Despite widespread devastation caused by America's opioid epidemic, an investigation by NPR found that doctors and other health care providers still prescribe highly addictive pain medications at rates widely considered unsafe.
Public data, including new government studies and reports in medical literature, shows enough prescriptions are being written each year for half of all Americans to have one.
Patients still receive more than twice the volume of opioids considered normal before the prescribing boom began in the late 1990s.
"We're 5% of the world's population, but we consume 80% of the world's prescription opioids," said Dr. Jonathan Chen, a physician and researcher at Stanford University Medical Center who studies prescribing patterns.
Critics say the practice exposes tens of millions of patients each year to unnecessary risk of addiction, overdose and death. It also floods communities with vast quantities of opioid medications that go unused, building up a deadly reservoir of drugs in home medicine cabinets that often wind up being abused.
"It's not just a handful of doctors doing it. We kind of all are. It's become part of our culture that this is normal," Chen said.
His view reflects a growing body of research by doctors and scientists who have begun to voice alarm about the lack of progress in scaling back medical opioid consumption.
A lot of pills, a lot of deaths
The peril for patients remains high. In 2018, the last year for which complete data is available, more than 1 in 5 Americans had an opioid prescription filled, according to the Centers for Disease Control and Prevention.
That same year, roughly 40 Americans died each day after taking prescription opioids.
Experts say far more people are dying after developing an addiction to legal pain medicines, then shifting to far more dangerous opioids such as heroin and black-market Fentanyl.
Even without overdose and death, opioid addiction can be devastating, derailing lives, destroying families and disrupting whole communities.
"We've had an attitude about opioids that they are similar to antibiotics, where you can prescribe and forget," said Travis Rieder, a bioethicist at Johns Hopkins University. "That's a crazy view for a medicine like opioids."
Rieder himself has struggled with opioid use disorder since being prescribed large quantities of pain pills following a motorcycle accident in 2015.
"I'd just call the surgeon, and he'd up the dose. They kept writing the prescriptions, and I kept taking them," he said.
Big Pharma made the pills, but doctors were the gatekeepers
The opioid epidemic has been blamed in large part on the pharmaceutical industry and high-profile companies like Purdue Pharma, which falsely marketed the powerful medications as safe and relatively addiction-free.
As early as 2007, drugmakers were paying out massive settlements for their role sparking a wave of addiction that left more than 450,000 Americans dead. Thousands of communities have filed civil lawsuits hoping to recoup some of the staggering financial cost.
Doctors have faced far less scrutiny for their role in the crisis, but the medical profession has struggled for years to clean up its overprescribing culture. In 2014, the American Medical Association formed an opioid task force, charged in part with reforming physician practices.
"Physicians feel like we had a role to play and we wanted to be part of the solution," said Dr. Patrice Harris, who heads the AMA's effort. "Prescribing has been going down since 2012, but we wanted to get the word out that physicians should be more judicious."
In 2016, the CDC issued strongly-worded guidelines, urging doctors to avoid opioids or to minimize their use whenever possible. Roughly half the states have implemented some form of regulation designed to curtail prescribing.
But scientists, government officials and front-line medical workers interviewed by NPR say those efforts have fallen dangerously short.
A CDC study released in May found many physicians regularly ignore federal guidelines, prescribing large quantities of powerful opioid medications even when better treatment options are available.
"It's possible some clinicians just simply aren't aware of existing evidence-based recommendations," said Christina Mikosz, one of the CDC's lead researchers studying opioid prescribing.
"The other possibility is that they are aware and they just choose not to follow them."
Physicians still prescribe opioids heavily, despite research and warnings
Mikosz points to the way many doctors treat fibromyalgia, a condition that can cause severe and chronic pain. Most experts now agree opioids aren't the safest or most effective treatment, but physicians continue to prescribe opioid pain pills aggressively anyway.
"Patients with fibromyalgia were typically prescribed at least a full month supply of opioids," Mikosz said.
Remarkably, studies of prescribing practices reviewed by NPR show that physicians continue to regularly prescribe opioids even for relatively mild pain conditions, including lower back pain, muscle strain and headaches.
"There was a study of people who go to the hospital with a twisted ankle," said Keith Humphreys, who teaches and studies opioid prescribing at Stanford University. "One in eight of them is coming out with opioids. That's crazy."
This is happening despite research that shows even a single prescription for opioid medications comes with significant risk. A study published this year in Massachusetts found that between 1% and 4% of patients who are introduced to opioids develop opioid-use disorder.
Multiply that risk times tens of millions of patients, and you have the makings of another wave of opioid addiction.
"The number of adults that received any opioid prescription during the year was quite high," said lead researcher Laura Burke, an ER doctor who teaches at Harvard Medical School.
Burke said the impact of overprescribing is still painfully visible in the emergency rooms where she works.
"Many many shifts, probably most, I see the devastating consequences of addiction and overdose and all the complications associated with opioid use disorder," she told NPR.
American dentists also prescribing opioids at dangerous levels
Studies show doctors aren't the only medical professionals overprescribing. Data released this year by researchers at the University of Pittsburgh showed as many as half of opioids given out by American dentists are unnecessary and inappropriate.
Often, powerful pain pills were prescribed following oral procedures associated with mild pain that experts say could be treated with Tylenol or an ice pack.
"We found that over time, overprescribing of opioids by dentists actually increased," said Katie Suda, lead researcher on the project. She noted that up to 10% of medical opioids distributed in the U.S. each year are now prescribed by dentists.
One particular red flag turned up in her study: Dentists regularly give high-power opioid pills such as oxycodone to younger patients who are most vulnerable.
