A lot of Dr. Jeffrey Miller’s patients come to him in severe pain after car accidents, traumatic falls and sports injuries.

But over the 22 years the orthopedic surgeon has been practicing in New London, he’s seen a marked change in attitudes within the medical community, from patients themselves and from health care regulators, toward how that pain is treated — a change that has become even more pronounced with the recent heroin crisis.

“Twenty years ago, the message physicians were getting was that we weren’t treating pain well enough, and that patients had a right to be pain free,” he said Thursday. “We had to show that we were treating pain to document that we were practicing appropriately.”

At that time, medications like Oxycodone, Vicodin and Percocet were becoming widely available, and doctors were being pressured to prescribe them readily, he said.

But now, as the highly addictive nature of these narcotic painkillers has become more widely known and their abuse often cited as a pathway to their chemically related illegal and cheaper cousin — heroin — fewer patients complain when he prescribes only very small amounts or none at all.

“Now, it’s much easier for me to say to a patient, ‘that’s all I’m going to give you,’” Miller said. “Overall, I’m prescribing fewer of these pills to fewer numbers of patients.”

In the aftermath of the recent spike in heroin and prescription opioid overdoses and deaths in the region, families of addicts, addiction recovery experts and former addicts have often cited easy access to prescription pain pills — whether obtained legally, stolen or purchased on the black market — as a main culprit in the crisis.

That finger-pointing, however, may be somewhat out of date, not recognizing the steps that have been taken to better monitor and curtail prescription narcotics abuse, doctors and others say.

“More than 18,000 prescribers are now registered on our prescription monitoring and reporting system,” said Jonathan Harris, commissioner of the state Department of Consumer Protection, referring to the state’s online drug registry. “This is a crucial tool in the war against opioids.”

A 2008 state law created the registry, but it wasn’t until Oct. 1 that doctors, advanced practice registered nurses, dentists and other health care providers who can prescribe medications were required to use it.

Now, prescribers are obligated to check the registry before patients are given more than three days’ worth of narcotics, to make sure they haven’t just gotten some elsewhere.

Called the Connecticut Prescription Monitoring and Reporting System, it shares data with 18 other states, and New York will be added soon, Harris said.

“There are discussions going on about getting more states involved,” he said.

Because use of the system is new, the level of compliance isn’t yet known, he said, though his department is actively promoting it.

In addition to requiring physicians check before prescribing a more than 72-hour supply of narcotics, the monitoring law passed last year also requires doctors to review the patient's record every 90 days if they are using narcotics for prolonged treatment.

“We are trying to get people to follow the law and make this a crucial part of their practice,” he said.

Dr. John Paggioli of the Eastern Connecticut Pain Treatment Center, said the registry is helping him identify patients who are “doctor shopping” for pain pills, and that overall he is prescribing fewer narcotics in favor of injected steroids, nerve blockers and other alternatives for pain relief.

For the past few years, he’s also been using an in-office urine test system that gives him immediate results showing traces of 10 different drugs, including alcohol and narcotics.

If he needs further information, he’ll send the sample to an outside lab to quantify the amount of the substance.

He also checks hospital emergency room records routinely before prescribing narcotics.

“There are a lot less narcotics going out to the street from doctors’ offices,” said Paggioli, who practices out of offices in Norwich, Waterford and Putnam. “Doctors have become more careful because of the addiction problem.”

For those patients who need prescription narcotics, Paggioli said, he emphasizes keeping their supplies locked up, particularly if teenagers live in or visit the home.

“Some teenagers will become addicted. It’s a genetic predisposition,” he said. “The public has to safeguard their supply from their own family members.”

But tightening up on the availability of prescription narcotics has had an unintended downside, according to Dr. Samuel Silverman, psychiatrist at Rushford Center and president of the Connecticut Chapter of the American Society of Addiction Medicine.

Rushford is part of the Hartford HealthCare network, which also includes The William W. Backus Hospital in Norwich.

Too many people got used to being able to get prescription narcotics whenever they needed — or wanted — them, he said.

Doctors, often pressed for time, chose the quickest remedy, and, in may cases, the only one insurance companies would reimburse for, he said.

The demand didn’t ebb when doctors started getting stingy.

“Heroin filled the vacuum,” Silverman said. “Prescription medications were harder to get, and heroin is cheaper.”

At the same time, heroin production in Mexico was increasing, as marijuana farmers were switching to growing opium poppies as a more lucrative alternative after illegal pot started losing customers to legal supplies available in Colorado and other states.

The current heroin crisis, he said, is the result of a confluence of these forces — overprescribing in the past that established the demand, coupled with the ramping up of the heroin supply.

The street value of prescription narcotics ranges from $30 to $80 per pill, while a bag of heroin currently sells for about $5.

“There’s enough dysfunction to go around,” Silverman said.

At least now, he said, the issue is finally getting the attention it needs, and efforts are being made to expand treatment capacity and make anti-addiction drugs more available.

“Three years ago, no one was talking about this,” he said. “Now, the people with the money and clout are finally becoming aware that this is a problem that wasn’t getting addressed.”

Greater awareness has reached virtually all sectors of the medical community, including dentists, said Dr. William MacDonnell, dentist, anesthesiologist and past president of the Connecticut State Dental Association.

Now, he said, dental practices that once automatically gave prescriptions for narcotic pain pills for a toothache or after dental surgery follow a different routine. 

That may include longer acting anesthetics in addition to prescription-strength versions of Advil and Tylenol.

“The new gold standard for treating moderate-to-severe pain is to give 400 to 600 mg of ibuprofen every four to six hours, alternating with acetaminophen every three hours,” said MacDonnell, who also teaches at the University of Connecticut Dental School. “We’re trying to get away from prescribing narcotics as the first line of defense. Half or more or our patients don’t really need narcotics.”

Patients increasingly skittish about using prescription narcotics to control pain also are turning to alternative medicine, including acupuncture and natural remedies, for relief, said Ana Reudiger, a naturopathic physician at Natura Medica in Mystic.

Often, she said, patients come to her before an upcoming surgery for pain management techniques and treatments.

Dr. Mark Kraus, chairman of the Connecticut State Medical Society's Addiction Medicine Committee, is also a proponent of greater use of non-medical methods for pain relief, including moist heat, massage, physical therapy, acupuncture and electrical stimulation.

More medical schools are adding requirements for classes in addiction and pain management, noted Kraus, a Cheshire internist and assistant clinical professor at the Yale School of Medicine, and physicians’ groups including the state medical society are offering continuing education workshops on these topics.

In April, the group is hosting a talk by Dr. Seddon Savage of the Dartmouth Center on Addiction, Recovery and Education titled, “Interdisciplinary Approaches to Opioid Prescribing.”

Instead of blaming overprescribing of opioids for the heroin problem, Kraus said a more productive approach would be to understand addiction as a brain disease that is best combated through prevention.

“This is a chronic neurological brain disorder, and there is no cure,” he said. “There is treatment.”

Silverman, the Rushford Center psychiatrist, agreed.

“Prevention is more important than treatment,” he said.

Since addiction usually begins with behaviors that start in the teenage years, he advocates “earlier and earlier interventions” through school nurses, pediatricians and others who can identify substance abuse at its first stages, along with more mental health counseling for youth. 

Rushford Center is involved in a pilot program underway at 15 pediatric practices in the state that is teaching pediatricians to screen patients at risk for addiction, and channel them toward early treatment.

“Addiction is a solution that becomes a problem. Kids take these substances to feel better,” Silverman said. “Then it leads to problems and risky behaviors. We’ve got to address mental health issues.”

j.benson@theday.com

Twitter: @BensonJudy