Patient reactions are ranging from dismay to newfound hope as doctors cut back on narcotic painkiller prescriptions for chronic pain in an effort to combat addiction.
Linda Stotts, who lives in the town of Rogue River, said she has tried almost every available painkiller since rupturing disks in her back while trying to lift a desk in 1987. She has taken methadone for four years to ease her pain, but has been told she must taper off the drug until she is methadone-free in two months.
As she reduces her dose and her pain worsens, Stotts said she is contemplating suicide.
"I'm thinking about it myself. How much longer can I go on?" she asked.
Stotts, 69, said she fears she no longer will be able to care for herself and will have to move to a nursing home. She said she has been classified as a drug addict because of her painkiller use.
"I hate to think of other people and the misery they're in," she said.
Commonly used to help people beat addiction to heroin and other illegal street drugs, methadone is also used as a long-lasting painkiller that doesn't produce a sudden, highly addictive euphoria.
However, it can suppress breathing and prove deadly, especially when combined with other drugs or alcohol, or if a patient is overweight. Methadone accounts for 2 percent of painkiller prescriptions but is tied to more than 30 percent of painkiller overdose deaths, according to Jackson County Health and Human Services.
Dr. Jim Shames, medical director for Jackson County Health and Human Services, has been spearheading the local effort to curb use of addictive opioid painkillers.
"The big, big problem is that we have been overprescribing pain pills for two or three decades," Shames said. "We were so skimpy with them before. People with cancer and post-surgery pain were not given the compassionate care they deserved."
Statewide, prescription opioid overdose deaths skyrocketed from 48 in 2000 to 239 in 2006, when deaths peaked. Deaths have been trending downward to 150 in 2013, following concerted efforts by the medical community to prescribe opioids more cautiously.
"These drugs are powerful, addictive and dangerous," Shames said. "But at the same time, people are in pain and we're bringing their doses down. They're in a tough place and I recognize that. The trick is how to compassionately put them in a safer place and give them better tools to manage pain. Nationwide, there are millions of legacy patients on high doses. No one is trying to be cruel."
Shames said the pharmaceutical industry oversold the benefits of opioid painkillers. New research shows they are only about 30 percent effective in treating chronic, long-term pain.
Exercise, physical therapy, adequate sleep and cognitive behavioral therapy can yield better results, he said.
Some researchers have reported long-term use of opioids can leave patients hyper-sensitive to pain. Shower spray can feel like needles driving into the skin, for example.
Because of opioids' addictive nature, patients become physically dependent on them. Without the medications, patients can suffer withdrawal symptoms such as nausea, vomiting, diarrhea, muscle pain, sweating, chills, insomnia, anxiety, irritability and low energy.
Touchstone Interventional Pain Center in Medford is among local medical groups working to transition patients to safer doses or off opioids altogether.
A few months ago, the center sent a letter to 1,500 patients saying changes in the field of pain management likely will cause adjustments to pain medication prescriptions.
The high risk of overdose death, coupled with studies showing many patients with chronic pain failed to show substantial improvements in pain, have caused a shift in policy about prescriptions, the letter said.
Patients on high doses were told they would need to taper down to safer levels within three to six months.
"For the majority of patients, this transition can be done slowly and in a way that is tolerable," the letter said. "Many patients may even notice an improvement in their pain as several studies suggest that pain medication over time may actually worsen pain."
Dr. Shawn Sills, a pain expert with Touchstone, said most patients have been understanding about the changes.
He battled opioid addiction himself several years ago and was the subject of an Oregon Medical Board investigation. After undergoing treatment, Sills opened Touchstone in 2012 with firsthand knowledge of the addictive power of opioids. He is also the medical director for Addiction Recovery Center and Rogue Valley Fresh Start Detox in Medford.
Sills said the drugs pose many risks.
"If opioids worked, we would be happy to continue prescribing them," he said. "But the majority of patients develop tolerance. Doses go up, they get tolerant, the dose escalates, and then they're at risk of dying — even when they're not abusing and they're taking their medication as prescribed."
Sills said some patients are having difficulty as dosages are reduced.
"As they cut down on medications, they experience withdrawal. It's really hard for our patients, and not all of them understand why they're being cut down," he said. "They say, 'I've been taking these for years and I haven't died.' We try to discuss research with them that opioids can make pain worse. If we slow down the taper and educate them, most understand. About 10 to 15 percent are really struggling and may need to be kept on those higher doses."