"Dentists are the primary prescribers of opioids to adolescents and young adults, who are at high risk for opioid misuse," Suda said.
Another study published this year by researchers in Michigan found dentists regularly hand out opioids after routine wisdom teeth extractions, despite evidence that patients experienced equal relief using other, safer treatments.
There is some good news. Data shows prescription rates overall have declined significantly from their peak in 2012, with the steepest reductions coming in the last few years. In some parts of the U.S., health care workers have become far more cautious.
In those communities, opioid prescribing now resembles the safer approach seen in Europe, where physicians and dentists view medications such as oxycodone and Vicodin as a last resort rather than a first option.
In much of America, the opioid boom never ended
Even with those gains, however, medical experts warn that the total volume of opioid medications prescribed to patients nationwide remains perilously high and progress is stubbornly uneven.
CDC data shows clinicians in some parts of the U.S. still write opioid prescriptions at rates between two and six times the national average.
In 11% of American counties, often in rural communities clustered in the South, enough opioid prescriptions are being written each year for every man, woman and child to have one.
Many of those doctors and dentists work in communities already hard hit by the opioid epidemic.
"We found more prescribing in counties with a higher percent of white residents, with higher rates of un-insurance and unemployment," said Gery Guy, a CDC researcher who studies geographic disparities in opioid prescribing rates.
While highlighting overall progress cutting opioid prescribing, the AMA's Harris said more focus is needed in areas where pills are being dispensed at a high rate.
"We should go to those counties and look at what's going on," she told NPR.
Experts interviewed by NPR agree opioids are an important medication when used properly. They say pain management is one of the most complicated and frustrating challenges physicians face.
Studies also suggest some of the overprescribing that continues in 2020 reflects a kind of hangover caused by past practices. By some estimates, as many as 10 million Americans were improperly exposed to high doses of medical opioids and are now profoundly addicted.
"They've been on opioids for 15 years and probably shouldn't be," said Stanford researcher Keith Humphreys. "But if you take it away, they could crash or experience horrible withdrawal or make a suicide attempt. You have to manage that legacy."
Why is this still happening?
But researchers say that doesn't explain why so many doctors and dentists continue to prescribe pills aggressively to new patients and young people with no history of opioid dependency.
NPR found widespread debate, disagreement and even confusion over the reasons for this kind of overprescribing.
In some instances, the behavior seems almost cavalier. One study found physicians often hand out a high number of opioid pills to their patients simply because that's the first option offered on the dropdown menu of their medical smart devices.
"You just click a box and it's 28 pills," Humphreys said. "Some studies show if you change that number and make it 12 pills, a lot of physicians pick 12. Which is a little scary."
Experts also say opioids remain temptingly convenient for doctors, whatever the long-term risk.
In a health care industry where patient consultations are measured in minutes and time pressure in emergency rooms and surgery units is intense, it's often easier to write a scrip for pain pills rather than engage in a complicated discussion of pain management.
Indeed, some studies suggest health care workers are actually writing prescriptions for more opioid pills because of time constraints, that's because government regulations have made prescribing more complicated and time-consuming.
"Dentists are prescribing just a couple more tablets, so they don't have to rewrite the prescription" during follow-up patient visits, said Suda at the University of Pittsburgh.
If that happened once or twice, it might not matter.
But Suda's study found dentists making that choice again and again with patients across the country, pushing roughly 14 million extra opioid tablets into circulation each year.
Surgeons, too, give out so many extra pills that as many as 70% of tablets are never used for their prescribed purpose.
Experts say millions of these highly addictive tablets dispensed legally each year are eventually diverted and misused.
"It's remarkable this continues and that we put this much potentially deadly drug out on the street every year. But that's the situation we're in," Humphreys told NPR.
Lack of training and resources appear to drive some decisions
Physicians say another major factor causing them to overprescribe opioids is they often don't have the resources to offer alternatives, especially in rural areas where physical therapists and pain specialists are in short supply.
In many cases, insurance companies are also willing to pay for opioid pills while sharply limiting coverage for non-opioid treatments that are safer and often more effective.
It's also difficult for some patients to afford the multiple co-pays and time off work needed for non-opioid pain treatments.
"Doctors are absolutely willing to have alternatives if they are in the toolbox," said the AMA's Harris. "We have to make sure the solutions, the alternatives to opioids, are equitably available."
But another major driver of overprescribing, cited most frequently by critics and researchers, is a cultural attitude among many American doctors, surgeons and dentists.
For two decades, front-line medical workers were trained to view pain as "the fifth vital sign," a condition that required immediate and aggressive treatment.
Studying in medical programs funded in part by the pharmaceutical industry, they learned to think of opioids as a convenient, safe solution.
Numerous studies reviewed by NPR suggest those attitudes remain deeply entrenched. An article in March in the Rhode Island Journal of Medicine blamed America's opioid epidemic, in part, on "an inherent cultural ethos" within the medical community that tends to favor high-power pain pills like oxycodone.
"That's the way I was taught," acknowledged Chen at Stanford University. "If the patient tells you they're in pain, it's better to just believe what they say and give them enough medication until they say they feel better."
He said it took years before he realized this approach was dangerous. "I realized, wait a minute, I think I'm actually contributing to the problem."
Many experts studying this problem told NPR that they believe the next generation of physicians and dentists will be more vigilant with opioids. But Stanford's Keith Humphreys said Americans should be outraged that doctors practicing now keep getting this wrong.
"They should be angry and at least some of them are, particularly people who've buried loved ones," he said. "It is remarkable that medicine still has the trust that it does after these past 20 years."