A Doctor In Pain

Jacob Sullum has the scoop on Virginia pain doctor William Hurwitz and his recent conviction for drug trafficking:

The prosecutors did not dispute that Hurwitz had helped hundreds of patients recover their lives by prescribing the high doses of narcotics they needed to control their chronic pain. Instead they pointed to the small minority of his patients—5 to 10 percent, by his attorneys' estimate—who were misusing the painkillers he prescribed, selling them on the black market, or both.

The prosecutors did not claim Hurwitz, who faces a possible life sentence, got so much as a dime from illegal drug sales. Instead they pointed to his income as a physician, which they said was boosted by fees from patients who were faking or exaggerating their pain.

The prosecutors did not allege that Hurwitz had any sort of explicit arrangement with those patients. Instead they described a "conspiracy of silence," carried out by "a wink and a nod."

The evidence supporting this theory was, not surprisingly, ambiguous at best, leaving plenty of room for reasonable doubt. Yet the prosecutors got the jury to overlook the obvious weaknesses in their case and convict Hurwitz, in essence, of trusting his patients too much.

That verdict sends a clear message to doctors that it's better to err on the side of suspicion.

This is a sad day for the practice of medicine, but I've got to say it makes me happy that I'm going into pathology. I'm relieved that I'll never have to face the decision to look out for my own self-interest or that of my patient. Usually they are one and the same, but not when the DEA gets involved.

But have no fear, say the federal agents - "good" doctors need not be concerned. Writes Karen Tandy:

In 2003, DEA arrested only 50 doctors out of the almost 1 million who are registered with us. Those 50 doctors committed egregious acts, such as exchanging prescriptions for sexual favors or kickbacks.

Two problems: The accepted facts of this trial indicate that Hurwitz neither accepeted sexual favors nor kickbacks, so where does he fall into this statistic? And maybe, accepting her numbers as fact, the other 999,950 doctors have been so thoroughly scared by DEA regulators that they just leave their patients in inappropriate pain rather than do anything to draw suspicion.

Sullum has this for Tandy:

Writing in USA Today during Hurwitz's trial, Karen Tandy, head of the Drug Enforcement Administration, said "doctors acting in good faith and in accordance with established medical norms should remain confident in their ability to prescribe appropriate pain medications." Notice that "good faith" is not enough to keep the DEA at bay. Doctors also have to prescribe "in accordance with established medical norms," as determined by the DEA, and prescribe only those medications and dosages the DEA deems "appropriate."

With reassurances like that, who needs warnings?

The most infuriating thing about this is that physicians now have to bear the cost of regulation of pain medications. If the profession is going to become a branch of the DEA, I think at least we should get a salary. The increase cost to taxpayers might make some people stand up and take issue.

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Amazing. The DEA head's USA

Amazing. The DEA head's USA Today piece starts off with,

Chronic pain is a serious problem for many Americans, and the Drug Enforcement Administration's (DEA) goal is to ensure that patients with legitimate need have access to pain medications that relieve suffering and improve quality of life.

(emphasis added) Man, it must take the secure, numb cynicism of a well-entrenched bureaucrat to be able to lie so brazenly, obviously and publicly... :furious:

One of these days one of

One of these days one of those bureacrats WILL get a terminal illness. And then they will suffer. (Or more likely, they'll use their corrupt power and influence to bypass the rules.)

Why anybody has any respect for "the law" anymore is completely beyond me.

Our insane drug policy, pt.

Our insane drug policy, pt. 2
As I've said before, in an ideal world everyone who needs pain relievers would get them and people who only want them to abuse would... well... drink booze I guess. But we don't live in an ideal world, so we...

Lisa Are you insane? Did

Lisa

Are you insane? Did you not just read that a doc got thrown in jail for NOT asking those questions and taking that attitude? Do you think our attitudes and suspicions are going to be less now? Feel free to write your congressman. Until then, expect probing questions.

GRAND ROUNDS #13: THE SEX OF

GRAND ROUNDS #13: THE SEX OF MEDICAL BLOGS
Welcome to Grand Rounds #13. In the beginning I believed that the geometric proliferation of medical blogs indicated strict reproduction by cellular division. It looked like the simple production of two progeny produced by one parental act of division. I

Bureacrats governing the

Bureacrats governing the practice of a profession! Heavens to Betsy, what's next? Insurance trusts conspiring to control the healthcare market?

Leaving the 'war on drugs' issue aside, aren't we overlooking the fact that the physician is also alledged to have mistreated up to ten percent of his clientele and that his own attorney acknowledged as much?

As practitioners we must acknowledge that many medications create their own set of problems and any medication that creates the potential for addiction or dependance must carry the additional burden/duty of skepticism.

Leaving the ‘war on

Leaving the ‘war on drugs’ issue aside, aren’t we overlooking the fact that the physician is also alledged to have mistreated up to ten percent of his clientele and that his own attorney acknowledged as much?

That is NOT what his attorney acknowledged. Rather, 5-10% of PATIENTS were misusing the narcotics by selling them on the black market. Prosecutors denied any explicit arrangement between him and the patients, and even the patients who interviewed him said at worst that he was naive.

