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Feature: Pain Patients, Pain Contracts, and the War on Drugs

Pain contracts. Pain management contracts. Medication contracts. Opioid contracts. Pain agreements. They go by different names, but they all mean the same thing: A signed agreement between doctor and patient that lays out the conditions under which the patient will be prescribed opioid pain medications for the relief of chronic pain. (To see a standard pain contract, click here.)

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Oxycontin pills
For some of the tens of millions of Americans suffering from chronic pain, opioid pain medications, such as Oxycontin or methadone, provide the only relief from a life of agony and disability. But with the Office of National Drug Control Policy's ongoing campaign against prescription drug abuse and the Drug Enforcement Administration's (DEA) ongoing crackdown on physicians it believes are prescribing opiates outside the bounds of accepted medical practice, the medical establishment is increasingly wary of pain patients and adequate treatment of pain is a very real issue for countless Americans.

In recent years, doctors and hospitals have turned increasingly to pain contracts as a means of negotiating the clashing imperatives of pain treatment and law enforcement. Such contracts typically include provisions requiring patients to promise to take the drugs only as directed, not seek early refills or replacements for lost or stolen drugs, not to use illegal drugs, and to agree to drug testing. And as the contract linked to above puts it, "I understand that this provider may stop prescribing the medications listed if... my behavior is inconsistent with the responsibilities outlined above, which may also result in being prevented from receiving further care from this clinic."

"Pain agreements are part of what we call informed consent," said Northern Virginia pain management and addiction treatment specialist Dr. Howard Heit. "They establish before I write the first prescription what I will do for you and what your responsibilities are as a patient. They are an agreement in order to start a successful relationship that defines the mutual responsibilities of both parties. More and more states are suggesting we use agreements as part of the treatment plan with scheduled medications. Such agreements are not punitive; they protect both sides in functional way."

If Heit sees a cooperative arrangement, others disagree. "This is really an indication of how the current DEA enforcement regime has created an adversarial relationship between patients and physicians where the doctors feel the need to resort to contracts instead of working cooperatively with patients," said Kathryn Serkes, spokesperson for the Association of American Physicians and Surgeons (AAPS), which has been a fierce critic of criminalizing doctors over their prescribing practices. "The pain contracts are a tool to protect physicians from prosecution. He can say 'I treated in good faith, here's the contract the patient signed, and he violated it.' It's too bad we live in such a dangerous environment for physicians that they feel compelled to resort to that," she told the Chronicle.

"Patients aren't asked to sign contracts to get treatment for other medical conditions," Serkes noted. "We don't do cancer contracts. It is a really unfortunate situation, but it is understandable. While I am sympathetic to the patients, I can see both sides on this," she said.

"There is no evidence these pain contracts do any good for any patients," said Dr. Frank Fisher, a California physician once charged with murder for prescribing opioid pain medications. He was completely exonerated after years of legal skirmishing over the progressively less and less serious charges to which prosecutors had been forced to downgrade their case. "The reason doctors are using them is to protect themselves from regulatory authorities, and now it's become a convention to do it. They will say it is a sort of informed consent document, but that's essentially a lie. They are an artifact of an overzealous regulatory system," he told the Chronicle.

"When this first started, it was doctors using them with problem patients, but now more and more doctors and hospitals are doing it routinely," Fisher added. "But the idea that patients should have to sign a contract like that or submit to forced drug testing is an abrogation of medical ethics. Nothing in the relationship allows for coercion, and that is really what this is."

The pain contracts may not even protect doctors, Fisher noted. "When they prosecute doctors, they can use the pain contract to show that he didn't comply with this or that provision, like throwing out patients who were out of compliance. The whole thing is a mess."

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Michael Krawitz (photo courtesy Drug Policy Forum of Virginia)
It is a real, painful mess for a pair of veterans trying to deal with chronic pain through the Veterans Administration -- and it is the drug testing provisions and the use of marijuana that are causing problems. Michael Krawitz is an Air Force veteran who was injured in an accident in Guam two decades ago that cost him his spleen, pancreas, and part of his intestine. Krawitz also suffered a fracture over his left eye, received an artificial right hip, and has suffered through 13 surgeries since then. He had been receiving opioid pain medication at a VA Hospital in Virginia, but things started to go bad a year ago.

"Last year, I refused to sign the pain contract they had just introduced there, and they cut me off my meds because I refused," Krawitz told the Chronicle. "Then I amended the contract to scratch off the part about submitting to a drug test, and that worked fine for a year, but the last time I went in, they said I had to do a drug test, and I again refused. I provided a battery of tests from an outside doctor, but not an illegal drug screen. That's when my VA doctor sent an angry letter saying I was not going to get my pain medicine."

