Los Angeles Times
THE
NATION
Painful Rift Unnerves Doctors
The clash over the
use of opioids to treat patients intensifies.
Where law enforcement
officials see a drug pusher, many in medicine
see a
pioneer.
By Ralph Vartabedian, Times Staff
Writer
Federal prosecutors launched one of their highest-profile and most
controversial assaults in the war against prescription drug abuse
recently when they indicted Dr. William E. Hurwitz, a 57-year-old
Virginia pain treatment specialist.
Hurwitz, a Stanford University
medical graduate who also has a law
degree, was depicted as a "street-corner
crack dealer" by federal
officials during a court hearing last month. He
remains in a Virginia
jail, unable to post bail set at $2
million.
Although medical boards have suspended Hurwitz's license three
times
in the last decade and federal officials have depicted him as
corrupt, the case has evoked unexpected support from medical
groups.
Hurwitz is regarded as a pioneer in pain treatment by many
doctors,
academicians and medical groups, who have decried his prosecution.
The case, along with other prominent criminal prosecutions, is
putting a
chill on legitimate pain treatment by doctors who fear
prosecution, they
say.
The Hurwitz case has exposed a deepening rift between law
enforcement
and the medical community over the use of opioids in modern pain
treatment. These powerful drugs, including OxyContin, Vicodin and
Dilaudid, are based on natural or synthetic opium.
Over the last
decade, a revolution in medical thinking has discarded
the idea that people
should just cope with profound long-term pain,
and instead holds that they
should be helped with high doses of
opioids. Without such treatment, the
victims of serious disease and
injury are often bedridden, unemployable and
depressed, and in some
cases suicidal, doctors say.
At the same time,
abuse of these drugs has soared. An estimated 6.4
million Americans
illegally used opium-based painkillers in 2001,
more than the 4.1 million
who used cocaine, according to the
Substance Abuse and Mental Health
Services Administration. OxyContin,
introduced seven years ago and hailed as
a breakthrough drug, has
become the most abused pain pill in the
nation.
Illegal use of opioids has been going up 27% annually, according
to
surveys. Among the most recent high-profile cases is that of talk
show host Rush Limbaugh, who recently admitted he is a pain-pill
addict.
Despite such abuse, national health organizations argue that
serious
pain is undertreated and have criticized the Justice Department and
local law enforcement agencies for causing widespread fear among
doctors
that they can not prescribe opioid painkillers, particularly
OxyContin,
without risking prosecution.
"There is no question that doctors now fear
being held liable if they
prescribe painkillers," said Dr. Michael Fleming,
a practicing
Louisiana doctor and president of the 94,000-member American
Academy
of Family Physicians. "We have let our members know what is going
on.
There is a heightened awareness by the Drug Enforcement
Administration."
A broad range of experts, including pain
specialists, directors of
hospice facilities, academicians and the
pharmaceutical industry,
have come to the same conclusion. Even law
enforcement officials
agree that legitimate doctors are spooked, although
officers have
sought to assure them that they have nothing to worry
about.
"What happens typically is that 99% of the physicians, who are
good,
decent people, can become paranoid," said John Burke, head of a drug
enforcement task force in Ohio and vice president of the National
Assn.
of Drug Diversion Investigators. "This is a very touchy issue.
We do not
want to impact legitimate pain patients or their
physicians."
Prosecutors and investigators say doctors violate the
law when they
prescribe pain pills to patients who they know - or reasonably
should
know - are selling or abusing the drugs. The most flagrant cases
involve doctors who spend little time with patients, write them
identical pain-pill prescriptions and ignore repeated signs that they
are attracting addicts to their office. A patient overdose death, not
evidence on its own of illegal prescribing of pain pills, often
attracts
close scrutiny.
The medical use of marijuana, which received a favorable
ruling last
week from the Supreme Court, is another issue on which federal
prosecutors are clashing with doctors. But with official estimates
that
75 million Americans suffer from persistent pain, opioids have a
vastly more
important and accepted role in medicine.
*
Trying to Curb
Abuse
The DEA, which regulates controlled drugs such as opioids, denies
that it has ramped up prosecutions or adopted tougher investigation
tactics, but rather says it is trying to hold the line on the abuse
of
pain medications, which has caused serious social and economic
problems.