Further, the "war on drugs" issue cannot simply be left aside as black markets exist when scarce goods are not voluntarily exchangable.

As practitioners we must acknowledge that many medications create their own set of problems and any medication that creates the potential for addiction or dependance must carry the additional burden/duty of skepticism.

Of course many medications create their own set of problems. If you notice, the most recent post on this blog by Trent is entitiled "Breaking News: All Medicines Have Risks". Skepticism is all well and good, especially against people who have the power to determine who is allowed access to pain medications. It does not follow that doctors should be THROWN IN JAIL for providing pain medication to people who desire them.

Making the physician face jailtime ("burden/duty" as you put it) for being compassionate only hampers the patient-physician relationship making it one of suspicion and conflicts of interests. The onus should be on the patients to use their pain medications appropriately after getting advice from their doctors. It's time to treat patients like grown-ups instead of like infants.

"Any medication that creates

"Any medication that creates the potential for addiction or dependance must carry the additional burden/duty of skepticism." WHY??????? Why must my access to pain medication depend on whether I can say the right things to satisfy you that I'm not a junkie? Are you really OK with exercising that "duty" to be skeptical and possibly leaving patients who aren't lying to get drugs in pain? Does it even matter to you? I've met a lot of doctors in my time, both as a patient and in classes, and my very strong impression is that they think everybody's a drug-seeking junkie. I'm really not kidding about this. Their whole attitude is this paternalistic, patronizing "I'll decide how much pain you're in and how much relief you need." I guess it's ok for the doctors, since it's all the same to you guys whether your patients suffer or not! Don't act like it's some kind of burden you're carrying, because it's not your pain. No one's coming after you because your patients are suffering. Sorry, but this one pushes all my buttons about doctors and government. I can't believe how doctors approach the whole thing. The attitude of callousness, paternalism, and c'mon-it-can't-really-be-that-bad toward people in pain is enough to make you scream.

Failure to properly manage a

Failure to properly manage a patients medication use is mistreatment. Providing medication to a person who either misuses, or illegally distributes that medication is mistreatment. Didn't know is not an excuse for should have known. Does anyone honestly think that all patients act solely from entirely honest and good natured motives?

Read between the lines, this practitioner's own clinical records failed to substantiate the need for the very medications he was prescribing to 5-10% of his entire clientele. Just how many people was this? Once again, the attorneys choice of percentages vs. actual numbers speaks volumes.

Good intentions never grant absolution. If you don't like the fact that failure to abide by these principles may open you to legal consequences; I share your concern, but until things change this is the world we live in.

To 90% of his patient load this physician was a Godsend. Unfortunately for another 10% he was doctor feelgood. Maybe he was just an easy mark, maybe he had an alternate take on the duty to prevent drug misuse, maybe he turned a blind eye. In any circumstance he had a duty to exercise caution and judgement, a duty by the way, that comes linked to the priviledge of prescribing. He failed, and he is paying a phenomenally high price.

Personally, I hope there is more to the story. More that would indicate some sort of guilty mind on the part of this guy. Otherwise I find criminal prosecution a far (but legal) stretch. But how much of this stems from a failure of the profession? If Medical Boards could show some sort of serious effort at policing their own maybe they could get the DEA to back off, we all know there are bad actors out there, we all see the problems they create, just how often to you see them getting the attention they need?

We (most) all recognize the pain and suffering that accompanies the undertreatment of pain. But how many of us actually take the time to see the pain and suffering, waste, abuse, criminality, human debasement and neglect that accompanies drug abuse and drug diversion? Does the 90% good outweight the 10% bad? I don't know.

Lisa, You said: "No one’s

Lisa,

You said: "No one’s coming after you because your patients are suffering."

Au contraire. Not only can we be clapped in jail for life without parole if we prescribe too many pain relievers, but we can also be sued for everything we own by the pirates of the plaintiff's bar if we prescribe too few.

There was a recent $1.5 million award in California against a doctor for failing to adequately treat a patient's pain. See http://www.mywhatever.com/cifwriter/library/39/baz978.html.

Society has gone completely berserk on medical issues. We physicians can't possibly live up to such ludicrously unrealistic expectations. I just thank God I'm in a specialty where I hardly ever have to prescribe pain meds.

Reasonably, though, suits

Reasonably, though, suits for negligent undermedication of pain are still rare as hens' teeth. I think if you polled clinicians and asked which they're more worried about - a patient suing if they undermedicate, or the DEA coming down on them with both feet if they prescribe adequate medication - the result would indicate far more worry about the DEA. Not only is DEA action more likely, but DEA action can result in loss of license or imprisonment, whereas the worst that can happen as a result of a lawsuit is monetary ruin (not that that's OK, but it's less devastating than what the DEA can do to you.)

If the phrase "drug seeking" were banned from the profession it would make for better care. But I agree we can't expect doctors to look at treatment for pain from the perspective of the patient's well-being when they have this sort of sword hanging over their heads.

