Pubdate: Tue, 29 Jan 2002
Source: Seattle Times (WA)
Copyright: 2002 The Seattle Times Company
Contact: opinion@seattletimes.com
Website: http://www.seattletimes.com/
Details: http://www.mapinc.org/media/409
Author: Carol M. Ostrom

DOCTORS LEERY OF U.S. CRACKDOWN ON PAIN DRUGS

Most doctors, no matter where they stand on assisted suicide, aren't
enthusiastic about the federal government second-guessing their
prescribing practices.

As a result, many are looking warily at Oregon, where U.S. Attorney
General John Ashcroft has threatened to slap federal penalties on
doctors who prescribe any government-controlled medication that
patients use to end their lives.

The issue has taken on broader, national implications because
medications in this category also can be used by gravely ill patients
to control their pain.

The question is this: Will federal intervention in Oregon make
doctors everywhere more reluctant to prescribe strong pain medication?

What, some wonder, would happen to doctors intent on relieving pain
in dying patients who prescribe so much medication that it hastens
death?

Before the Ashcroft directive hit in November, it seemed Oregon was
moving toward improving the shoddy state of pain management in
terminally ill patients, a problem identified in scores of studies.

Now, those on both sides of the assisted-suicide issue fear that
doctors, worried about jeopardizing their practices by prescribing
pain medication, will just say no.

A lawsuit by patients, doctors and the state of Oregon, where voters
twice passed a law allowing terminally ill, competent patients to
request and receive lethal medication, has challenged the federal
intervention. Within the next few months, the issue will be decided
in federal court in Oregon.

Pain experts who have filed a friend-of-the-court brief supporting
the lawsuit say the intrusion of the Drug Enforcement Administration
(DEA) into physicians' decision-making will create "panic and fear"
among doctors.

"Faced with the threat of criminal investigation, revocation of their
prescription licenses and even possible imprisonment, physicians are
responding by undertreating those patients with the most severe
pain," they wrote.

A federal judge has put Ashcroft's directive on hold while both sides
make their case for a summary judgment. A big question in front of
the judge is whether the feds can legally control this aspect of
medical practice, which has long been the province of the states.

The Ashcroft directive, sent to DEA Administrator Asa Hutchinson,
said "prescribing, dispensing or administering federally-controlled
substances to assist suicide" violates the Controlled Substances Act
of 1970.

Assisting suicide, Ashcroft said, has no "legitimate medical
purpose." His statement echoed last year's U.S. Supreme Court case
outlawing marijuana-buyers clubs for ill patients.

Ashcroft attempted to reassure doctors that the directive was not
meant to deter prescribing controlled substances, such as morphine,
to alleviate pain.

Despite the assurances, "everybody thinks, rightly or wrongly, that
the feds will look at narcotic-drug prescriptions," particularly
those prescribed to terminally ill patients, said Thomas Preston, a
retired cardiologist in Seattle.

"I've talked to my former colleagues and people I see randomly, and
they say, 'It's a little scary. I steer clear of that stuff. I don't
want to get involved,' " said Preston, one of the physician
plaintiffs in a 1994 Washington lawsuit asserting a constitutional
right to suicide assistance.

Though the U.S. Supreme Court concluded there was no such right, its
opinion was broadly interpreted as having left open the door for
experimentation in the "laboratory of the states."

Not everyone thinks the Ashcroft directive will cause doctors to
skimp on pain medications.

Dr. Gregory Hamilton, a Portland psychiatrist and longtime opponent
of assisted suicide, called such talk "scare tactics." The Justice
Department's assurances should be enough to reassure doctors that
pain management is "good medical care," he said.

But Ann Jackson, head of the Oregon Hospice Association, said even
hospice workers, many of whom believe strongly that assisted suicide
is wrong, are worried about anything that increases doctors'
reluctance to help patients in pain.

"We're hearing about more problems," Jackson said, including reports
from hospices that patients are coming in "with their pain not under
very good control."

"It's truly disgusting," Jackson said. "We have hundreds of thousands
of people who do not have adequate pain management. Not all are
terminally ill - some are chronically ill, some are surgery patients."

It's not easy to find a doctor who admits skimping on pain medication
- at least not since Compassion in Dying, an organization that
assists terminally ill patients, began filing complaints and lawsuits
against medical providers who don't offer adequate pain medication to
patients.

But many say physicians are afraid of raising "red flags" or being
investigated. The easiest thing for physicians, Jackson said, is to
simply avoid prescribing, especially to anyone who might die.

Dr. Louis Saeger, a pain specialist in Bremerton and president of the
Washington-Alaska Cancer Pain Initiative, said he's "very much
opposed" to physician-assisted suicide.

"But I'm equally opposed to the likes of John Ashcroft overriding
legitimate public opinion and sending out DEA agents to ride herd on
Oregon doctors," he added.

"If I prescribe four grams of morphine a day, does that mean I'm
trying to kill my patient?" he asked.

Federal authorities have indicated only doctors in Oregon who
participate in the assisted-suicide law would face scrutiny under the
Controlled Substances Act.

But Kathryn Tucker, legal director for Compassion in Dying, said
that's unworkable and perverse.

"The abuse occurs when you're in the back alleys, when you don't have
consultations and all those safeguards," she said.

For many terminally ill patients, just getting the prescription makes
them feel better "because they've taken a cautionary step in case
things go wrong," said Jackson, the Oregon Hospice Association
official.

Since the Oregon law was implemented, less time has been spent
debating the issue and more spent making terminally ill patients less
likely to choose suicide, Jackson said.

For example, doctors have learned more about pain management, and
more are referring patients to hospice, she said.

The measure requires a 15-day waiting period and has other safeguards
to ensure those who choose to end their lives are mentally competent,
not depressed, and have time to reconsider.

The law was used by 70 patients in its first three years, the most
recent available figure.

"There's no one in this state, regardless of where they stand (on
assisted suicide), who wants people to use physician-assisted suicide
as the first line in a terminal illness," Jackson said.

Some think that legalizing assisted suicide took the heat away from
Oregon doctors who prescribe controlled substances for other reasons;
now there is no suspicion of surreptitious suicide assistance.

Compassion's Tucker said plaintiffs - including the state of Oregon,
terminally ill patients, physicians and pharmacists - will hit the
Ashcroft directive on several fronts.

Some of the most important will focus on the issue of federal
intervention in the state's control of medical practice and the use
of the Controlled Substances Act to do it.

If the judge sends the case to trial or it goes to an appeal, Tucker
expects to address the directive's effect on doctors' willingness to
give patients adequate pain control and comfort care.

But for this round, in which both sides are asking for "summary
judgment," only factual issues can be argued. And patients' pain,
like doctors' fear, is, at least at this point, not a fact but a
feeling.