Pat Good, a senior official at the DEA's office of
diversion control,
said the agency was focusing on doctors who ran
"prescription mills"
or whose entire practices involved pain medications
diverted to
illegal uses. And allegations that the agency is putting a chill
on
pain treatment are not new, she said.
"We have heard that same
issue for years," Good said. "Obviously,
there is an increase in abuse and
an increase in our reaction to it.
We have gone out of our way to reassure
people that legitimate
practice is not the issue."
This month, the
DEA doubled its fees on doctors, pharmacies and drug
makers for
controlled-substance registrations, an administrative
action that will raise
an additional $60 million annually for the
DEA's program to fight the
diversion of controlled drugs. The funds
will provide for a modest increase
in DEA enforcement efforts, Good
said.
Good said nearly 1 million
doctors held DEA controlled-substance
registrations allowing them to
prescribe opiates, whereas the agency
had just 400 investigators. In 2002,
68 doctors were arrested for
crimes involving controlled substances; in 2001
there were 76
arrests. The annual number of prosecutions has ranged from 50
to 80
for years, Good said.
Critics say the official statistics
vastly understate the magnitude
and growth of the prosecution efforts,
because 95% of cases are
plea-bargained or handled administratively by state
medical boards in
collaboration with the DEA and local law enforcement
groups.
Even doctors who adhere carefully to rules can run afoul of law
enforcement agencies, according to David Brushwood, an expert on
opioid
legal issues and a professor of pharmacology at the University
of
Florida.
"Something is terribly wrong with the way some criminal justice
authorities have begun to enforce the law against physicians and
pharmacists who prescribe and dispense high-dose opioids to treat
chronic pain," he said. "The necessary balance has tipped drastically
in
the direction of ruthless drug control."
Brushwood, who was long regarded
as a moderate voice on such legal
issues, pointed to the prosecution of Dr.
Frank Fisher. A Harvard
Medical School graduate who ran a clinic for
low-income residents in
Shasta County, Fisher was charged in 1999 with
murdering five of his
patients, along with billing fraud and drug
dealing.
On the first day of his trial in Superior Court, the charges
were
dismissed, though lesser charges are still pending. Fisher says he is
financially ruined and now lives with his father. "This is a
situation
that defies common sense," he said.
Patrick Hallinan, Fisher's San
Francisco attorney, said honest
doctors all over the country were being
targeted by the DEA when
their patients violated the law without the
doctor's knowledge.
Agents are using the same tactics against honest doctors
that are
used against narcotics dealers, he said.
"There isn't any
doubt that these prosecutions are increasing under
the Bush administration,"
Hallinan said. "It is like busting a car
dealer because somebody runs off
the road and kills somebody."
Rather than tip off doctors that their
patients may be dealing drugs
on the street, the DEA strikes deals with the
patients to testify
against the doctors, according to doctors and defense
attorneys.
Doctors are vulnerable because they have no physical test to
determine whether a patient is in real pain, and they have no control
over what happens after patients leave a clinic, they add.
Jeri
Hassman, a Tucson doctor indicted in March, said she was never
informed of
any concerns about her practice over the last 17 years.
She was charged
after an undercover sting that used a three-time
convicted felon, along with
two undercover DEA agents, said Hassman's
attorney Bates Butler.
But
Burke, the narcotics investigator in Ohio, said most good police
departments
did tip off doctors that patients were diverting drugs
before they launched
investigations.
"Physicians are not targeted because of one patient but
rather an
overwhelming pattern of activity," he said. "There is nothing
illegal
about being duped by your patient. Everybody gets duped. The doctors
we target are well-aware they have bad patients."
Of course, not
every local department adheres to such policies. Good,
the DEA official,
said, "Some locals have behaved differently than
the DEA
would."
Still, even in states with progressive medical regulations, like
Minnesota, doctors are growing increasingly worried about
prosecution,
said Dr. Thomas E. Elliott, director of St. Mary's
Hospice in
Duluth.
The prescription volume for doctors who specialize in pain
treatment
- especially those with hundreds of pain patients who travel from
around the country - can create the appearance of a major illegal
drug
distribution operation.