Krawitz has provided documentation of his correspondence with the VA, as well as his so far unheeded complaint to the state medical board. As for the VA, some half-dozen VA employees ranging from Krawitz' patient advocate to his doctor to the public affairs people to pain management consultants failed to respond to Chronicle requests for interviews.

For Krawitz, who has used marijuana medicinally to treat an eye condition -- he even has a prescription from Holland -- but who says he is not currently using it, it's a fight about principles. "I will not submit my urine for a non-medical test," he said. "The VA doesn't have the authority to demand my urine. It's an arbitrary policy, applied arbitrarily. The bottom line is that we vets feel very mistreated by all this. Some of us have sacrificed limbs for freedom and democracy, and now the VA wants to make us pee in a bottle to get our pain medication?"

The imposition of pain contracts is not system-wide in the VA. A 2003 Veterans Health Administration directive on the treatment of pain notes that "adherence with opioid agreement, if used" should be part of the patient's overall evaluation.

Krawitz is preparing to file a federal lawsuit seeking to force the VA to treat him for pain without forcing him to undergo drug testing. For Tennessee vet Russell Belcher, the struggle is taking a slightly different course. Belcher, whose 1977 back injury and spinal fusion had him in pain so severe he couldn't work after 2000, was cut off from pain meds by the VA after he tested positive for marijuana. Belcher said he used marijuana to treat sleeplessness and pain after the VA refused to up his methadone dose.

"It's a wonder to me that some vet ain't gone postal on them," he told the Chronicle. "They pushed me pretty close. To me, not signing the substance abuse agreement is not an option. If you sign it you're screwed, if you don't sign it, you're screwed. I complained for months about the dose being too low, but they said that's all you get and if you test positive for anything we're kicking you out. When the civilian doctors would find marijuana on a drug screen, they told me they would prefer I didn't do that because it was still illegal, but they didn't kick me out of the program. I was using it for medicinal purposes. I have tremendous trouble sleeping, muscle cramps that feel like they'll pull the joint out of the socket. I had quit using for a long time because of this mess with the drug testing, but then they wouldn't increase my pain medicine. I thought I have to do something; it's a matter of self preservation," he said.

"The pain clinic at the VA has discharged me from their care and said the doctor would no longer prescribe narcotics for me unless I attend the substance abuse program," Belcher continued. "They aren't going to be satisfied until I spend 30 days in the detox unit." While Belcher would like to join Krawitz in taking on the VA, in the meantime he is looking for a private physician.

When asked about the veterans' plight, Dr. Fisher was sympathetic. "They made Krawitz sign a contract under duress with forced drug testing as a condition of his continued treatment," he pointed out. "That violates basic rights like the right of privacy. There is no suspicion he is a drug addict. They want to treat all patients as if they were criminal suspects, and that has little to do with what the nature of the doctor-patient relationship should be."

Dr. Heit, while less sympathetic than Dr. Fisher, was decidedly more so than the VA. When asked about the cases of the vets, he explained that he would be flexible, but would also insist they comply with the terms of their agreements. "In the end, you have to choose whether you want me to do pain management with legal controlled substances or you want to use illicit substances, but you don't get to choose both," he said. "I don't disagree that marijuana may help, but the rules are it's an illicit substance. I can't continue to prescribe to someone who is taking an illicit substance."

And here we are. Patients seeking relief from pain meet the imperatives of the drug war -- and we all lose.

Feature: Reefer and Religion -- Nevada Clergy Embrace Marijuana Legalization

It was the press conference heard 'round the world -- or at least around the country and in every corner of Nevada. Last Tuesday, four Nevada clergymen stood side by side with organizers of the Nevada initiative to regulate and control marijuana to publicly endorse the measure. They spoke for at least 33 Nevada clergy who endorsed Question 7, as the initiative is known on the ballot.

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The measure would allow adult Nevadans to legally possess small amounts of marijuana and to purchase it at state-regulated stores. Under current Nevada law, possession of less than an ounce is a misdemeanor offense and all sales are illegal.

Preachers for pot legalization -- for the media, that was as good as man bites dog, and the press coverage showed it. According to a list compiled by the Interfaith Drug Policy Initiative (IDPI), who spearheaded the effort of bringing the clergy on-board, media hits included CNN, MSNBC, every major newspaper in Nevada, repeated features on Nevada TV stations, and an Associated Press story that was picked up by at least 37 media outlets nationwide.

