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Making Sense of the DEA's New Proposed Policy Statement on Pain Prescribing

There are definitely mixed feelings in the pain medicine community when it comes to the DEA's new proposed policy statement on prescribing pain medications. While everyone is pleased that the agency has loosened up its prescribing rules—allowing doctors to write three one-month pain med prescriptions at a time—there is some dispute over whether the DEA's latest policy statement represents anything other than the agency doing business as usual. For Dr. Frank Fisher the new policy statement represents little more than "window dressing," he told the Chronicle this week. The problem, Fisher said, was that physicians are still intimidated by the DEA and as a result, chronic pain patients are going untreated. Siobhan Reynolds of the patients' and physicians' advocacy group the Pain Relief Network used the exact same word, "window dressing," to describe the new policy statement. Reynolds, whose husband, a chronic pain patient, died just weeks ago as the family traveled across the country seeking relief for him, talked about a DEA "reign of terror that has cost people their lives, including my husband Sean." But some physicians working in the pain management and addiction medicine fields have a much brighter view. Dr. Howard Heit, a Fairfax, Virginia, physician called the new prescribing rules "a great step forward." The DEA is "responding to the health care community," he said. There is much more. Look for a Chronicle article tomorrow that delves deeper into this. As for those Louisiana heroin lifers, I guess they'll just have to wait another week. None of the people who asked me so urgently to write about their plight three weeks ago have managed to return my repeated calls seeking more information.
Location: 
United States

ONDCP: Senate Panel Recommends Cutting Salaries at Drug Czar's Office

The Congress is getting increasingly testy with the Office of National Drug Control Policy (ONDCP), and in a sharp signal of its unhappiness with the performance of ONDCP head John Walters, the drug czar, a Senate panel is recommending that salaries and expenses at ONDCP be slashed by well over half, from $26.6 million this year to $11.5 million next year.

Although Walters has been able to tout such successes as marginal declines in drug use rates among selected groups -- especially teenagers -- he has come under tough attack from congressional drug warriors, especially over ONDCP's halting response to the spread of methamphetamine. Walters and ONDCP are also taking flak for supporting the Bush administration's calls to slash funding for grants to help local law enforcement form drug task forces and the High Intensity Drug Trafficking Areas.

ONDCP has 111 full-time employees. As its director, Walters earns $183,000 a year.

He isn't worth it, the Senate Appropriations Committee signaled. In its July vote on an appropriations bill, the committee recommended the deep cuts, saying the reductions would "more closely reflect actual performance."

In that legislation, the committee called for independent evaluations of ONDCP and demanded documentation of travel records, salaries, and contracts. The committee also complained that Walters and ONDCP have been unresponsive to congressional requests for information and have prevented program directors from meeting with the committee.

"This kind of unresponsiveness... results in an unnecessary waste of time and energy," the bill states. "Numerous follow-up communications are required in almost every instance."

Sen. Kit Bond (R-MO) chairs the subcommittee with oversight over ONDCP. His spokesman, Rob Ostrander, told the Associated Press Walters had a bad habit of not paying attention to committee requests. "Unfortunately, this has been a long-term problem," Ostrander said. "The agency has a record of being unresponsive to committee staff. We hope that changes, because at the end of the day we need to ensure taxpayers' money is being spent wisely."

Sen. Joe Biden took to the Senate floor last week to complain about Walters. "Under him, the office operates like an ivory tower rather than the command center for our national drug control policy," Biden said.

The budgets cuts are likely to end up being restored, but even threatening to cut the once sacrosanct drug czar's budget is an indication that times are changing.

Latin America: In Break With Campaign Promises, Peru's New Government Will Accelerate Coca Eradication

When new Peruvian President Alain Garcia was in a tight race against pro-coca populist upstart Ollanta Humala earlier this year, he promised his government would oppose coca eradication because Peruvians consider the leaf sacred and a part of their tradition. But Reuters reported Wednesday that the Garcia government is now seeking US support for a new push against coca production in what is now the world's second largest coca producer.

http://stopthedrugwar.com/files/cocafield.jpg
coca field
According to the UN Office on Drugs and Crime's annual report on coca production, Peru produces 30% of the Andean coca crop. Colombia accounted for 54%, while third place Bolivia accounted for 16%. While the UN reported a slight decrease in Peruvian coca cultivation last year, the US government estimated production had actually increased by 38%.

While some coca is cultivated legally and sold to the Peruvian national coca monopoly to be made into various products, some doubtless is diverted to the black market and made into cocaine. Peruvian police report busting some 500 cocaine labs last year.

More than $330 million in US aid since 2000 has failed to rein in Peru's coca-growing peasantry. Now, the Peruvian government wants more. "We want a greater state presence in coca-growing areas, more effective coca eradication, coca crop substitution and security for export cargo to limit smuggling," Peru's anti-narcotics chief Romulo Pizarro told Reuters. "We can't let these traffickers continue to poison people's lives."

