Over the past two decades, the rate of overdose deaths from prescription painkillers known as opioids has quadrupled in the United States. Federal authorities say 78 Americans die every day from an opioid overdose. Health care officials in Montana report that the abuse here is worse than the national average. But the casualties of the opioid epidemic are not all addicts and drug abusers.
The others call themselves pain refugees. They say that finding doctors willing to help them in Montana is almost impossible, and the only way they can get the treatment and relief they need is to fly out of state.
On a recent mid-afternoon flight out of Missoula, Gary Snook is among three chronic pain patients leaving in search of relief.
Before Snook drops into his seat, he pauses in the aisle, pressing his fingertips into his upper thigh. He bends his knees slightly and moves his hips side to side. He’s getting one final stretch in before takeoff.
"Had I stayed in Montana, I would have killed myself," Snook says as the plane carries him west. "I just want humanitarian care, and I get that in California."
Snook has been taking opioids since he had surgery on his spine for a ruptured disk 14 years ago.
After the surgery, he was in so much pain he couldn’t work. He’s done all kinds of things to try to get better.
"Well I got a surgery, epidural steroid injections, acupuncture, anti-inflammatories, physical therapy, pool exercises," he says. "I’ve tried anything that anyone has ever suggested me to try. Unfortunately what I do right now is the only thing that works."
Snook is desperate like an addict, which he says he’s not. He says he’s not craving a quick fix. He leaves his home for medical treatment because he has no confidence in the doctors in Montana. He wants to be healed.
"I believe pain control is a fundamental human right, or at least an attempt at pain control," he says. "To deny someone with a horrible disease like me access to pain medications is the worst form of cruelty."
It's dark outside when Snook, his wife, and two other pain patients get off the plane in Los Angeles. They wheel their suitcases to a budget car rental and find a midsize SUV. When they get to the hotel they smile and greet the lobby clerk by name.
This whole trip has become routine. Every 90 days, they come here to see a doctor who gives them care and prescriptions they can’t get at home.
Fear Among Montana Doctors
In the winter of 2015, Helena Doctor Mark Ibsen shut down his practice after being investigated by the State Board of Medical Examiners. The Board said he was over-prescribing narcotics.
"We as physicians are terrified that we are going to go to prison, or lose our license over prescribing pain pills to patients," Ibsen says.
He says he’s done nothing wrong.
In March Ibsen testified before a state interim legislative committee about pain treatment and opioid access in Montana.
"It's like turning the light on in the kitchen and the cockroaches have fled," he said. "There is no one willing to prescribe opioids for patients who they don’t know, who they don’t trust."
Ibsen says pain management has never been easy for a doctor or a patient, and it’s getting harder as the concern over opioid abuse grows.
"There is no objective measurement of pain," Ibsen says. "If you don’t take people at their word that they are in pain, and you are suspicious of them, you can’t have a therapeutic relationship. No miracles happen between you and me as a patient and a doctor if I suspect that you’re a scumbag."
In a recent meeting, a member of the Montana Board of Medical Examiners said one of the reasons doctors are declining pain patients is because they are afraid of being followed around by the federal Drug Enforcement Administration.
In the past several years the board has taken on several high profile cases of doctors they considered to be over-prescribing opioids. At least two Montana doctors have had their licenses suspended for irresponsible prescribing since 2014.
Montana Board of Medical Examiners Executive Director Ian Marquand said he couldn’t say whether the board’s disciplinary actions on doctors had anything to do with them deciding to cut back on their opioid prescriptions.
“[The] Board doesn’t play favorites," Marquand says. "The Board does not encourage particular kinds of doctors, it does not discourage particular kinds of doctors. The door is open in Montana for any qualified, competent physician to come in and practice.”
Ibsen has appealed the suspension of his license in state court. He says he will apply for medical licenses in other states if he ever can’t practice in Montana.
There's a fear in Montana's medical community around prescription painkillers.
Doctor Marc Mentel chairs the Montana Medical Association’s committee on prescription drug abuse. He acknowledges that there’s fear in Montana’s medical community around prescription painkillers.
"Patients are in pain. We don’t have great tools for them, and we need to recognize that this is usually going to be a chronic disease state," Mentel says. "They may be in pain for the rest of their life. So, how do we address that, how do we treat them without actually harming them?
"It takes a lot of time, and it takes a lot of work, and it’s not something that you say, ‘here is some medicine, go off and do okay,'" Mentel says. "You need frequent follow up, frequent counseling, and you need a lot of tools in place to help manage their pain. So that is the one hand, and then there are other physicians who are afraid to prescribe these, or are starting to become fearful because of the backlash that has been out there."
Mentel, who started practicing in the 1990s, says medical education when he was training didn’t include anything about treating chronic pain. He says America’s medical community is still experimenting with how to do it.
"The perfect tool, the perfect medicine that would take away a person’s pain and allow them to function normally does not yet exist," he says. "So we are trying to use any tool, any means we can to help lessen the severity of their pain."
The California Solution
For some Montanans who suffer from chronic pain, like Gary Snook, relief is found at a small strip mall clinic in suburban Los Angeles.
"I see a lot of tragedy," says the doctor who runs it, Forest Tennant. "But on the other hand, I’m a doctor who is supposed to help deal with that. That is part of my job."
Tennant is a former Army physician who has consulted for the National Institute on Drug Abuse, the National Football League and NASCAR.
He carries about 150 patients; half local Californians, and half out-of-staters.
Tennant says there are some legitimate reasons to be concerned about opioids, but he says that’s why doctors need to specialize in pain management.
"Somebody said we have this opioid epidemic, I guess they are talking about the overdoses, which are up, there is no two ways about it," Tennant says.
"Apparently there are states where too many opioids have gotten out on the street. And again, doctors can get conned, get the wrong patient," he says. "So I think that it is true that we've had a lot of opioids that get out on the street, and people get them, whether they are teenagers or addicts. In other words, it has been known since I started doing addiction medicine 40 years ago, opioid addicts are going to go get opioids, whether it is heroin or a prescription opioid. And they are going to go where they can get them."
But Tennant says, opioids can help people. And because of that, he says the drugs shouldn’t be stigmatized, but used responsibility.
"This morning I had a women in from Massachusetts," Tennant says, "she's got a rare cancer that is in her neck and in her chest, and she also had at one time a traumatic brain injury. So, yeah, she does take a lot of opioid drugs. She’s not going to live very long. But are we going to just tell these people we are not going to help them. You see what I’m getting at?"
Permission to Die
Pain has turned Lolo resident Gary Snook’s life into something that resembles a spectator sport. He spends a lot of time lying down, isolated in a feeling no one can see. Sometimes, he talks about his life like it was something he had once, then lost.
"I mean, that’s life and death in that bottle," Snook says, gesturing to his pain medication, "at least it’s my life."
His wife Kathy says, "it is the most horrible thing, because it is somebody you love."
"I am terrified for him not to be able to get the opioids that he needs to even just kind of put a damper on the pain," Kathy says. "It never gets rid of it entirely, but it makes it so he can cope, how he can have some semblance of life. And every day we live in fear that he may not be able to get his medication that he needs.
"I would never want to see him lay in bed with torturous pain, with no hope of getting better" she says, "and I have given him permission, if we're ever in that situation, that I would understand if he chose suicide."
Read part two of this series on pain patients' access to opioid painkillers in Montana.
This story was made possible, in part, by a grant from the Montana Health Care Foundation.