NOEL KING, HOST:
For years, we have called what's happening in this country an opioid epidemic - hundreds of thousands of Americans dead of overdoses, children taken from their parents, addicts fighting to recover. And doctors are still prescribing opioids at dangerously high rates. Here's NPR's addiction correspondent Brian Mann.
BRIAN MANN, BYLINE: For nearly a decade, medical studies, congressional hearings, news reports, they all sounded the alarm about doctors overprescribing opioid pain pills in deadly amounts.
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PRESIDENT BARACK OBAMA: Has to be something that is right up there at the top of our radar screen.
MANN: By 2016, overdoses were killing more Americans than car crashes or guns. President Barack Obama hosted a summit at the White House demanding reform.
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OBAMA: We have to have a change in the medical profession and the drug companies. And we have to hold them more accountable.
MANN: There were criminal investigations. Some doctors went to prison. A year later, President Trump declared the opioid crisis a public health emergency. You'd think the message would've gotten through loud and clear. But an investigation by NPR looking at publicly available data found doctors and other clinicians still dispensing these highly addictive medications at rates two to three times higher than before the opioid boom began.
JONATHAN CHEN: If you look worldwide, we're, like, 5% of the population, but we consume 80% of the world's prescription opioids.
MANN: Jonathan Chen is an emergency room doctor who studies prescribing patterns at Stanford University. For a long time, he says, much of the attention focused on those crooked doctors running illegal pill mills. But a growing number of studies show that was never the real problem.
CHEN: It's not just a handful of doctors doing it, we kind of all are. It's really become a part of our culture that this is normal.
MANN: Normal and deadly. In 2018, the last year we have good records, 40 people were still dying every day from prescription opioid overdose. Millions more saw their lives shattered by addiction.
TRAVIS RIEDER: They just kept writing the prescriptions. And I kept taking them.
MANN: Travis Rieder was in a motorcycle accident in 2015. Weeks after his last surgery, Rieder says his doctors were still raising his opioid dose. By the time he realized it was a problem, Rieder was hooked.
RIEDER: Like, one of the worst symptoms of withdrawal is the jitters or tremors. It never goes away. And it doesn't let you sleep.
MANN: Rieder's not your typical patient. He's also a bioethicist at Johns Hopkins University. So while in recovery, he started asking questions, doing his own research. What he found made him angry.
RIEDER: We've had an attitude about opioids that they are relevantly similar to, say, antibiotics, right? You can prescribe and forget. And that's a crazy view for a medication like opioids.
MANN: It's important to say, clearly, opioids can be a really important medication. When used correctly, they make life bearable for people suffering the most extreme kinds of pain. All the experts NPR talked to say the same thing. Pain is complicated. It's hard to treat. But researchers say none of that explains why so many doctors still give out large quantities of these pills to so many patients, often in a way, critics say, seems reckless.
KEITH HUMPHREYS: It is remarkable that medicine still has the trust that it does.
MANN: Keith Humphreys teaches medical students at Stanford and has studied opioid prescribing patterns for years.
HUMPHREYS: People who go to the hospital with a twisted ankle, one in eight of them is walking out with a prescription for opioids. That's crazy. And that's happening now.
MANN: It's not just patients still being put at risk by overprescribing. Humphreys and other researchers found doctors and surgeons are handing out so many pills every year, the extras get diverted. We're talking millions of medications.
HUMPHREYS: So they go into the American medicine cabinet. And you have this incredible reservoir of pills that doesn't exist in other countries. It's remarkable this continues and that we put this much potentially deadly drug out on the street every year. But that's the situation we're in.
MANN: There is some good news. Opioid overprescribing has come down from levels in 2012 and 2013 that everyone agrees were astronomically dangerous. But in a baffling number of cases, doctors still ignore safety guidelines set by the Centers for Disease Control and Prevention. Dr. Christina Mikosz published a new CDC study this year.
CHRISTINA MIKOSZ: What we found is that opioid prescribing rates, the day's supply of opioids that was given the patients and the dosage that was prescribed to patients did not align with evidence-based guidelines.
MANN: What that means is that even after all the deaths and despite a growing body of science about the risk of even a single opioid prescription, a lot of doctors still get almost everything wrong when treating pain. Often, they use opioids for ailments like headaches, lower back pain and muscle soreness that could be treated with Tylenol or an ice pack. Mikosz says it's unclear why doctors are doing this.
MIKOSZ: It's possible that some clinicians just simply aren't aware of existing evidence-based recommendations. The other possibility is that they are aware and they just choose not to follow them.
MANN: A lot of scientists, doctors and pain management experts NPR talked to do have a theory about this behavior. They blame an opioid marketing campaign launched by the pharmaceutical industry in the late 1990s.
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UNIDENTIFIED DOCTOR: They do not have serious medical side effects. And so these drugs should be used much more than they are for patients in pain.
MANN: Companies like Purdue Pharma put doctors in advertisements, like this one, aimed at convincing other doctors that opioids are convenient, safe and effective. Jonathan Chen at Stanford says it worked. It changed the way American doctors think.
CHEN: If the patient tells you they're in pain, you should just believe and you should just treat them and give them enough medication until they say they feel better.
MANN: That sounds really dated now. After so many deaths, so many communities ravaged by addiction, surely, things have changed. But experts interviewed by NPR say, for a lot of doctors, even good, ethical doctors, that cultural attitude remains deeply entrenched. They say yes to opioids even when they're not the best or the safest option. Chen says it shocked him when he realized how often this happens.
CHEN: Before I was in medical school, I was an engineer. I thought you go to the doctor, you tell them what's wrong with you, they give you the correct treatment and you get better because, why wouldn't they? The reality is, for so many things - opioids and beyond - you have one disease or one condition, you go to 10 different doctors, you could get 10 different prescriptions. And a lot of that is cultural variation in what has become acceptable norms.
MANN: Stanford researcher Keith Humphreys agrees. For a lot of clinicians, giving out so many pills is still, stubbornly, normal medical practice. One surprise, he says, is that more people aren't angry about it.
HUMPHREYS: They should be angry and at least some of them are, particularly people who have buried loved ones.
MANN: The CDC says these prescription opioids have killed more than 230,000 Americans so far.
Brian Mann, NPR News.
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