St. Joseph County slaying shows tough balance doctors face with opioid prescriptions | Public Safety

A few times each year, as the opioid addiction crisis has accelerated, a handful of doctors across Indiana have made headlines after police raided their offices and arrested them on charges of recklessly writing prescriptions for powerful pain medicine.

This week, authorities said, a local doctor did the opposite by refusing to prescribe an opioid — and paid with his life.

The Wednesday shooting death of Dr. Todd Graham, who practiced at South Bend Orthopaedics, was an extreme example of the ire doctors risk when they deny painkillers to a patient, just as the arrests of doctors are the rarest cases of over-prescribing.

But the dispute that led to Graham’s death stands out as a jarring example of the balancing act doctors face on the front lines of the war against opioid abuse.

On one hand, new laws and regulations have increased the pressure on doctors to use caution when prescribing pain medicine and to be on the lookout for fraud by using drug tests and other measures. On the other hand, patients with a legitimate need for pain relief have been frustrated by the new obstacles.

“We all live under a little fear as patients have felt the tightening of laws and regulations regarding opioids,” said Dr. Natali Balog, a rheumatologist at South Bend Clinic and president of the St. Joseph County Medical Society.

“Even our normal patients who are very straightforward, they feel criminalized.”

Reacting to the epidemic of abuse and overdoses from heroin and related opioid painkillers, Indiana’s legislature in 2013 passed a law that set up a host of new rules for primary care doctors who prescribe opioids.

Experts have said many heroin users become addicted to opioids after being prescribed the painkillers for legitimate injuries or chronic pain.

As recently as 2012, Indiana was among the 13 U.S. states that prescribed the most opioids per capita, according to the U.S. Centers for Disease Control. That year, more than 100 opioid prescriptions were written for every 100 people in Indiana.

Last year, about 6.42 million opioid prescriptions were filled in Indiana, a slight drop from the 6.46 million prescriptions dispensed in 2015, according to a study published by the Center for Health Policy at Indiana University’s Richard M. Fairbanks School of Public Health.

To get a prescription of 60 pills or more from a primary care physician, the 2013 law requires a patient to fill out an addiction questionnaire and other paperwork, sign a pain-management contract and submit to a physical and urine test.

Lawmakers added further restrictions this year, limiting an opioid prescription to seven days’ worth of medicine except in the cases of cancer, end-of-life care or exemptions set by the Indiana Medical Licensing Board. Otherwise, a doctor may prescribe an opioid after finding that other pain relievers are unsuitable, but must file a written notice of the decision.

Doctors who violate the rules can face discipline by the licensing board, have their licenses revoked or even be charged with a crime.

The focus on slowing the tide of opioid abuse has left many doctors reluctant to prescribe the medications at all, said Dr. Kathryn Park, a pain specialist with South Bend Clinic. Within the past 20 years, doctors were trained to place a greater focus on treating pain, even to treat it as the “fifth vital sign.” But now, the “pendulum has swung the other way,” she said.

“A lot of doctors are fearful that they’re going to do something wrong,” she said. “Education is good, but when a doctor is fearful to prescribe medication to someone who is in pain, that’s also not good.”

Park said she tries to avoid opioids if possible, opting for anti-inflammatories such as aspirin or ibuprofen, sometimes combined with physical therapy. Doctors say other types of medications, such as muscle-relaxants and drugs for seizures, can also be used as pain relievers.

Similarly, primary care doctors will generally start with an anti-inflammatory when a patient complaints of a condition such as lower back pain, Balog said. If the pain persists, the doctor may use imaging to identify a more serious problem before referring the patient to pain management. Because a long-term pain management plan requires an appointment every three months, Park said, many primary care doctors find them to be inconvenient.

Emergency rooms also have cut back on opioid prescriptions, Park said, choosing to call a patient’s family doctor for guidance, especially if a patient has a pain contract that requires other providers to consult that doctor.

Balog said many doctors had long used caution in prescribing narcotics. But that caution has increased, and in some cases primary care doctors have even quit prescribing opioids except in very small amounts, choosing instead to refer patients to pain specialists.

Still, the doctors acknowledged some patients need the stronger painkillers, either because of severe chronic pain or because they cannot take other types of medicine.

“What about Grandma, who has horrible arthritis but can’t have surgery because of a heart condition and can’t take anti-inflammatories because she’s on a blood thinner?” Park said. “You have to give them pain medicine — otherwise, they’re going to be miserable.”

The reluctance to prescribe opioids also has led to more instances of conflict between physicians and people who are intent on getting the painkillers.

Balog said the local medical community was in disbelief over Graham’s fatal shooting by 48-year-old Michael Jarvis, who police said attacked the doctor after he declined to prescribe an opioid to Jarvis’ wife. But Balog said she and her colleagues have previously seen more subtle conflicts over the drugs.

It’s become more common for patients to become angry or verbally abusive after doctors deny or end an opioid prescription. Those encounters have ended after security escorted the patients from the building, but they’ve had an unsettling effect, Balog said, pointing out that the pain-management offices at South Bend Clinic are the only ones where all the doors are secured with key-card systems.

On Tuesday, police said, Jarvis and his wife had an appointment with Graham, who declined to prescribe an opioid to Jarvis’ wife. A couple of hours later, Jarvis came back to the South Bend Orthopaedics campus and confronted Graham in the parking lot. Police said he told two witnesses to leave the area before shooting the doctor twice.

“Unfortunately, this incident might start more conversation about, what are our risks that we need to de-escalate,” Balog said .

At a news conference Thursday, St. Joseph County Prosecutor Ken Cotter said Graham “did what we ask our doctors to do” by not over-prescribing opioids. Cotter said he received calls from doctors after the shooting and hoped to start a “dialogue” with the medical community about how to prevent such incidents in the future.

On Saturday, Cotter said three of the area’s major medical providers have asked about “threat assessments” by law enforcement that could help identify and reduce risks of violence in hospitals or doctor’s offices.

“Nobody can do their job if they’re constantly looking over their shoulder saying, ‘is somebody going to hurt me because I’m doing my job,’” Cotter said. “They need to be safe first.”

Tribune staff writer Jeff Parrott contributed to this report.

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