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April 04, 2005

Treating Healers Like Pushers

I hope you never ever have to live with chronic pain. I hope none of your loved ones ever has to live with chronic pain. It is a hell that no individual should have to live with. Medically, there is only one treatment – high doses of pain-killing drugs, including opiates. Trust me – I know. My wife is one whose only relief comes from a pharmaceutical cocktail.

Doctors are hesitant to prescribe these drugs because writing “too many” prescriptions for “too many” pills at “too high” a dosage brings scrutiny that doctors would prefer not to face. My wife’s pain management doctor recently informed us that he had changed office policy to forbid a practice that is standard in most physician’s offices – giving refills to a pharmacy by phone. If my wife (and every other patient) wants a refill, she must make an office visit and be seen by the doctor. Why? Because of cases like this one.

In December, after a federal jury convicted McLean, Virginia, pain doctor William Hurwitz of running a drug trafficking operation, the foreman told The Washington Post "he wasn't running a criminal enterprise." Don't bother reading that sentence again; it's not going to make any more sense the second time around.

Hurwitz, who is scheduled to be sentenced on April 14 and will go to prison for life if U.S. District Judge Leonard Wexler follows the prosecutors' recommendation, was charged with drug trafficking because a small minority of his patients abused or sold narcotic painkillers he prescribed for them. Prosecutors argued his practice amounted to a "criminal enterprise" based on a "conspiracy of silence"—i.e., a conspiracy in which Hurwitz did not actually conspire with anyone—because he charged for his services and should have known some of his patients were faking or exaggerating their pain.

Judging from the comments of the jury foreman, Ralph Craft, the jurors did not really buy this theory. Perhaps they still harbored the legally unsophisticated notion that drug traffickers are people who engage in drug trafficking. But they convicted Hurwitz anyway, because they didn't like the way he practiced medicine.
"I'm not an expert," Craft conceded, while expressing the opinion that Hurwitz was "a little bit cavalier" in prescribing opioids. "He ramped up and ramped up the prescriptions very quickly," he said. "This is stuff that can kill people. He should have been extra careful."

Craft and his fellow jurors were appalled by the sheer number of pills Hurwitz prescribed. "The dosages were just astounding," he said, calling them "beyond the bounds of reason."

But they are not beyond the bounds of reason. The body builds up a tolerance to these medications, as a physical dependency develops. Where one pill getting up and one pill at dinner might have provided relief early on, in a year or so the dosage will need to reach four pills a day, just to be able to move around the house. From there the dosage must increase, or a new medication must be introduced. Some medications are not even considered – Oxy-Contin, for example, because of the scrutiny it brings due to the high level of abuse. And even with all the changes and increases, the pain continues to progress. Still more medication is necessary, just to have some semblance of a normal life.

Those dosages are pretty intense. I was recently prescribed one of my wife’s medications when I had a muscle spasm in my neck and back that went on for two weeks. My dosage was lower, and less frequent than what my wife regularly takes. The first dose took away all my pain – and left me incapable of walking any further than the bathroom for the next six hours – and so frightened that I refused to take the medication again. My wife, on the other hand, is completely clear-headed when she takes a dosage twice as high four times a day. Why? Because her body has built up a tolerance to the medication, and its effect on a systemic neuro-muscular disease is palliative, not intoxicating.

In a letter they wrote before the verdict, six past presidents of the American Pain Society rebuked Ashburn for this statement, along with several other misrepresentations of pain treatment standards. "We are stunned by his testimony," they said. "Use of 'high dose' opioid therapy for chronic pain is clearly in the scope of medicine."

As these pain experts recognized, Hurwitz was not the only person on trial at the federal courthouse in Alexandria. So was every doctor who has the courage to risk investigation by treating people who suffer from severe chronic pain with the high doses of opioids they need to make their lives livable.

In poignant letters to Judge Wexler, who has fairly wide latitude in punishing Hurwitz now that the U.S. Supreme Court has made federal sentencing guidelines merely advisory, dozens of his former patients recount how he saved them from constant agony caused by migraines, back injuries, reflex sympathetic dystrophy, and other painful conditions that left them disabled, homebound, despondent, and in some cases suicidal. They outline the difficulties they had in getting adequate treatment before they found Hurwitz and the trouble they've been having since the government put him out of business.

"Good pain doctors are hard to find," writes one. "I am saddened that Dr. Hurwitz is branded a criminal for helping me and helping people like me." Another argues that Hurwitz's "crime"—trusting his patients—was one of his greatest virtues. "It is to Dr. Hurwitz's credit," he says, "that he chose to trust that his patients were genuinely seeking relief from pain that cannot be objectively measured. This trust is, in my experience, all too rare." Threatening doctors with prison for viewing their patients with inadequate suspicion will make it even rarer.

What has happened here is that the War on Drugs has turned into a War on Doctors – and by extension, into a War on Patients. Prosecutions like the Hurwitz case make it harder for patents like my wife to get needed medications in therapeutic doses. And it leaves me asking uncomfortable questions.

Will the day come that my wife’s doctor is going to refuse to give her the medication she needs in order to keep out of jail?

Will this kind and decent man be put on trial because some patient overdoses or sells medication?

Will some prosecutor be second–guessing my wife’s medical care?

Or will needed medications, and the physician's to prescribe them, remain available?





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