That was music to the ears of Susan Keogh, narcotics affairs director at the US embassy in Lima. She said eradication must be part of the new campaign because alternative development alone would not be enough to end the drug trade. "There are so many illegal drug laboratories that they're like the McDonald's on every corner (in Peru's coca regions)," Keogh told Reuters. "You can't just flood those areas with development, you need eradication too."

While not as politically potent as their Bolivian counterparts, Peruvian coca growers are increasingly organized, if fractious, and they and their representatives in the parliament, like coca grower union leaders Nancy Obregon and Elsa Malpartida, are bound to make life miserable for the Garcia government over this issue. It won't help matters that Garcia is breaking his vows to them.

Panel Advises Cutting Salaries at Agency (ONDCP)

Location: 
Washington, DC
United States
Publication/Source: 
Associated Press
URL: 
http://dwb.sacbee.com/24hour/politics/story/3371410p-12405350c.html

Heroin Lifers, DEA Pain Guidance, California Lowest Priority Initiatives

Those are the feature stories I think I will be doing this week. It doesn't always happen that way, though. Some readers may recall that I was going to do the Louisiana heroin lifer story last week, but I didn't manage to get ahold of any of the people critical to the story. I'm back on it again this week. Similarly, something may break during the week. This typically happens on Thursday, the day we're supposed to be wrapping up the Chronicle. I'll also be looking into the DEA's release last week of a new policy statement on pain management. Some reformers have hailed it as a victory for the movement, but others are not so sure, and neither am I. I'll be talking to a wide range of people who are involved in this issue to try to find out what this really means. Meanwhile, elections are only a matter of weeks away. I'll be taking a look this week at how things are going in Santa Barbara, Santa Cruz, and Santa Monica, the three California cities where "lowest law enforcement priority" marijuana initiatives are on the ballot. And, of course, there will also be the seven or eight shorter pieces we do each week.
Location: 
United States

Hastert's Office Balks at Counter-Narcotics Plan

Location: 
Washington, DC
United States
Publication/Source: 
The Hill
URL: 
http://www.thehill.com/thehill/export/TheHill/Business/091206_narcotics.html

My Border Blues

I really dislike crossing international borders. I've been doing a lot of it lately in the past few years, particularly since my partner and I got a summer place outside Nelson, BC. Even when I was spending a few weeks or months in Nelson, I was often off to the US—for a meth conference in Salt Lake, the NORML annual conference in San Francisco, to score cheap cigarettes on the Indian reservation in Washington state—or crossing into the US to get to the nearest big time airport to fly off to more exotic locales. And I'm tired of it, particularly along the US-Canadian border. The US border guards have a worldwide reputation for being hard asses, but I find that to be true only about half the time. The Canadians, on the other hand, have a reputation for politeness, but they are also an intensely bureaucratic nation, and they sometimes subject visitors to relentless questioning and truly bizarre questions: "Do you have a copy of the title to your home with you?" One wants to reply: "Ah, gee, I must have left it in my other jacket." I don't like dealing with these border cops because I like my freedom and I like my freedom to travel, and when I arrive at the border, I suddenly enter a "no rights" zone. Not only can I be stopped from crossing that invisible line, but I also get to be interrogated, searched, and possibly probed in the bargain. And have my belongings rummaged through, my notebooks read, my vehicle turned apart. We have this international system where money flows across the globe at the push of a button, massive amounts of commodities (licit and illicit) flow across borders through the channels of commerce, and jobs fly to wherever offers the lowest wage. Why can't we just flow like everything else? I guess I don't see any way of getting around borders short of the dreaded UN global government, but I'm starting to think North America should emulate Europe, where the European Union allows free movement among its member countries. Here's a link to the Wikipedia pages on North American Union, not because I think Wikipedia is the holy scripture on contentious topics, but because I think it shows the nature of some of the debate around the whole notion. I'm interested in borders as a drug policy issue, but also as a human rights issue, and I feel that very personally each time I have to deal with these uniformed agents of various national governments. I guess I feel especially cranky (if not crankish) about the issue today because I just had to recross the border back into the United States from Canada, then come back into Canada with certain papers they had never wanted before. That made it my second cross-border trip to deal with this particular issue, a grand total of four border crossings on Friday and Monday. Enough with those borders!
Location: 
United States

Marijuana: In Annual Harvest Roundup, 98% of All Marijuana Seizures Are Ditchweed

The fact may get lost in the hype about multi-million dollar outdoor marijuana garden seizures at this time of year, but the vast majority of all marijuana plants seized by law enforcement are ditchweed. For those who didn't grow up in the Midwest, ditchweed is feral marijuana descended from the hemp plants farmers produced as part of the war effort in World War II.

http://stopthedrugwar.com/files/dodgecounty.jpg
National Guard marijuana (or more likely ditchweed) eradication team, Dodge County, Minnesota
Like the hemp plants whence it came, ditchweed has negligible levels of THC, the psychoactive component of marijuana. An old saying in the Midwest is that you could smoke a joint of it the size of a telephone pole and all you would get is a headache.

