Editorial:
Not
Just
in
Texas
7/3/03
David Borden, Executive Director, [email protected], 7/3/03 One of the greatest but least-discussed problems in modern medicine is the under-treatment of patients living with severe, chronic pain. More than 30 million patients suffer from chronic pain, and seven million of them cannot relieve their pain without opiates (narcotics), but only 4,000 doctors in the country are willing to prescribe them, according to the National Chronic Pain Outreach Association. A New England Journal of Medicine editorial stated that 56 percent of cancer outpatients and 82 percent of AIDS outpatients were under-treated for pain, as were 50 percent of hospitalized patients with a range of conditions. Today's massive denial of pain medication is a consequence of the social, regulatory and law enforcement climate created by the war on drugs. Doctors can suffer loss of license or even incarceration, when the inevitable mistake of providing medicine to a real or pretend patient who may be misusing or diverting medication, or using it for non-sanctioned purposes, takes place. The climate has led to a situation in which most physicians are incorrectly trained in pain management and under- or non-treatment of pain is the norm. Doctors who treat pain correctly typically must exceed the usual prescribed dosages, and in so doing draw the scrutiny of state medical boards, the DEA and other agencies. Any overdose, any death of an ill or elderly patient, any billing of public health insurers (e.g. Medicare, Medicaid) to pay for opiates therapy, is a potential red flag, no matter how reasonable the prescription or how innocent the circumstances. And for the typical physician, the possible legal and financial ramifications, even if imposed only infrequently, tend to represent a greater legal and financial risk than they are willing or able to afford. One of the most recent possible "witch-hunts" in this arena is that of Dr. Daniel Maynard, whose Dallas home, office and bank were raided by dozens of state and federal cops three weeks ago. The massive force of massively armed anti-drug agents handcuffed 30-40 of Maynard's patients while running warrant checks on them and seized Maynard's records, and the state of Texas has frozen his ability to be reimbursed by Medicare. Maynard is of course being tried in the media for his supposed crimes, and his former patients are scrambling to find new doctors who will take their pain treatment needs seriously. I'd bet money at least one of them gets treated for handcuff bruises. The reason for the raid? Eleven of Dr. Maynard's patients had died subsequent to receiving opiate prescriptions from him. But it is unclear what relation some of the reported causes of death would have to opiate use -- hypertensive cardiovascular disease and chronic alcoholism, for example -- and in those cases where drug overdose was a possible cause, it is unclear whether the fault or responsibility would lie with Dr. Maynard as opposed to the patients themselves. And this is only based on the limited information that came out in the press. The real facts, once they are presented, may tell a different story yet. I don't know enough about Dr. Maynard's case to say with certainty whether he is being persecuted for nothing or whether his prescribing practices did have problems. My guess is the former, but only the medical evidence, interpreted correctly, with the benefit of medical experience and knowledge and free from the mind-numbing grip of opiophobia, can tell for sure. At least one of Dr. Maynard's patients has spoken out publicly in his defense. What I don't need the evidence to be able to say, with substantial confidence, is what will happen -- or rather what is already happening -- to those of Dr. Maynard's patients who live with painful, long-term conditions, and who need narcotics in relatively strong doses to be able to manage. Those patients will go to their new doctors, and those doctors, regardless of their professional opinions, will decide -- or rather, have already decided -- that they would be crazy to write the same kinds of prescriptions, that doing so would be equivalent to asking a District Attorney to investigate them and the medical board to suspend their right to practice, or for comparable assaults on their practices, reputations and freedom. Those doctors will assume that some of the very seriously ill patients formerly treated by Dr. Maynard will die during the period of time for which they are those doctors' patients -- due to their age or illnesses, in all likelihood, because they intend to be careful -- but they will assume that any such death will draw scrutiny with a greatly increased likelihood of prosecution, administrative sanctions or lawsuits, and that their colleagues as a group won't take a stand on their behalf. I also don't need Dr. Maynard's records to determine what will happen -- or rather, has happened -- to doctors and patients in Dr. Maynard's county or state, indeed throughout all the United States. Cowboy drug enforcement isn't limited to Texas. Doctors will conclude -- long have concluded -- that prescribing narcotics beyond a certain dosage level, or to more than a certain number of patients, right as that may be, is far too risky an endeavor under the prevailing police state of medicine. Most won't write those prescriptions, and countless needless tragedies will take place -- have taken place -- every day. Or rather, day after day, for the suffering people whose palliative is known and available, yet not truly available enough. So be Dr. Maynard without fault, or have he fault, the state's approach to him is wrong and works great destructive effect against the welfare of patients everywhere. The police state of medicine is the enemy of health, not the friend. Dr. Maynard has the benefit of my doubt, at least, but the state does not.
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