In California, an initiative designed to increase the caps on medical malpractice awards is catching the attention not only of powerful legal and medical interests, but also drug reformers. That's because, in what opponents call a cynical ploy, the malpractice initiative leads with a provision to impose drug testing on doctors.

[image:1 align:left caption:true]Proposition 46, whose controversial ballot title is "Drug and Alcohol Testing of Doctors, Medical Negligence Lawsuits. Initiative Statute," would, if passed, make California the first state in the nation to impose drug testing on doctors. According to a Ballotpedia summary, it would:

• Increase the state's cap on non-economic damages that can be assessed in medical negligence lawsuits to over $1 million, from the current cap of $250,000.
• Require drug and alcohol testing of doctors and reporting of positive tests to the California Medical Board.
• Require the California Medical Board to suspend doctors pending investigation of positive tests and take disciplinary action if the doctor was found impaired while on duty.
• Require health care practitioners to report any doctor suspected of drug or alcohol impairment or medical negligence.
• Require health care practitioners to consult the state prescription drug history database before prescribing certain controlled substances.

The fight over Prop 46 is shaping up to be the most expensive initiative campaign ever, with rival groups having already raised nearly $70 million. The vast majority of that funding is coming from opponents of the initiative, primarily the very well-heeled state medical community. The No on 46 campaign committee alone has raised nearly $57 million to kill it.

The stakes are huge. Portrayed by supporters -- mainly trial lawyers -- as a boon to patients harmed by medical misconduct and hamstrung by state laws limiting malpractice awards, state analysts estimate that it could cost state health care programs "tens of millions to several hundred million dollars annually," while a legion of hospitals, health clinics, medical practices, and other health care professionals warn that Prop 46 would drive up health care costs across the board while primarily benefiting the bottom line of malpractice lawyers.

Law firms and attorneys' groups are the biggest backers of Prop 46, but they aren't the only ones. The advocacy group Consumer Watchdog is also backing it to the tune of more than $2 million, and has laid out some arguments in favor of it.

"According to a study published in the Journal of Patient Safety, medical negligence is the third leading cause of death in the country behind only heart disease and cancer. As many as 440,000 people die each year from preventable medical negligence. That's like a 747 crashing every 10 hours," the group said in a March flyer. "The California Medical Board estimates that almost one-in-five doctors (18%) suffer from drug and/or alcohol abuse at some point during their careers -- and leading medical safety experts have called for random drug testing to curb substance abuse and ensure patient safety."

In that same flyer, Consumer Watchdog also warned that "doctors are the biggest suppliers for chronic prescription drug abusers" and that "drug prescribed by doctors caused or contributed to nearly half of recent prescription drug overdose deaths in California." But such scary claims beg the question of who else would be expected to supply prescription drugs.

[image:2 align:right]While lawyers and some consumer advocates are lining up to support Prop 46, it is also generating a huge and powerful group of opponents, including hundreds of medical groups, health care providers, hospitals, insurance companies, and clinics and private practices worried about rising malpractice insurance costs. It is also opposed by dozens of county medical associations, the state Chamber of Commerce and many local affiliates, along with more than a dozen labor unions.

The strange bedfellow opposition extends even further, with the state Republican Party, the state American Civil Liberties Union (and its local affiliates), and the California NAACP all among groups coming out against Prop 46. Also among its foes are most of the major newspapers in the state, which have thoroughly condemned it.

"If doctors are drug-addled, other doctors and nurses have a duty to report them," the Sacramento Bee editorialized. "If doctors make horrible mistakes during surgery, there might be cause for testing. But Proposition 46 would impose the insulting requirement of random testing on all doctors who have hospital privileges, and require that the Medical Board of California discipline any doctors whose tests are dirty. In its propaganda, Consumer Watchdog jokes about privacy concerns in a lowest-common-denominator video showing that other professionals must provide urine samples. Simply because laws allow for testing of some workers doesn't mean physicians' privacy should be trampled."

The conservative San Diego Tribune was similarly irked by the use of doctor drug testing as a come-on designed to induce voters to favor the initiative, calling it "a pathetic scam" in the title of its editorial.

"Plainly, the doctor drug-testing provision is 'the ultimate sweetener' designed to make this foul brew go down better. It wasn't a critic who used that term," the newspaper noted. "It was Jamie Court, president of Consumer Watchdog, in an interview with The Los Angeles Times. Such an openly cynical attempt to manipulate voters shouldn't be rewarded. Vote no on Proposition 46."

The drug testing provision has also provoked opposition from the state's largest marijuana consumer organization, CA NORML, and the Drug Policy Forum of California, which urged supporters to vote no on Prop 46 in its 2014 Election Guide.

[image:3 align:left caption:true]"Drug testing is about marijuana," explained CA NORML head Dale Gieringer. "More than half the drug test positives out there are marijuana. This initiative deceitfully claims to be about alcohol and prescription drug abuse by doctors, but drug testing is almost useless with alcohol -- unless you're actually drunk at the time, I suppose -- and if you closely read the text of the initiative, you see that prescription drugs are perfectly excusable as long as the doctor has a prescription. So, there's a medical excuse for the prescription drugs mentioned in the ads, but not for medical marijuana, since the initiative only allows exemptions for prescribed controlled substances."

The drug testing regime proposed by the initiative is antiquated, too, Gieringer said.

"This thing is using urinalysis drug testing standards promulgated by the feds a generation ago," he pointed out. "The list of illegal drugs includes PCP -- yeah, that's a major problem, all those docs on PCP -- but doesn't include the new synthetics. And the list specifically includes marijuana metabolites, but not THC. That's because they're relying on urinalysis, which can't detect active THC, so only the inactive metabolite is being considered under this insidious proposition."

In other words, the drug tests wouldn't catch doctors with alcohol problems unless they were literally drinking on the job, would excuse the presence of prescription drugs if the doctor had a prescription, and wouldn't find doctors who were actually high on pot, but would find those who had used the substance days or weeks earlier. But it sounded good in focus groups.

"As we know, the drug testing provision was an afterthought," Gieringer said. "This is being done by trial lawyers, and the basic purpose is to heighten the limits on malpractice liability. But those focus groups showed everybody liked the idea of drug testing doctors."

The drug testing provision may indeed have been a sweetener designed to improve Prop 46's chances at the polls next month. But the well-funded and broad-based opposition campaign is taking its toll.

Although it polled well in a June Field poll, coming in with 58% support, support has declined since then. An August Field poll saw support plummet, with only 34% in favor, 37% opposed, and 29% undecided. But it isn't over until it's over. The number of undecideds less than a month out is big enough to swing the results either way.

The airwaves across California are already filled with Prop 46 campaign ads. We can only expect them to increase in the next few weeks as the deep-pocketed contenders throw everything they've got at the voters in the final days of campaigning.