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This doctor wrote 130 opioid prescriptions a day. She says she did nothing wrong.

Overprescribing caused the opioid epidemic. But not all doctors feel bad about what they did.

A bottle of prescription painkillers. Education Images/UIG via Getty Images

Katherine Hoover gave more than 335,000 opioid painkiller prescriptions under her name from December 2002 to January 2010 — meaning the West Virginia doctor wrote about 130 prescriptions per day, assuming she worked seven days a week.

But in a new story by Corky Siemaszko at NBC News, Hoover argued she did nothing wrong. “I prescribed narcotics to people in pain. I did everything I could to help people have a better life, which I told the FBI,” Hoover said. “Every prescription I wrote was justified for the person who had gotten it.”

That contradicts court records and what others closely involved with Hoover’s clinic told NBC News. According to them, the clinic was basically a for-profit pill mill — charging $450 in cash for first-time appointments, and the doctors often didn’t even see the patients to whom they were giving prescriptions.

Unlike some of the doctors and clinics that have been prosecuted during the opioid epidemic, Hoover wasn’t charged and convicted for the excess prescriptions. When the police raided her clinic in 2010 due to its excessive opioid prescribing, she went to the Bahamas (where she owns an island and reportedly hopes to start a nudist resort).

Since then, she no longer appears to be a doctor, although court records obtained by NBC News “suggest she and [her husband] have been shuttling between Michigan, Georgia, California, Florida and West Virginia for much of the last 10 years.”

Legal experts told NBC News that it would not have been difficult to extradite Hoover when she went to the Bahamas. But she was never prosecuted. One theory offered by legal experts and NBC News is the case against her may be difficult to prove — since she insists she did nothing wrong and took steps, like requiring patients take X-rays, to provide cover for her prescriptions. Another is that she may have been a government witness. We might never know the truth.

What we do know is Hoover prescribed more opioid painkillers than anyone in West Virginia — fueling the opioid crisis in the country’s hardest-hit state. To this day, West Virginia leads all other states in drug overdose deaths: According to the latest full federal data, the state had an age-adjusted drug overdose death rate of 52 per 100,000 people in 2016. Second-worst Ohio was at 39.1, nearly 25 percent below West Virginia’s extraordinary rate of deaths.

This opioid epidemic was, particularly in its earlier stages, fueled in large part by doctors like Hoover, but also well-intentioned doctors who (often wrongly) thought opioids were the best way to treat pain. A previous investigation by the Charleston Gazette-Mail in West Virginia found that from 2007 to 2012, drug firms poured a total of 780 million painkillers into the state — which has a total population of about 1.8 million. America now leads the world in opioid prescriptions.

The proliferation of prescriptions enabled misuse by patients, but also misuse by recreational users who could buy, steal, or otherwise obtain a new supply of excess pills from friends, family, and the black market.

In recent years, the opioid epidemic has become more about illicit drugs like heroin and fentanyl, with synthetic opioids like fentanyl in particular now the leading cause of drug overdose death. But even in these cases, much of the misuse and addiction that eventually led to overdose started with painkillers; a study in Addictive Behaviors found 51.9 percent of people entering treatment for opioid use disorder in 2015 started with prescription drugs, although that was down from 84.7 percent in 2005.

Doctors like Hoover are partly to blame for this crisis. But at least in Hoover’s case, there doesn’t seem to be much remorse.

There’s now a big effort against overprescribing

In response to sky-high prescription rates, different levels of government have taken steps to pull back opioid prescribing. You can see that in the West Virginia story, as law enforcement agencies go after prescribers and clinics accused of supplying too many of the drugs.

A common proposal, adopted by some states, has been to cap how many days opioid prescriptions can be written for acute pain, along with other restrictions for chronic pain prescriptions.

For a recent piece on America’s painkiller problem, drug policy experts told me that strict limits were not the right approach — because they might constrain prescriptions too much, and might scare way doctors from prescribing opioids at all, leaving patients who really do need the drugs without options. Stanford drug policy expert Keith Humphreys told me that strict legal limits “will cause a lot of suffering” among pain patients who won’t be able to get drugs that they genuinely need.

Instead, experts pointed to what they described as policy nudges. For example, a study published in Science in August told 388 clinicians in San Diego County, California, via a letter sent through the medical examiner, that one of the patients they had prescribed a drug to had died, while providing instructions and recommendations from the Centers for Disease Control and Prevention on proper opioid prescribing. It then compared the clinicians’ prescribing patterns to another 438 clinicians who had patients die but were not sent letters.

The results: Clinicians who got the letters prescribed nearly 10 percent fewer opioids than those who did not receive a letter. The letter-receiving clinicians were also less likely to start patients on opioids and less likely to give patients higher doses of opioids.

“It’s one piece of the puzzle; it’s not the end-all solution,” Jason Doctor, the lead researcher on the study, told me. “I think we’re going to need a lot of these nudges to bring prescribing down.”

Another example, cited by Humphreys: A recent study in JAMA found that simply lowering the default number for opioids prescribed in an electronic medical record system significantly cut the number of pills prescribed, even though the system still let prescribers manually increase or decrease the number of pills that were doled out.

“The idea is not to constrain clinical decision making,” Andrew Kolodny, an opioid policy expert at Brandeis University, told me, “but to make it a little harder for doctors to casually overprescribe.”

Crucially, experts also argued that these kinds of nudges have to be paired with efforts to provide non-opioid pain treatments.

“We can’t just go in and impose limits without providing a sufficient infrastructure of alternatives,” Beth Darnall, a Stanford pain psychologist, told me. “If we’re taking opioids away, we have to give people something else — information, education, support, non-opioids, it might be pharmacological strategies, it might be movement-based therapies. But the imperative is to treat pain better, not just to limit opioids.”

For more on the solutions to opioid overprescribing, read Vox’s explainer.