Across Nevada and the country, readers and viewers heard people like the Rev. Ruth Hanusa, chaplain at the Campus Christian Association at the University of Nevada-Reno, explain why they supported changing the marijuana laws. "Some of us Protestants believe that one of the functions of government is to curb sinful behavior," she said. "But our marijuana laws are not curbing marijuana use and they are causing more harm than good by filling the pockets of dangerous criminals and ensuring that children have the easiest access of anyone," she said.

They also got to hear the Rev. Paul Hansen, senior pastor at Holy Spirit Lutheran Church in Las Vegas explain why he supported Question 7. "On its face, our current marijuana laws appear to be moral, but it is a cosmetic morality," said Hansen. "Our current laws are causing virtually unfettered access to marijuana. Marijuana is far easier to access than alcohol because drug dealers don't card," he said.

"This became a big story because most people think that the religious community is the last place on earth to find support for ending marijuana prohibition," said IDPI's Troy Dayton, who has spent much of the year in Nevada. "It is making such a difference because by its very nature it reframes the debate. This marijuana issue is up against a lot of cultural baggage, decades of a government misinformation campaign, and a strong puritan ethic which embraces a spirit of punishment. In addition, many voters think they are voting on whether or not they think marijuana is good or not; not what the best policy regarding marijuana best serves the community."

Gaining the support of such respected community leaders is critical for gaining support for the cause, Dayton told Drug War Chronicle. "It doesn't matter if our side has better reasoning if the average voter dismisses the issue without a careful and open-minded inquiry," he said. "When the average voter hears about religious leader support, first his attention is grabbed, and secondly the cognitive dissonance of this reality forces a reframing of the issue in his mind. No one could accuse these religious leaders of being in favor of marijuana use and they are clearly respected moral leaders in the community. So this makes people wonder, 'Why are they supporting this?'"

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The faith-based support is providing a boost for a campaign that is in a tight uphill battle to put Nevada over the top as the first state to vote to regulate and control marijuana, said initiative supporters. "To have so many people in the faith-based community who represent so many denominations is a big plus for the campaign," said Patrick Killen, communications director for the Committee to Regulate and Control Marijuana (CRCM), the group behind the campaign. "Having these people of faith come forward on this shows that creating a sensible alternatives to our state's marijuana laws is an issue that resonates with a diverse array of people in Nevada," he told the Chronicle.

"As far as we know, this is the first time that so many clergy from different denominations have explicitly called for legally regulated sources of access for marijuana," said IDPI executive director Charles Thomas. "And it came about because of a lot of hard work. We had Troy in Nevada for about five months, and our Tyler Smith joined him for a few weeks. They traveled the state and sat down and talked one-on-one with religious leaders, and a number of those people not only took the information and read it, but also took a few days to pray about it. Praying is a way to really reflect on what your deepest values are."

One of those doing some serious reflecting was Pastor Hansen. "Some people from the campaign contacted me this spring, and I was skeptical at first," said Hansen. "I thought it was about a bunch of people who smoked marijuana and wanted a license to do it, but as I began to research the issue, I saw there is a movement in the Western world to rethink our policies toward marijuana, and I thought this was a just position," he told the Chronicle. "When I look at the issue and what they're doing in Holland and all the unforeseen negative consequences of alcohol prohibition, I see a lot of the same things happening in terms of organized crime profiting from an underground criminal marijuana market."

Pastor Hansen made clear he was speaking for himself -- not representing his church or congregation -- as he addressed the issue. While his public stance in favor of Question 7 has won him support, "I've also gotten a few people who expressed their displeasure," he noted wryly. "Lutherans are not all of one mind on lots of issues."

Nor are members of other denominations. But having religious leaders speaking out for marijuana legalization is an advance for the cause. And with Question 7 trailing in some polls and leading narrowly in others, the divine intervention would be most welcome.

