Prompted by an ever-mounting list of physicians charged with over-prescribing opiate painkillers and the indictment of a Tucson physician in March, a Tucson-based medical association representing some 5,000 doctors has warned its colleagues not to prescribe opiates for pain relief and to take elaborate -- and expensive -- precautions if they do. On July 1, the Association of American Physicians and Surgeons (http://www.aapsonline.org), a free market-oriented group, sent out a memorandum titled "Advice to Doctors Re: Pain Management (or What the Government Has Taught Doctors)."
"If you're thinking about getting into pain management using opioids, DON'T," said the AAPS memo. "Forget what you learned in medical school -- drug agents now set medical standards. Until wrongs are righted and procedural changes are made, physicians have little choice other than to be unusually suspicious of new patients, to require unnecessary and expensive tests, to waste time on excessive documentation, or to turn away suffering patients, even if they think the patients may not find anyone else to treat them.
If you are already prescribing opioids," the memo continued:
Beware of new patients. If you accept a new patient, do background checks, demand old records before writing the first Rx, obtain urine screens and get them to sign opioid contracts. It is safer to turn them down, explain why, and give them an action item (call their congressman, for example)."We don't really want to give doctors this advice," said Dr. Jane Orient, executive director of the AAPS, "but something has got to be done. A lot of doctors are afraid to prescribe opiates even for desperately ill patients -- it's not worth spending the rest of your life in prison for prescribing pain medications," she told DRCNet.
That's the prospect confronting Tucson pain management specialist Dr. Jeri Hassman (http://www.drhassman.com), who faces a 66-count indictment charging her with prescribing opioid painkillers to six patients without a legitimate medical reason. Those drugs included morphine, methadone, Vicodin and Oxycontin. She is also charged with defrauding TRICARE, a managed health-care group serving US military retirees and their families, and is facing DEA administrative hearings and a state medical board investigation, according to her lawyer, former US Attorney for Arizona Bates Butler. According to the DEA and federal prosecutors, Dr. Hassman's patients included a number of suspected "doctor shoppers," or people who go to multiple doctors seeking to obtain large amounts of controlled substances.
"Why in the sam hell didn't they go to her if they thought some of her patients were doctor-shopping?" fumed Butler. "They didn't inform her of a potential problem, they just sent in an undercover agent claiming he was in pain."
There is a common practice across the country that seems designed more to cripple doctors than to achieve justice, Butler said. "What happens is the DEA suspends the doctor's license to prescribe, then the doctor appeals and the case is set for an administrative hearing. Now the doctor has to reveal to the DEA the specific defense to the charges, which effectively wipes out your Fifth Amendment privilege," he explained. "After the DEA gets a look at your defense, but before the actual administrative hearing, here comes a criminal indictment. Now, the doctor's lawyer is going to tell him to put the administrative appeal on hold because there are more serious matters to deal with. So what we have is the DEA forcing doctors to spend time and money to defend themselves at these administrative hearings, while the DEA uses that process to build a criminal indictment. And, of course, there are also state medical board hearings, so it's a triple whammy, and it's an abuse of civil proceedings by the DEA."
At a press conference June 26 in Tucson, Dr. Hassman told reporters she had spent $100,000 on her defense so far and feared the bill could reach half a million dollars. While Dr. Hassman's practice remains open, her employees have had to take pay cuts, she said. And while Dr. Hassman conceded that there are people who "doctor shop" to seek drugs, she said the DEA should work with doctors to identify them instead of targeting doctors. And, she said, DEA efforts to thwart abuses should not get in the way of legitimate medical needs. "You cannot ignore there are millions of people who suffer severe and chronic pain," she said.
Dr. Hassman feels alone, Butler said, but her case is not unique. According to the AAPS, there have been at least 32 similar prosecutions of pain management specialists in recent years. Nor is Dr. Hassman alone professionally. At least four Tucson-area pain specialists are prepared to testify that Hassman was engaged in legitimate medical practices, including local pain treatment expert Dr. Jennifer Schneider and the immediate past president of the Arizona Medical Association, Dr. Richard Dale.
And while the Arizona Medical Association was reluctant to comment directly on Dr. Hassman's case, the group's executive director, Chic Older, told DRCNet the issue of legitimate pain treatment was becoming increasingly important. "We are watching to see what will happen," Older said. "Our medical association is on record saying we feel physicians ought to be able to act in the best interests of their patients. We don't think physicians should have to worry about losing their license for treating a dying patient in intractable pain. Sometimes there are cases whose outcome really sets a marker, and this could be one of them," he said.
Regardless of the outcome in this particular case, said Older, prosecutions like this one can deter physicians from properly treating pain. "This is part of the criminalization of medicine," he said, "and that has a chilling, chilling effect on physicians' willingness to prescribe necessary medications. The whole notion of the enforcement and judicial arms of government overseeing physicians and looking for criminal intent is becoming a very significant issue in this country," Older said.
Also attending Dr. Hassman's press conference were about a dozen of her former patients, who passionately defended her. One of them, Don Hayden, 48, told reporters he had been bedridden with chronic pain for years before finding Dr. Hassman. "She prescribed the proper pain medication to make me a functioning member of this society," Hayden said. Other patients said they were having trouble getting the medications they need since Dr. Hassman's certificate to prescribe was suspended by the DEA.
"The DEA says the justification for these arrests of doctors is the public health," Bates said, "but Dr. Hassman had over 200 patients who were receiving controlled substances for pain relief. What about the public health when 200 patients can't go to their doctor? What makes this even more frustrating is that of those patients of Dr. Hassman who have managed to find another doctor, 97% of those we can find are now on the same or higher doses of controlled substances."
"This is a serious problem," said AAPS' Dr. Orient. "We have physicians being prosecuted like drug kingpins. We need real legal reforms so that a doctor who gets taken in by an undercover agent or a talented actor does not face life in prison. We need a nationwide educational program about the difficulty patients are already having getting pain medications. It's only going to get worse," she said. "Doctors need to be seen as allies in the war against drug diversion, not the enemy. Doctors are not cops, they don't have lie detectors. If law enforcement was seriously interested in stopping drug diversion, it would work with doctors, not target them."
"They've already lost the war on drugs," said Bates, who spent a career prosecuting drug cases as US Attorney. "Now they want to turn it into a war on doctors. There's a certain amount of ego gratification in this for prosecutors," he said. "It's much more exciting to take down a doctor, a lawyer, or some other professional than just to prosecute another kid caught coming across the border with a backpack full of dope."