Under-treatment of Pain

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Pain Medicine: Advocacy Group to Challenge Controlled Substances Act In Lawsuit Aimed at Protecting Physicians, Patients

Haysville, Kansas, physician Dr. Stephen Schneider and his nurse wife, Linda Schneider, were arrested on a 34-count federal indictment last month for allegedly improperly prescribing opioid pain medications and causing the deaths of at least four patients. The Schneiders are only the latest pain management health care providers to fall victim to the federal government's war against prescription drug abuse and diversion, and now a leading pain relief advocacy group is vowing to take the government to court to block further harassment of physicians and the pain-ridden patients who rely on them.

Last Friday, the Pain Relief Network announced it will seek a civil injunction barring the Justice Department from prosecuting the Schneiders. But the lawsuit could have much broader implications than the couple's freedom. It will argue that the way the federal Controlled Substances Act is applied to doctors and patients is unconstitutional.

"I want a judge to take a look at this and see if the United States has authority to prosecute," Pain Relief Network head Siobhan Reynolds said during a press briefing last Friday. Reynolds cited a ruling in a similar case that such prosecutions give the government unrestrained power to interfere in the doctor-patient relationship.

The real victims of the government's crackdown on the Schneiders and other health care professionals prescribing opioid pain medications are patients, said Reynolds. "These patients are in real harm's way," Reynolds said. "They are being attacked by the Department of Justice."

While some of Dr. Schneider's former patients have filed malpractice lawsuits claiming they became addicted because of his prescribing, other patients said he had been a godsend and that they are suffering now without him.

One was Jamie McGuire, 49, who had been receiving pain meds for severe arthritis in his spine, hips, and shoulders resulting from an auto accident. Since Schneider was jailed, he has been unable to even get a referral to another doctor. "I think they railroaded him," he said of the prosecution. McGuire told reporters he is almost out of pain medication and his situation is dire. "If they don't do something, I will take myself out," McGuire said.

Another patient, Martin Beatty, 46, also showed up to support his doctor. He said he opted for a regime of pain meds rather than surgery or steroids after falling from a roof 12 years ago and had been a patient of Schneider's for three years. He admitted being dependent on his pain meds, but said that shouldn't matter. "Addiction doesn't mean I am going to be a bad person," Beatty said. Now he worries about going through withdrawal without being under a physician's care.

This week, patients and advocates continued to fight for Dr. Schneider, who, along with his wife, remains jailed. They gathered at his offices to show support and sign petitions, one to join the federal lawsuit, the other to keep the Kansas Board of Healing Arts from moving to suspend his license. According to Reynolds, the clinic will be forced to close because the physician assistants now writing prescriptions are doing so under the auspices of working for a clinic owned by a licensed physician. Other doctors who once practiced at the clinic have been run off by fears of federal prosecution, she said.

"Right now we are calling on the medical board to refrain from joining in this attack on this clinic. This clinic has been hobbled by the Justice Department. These patients are living in mortal fear," Reynolds said.

Pain Medicine: Emergency Room Doctors More Likely to Prescribe Opioids to Whites Than Minorities

A new study has found that while emergency room prescribing of opioid pain medications for ER patients complaining of pain has increased in recent years, doctors are less likely to prescribe them for minority patients than white ones. Even in cases where patients complain of severe pain, such as kidney stones, the difference holds.

The study, "Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments," was published this week in the Journal of the American Medical Association. It analyzed more than 150,000 ER visits between 1993 and 2005 and found racial differences in prescribing in all US regions, in both urban and rural hospitals, and for all types of pain.

The study found that the prescribing of drugs for pain in the ER rose during the period in question, from 23% of those complaining of pain in 1993 to 37% in 2005. That increase reflects increased understanding of the necessity of pain management by physicians. Now, doctors in accredited hospitals must ask patients about pain, just as they monitor vital signs. But while prescribing is on the increase, the racial divide remains.

According to the study, 31% of white patients in pain were prescribed opioids, compared to 28% of Asians, 24% of Hispanics, and 23% of blacks. When it comes to the severe pain related to kidney stones, whites got opioids 72% of the time, compared to 68% for Hispanics, 67% for Asians, and only 56% for blacks.

"The gaps between whites and nonwhites have not appeared to close at all," said study coauthor Dr. Mark Pletcher of the University of California, San Francisco.

Researchers are looking for reasons for the discrepancy. Pletcher suggested to the Associated Press that minority patients "may be less likely to keep complaining about their pain or feel they deserve good pain control."

Linda Simoni-Wastila of the University of Maryland, Baltimore, School of Pharmacy told the AP the findings could reveal some doctors' suspicions that minority patients could be drug abusers lying about pain to get narcotics. She said that according to her own research, blacks are the least likely group to abuse prescription drugs.

The study's authors suggested that the finding could indicate either that doctors are less likely to see signs of pain reliever abuse in white patients or that they are underrating pain in minority patients. Whatever the reason, it seems that the racial injustice associated with drug prohibition reaches even into the emergency room.

"It's time to move past describing disparities and work on narrowing them," Dr. Thomas Fisher, an emergency room doctor at the University of Chicago Medical Center who was not involved in the study, told the AP. Fisher, who is black, said that even he needed to be careful not to let subconscious assumptions inappropriately influence his prescribing decisions. "If anybody argues they have no social biases that sway clinical practice, they have not been thoughtful about the issue or they're not being honest with themselves," he said.

Europe: British Drug Council Calls for Heroin, Cocaine Prescribing By Nurses, Pharmacists, Chides Government's Drug Strategy Consultation

The British Advisory Council on the Misuse of Drugs (ACMD) has criticized the Labor government's ongoing consultation on a new 10-year drug strategy as a "missed opportunity" because the government created a consultation paper that was "self-congratulatory" and focused on trying to claim the current 10-year strategy is a success. A day later, the ACMD's head announced the council was recommending that doctors be allowed to prescribe controlled substances such as heroin and cocaine.

In its response to the consultation, the ACMD was decidedly undiplomatic in its overall comments: "It is unfortunate that the consultation paper's 'key facts and evidence' section appears to focus on trying to convince the reader of success and progress; rather than providing an objective review and presentation of the current evidence. The ACMD found the consultation paper self-congratulatory and generally disappointing," the council complained.

The ACMD also scolded the government for lacking a firm evidence base and failing to acknowledge it: "It is of concern that the evidence presented, and the interpretation given, are not based on rigorous scrutiny. It is not acknowledged that in many cases the information is uncertain and sometimes of poor quality. It is disappointing that the consultation paper makes no mention of needing to improve the evidence base of drug misuse and treatments nor makes use of international evidence, for informing and guiding policy," the council chided.

"We consider that an opportunity has been missed to address the public health problem relating to drug misuse and the balance with law enforcement and the criminal justice system. We would also have welcomed a statement of ambition for the drug treatment system," the council added.

The ACMD was created as part of the 1971 Misuse of Drugs Act and it is mandated to advise the Home Office on drug policy. One of its primary functions is to recommend which classification various drugs should go in. While the ACMD is critical of the government's drug policy consultation process, it itself has been criticized for a lack of scientific basis in the drug classification system, most thoroughly by the Science and Technology Select Committee's 2006 report, Drug Policy: Making A Hash of It?

The ACMD's caustic words for the process gave fuel to the political opposition, with the Liberal Democrats quick off the mark. "The failures of the government's drugs policy are laid bare for all to see when their own advisory committee condemns the Home Office as being misleading and self-congratulatory," said Liberal Democrat leadership contender Nick Clegg. "When will the government wake up and acknowledge something many members of the public know: we are losing the war on drugs?" Clegg asked.

It wasn't just political foes. Steve Rolles of the Transform Drug Policy Foundation had last month called the consultative process "a sham," saying the government had already made up its mind to continue the current strategy. "The consultation process behind the new strategy has been woeful," he said.

Then, last Saturday, ACMD chairman Sir Michael Rawlins announced during the group's first public meeting in its 36-year existence that he had sent a letter to the Home Office proposing that the drug law be changed to allow nurses and pharmacists prescribe heroin and cocaine to hard-core users and pain patients. He wrote a letter to Home Office minister Vernon Coker making the proposal in a bid to help patients manage pain better, he said.

That proposal prompted quick criticism, too, this time from political opponents on the right, who called it a "white flag" approach. "If Gordon Brown signs up to this, it would show yet again that Labour merely seek to manage drug addiction rather than end it," said Conservative shadow home secretary David Davis. "The Conservative approach is different. We would stop -- not swap -- drug addiction by focusing the drugs budget on expanding the use of abstinence-based drug rehabilitation programs. This method has proved far more successful at getting people off drugs than the Government's white flag approach."

And so it goes in the countdown to the new British drug strategy, which is due in the spring. Meanwhile, the ACMD is considering whether ecstasy should be down-scheduled and marijuana up-scheduled. The drug debate in Britain is going to stay lively for awhile.

Update on Pain Physician Dr. William Mangino

In July and September I wrote here about the plight of Bill Mangino, a Pennsylvania physician who was decent enough to treat patients with the pain medications (opiates) that they needed, and was punished for these good deeds with a prosecution and now imprisonment -- all over a crime that never happened and for which no evidence exists happened. Yesterday I heard from Dr. James Stacks, a Mangino supporter and board member of the Pain Relief Network, with the news that Dr. Mangino had asked we post correspondence he sent to a judge prior to a hearing today that he hopes will get him a new trial and freedom in the meantime. The briefs were put together by Mangino himself, written by hand, but has been scanned for our edification online as well. Interested parties can read some commentary on it by Alex DeLuca here, or go straight to the briefs online here or here. A cutting quote that Dr. Mangino used as his signature line in the documents:
Statutes must mean what they say... and say what they mean.
Location: 
PA
United States

Paey Starts Afresh with Call from Crist

Location: 
FL
United States
Publication/Source: 
St. Petersburg Times
URL: 
http://www.sptimes.com/2007/09/22/Pasco/Paey_starts_afresh_wi.shtml

Pain Patients: Florida Prisoner Richard Paey is Pardoned

Richard Paey, the wheelchair-bound Florida pain patient sentenced to 25 years in prison as a drug dealer for seeking desperately-needed medications, may be a free man by the time you read this. Florida Gov. Charlie Crist (R) granted Paey a full pardon on Thursday after a brief hearing in Tallahassee. Paey and his family had only sought clemency.

Paey was severely injured in a 1985 auto accident. A New Jersey physician provided him with prescriptions for necessary pain relievers, but when Paey moved to Florida he took pre-signed prescription forms with him. He was arrested in 1997 and charged with illegally possessing and trafficking in about 700 pain pills obtained with those prescriptions.

Under Florida's draconian drug laws, persons in possession of that amount of pain medication are treated as drug traffickers. Standing on principle, Paey refused plea offers from the state and was ultimately convicted and sentenced to the mandatory minimum 25-year sentence.

Paey's case became a cause celebre for the country's growing pain patient and doctor movement. In August, the governor's office announced that it would grant a waiver allowing Paey to seek clemency. In most cases, inmates cannot seek clemency until they have serve 1/3 of their time.

Thursday, Gov. Crist and three members of the Florida cabinet heard Paey's appeal for clemency. Though the state's parole commission had recommended against granting time-served, Crist went further, granting him a full pardon and ordering he be released immediately. According to the St. Petersburg Times, Crist allowed Paey's attorney, John Flannery to speak for nearly 30 minutes -- the usual time limit is five minutes, then allowed Paey's wife, three children and a family friend to speak as well.

Crist then commented, "I want to move that we grant a full pardon," continuing, "We aim to right a wrong and exercise compassion and to do it with grace," the governor said. "Congratulations... and I state he should be released today."

For further information on the Paey case, click here.

Two People I Know Were Sentenced to Prison Last Week

The Paey Pardon, as Scott blogged about here and here, was a nice piece of news, of the kind that doesn't come around too often. The last such pleasant surprise I had came in late 2000, when Kemba Smith and Dorothy Gaines were pardoned by then-President Clinton. I immediately left a message for my friend Rob Stewart, who had played a major role in bringing the Gaines case to prominence by writing it in the old Drug Policy Letter (Drug Policy Foundation, predecessor to Drug Policy Alliance), which led to coverage of her case by Frontline. Rob told me later he had two messages on his voicemail -- one from me and one from Dorothy Gaines. These moments are rewards for all the rest of it. Unfortunately, not many political leaders seem to be of the moral caliber of Gov. Crist, and there are many more victims of the drug laws who remain unpardoned. Two of them, whom I happen to know, were sentenced to prison a week ago. One of them was Bryan Epis, the first person prosecuted by the feds for medical marijuana. He received the same 10-year sentence. The other was William Mangino, a pain physician in Pennsylvania, sentenced to 8 1/2 - 20 years. Bryan was allowed to remain free pending appeal. See our upcoming Chronicle newsbrief for some detail. Bryan actually told me a few days before the court date that he anticipated getting another 10 years, but being allowed to stay free pending appeal, and he was right. He says he has a good chance on appeal, and it sounds like it -- the prosecution really acted unethically in his case, and the judge, who is by no means biased toward defendants, commented that there are issues the appellate court may want to look at. Dr. Mangino predicted a harsh sentence, and that he would not be allowed to stay free pending appeal. Unfortunately, he was right too. Christine Heberle's blog post on the War on Doctors/Pain Crisis blog lays out the glaring absence of any crime. Accountability for injustices committed under the guise of law may be too much to hope for. But at least we should have justice now. I simply don't feel that letting people like Richard Paey and Bryan Epis and Bill Mangino live their lives unmolested by the government is asking for too much.
Location: 
United States

Richard Paey's Torturers Must be Held Accountable

As we celebrate Richard Paey's freedom today, it is important to remember that his tragic fate was no accident. Many people worked very hard at tax-payers' expense to put this innocent and miserable man behind bars. They deserve recognition today as well.

Certainly, these events vividly depict the insanity of a war on drugs that targets seriously ill people for trying to treat their own pain:
State prosecutors concede there's no evidence Paey ever sold or gave his medication away. Nevertheless, under draconian drug-war statutes, these prosecutors could pursue distribution charges against him based solely on the amount of medication he possessed (the unauthorized possession of as few as 60 tablets of some pain medications can qualify a person as a "drug trafficker"). [National Review]
Yet, as Radley Balko revealed at National Review, the persecution of Richard Paey involved so much more than the reckless enforcement of short-sighted laws. This was a prolonged and deliberate campaign on the part of malicious prosecutors and vengeful prison officials.

*Prosecutors blamed Paey's harsh sentence on Paey himself, claiming that he should have accepted a plea bargain. As Balko explains, they essentially retaliated against him for asserting his factual innocence and insisting on his right to a jury trial.

*Prison officials transferred Paey further away from his family after he gave a New York Times interview that was critical of the State of Florida.

*Prison medical staff threatened to withhold Paey's medication, also in apparent retaliation for his interview with the New York Times. Since he could die without it, this was the functional equivalent of a death threat and caused him great distress.

Now that Florida's Governor and Cabinet have concluded that Paey did nothing wrong, it is time to examine the way he was treated throughout this great travesty. If there are sociopaths working in Florida's criminal justice system, that's something Governor Crist would want to know about. If we can afford to imprison people for decades in order to protect ourselves from drugs, surely we can also afford to evaluate public servants who wield extraordinary power in order to ensure that they aren't deeply disturbed.

Mentally healthy people do not persecute the seriously ill, even if the drug war says it's ok.
Location: 
United States

Richard Paey Receives Full Pardon

The plight of Richard Paey has been shocking even by the drug war's rock bottom standards. Sentenced to 25 years in a Florida prison for possession of the pain medication he used to treat his own crippling back pain, Paey spent the last 3½ years behind bars.

Today, he is free:
Gov. Charlie Crist and the Florida Cabinet voted unanimously to grant Paey a full pardon Thursday morning for his 2004 conviction on drug trafficking and possession charges.

"We aim to right a wrong and exercise compassion and to do it with grace," the governor said. "Congratulations … and I state he should be released today."

With that, Paey's wife Linda, their three children, a family friend and attorney John Flannery II hugged and cried at the podium, the entire cabinet meeting room erupting into applause at 9:40 a.m. [St. Petersburg Times]
Justice in the war on drugs is a rare spectacle, and it is just delightful to witness. We've reported endlessly on this case, as have so many others, and it is wonderful to find that these efforts have not been in vain.
Location: 
United States

Good News: Pain Patient Richard Paey Pardoned by Florida's Governor

Location: 
United States
Publication/Source: 
St. Petersburg Times
URL: 
http://www.painreliefnetwork.org/prn/paey-given-full-pardon-crist-orders-him-freed-today.php

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