Continued opioid use may be appropriate for patients who experience pain relief and improvements in their ability to function. Some older patients also may be kept on their medication because they are less likely to escalate their dosages compared to younger patients, Sills said.
Many insurance companies are now covering other pain treatment methods, including physical therapy and counseling. There are also procedures that can target pain generators, such as radiofrequency ablation, in which a current targets nerve tissue, Sills said.
"It destroys the nerves that are sending the pain signals," he said. "That's the direction we see pain management going. We can use technology to block out pain."
Sills is also using the new Senza spinal cord stimulation system, which was approved in May by the federal Food and Drug Administration as a method to combat pain.
"There are a lot of breakthroughs. In this field we're having advancements that allow us to target pain we could never tackle before," he said. "That's the wave of the future — instead of using these dangerous medications."
Touchstone patient Don Morgan, 62, of Klamath Falls, had a temporary spinal stimulation device implanted two months ago to reduce pain from a ruptured disk and failed surgery to fuse two vertebrae. He takes medication that includes the narcotic painkiller oxycodone.
With medication alone, on a scale of one to 10, Morgan said he experiences pain levels of three to four on his good days but seven to eight on bad days. His prescribed dose has tripled over the years, but the pain remains.
Morgan said he is extremely careful to never take more than the prescribed dose of his pills. Instead, he just suffers through the worst days.
"I was never out of pain," he said.
The temporary spinal stimulation device reduced his pain consistently to a four or less, and was especially helpful in the morning — his worst time of the day because he hasn't yet taken medication. Morgan said he believes it could have helped even more, but he never turned it all the way up during the trial period when he had the device.
Morgan had hoped to have a permanent device implanted this month, but his health insurance has refused to cover the operation, saying it is unproven. He plans to appeal the decision.
"I'm pretty disappointed," Morgan said. "It's been seven years since my first back operation. I was hoping this could be a closing chapter. The insurance company is afraid of the unknowns, but technology is progressing."
Morgan said he believes the device could beat his pain down enough that he would no longer have to rely on pain medication. If his insurance won't cover it, he hopes to gain Medicare coverage next year and have the operation then.
Sills said the spinal stimulation device has been proven effective for years and is covered by Medicare. Insurance companies often follow Medicare's lead in deciding what to cover, he noted.
While Morgan is battling an insurance company, chronic pain sufferer Janet Eshoo of Medford is traveling a different path.
She had a series of hernia repair surgeries, but the mesh kept ripping out of her abdomen, causing chronic pain. Eshoo was not only on opioid painkillers, but medication for depression and insomnia.
"I couldn't even name all the medications I was on, there were so many," she said. "I was going along like a zombie. I didn't care about life anymore."
Her doctor wanted her to get off the heavy medication and referred her to Oregon Pain Advisors, a company operating out of the Jackson County Health and Human Services building at 140 S. Holly St. in downtown Medford.
Oregon Pain Advisors educates patients about pain and teaches them coping strategies that complement medical treatment, said Mark Altenhofen, chief executive officer of the company.
Eshoo said she resisted being taken off her medication.
"I thought they were taking away my pacifier. It was scary. I thought I needed my pills," she said. "I was fighting it tooth and nail, but much to my surprise, the more I got off the pills, the better I felt."
While attending pain resiliency group sessions, Eshoo said she learned opioids can be appropriate to treat short-term acute pain from injuries such as a broken bone, but they can do more harm than good for chronic pain.
She learned relaxation, moving, breathing and stretching techniques, and how to manage the negative emotions and thoughts that come with chronic pain. Her quality of life has improved and she lost 70 pounds.
Opioid use can slow bowel movements and cause constipation. Some users develop a strong craving for sugary foods, avoid protein and experience weight gain, muscle loss and malnutrition, according to researchers.
Oregon Pain Advisors currently sees Oregon Health Plan patients and is funded by the local coordinated care organizations AllCare and Jackson Care Connect. The company eventually hopes to provide services for people with private insurance, Altenhofen said.
About one-third of Jackson County residents are on the Oregon Health Plan.
Altenhofen said chronic pain sufferers need to accept that their pain cannot be completely eliminated. But they can learn to improve many areas of their life in spite of pain.
The group aspect of the sessions helps sufferers overcome the isolation they often experience, Eshoo said.
"You tend to hibernate in your home. People don't want to be around people in pain. It's depressing," she said. "Now I'm not suffering from chronic pain nearly as much. It's set me free."