NJ WEEDMAN (Ed Forchion) to Appear on CNN's Glenn Beck Show 10/19

NJ WEEDMAN reports: On Tuesday Oct 10th, 2006 NJWEEDMAN did a interveiw for the Glenn Beck Show that will air on Thursday Oct 19th, 2006 - http://www.cnn.com/CNN/Programs/glenn.beck/
Location: 
United States

Hippie-Hating and -Baiting

Location: 
Colorado Springs, CO
United States
Publication/Source: 
Colorado Springs Independent
URL: 
http://www.mapinc.org/drugnews/v06/n1364/a07.html?397

From SAFER Colorado: Marijuana Initiative Campaign to Unveil Billboard Highlighting Drug Czar's Ad Calling Marijuana Use the "Safest Thing in the World"

MEDIA ADVISORY FOR IMMEDIATE RELEASE - October 10, 2006 On the same day the nation's Drug Czar is in town... Marijuana Initiative Campaign to Unveil Billboard Highlighting Drug Czar's Ad Calling Marijuana Use the "Safest Thing in the World" Amendment 44 proponents welcome the Drug Czar to town with hope that he will continue valuable education campaign Amendment 44 proponents to hold events in Colorado Springs (9:30 a.m.) and Denver (12:30 p.m.) to coincide with Drug Czar's visit Contact: Mason Tvert, SAFER campaign director, 720-255-4340 DENVER - On Wednesday, October 11, the proponents of Amendment 44, the initiative to make marijuana possession legal for adults in Colorado, will hold press conferences in Colorado Springs and Denver to unveil its first billboard of the campaign. These events will coincide with appearances by the nation's Drug Czar, John Walters (officially the Director of the White House Office of National Drug Control Policy (ONDCP)). This billboard will feature a quote from a new ad that is part of the Drug Czar's National Youth Anti-Drug Media Campaign. The quoted ad - which is designed to discourage teen marijuana use - is called "Pete's Couch" and refers to using marijuana and hanging out as the "safest thing in the world." One can watch the ad on this site - http://www.abovetheinfluence.com/the-ads/default.aspx - and the transcript of the ad is pasted at the bottom of this release. The press conference in Colorado Springs - which will feature a large banner replica of the Denver billboard - will take place outside of 2 N. Cascade Ave at 9:30 a.m. The press conference in Denver will be held beneath the new billboard in the lot of Family Trucks and Vans (2468 S. Broadway, on the NE corner of Broadway and Harvard). "Our campaign is not calling marijuana the 'safest thing in the world.,'" said SAFER Campaign Director Mason Tvert. "These are the drug czar's words. But it is important to highlight this phrase to counter the claims of our opponents - including the drug czar himself, ironically - that marijuana is a 'very dangerous' and 'addictive' substance. Clearly, the drug czar has recognized at some level that exaggerated claims about the harms of marijuana are an ineffective means of reducing teen use. The dramatic phrase in the Pete's Couch ad is far closer to the truth." "Now that the drug czar is being more honest with teens, we invite him to share this newfound honesty with adults in Colorado," continued Tvert. "Our only point in this campaign is that marijuana is less harmful than alcohol and, thus, it does not make sense to punish adults for using the safer substance. It seems like he agrees about the relative harms of the two substances. Now he just needs to get over his desire to punish adults for using a substance less harmful than alcohol. If he can do so, we welcome him to join us on the campaign trail." The Drug Czar will be holding an event of his own at South High School in Denver (1700 East Louisiana Avenue) at 11 a.m. This is just 2.5 miles from where the billboard will be unveiled at 12:30 p.m. "When the Drug Czar is done with his event," added Tvert. "We hope that he will come to the site of the billboard to discuss his motivation behind the new tone of the media campaign and his seemingly inconsistent desire to spend taxpayer dollars to travel to Colorado to spread age-old myths about marijuana's supposed harms." MEDIA EVENTS - Details Colorado Springs *** Photo opportunity - large banner replica of Denver billboard *** What: Amendment 44 press conference When: Wednesday, October 11, 2006, at 9:30 a.m. Where: In front of 2 N. Cascade Ave., Colorado Springs Who: Mason Tvert, lead proponent for Amendment 44 Denver What: Amendment 44 press conference to unveil new billboard When: Wednesday, October 11, 2006, at 12:30 p.m. Where: 2468 S. Broadway, on the NE corner of Broadway and Harvard (in the lot of Family Trucks and Vans) Who: Mason Tvert, lead proponent for Amendment 44 ================== Transcript of Pete's Couch ad (Provided by ONDCP at http://www.abovetheinfluence.com/the-ads/default.aspx): (Scene opens with a guy sitting on the couch talking directly to the camera) I smoked weed and nobody died. I didn't get into a car accident, I didn't O.D. on heroin the next day, nothing happened. (Shot widens to show the guy with two friends sitting on the couch) We sat on Pete's couch for 11 hours. Now what's going to happen on Pete's couch? Nothing. (Shot now shows the guys on the couch in the middle of the woods with some mountain bikers riding by. Then to a basketball court. Then an ice rink.) You have a better shot of dying out there in the real world, driving hard to the rim, ice skating with a girl. No, you wanna keep yourself alive, go over to Pete's and sit on his couch til you're 86. Safest thing in the world. (Shot now shows the guys on the couch outside a movie theater. The guy talking gets up from the couch and walks into the theater) Me? I'll take my chances out there. Call me reckless. (AbovetheInfluence.com logo appears)
Location: 
CO
United States

