A cancer patient in relentless pain, a young mother tormented by chronic pain from injuries sustained in an accident, and a senior citizen with excruciating back pain are among the South Carolinians experts say have had trouble getting narcotic pain medications in recent years.

The opioid crisis has shaped an environment, they say, that’s led some doctors to stop prescribing oxycodone and other pain medications, as well as some other controlled substances, leaving some patients desperate. 

And some turn to the street to buy pills they think are authentic, but are instead laced with deadly fentanyl, experts say.  

The pendulum, says Dr. Eric Loudermilk of the Piedmont Comprehensive Pain Management Group in Greenville and Anderson, has swung too far in the other direction. 

“A lot of physicians are afraid to prescribe opioids now,” he told Indexx Inc., publisher of Greenville Business Magazine, Columbia Business Monthly and Charleston Business Magazine.

“Patients who have legitimate pain from work injuries or cancer can’t get pain medications now,” he said. “It’s gone from one extreme to another.”

The current situation can be traced to 1996 when it was determined that pain was undertreated and needed to be considered “the fifth vital sign,” Loudermilk said. 

“Most of us saw this and said, ‘This is going to be bad,’” he said. “Everybody’s pain assessment is different. You cannot measure pain the way you measure blood pressure.”

Then came an intense marketing campaign for Oxycontin, said Dr. John Emmel, medical director for the state Department of Alcohol and Other Drug Abuse Services (DAODAS).

So doctors, prompted by federal guidelines and insurance reimbursement, began to prescribe more opioids to bring pain under better control, Loudermilk said. 

“And things spiraled out of control from there,” he said.

While doctors were prescribing in good faith, more people became dependent on opioids as a consequence, and doctors were subsequently told to cut back prescribing them, said Emmel, who is also medical director for The Charleston Center, Charleston County’s DAODAS provider.

“The peak was around 2012,” he said, “and after that the word was out, and doctors began to temper the dosage and number of pills they were giving.”

Meanwhile, the number of overdose deaths continued to rise. 

Last year, more than 107,000 people died of overdoses, according to the U.S. Centers for Disease Control and Prevention. 

And opioids factor in 72 percent of overdose deaths, the National Center for Drug Abuse Statistics reports. 

While the CDC originally published pain guidelines for physicians in 2016, those guidelines led a subset of medical professionals to worry that “Big Brother might be watching,” Emmel said.

As a result, some doctors began to eschew prescribing opioids, though there’s no good data on how many, he said, adding that those guidelines are now being revamped. 

“Anecdotally, we hear it. Some cut back and a few said I’m not taking any chances,” he said. “But there are the State Medical Board, the State Bureau of Drug Control, and the DEA (Drug Enforcement Administration) potentially looking over your shoulder, the latter two of which are primarily charged to deal with enforcement. It can create a worry in someone who is by their profession trying to help people with medication.”

“Doctors are refusing to write prescriptions for opioids (because) there is a strong concern that (government agencies) will come down on them and they will have their license restricted,” Loudermilk said.

Still others are worried about prescribing Benzodiazepines because they could be mixed with an opioid and cause respiratory depression in rare circumstances, he said.

So over time, Loudermilk said, his practice has been “flooded” with patients referred for pain medications by other doctors – including orthopedic surgeons and neurosurgeons – who won’t prescribe opioids. 

“These patients are miserable. But if they have, say, back surgery … they’ve got to have something until everything heals,” he said. “Those doctors … don’t want to get in trouble with the DEA. But it’s not fair to doctors who do prescribe these medications judiciously. We don’t want to get in trouble either.”

Compounding the situation, he said, is that pharmacies are getting limited supplies of pain medication based on federal regulations. So while he might write a prescription for 90 hydrocodone pills, the patient may only be given 40 and return to him for another prescription to a different pharmacy, which could make it look as though he’s overprescribing, he said.

“Plus, we don’t have the space to refill everyone’s hydrocodone every month,” he said. “Everyone’s family doctor ought to be able to do that if you have a fracture in your spine to provide some comfort in your last years.”

People in severe pain are desperate and not thinking clearly, so some turn to the street where the vast majority of pills now contain fentanyl, he said.

“Prescription opioids have decreased by 50 percent in 10 years, but opioid deaths have been skyrocketing,” he said. “It’s fentanyl that is really killing people all across the country.”

Loudermilk said he considers these deaths poisonings rather than overdoses because those people were taking what they thought were authentic medications not illicit drugs.   

Tricia Lawdahl, a former ICU nurse and director of health and wellness initiatives for FAVOR (Faces and Voices of Recovery) Upstate, says she’s seen people turn to the street for pain pills time and again though it’s “very, very risky … because you never know what you’re getting.”

Among them was the couple who’d been hit by a car whose provider subsequently cut them off from their pain medicine, she said. 

And there was the older woman with severe back pain whose provider suddenly closed, leading her to buy opioids on the street when she couldn’t get into another practice right away, resulting in an overdose she survived before coming to FAVOR, Lawdahl said.

“She went to the clinic one day and there was a closed sign,” she said. “There was no forewarning.”

Hubert Yarborough, who runs Yarborough Recovery Solutions in Greenville to help people recover from substance use disorders, said he’s also hearing from clients that some doctors are no longer prescribing controlled substances, leading some to buy on the street.

“I’ve had numerous people over last four or five years (in that situation),” he said. “One family I deal with lost a close relative (who) overdosed accidentally by going to the street to buy Percocet which was laced with fentanyl.”

The young mother had been in chronic pain from an accident but couldn’t get medication anymore and ibuprofen and other drugs didn’t work, he said. She left two children behind, he said.

“There are people who are legitimately needing these painkillers,” he said. “And unfortunately, fentanyl is everywhere.”

Lawdahl says that instead of being weaned off these drugs slowly to prevent withdrawal symptoms, some patients get “cut off at the knees,” leaving them frantic.

“There’s a lack of knowledge about opioid withdrawal and how severe the symptoms can be,” she said. “It should be a medically supervised situation.”

“Sometimes people are suddenly cut off – and the CDC did not want that to happen,” Emmel said. “Clearly there needs to be a better job of educating physicians on what is acceptable and safe.”

Lawdahl and Yarborough say some people can use pain management tools such as yoga, mindfulness, exercise, and physical therapy that may be helpful in reducing the medication over time.

But that doesn’t work for everyone. And many patients become dependent on prescription medications.  

“I’ve had several older folks, 65 to 70 years old, who have become addicted to painkillers, but they need them for certain ailments like osteoarthritis,” Yarborough said. “I’m sure it’s challenging for the health care professional to moderate this.”

One of the most difficult things to treat is a patient with chronic pain and opioid use disorder, said Emmel, noting there aren’t enough physicians skilled in either discipline.

There needs to be better education for medical professionals and the public on pain management options, he said, and also on the potential for drug dependence. 

At Loudermilk’s practice, there are six pain management physicians who perform medical interventions and refer patients for physical therapy to help control pain in addition to prescribing medications. Those on medications are screened for drugs and monitored carefully, he said.

Meanwhile, Loudermilk says there are alternatives that are safer, as effective, and less addictive than opioids, but often aren’t covered by insurance.

For instance, he said, one patient who’d had surgery and radiation for throat cancer was in terrible pain. But the safer drugs weren’t in the plan.

And a construction worker with intensifying back pain couldn’t afford the $650 he was charged for the alternative Loudermilk prescribed. 

“It’s a story that plays out every single day,” he said.

Because of the opioid epidemic, Emmel says there’s a lot of concern among pain management specialists that people with legitimate pain might be denied proper medication.

It’s a complex situation, he said, with no easy answers.

“But I think,” he adds, “that it’s gone a little not in favor of the patient sometimes.”