Failure to properly manage a

Failure to properly manage a patients medication use is mistreatment. Providing medication to a person who either misuses, or illegally distributes that medication is mistreatment.

Let's make a crucial distinction here.

Scenario A: Suppose the patient comes up to you and asks, "Doc, I need something for my back. It's killing me. I can't sleep. I can't do my job. My family needs me to be functional." You do your history, physical, tests, etc and conclude he could use painkillers. And you prescribe him the wrong medication, wrong dose, wrong route, or you prescribe it for the wrong patient. Who is at fault?

Scenario B: Suppose the patient comes up to you and asks, "Doc, I need something for my back. It's killing me. I can't sleep. I can't do my job. My family needs me to be functional." You do your history, physical, tests, etc and conclude he could use painkillers. And you prescribe him the correct medication, dose, and route for the correct patient. The patient gets the medication and sells it on the street. Who is at fault?

Surely, you can see a difference between the two scenarios. Every single fact that has come out from this story points to the second scenario, not the first.

Read between the lines, this practitioner’s own clinical records failed to substantiate the need for the very medications he was prescribing to 5-10% of his entire clientele.

What lines are these? Where does it imply that his records were faulty?

Good intentions never grant absolution. If you don’t like the fact that failure to abide by these principles may open you to legal consequences; I share your concern, but until things change this is the world we live in.

Is that right? Let's say a set of parents have 10 kids. Though they are doting, compassionate, prideful parents, one of the children turns out to be a drug addict when he grows up. Should we lock the parents up?

If we don't lock up parents - people who bear great responsibility for imparting values and habits upon their children - then should we be locking up doctors when 1 out of 10 patients of theirs lies to them to get drugs? Should we lock up a football coach when some of his players are caught taking drugs? Should we lock up the medical school dean when one of the students is caught drinking on his OB rotation?

To 90% of his patient load this physician was a Godsend. Unfortunately for another 10% he was doctor feelgood.

So the patients took advantage of him, lied to him, deceived him, and exploited his compassion and generosity. Lock him up?

If you don’t like the fact that failure to abide by these principles may open you to legal consequences; I share your concern, but until things change this is the world we live in.

I've never understood this sort of argument. Of course this is the world we live in. What other world is there? Isn't the reason we read and post on blogs to talk about how things should be? Of course I realize the poor guy is going to jail. I understand that perfectly well. It is the "world we live in". Why else would we be making a big stink about it?

We (most) all recognize the pain and suffering that accompanies the undertreatment of pain. But how many of us actually take the time to see the pain and suffering, waste, abuse, criminality, human debasement and neglect that accompanies drug abuse and drug diversion? Does the 90% good outweight the 10% bad? I don’t know.

I find this sort of attitude repugnant. The question of the patient's own capacity to make choices and take responsibility never enters the fray. Patients are simply chess pieces to be moved around the board by "society". They are viewed as mere children who cannot be entrusted to even cross the street or take risks and sometimes even fail, but ultimately bear responsibility. It's simply 10% bad which must be compensated for by innocent parties.

Medical paternalism's gotta go.

Blade doc, No, I'm not

Blade doc,
No, I'm not insane. If I thought writing my Congressman would do a damn bit of good, I would. Thanks for proving my point about doctors, callousness, and paternalism.

Dear Docs, what can be done

Dear Docs, what can be done about the prohobition attitude of the DEA? sorry about my spelling I am suffering from unrestorative sleep from undertreatment of pain, some uneducated people suggest writing to the congressman, who gave this insane power to the DEA to start with, those guys dont even buy thier own groceries and have no concept of reality, because thier own doctors will give them whatever they want kinda like Elvis.
Who is congress going to listen to? us who are the sufferers, and punished by doctors for having pain by being undertreated? The number one problem in America according to the pain foundation. some cancer patients in nursing homes getting asprin for pain. Or are they going to listen to doctor groups and orgainazations because they have the medical expertise to tell congress what pain is and who is suffering?
Genicide is going on as we speak of people suffering so badly they kill themselves and not just isolated incedents. I would have killed myself if I could have got up off the floor. How many have to die before someone comes to the legitamate pain patient rescue, we have been complaining for years, writing as Mark Twain called them the house for the crimanaly insane or congress, the result? now you have to sign for Sudafed and give your drivers Liscence to be entered in another useless government program, which has been shown not to do anything about criminals making meth, curbing the illegal appetite, or preventing any crime, congress is not the answer, these are the guys that created Al Capone through prohibition, got us in debt, paid Turkey billions not to grow opium which they did after we paid them, created the war on drugs by making the drugs so valuble they have a 17,000 percent mark up, so really what can common pain patients hope to accomplish with these mental giants? The only way congress moves is if one of them has pain or someone important like a "Movie star" or Ted Kennedy says something.
I really thought everyone who was intelligent knew "Write your congressman" is really another way to say there is nothing you can do and nothing they will do. Kinda like "The check is in the mail"? everyone knows it means the check is really not in the mail, I thought I might point that out to our friends who still dont know "write your congressman".. is another way to say " all is lost." :dunce: