Dr. Kenneth Choquette knows what kind of chronic pain his patients endure every day. Without opioid pills, some may not work, sleep or do simple tasks like washing the dishes.
"If I remove painkillers from a patient who correctly takes it for the right reasons, it means they're going to hurt more," said Choquette, a coordinated healthcare professional and a doctor for three decades.
"So are they addicted to medicine?" he said. "Absolutely."
But are they addicted to opioids?
It is the question of many healthcare professionals like practice in the United States, a country that is dealing with an opioid epidemic with a death rate exceeding car crashes. They have the task of balancing patient needs with the possibility that opioids will be abused.
Years before the opioid crisis gathered steam, the pendulum swung against overcrowding of the drugs to suppress the patient's pain. Now, some doctors say the pendulum has rocked too far in the other direction and leaves its patients with less access to the medicine they need to get through their days.
"We see those who have a healthy medical need treated as addicts where their problems and their problems. The ongoing medical condition is no longer taken seriously," Choquette said.
Choquette and four other healthcare professionals – an OB-GYN, an oral surgeon, a pharmacist and a social nurse – recently gathered for Morning Call's other community round table on the Opioi D crisis. They said that efforts to stop the epidemic failed to balance the legitimate use of opioids by patients and the illegal use of them by addicts.
Political leaders, law enforcement and insurance companies have responded with broad, rough strokes, the roundabouts said. The result has made opioids more difficult for patients who need them, which often causes patients unnecessary pain and leaves them as criminals.
Physicians' concerns corresponded to the first respondents who convened in February for Morning Calls's first round table talks.
The first respondents agreed that the nation's response to the ceaseless opioid epidemic, claiming more than 300 lives over Lehigh Valley last year, is insufficient. The use of an opioid-reversing drug called naloxone saves lives, but does not make any abuse, they said. They want money for treatment, laws to force addicts to court-treated treatment and education programs on the dangers of opioids.
Both round table groups want an overall approach to the problem where all those linked to the epidemic work together to break the crisis
"It's not a solution that suits all sizes," said Melissa Miranda, Nurse and Head of Neighborhood Health Centers in Lehigh Valley.
"Every conversation should talk about partnerships between communities. Because this is definitely more than a single conversation or solution."
Some doctors change their practice
With no solution available, doctors have found their own ways to deal with the crisis. They limit the amount of opioids they prescribe, treat pain with other methods and tell patients about the risks of opioid use.
Excessive opioid prescription can lead to so-called "diversion" of opioid drugs. When patients have more pills than they need, medicines are at risk for abuse and illegal sales.
OB-GYNs on the Lehigh Valley Health Network now write fewer pain relieving pills, says Dr. Amanda Flicker. A mother who recovers from a caesarean section receives about 20 pills. Before the epidemic becam An emergency for public health, mothers would get up to 60 years.
"We must not say" We will not give you opioid analgesic medication, "says Flicker." But we will give you 20 tablets, which is what the average user will take after a certain procedure. It minimizes the rest of the bottle that hangs out there in the medical cabinet and may eventually be diverted into other hands. "
Many doctors trust other ways to control pain, such as ice or heat in injured areas, physiotherapy and use non-narcotics for boring inflammation.
Dr. Robert Laski said he and his colleagues at Valley Oral Surgery no longer prescribes prescription for pain medication prior to surgery, instead awaits the day of a procedure for writing them. It helps prevent pills from being diverted.
They also use a non-opioid numbing medicine. mild pain, like toothache, prescribes the high motrin instead of opioids, says Laski.
Such efforts have resulted in drugstore service, where independent pharmacist Pauline Vargo said she had filled fewer recipes for opioid drugs.
"I have definitely noticed a trend, "she said." When I first started training, they became more free. Now they are definitely using more caution. "
Doctor's New Methods – Alternative pain management, fewer pills – may cause patients to feel a bit of pain. But it's good. The hope that patients do not feel any pain has contributed to a major abuse problem, the
Laski, who was educated as an Oral Surgeon at the beginning of 2000- said he was taught to take care of patients, a doctor must eliminate his pain.
"You are also better off giving a little more than you may need in case because if you do not handle your pain, you do not really take care of the patients, "he says, describing the standards at that time. "Are you kind enough to leave your patient because there is no better description, high and dry? And now they need to find care in any way?"
It is a reason that doctors often get saddled with the guilt for the overprescriptions that burned the opioid epidemic. But Laski and others gathered in the round table agreed that it was unfair for them to take on all responsibilities because they were once taught to eliminate pain and because data and marketing initially characterized opioids as safe and non addictive.
