Source: Washington Examiner
Date: 11 May 2005

Pain relief is major casualty of drug war

As federal prosecutors target physicians who prescribe large doses of pain-killing drugs because they can also be abused, doctors are increasingly afraid to provide relief for sick people with intractable pain. As Pain Relief Network President Siobhan Reynolds said, "Ninety-eight percent of doctors won't touch [chronic pain patients] with a 10-foot pole."

Her view was echoed by Dr. Russell Portenoy, chairman of the Department of Pain Medicine and Palliative Care at New York's Beth Israel Medical Center. Just this week, the former head of the American Pain Society told The Examiner he received e-mails from desperate patients unable to find local doctors willing to prescribe opioids, including one from the Baltimore-Washington area.

Following the high-profile conviction of a McLean pain doctor in December, the Bush administration is now proposing new Drug Enforcement Administration guidelines that limit patients to a 30-day supply. Doctors were previously allowed to future-date prescriptions to spare stable pain patients the trouble, expense and pointless paternalism of a monthly doctor's visit.

The DEA also pulled guidelines for prescribing opioids from its Web site around the time a federal jury in Alexandria convicted Stanford-educated internist William Hurwitz - one of the first physicians charged with conspiracy to run a prescription drug ring out of his office. However, there was no evidence Dr. Hurwitz directly profited from illicit sales uncovered in the three-year investigation triggered by a rash of OxyContin overdoses in Appalachia.

Prosecutors called Dr. Hurwitz "no better than a crack dealer" for prescribing 1.8 million pills to a handful of patients, some with visible track marks on their arms. Four later died. Last month, the former Peace Corps medical director who was featured on "60 Minutes" was sentenced to 25 years in jail. His is one of seven such cases currently under appeal.

Now every pain specialist in the country is acutely aware that merely writing a prescription for a legal drug could land them in jail if the medication winds up in the wrong hands.

In a Dec. 10 letter, Dr. Portenoy and other nationally known pain doctors questioned "serious misstatements of consensus in the field" made by the prosecution's medical expert, which, he added later, "greatly increase the potential damage to public health by greatly increasing physicians' concern about prescribing."

The aftereffects of the Hurwitz case are serious and widespread.

"They're very reluctant to talk about it, but general practitioners are completely afraid to prescribe even low doses [of opioids]," Dr. James Campbell, professor of neurosurgery at Johns Hopkins School of Medicine, told The Examiner. Dr. Campbell testified at the trial that even the very large doses of medication Dr. Hurwitz was prescribing to his patients "was within the bounds of medical practice."

Dr. Hurwitz's conviction did not clarify when he crossed the line into criminality. The resulting uncertainty, Dr. Campbell says, is making physicians nationwide afraid to adjust doses upward until their pain is relieved. They simply don't know where the line is between a legal dose and a prescription that will land them in jail.

"I've seen patients who were by definition undertreated by nationally known pain experts returned to useful, productive lives by Dr. Hurwitz. I'm not sure the DEA understands the magnitude of the problem that faces patients who can't find a doctor to treat them," Dr. Campbell noted. "Our best indicator [of effectiveness] is what patients tell us. When doctors are required to be policemen, nobody believes anybody - and the system is broken."

The system is indeed broken when the federal government is more concerned about the welfare of drug addicts than the 25 million Americans identified in a 2002 National Institutes of Health study who live with unrelenting pain - while the means to alleviate it remains just beyond their reach.

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