Under-treatment of Pain

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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."

DEA Issues Policy Statements on Pain Management, Prescribing Practices

Here are the links to the two DEA policy statements. I tried pasting them into this blog, but that crashed it. Sorry about that.

http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/pdf/E6-14517.pdf

Drug Enforcement Administration

Dispensing Controlled Substances for the Treatment of Pain

ACTION: Policy Statement.

---------------------------

http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/pdf/E6-14520.pdf

Drug Enforcement Administration

Issuance of Multiple Prescriptions for Schedule II Controlled Substances

Location: 
Washington, DC
United States

Jacob Sullum on the Hurwitz Case

Jacob Sullum of Reason magazine has opined once again on the Hurwitz pain case in The Accidental Drug Trafficker: A repudiation of prosecutions that treat doctors’ errors in judgment as felonies. If you haven't already, check out our news feature on this story <?php print l('here', 'chronicle/450/hurwitz_drug_convictions_overturned', NULL, NULL, NULL, NULL, TRUE); ?>.
Location: 
United States

Feature: Pain Doctor William Hurwitz to Get New Trial

In a closely watched case with national implications, a federal appeals court has granted a new trial to a well known Northern Virginia pain doctor sent to federal prison for 25 years as a drug dealer. Pain patient advocates and medical associations praised the ruling in the case of Dr. William Hurwitz, who was convicted in late 2004 of 50 counts in a 62-count indictment, including conspiracy to distribute controlled substances.

Hurwitz appealed his conviction, arguing that trial Judge Leonard Wexler erred by not instructing the jury that Hurwitz should not be convicted if he acted in "good faith." Typically in cases where the quality of medical care is in question, such matters are decided by medical boards or civil courts in the form of malpractice suits. Only doctors who are not prescribing in good faith that they are in line with accepted medical practices face criminal charges. In his jury instructions, Judge Wexler removed Hurwitz' only effective defense.

https://stopthedrugwar.org/files/hurwitz.jpg
Dr. Hurwitz in 1996 (photo courtesy Skip Baker)
For federal prosecutors, who pointed to multiple examples of high-dose prescriptions Hurwitz had written and who claimed he should have recognized some of his patients to be addicts or dealers, Hurwitz was nothing more than a Dr. Feelgood, no different from -- or perhaps worse than -- the kid slinging crack on the street corner. But for patient advocates and a growing number of medical professionals, the case was the highest-profile example yet of a Justice Department and DEA creating a chilling climate toward doctors' willingness to treat chronic pain with opioid pain medications.

That is why even though even some questioned Hurwitz's prescribing practices, his appeal nevertheless won the support of professional organizations like the American Academy of Pain Medicine, the American Pain Foundation, and the National Pain Foundation, all of which filed briefs in his support. Also joining the fray was the Drug Policy Alliance, which filed its own brief on behalf of pain specialists.

A three-judge panel in the 4th US Circuit Court of Appeals in Richmond agreed with Hurwitz and his allies in its opinion Monday. The panel held that Judge Wexler had erred when he told jurors they could not consider whether Hurwitz had acted in "good faith" when he prescribed large doses of opioid pain relievers like Oxycontin to patients.

"A doctor's good faith in treating his patients is relevant to the jury's determination of whether the doctor acted beyond the bounds of legitimate medical practice," wrote Judge William Traxler. "The district court effectively deprived the jury of the opportunity to consider Hurwitz's defense." That was a fatal error, the panel held. "We cannot say that no reasonable juror could have concluded that Hurwitz's conduct fell within an objectively-defined good-faith standard," wrote Traxler.

"We are very gratified by this decision," said Dr. Jane Orient, executive director of the libertarian-leaning Association of American Physicians and Surgeons, a group that has been in the vanguard of the medical profession on the issue of protecting pain doctors and patients. "Overturning one of these verdicts is something that almost never happens, and we hope it represents a tipping point," she told DRCNet. "We hope that the courts will finally begin to pay attention to the fundamental issues of justice involved here. A doctor is not a drug dealer, and neither is he a policeman. Doctors cannot be held responsible for patient misbehavior."

"I'm delighted," said Dr. Frank Fisher, a California physician originally charged with five counts of murder over his prescribing practices by overzealous prosecutors and state agents, but who was eventually completely exonerated. "This means they will have to let Billy out. The appeals court was absolutely correct in its decision," he told DRCNet.

The appeals court decision is a victory for Hurwitz and his supporters, but it is only one battle in a larger war over who controls the prescribing of pain medications -- the medical profession or the cops -- and in the meantime, doctors and patients are the casualties.

"They are still harassing and investigating doctors," said Orient. "And that in itself can destroy your practice. There are still doctors languishing in prison because they tried to do their best for their patients and there are still patients having difficulty finding physicians willing to do the pain treatment necessary to make them functional instead of bed-ridden suicidal people in severe pain," she said. "More doctors are aware of the extreme risk they take in getting involved with chronic pain patients. The DEA wants them to treat patients like they were suspected criminals."

Fisher pointed to the case of Dr. Richard Heberle, an Ohio physician, of how devastating even defending oneself from such charges can be. "Look at what happened to Dr. Heberle," he said. "He won, but his practice is ruined, his reputation is ruined, his life is ruined. The only thing worse than winning one of these cases is losing one, or maybe coming down with a bad case of chronic pain."

Pain Sufferers Turn to "Shrooms"

Location: 
United States
Publication/Source: 
Chicago Sun-Times
URL: 
http://www.suntimes.com/output/news/cst-nws-shrooms16.html

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