Their views have changed. Drug addictive properties are obvious, and the days of prescribing enough Vicodin to eliminate pain after surgery are over.
There are things patients need to know, says Laski.
"Many patients think post surgery, you should not be hurt," he says. "It's unrealistic."
Patients should be open to having difficult conversations with their opio users, says Flicker. This is especially important for pregnant patients, for whom the efforts are higher because "you have two lives at stake".
Some of the Flicker patients use opioids during pregnancy. Others pass, but all of them know the risks.
"It's a sincere and sincere conversation with the patient about what is happening to health care and what options she can have and what risk she puts her fetus and her newborn at through continuous medicine," she said.
Conversations have also worked for Vargo. She and other doctors in Lehigh Valley now distribute a page about brochures about opioid addiction.
"We would distribute them with recipes and have a small conversation," she said. "To say no guilty, they need it, but (say) if they ever felt there was something (they needed), here's what you can get some help to look at."
At least two of Varga's patients have sought treatment because of these conversations, she said.
A Useful Tool
While doctors have taken measures to limit them, opioid prescriptions are still written for patients who treat severe pain. But measuring pain is a challenge for doctors. It's subjective, says Flicker.
That's why the doctors applauded Pennsylvania's prescription drug monitoring programs, which they say helps them ensure that patients do not secretly collect prescriptions for controlled topics from multiple suppliers. , adopted in 2014, monitors patients' prescription history.
It has helped – opioid prescriptions in the state fell by 12 percent in the last quarter of 2017 compared with the previous year, but the death rate of opioid overdose continues to increase.  In addition to the control, insurance companies have moved to restrict recipes. In February, Lehigh Valley announced the insurer Highmark that it would limit patients who start opioids for a seven-day delivery and demanded approval from the insurance provider before making a prescription. Capital Blue Cross, another local insurer already in place, said in March that the number of patients who used opioids decreased by 12 percent in mid 2017.
But doctors on the round table conversation were briefly famous for insurers. They said that companies controlled how they were to take care of patients with a top-down strategy that restricted their ability to practice medicine. It broke the balance between taking care of the patient's pain and avoiding opioid abuse.
"We need to look at a better way of dealing with the crisis than to label people who need the drug as addicts," says Laski.  Full coverage: "Emergency mode: Opioid crisis" "class =" trb_em_ic_img "title =" Full coverage: "Emergency mode: Opioid crisis" "data-c-nd =" 2048×1365 "/>
Limits can make it harder for people with chronic pain to fill the recipe they need, sometimes they worry or blame for their opioid use, says a doctor. Sometimes patients leave a binding if they can not get to a pharmacy on the day
"It puts me as a pharmacist in a bad situation, you know, do what is right or legal, or use my heart and say, "I want to give this patient what they really need," said Vargo.
"It will be a little ridiculous."
Although data show that there are fewer opioid pills prescribed since these restrictions were established, there is not enough evidence to prove that these restrictions are driving down addiction, said the doctor. People who abuse substances likely to not stop because they receive fewer opioid pills from a doctor.
"They find it on the streets," says Miranda, social nurse. "They will find a little substitute. They will find something."
Choquette simply stated: "Pills do not abuse." People who are at risk of abuse are at risk of abusing pills, drugs or alcohol, not just opioids. "
" It's like no-one knows what to do, so let's just stop making pills, "he says.
The doctors, like the first respondents in front of them, agreed that treatment is crucial to reverse the epidemic. They can encourage their patients to get help, but it is only effective if help is available – and sometimes it is not.
"We look forward to the government to provide more resources to these facilities so that we can help manage our pregnant and non-pregnant patients who have substance abuse problems, says Flicker.
It leaves a doctor at the center of the nation's opioid crisis, without end or simple solution in sight.
B out they hope they will not be left there alone. Choquette, the pain specialist at Coordinated Health said others – legislators, patients, insurers, the media – finally acknowledges the need to balance pain management with opioid abuse.
"We have had decades and decades of people who abuse drugs because they try to deal with some issues … like psychological, advanced depression. They have an addictive personality, he says." This is not new. What is new and good is that everyone becomes a bit more aware that this is happening and we really open our eyes to the serious complications that may arise when it happens.
Perhaps it will cause the commute to rest.
Editor's Note: The opioid epidemic affects all parts of our society. From families to caregivers to the first respondents who rush to the stage for overdose, it is truly a community crisis. As part of a prolonged multimedia series on the opioid epidemic, The Morning Call is hosting a series of roundabout discussions with community members affected directly.
] Twitter @ Bhuang2012