly 300 people with chronic pain in Lamoille County, they would have gone through 2.1 million pills.
“I would say the majority (of opioids) go to about 1 percent of the population who is dealing with chronic pain,” Marvin said.
Who gets opioids?
Vermont laws updated this year set rules for prescribing opioids, which include scheduling follow-up visits and evaluations “at a frequency determined by the patient’s risk factors, the medication dose and other clinical indictors.”
Marvin was part of a group that worked with then-Health Commissioner Harry Chen to come up with the guidelines.
She said these days, she is wary about prescribing any opioids, especially for children.
“I am so strict when it comes to kids,” she said. “When I get reports from the ER or the dentist and find out they got opiates, I call their parents.”
Patients with chronic pain can be tough, too. Sometimes she gets patients from doctors who have retired, doctors who were part of the generation that gave out opioid prescriptions more readily than younger, newer doctors.
The job, for her, becomes getting those patients onto some other regimen.
When it comes to end-of-life care, though, Marvin has little problem giving the patients what they want. She said she recently had a patient diagnosed with terminal cancer.
“And I guarantee I will prescribe him a lot of opiates over the next few months,” she said.
Withdrawal not easy
Sometimes, just curbing the prescriptions aren’t enough.
“For me, weaning someone off of opiates is one of the most difficult things that we do,” Marvin said. “It’s hard for a doc when you’re faced with a patient who says, “Hey, look, I can’t live my life without this,’ and for us to say no.”
That’s largely because of the withdrawal symptoms associated with quitting an addictive substance. It’s also because of the stigma surrounding addiction.
Marvin remembers an older patient who thought she had the flu — she was all sweaty, had diarrhea. Marvin realized the woman had surgery recently and was likely suffering from drug withdrawal symptoms.
“And this poor little 70-year-old was, like, ‘Are you saying I’m an addict?’” Marvin said. Her answer to her patient: “Absolutely not.”
She is certified to administer buprenorphine to patients who are addicted to opioids — doctors and health department reports prefer the term “opioid use disorder.”
Travis Rieder is a doctor and author of the book “In Pain,” which he wrote after a gruesome motorcycle crash left his foot a “fat, shapeless mass” that required numerous surgeries to repair. It also required a whole lot of morphine, fentanyl and other painkillers, which left him hooked on opioids, aware he was hooked, and with few answers from fellow physicians on what to do about it.
In an interview last month on National Public Radio’s “Fresh Air,” Rieder said that after his surgeries were over and he wanted advice on how to taper from the opioids, no doctor wanted to touch the subject. He said he went to numerous pain clinics, “And they said the same thing. You know, we prescribe opioids. We don’t deal with tapering.”
The pain experts advised him to go to an addiction clinic.
“And they very nicely and very gently said, ‘boy, you are not our job,’” Rieder said in the interview. “‘We're dealing with people who might die from a heroin overdose, you know, anytime they get turned away. We're triaging here. You just took too many pain meds.’”
Who’s to blame?
Some think blame can be laid at the feet of pharmaceutical manufacturers, who for years promoted opioids while downplaying their addictive qualities.
Stefani Capizzi, who was director of the North Central Vermont Recovery Center in Morrisville for seven years, said that when she was a nurse, she saw pharmaceutical representatives come in and out of the office, “selling the docs this, that and the other thing.”
That predates Marvin’s time at Stowe Family Practice. Marvin says she “missed that boat” by the time she became a doctor, and the office removed all prescription samples about a decade ago.
It wasn’t just opioids that salespeople were trying to get the doctors to order, but things like Viagra and valium, even inhaler medicine.
“There’s no gift exchanges, no incentives, no trips to Disney World,” she said.
Aside from the dangers of the opioids, though, “prescriptions are so insanely expensive” that Marvin said there were some good things about the free samples — like, if a family without insurance could get a free inhaler.
Family practitioners weren’t as swayed by big pharma as more big-name doctors, she said. She doesn’t make nearly as much as a surgeon or other specialists and isn’t willing to risk “all the millions of hours we put into medical school to take the Hippocratic Oath.”