Steps doctors take to protect themselves include
keeping careful
medical records, documenting that opioids are improving
patients'
conditions and requiring patients to sign contracts.
Modern
pain treatment can seem extreme to the uninitiated. The goal
is to provide
as much opioid medication as needed to negate pain - in
some cases, dozens
of pills a day. Although patients may become
physically dependent and will
go through withdrawal if the drugs are
suddenly stopped, they are not
addicted in the traditional sense.
A patient taking opioids for serious
pain reaches a tolerance level
within a few weeks; there is no sensation of
euphoria,
pharmacologists and doctors say, even though the drugs still
cancel
the pain.
Henry Farkas, an emergency room and hospice doctor
in Elkton, Md.,
said he has grown more cautious about prescribing opioids as
he has
heard about prosecutions around the country.
"I worry about
this more than I have in the past," Farkas said.
"These prosecutions are of
good doctors who sound like they were
doing the right thing. But the
government is pursuing them and
charging them with being drug
kingpins."
Medical boards and civil juries have ruled against doctors who
have
failed to adequately treat pain - particularly at the end of life,
when people sometimes go through agonizing ordeals. As a result,
doctors
are often reluctant to say they will not treat pain.
Dr. Ronald Myers,
who operates five clinics for low-income people in
the Mississippi Delta
region, said he too had grown more reluctant
about prescribing painkillers.
Myers, a Baptist minister and regional
advocate for pain treatment, says
that before he writes a
prescription for OxyContin or other opioids, he
requires a patient to
see a pain management specialist.
"But in some
cases, even if the pain management specialist recommends
them, I still won't
write them because I am afraid of the DEA and the
medical board shutting me
down."
*
High Doses Encouraged
It was high-dosage
treatments that Hurwitz helped to pioneer,
according to Brushwood and many
others.
Hurwitz seems like an unlikely champion for the cause of pain
treatment, given his history of run-ins with authority. Before his
arrest late last month, Hurwitz had his medical license revoked once
in
Washington, D.C., and twice in Virginia. His supporters blame the
suspensions on the medical establishment's efforts to block his
campaign
for use of high doses of opioids to treat serious pain.
After his arrest,
the Assn. of American Physicians and Surgeons -
along with the American Pain
Institute, the Pain Relief Network and
the National Foundation for the
Treatment of Pain - condemned the
prosecution at a news
conference.
"It seems to us that the DEA has shifted its focus from
street thugs
to doctors, because doctors are easier targets," said Kathryn
Serkes,
a policy executive at the association of physicians and surgeons.
The
group now flatly advises its doctors not to prescribe
opioids.
The American Medical Assn. has not weighed in on the Hurwitz
case,
but last July fired a warning shot by posting on its Web site a
statement that it "wants no doctor harassment over pain medication"
and
pledging to take the case to President Bush and Atty. Gen. John
Ashcroft.
Good, the DEA official, said that the AMA has not contacted
the agency since
making that statement.
The charges against Hurwitz depict him as a
corrupt and ruthless
profiteer. His arrest is part of Operation Cotton
Candy, in which
federal prosecutors have obtained convictions of more than
15 Hurwitz
patients who were selling pain pills from him on the
street.
The indictment alleges that one of Hurwitz's patients died of a
morphine overdose within 33 hours of her first visit to his office.
Another patient was a pregnant woman whose baby was born with an
addiction, the indictment charged. Assistant U.S. Attys. Gene Rossi
and
Mark Lytle said in a bail hearing that they had tape-recorded
evidence that
a patient told Hurwitz he was dealing painkillers on
the street and the
doctor still wrote a prescription.
Hurwitz's attorney James Hundley said
prosecutors have falsified a
number of claims, such as asserting Hurwitz
earned $2 million in
illegal profits. The $2 million represented Hurwitz'
gross revenues
over a four-year period and included funds needed to cover
staff
salaries and clinic expenses, he said.
And Hurwitz's supporters
remain unshaken.
"Hurwitz is a wonderful doctor, completely dedicated to
his
patients," said Ronald T. Libby, a professor at the University of
North Florida who is writing a book about the friction between law
enforcement and doctors. "If it were not safe for Hurwitz to
prescribe
meds, who would it be safe for?"
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