According to official DEA figures, police seized an estimated 223 million marijuana plants last year. But 219 million of them, or 98%, were ditchweed. That figure is in line with previous years. And a whopping 212 million plants came from Indiana alone. Missouri came in second with 4.5 million plants, Kansas third with 1.1 million, and Wisconsin fourth with 272,000. Most states reported no ditchweed seizures.

The DEA pays for the ditchweed eradication boondoggle, something for which National Organization for the Reform of Marijuana Laws executive director criticized it in a statement noting the annual seizure figures. "The irony, of course, is that industrial hemp is grown legally throughout most of the Western world as a commercial crop for its fiber content," he said. "Yet the US government is spending taxpayers' money to target and eradicate this same agricultural commodity."

Your tax dollars at work.

DEA Feeling the Pain

The DEA’s war on pain doctors got a facelift today as explained in their ironically titled press-release “Working Together: DEA and the Medical Community”.

From DEA.gov:

Today, DEA is unveiling a proposed rule that will make it easier for patients with chronic pain or other chronic conditions, to avoid multiple trips to a physician. It will allow a physician to prescribe up to a 90-day supply of Schedule II controlled substances during a single office visit, where medically appropriate. The Notice of Proposed Rulemaking is accompanied by a policy statement, “Dispensing Controlled Substances for the Treatment of Pain,” which provides information requested by medical professionals regarding DEA’s position on this important issue.

It’s nice to see the spirit of cooperation take hold at DEA, but recent history tells a different story. I’d bet the average pain management specialist feels less like a partner here and more like the groom at a shotgun wedding.

Indeed, this is a not-so-subtle attempt to smooth over the public relations nightmare that has resulted from the agency’s relentless harassment of pain management doctors:

Also new today, DEA is launching a new page on its website (www.dea.gov) called “Cases Against Doctors.” Everyone will be able to see for themselves the criminal acts committed by those few physicians who are subject to prosecution or administrative action each year.

The Cases Against Doctors page reeks of insecurity on DEA’s part, suggesting that widespread criticism may have affected Karen Tandy, who’s usually numb from heavy doses of self-righteousness.

Update: USA Today and Washington Post have the story. Both note the hostile relationship DEA has fostered with the medical community. Washington Post describes the regulations as an unambiguous concession to the medical community, which has generally gotten the cold shoulder from DEA on this issue.

Still, to the extent that DEA has capitulated here, it probably has more to do with last month’s reversal of the Hurwitz conviction than any sudden recognition that maybe doctors have useful ideas about how to define legitimate medical practices.

Location: 
United States

Pain Medicine: DEA Set to Ease Restrictions on Schedule II Prescriptions

Under a proposed rule unveiled Wednesday, the Drug Enforcement Administation would allow doctors prescribing Schedule II drugs, such as morphine or Oxycontin, to fill prescriptions for 90 days instead of 30 days. Currently, pain patients can only get 30-day non-refillable prescriptions, requiring them to make additional visits to the doctor's office just to get a new prescription written. Doctors and patients have complained that the DEA's strict regulation of Schedule II drugs has forced doctors to limit their prescriptions, with patients going untreated as a result.

At a Wednesday press conference in Washington, DEA administrator Karen Tandy attempted to signal that the agency was hearing those concerns. "Today's policy statement reaffirms that DEA wants doctors to treat pain as is appropriate under accepted medical community standards," said Tandy in remarks reported by the Associated Press. "Physicians acting in accordance with accepted medical practice should be confident that they will not be criminally charged."

While the number of doctors who faced federal charges over their prescribing practices is relatively small, it is increasing -- from 38 in 2003 to 67 last year. Other pain management physicians have faced state criminal charges of administrative sanctions, and pain patient and physician advocacy groups complain that the agency is interfering with and having a chilling effect on the practice of pain medicine.

The move was welcomed by the American Medical Association, with AMA board member Dr. Rebecca Patchin telling the AP it was a step toward improving the care of pain patients. "Relieving suffering while doing everything we can to prevent the abuse of controlled substances reflects appropriate patient care, a standard which is easier to achieve when a strong patient-physician relationship exists," said Dr. Patchin. "We need to provide access to pain relief for patients with legitimate needs, and the DEA proposal would help in doing this."

Others were less sanguine. "Ms. Tandy states here, as she has on many occasions, that doctors need not fear criminal prosecution as long as they practice medicine in conformity with what these drug cops think is 'appropriate,'" said Siobhan Reynolds, president of the Pain Relief Network. "If that isn't a threat, it will certainly pass for one within the thoroughly intimidated medical community."

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