Marijuana Initiative Backers Huff, Puff After Campus Voters

Location: 
CO
United States
Publication/Source: 
Rocky Mountain News
URL: 
http://www.rockymountainnews.com/drmn/elections/article/0,2808,DRMN_24736_5054992,00.html

Medical Marijuana Turns 10: New Report to Examine Impact of California's Landmark Proposition 215

First Comprehensive Analysis of Medical Marijuana's Impact to Feature New Polling From All 11 Medical Marijuana States CONTACT: Bruce Mirken, MPP director of communications, 202-215-4205 or 415-668-6403 WASHINGTON, D.C. -- With the tenth anniversary of America's first effective medical marijuana law, California's Proposition 215, coming up Nov. 5, the Marijuana Policy Project (MPP) in Washington, D.C. is preparing to release the first-ever comprehensive analysis of the law's impact. Prop. 215 started a wave of medical marijuana laws now covering 11 states, including over 20 percent of the U.S. population. The report, to be issued approximately Oct. 26, will include: **New polling in all 11 medical marijuana states -- Alaska, California, Colorado, Hawaii, Maine, Montana, Nevada, Oregon, Rhode Island, Vermont, and Washington -- examining voter approval of the laws now that they have lived with them for a number of years. **Analysis of predictions made by Prop. 215's opponents, including then-White House Drug Czar Gen. Barry McCaffrey and U.S. Sen. Dianne Feinstein (D-CA), that the measure would increase teen drug use and effectively "legalize marijuana for everyone." **Profiles of real patients who have benefited from state medical marijuana laws, as well profiles of patients in states lacking such legal protection, who have "come out" in an effort to reform their states' laws. Journalists wishing to receive an embargoed copy of the report in advance of the official release date should contact MPP Director of Communications Bruce Mirken at [email protected]. With more than 20,000 members and 100,000 e-mail subscribers nationwide, the Marijuana Policy Project is the largest marijuana policy reform organization in the United States. MPP believes that the best way to minimize the harm associated with marijuana is to regulate marijuana in a manner similar to alcohol. For more information, please visit http://MarijuanaPolicy.org. ####
Location: 
United States

Hundreds Rally to Legalize Marijuana

Location: 
Madison, WI
United States
Publication/Source: 
Wisconsin State Journal
URL: 
http://www.madison.com/wsj/home/local/index.php?ntid=102311&ntpid=1

Voter Power Fundraising Dinner

You are invited to a Voter Power fundraising dinner on Saturday, October 28, at 8 p.m. at the Saigon Kitchen at 3829 SE Division Street in Portland, Oregon. The dinner will begin after our open house. Elvy Musikka, one of the few remaining patients receiving medical marijuana from the United States government will be our guest of honor. Voter Power was formed in response to the 1997 attempt by the Oregon Legislature to recriminalize marijuana and Voter Power’s Executive Director and Legal Counsel helped draft the original Oregon Medical Marijuana Act (OMMA). Voter Power campaigned for the passage of OMMA and the defeat of marijuana recriminalization by designing and implementing the successful “Yes on 67, No on 57” campaign in 1998. Voter Power successfully lobbied the Oregon Legislature to fund OMMA and has registered over 30,000 new Oregon Voters. We provide marijuana law victims with a voice, empower voters to improve our laws and policies, and continue to fight for medical marijuana patients’ safe access to medicine. We need your help to continue this fight. Please attend our fundraising dinner. The dinner will be buffet-style and the cost is $25. Space is limited, so please RSVP via e-mail or telephone by Monday, October 23. Sincerely, Anthony Johnson Political Director (503) 224-3051 [email protected]
Date: 
Sat, 10/28/2006 - 8:00pm - 11:00pm
Location: 
3829 SE Division Street
Portland, OR
United States

Review of Cannabis Laws as Drug-Fueled Violence Spirals

Location: 
United Kingdom
Publication/Source: 
This Is London
URL: 
http://www.thisislondon.co.uk/news/article-23369774-details/Review%20of%20cannabis%20laws%20as%20drug-fuelled%20violence%20spirals/article.do

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