Pubdate: Sat, 23 Mar 2002 Source: News & Observer (NC) Copyright: 2002 The News and Observer Publishing Company Contact: http://www.news-observer.com/ Details: http://www.mapinc.org/media/304 Author: SARAH AVERY PAIN RELIEF EXPERTS TESTIFY RALEIGH - A pain specialist from Wake Forest University's medical school said Friday he had concerns about how Dr. Joseph Talley prescribed narcotic pain relief to patients without first performing physical examinations. Dr. Richard Rauck, a professor of anesthesiology at Wake Forest University Baptist Medical Center, spent most of the day testifying as an expert witness during a second day of hearings before the N.C. Medical Board. The board has accused Talley of deviating from accepted standards of practice in his treatment of patients, particularly as he prescribed powerful narcotics such as OxyContin, morphine and methadone. After the hearings, board members will decide whether to revoke Talley's license, tender a lesser sanction or clear him. Talley, 64, contends he has done nothing wrong, and late Friday afternoon he put on his own expert witness -- a nationally renowned pain expert from Texas who said Talley's treatment was exemplary. "He was well within the standard of care," testified Dr. C. Stratton Hill Jr., professor emeritus from the University of Texas in Houston. Reputation spreads At the center of the medical board's examination are 12 specific cases of patients, identified only by letters of the alphabet. "Patient X" was a woman who received 4,875 mg of OxyContin for arthritis, osteoporosis and degenerative disc disease; "Patient D" was a woman whom Talley kept on methadone during her pregnancy; "Patient N" was a drug addict. The patients flocked to Talley's practice across the street from a bedspread mill in Grover, a tiny town south of Charlotte. Some came from as far away as Michigan, having heard about Talley from other doctors who treated chronic pain. And most received prescriptions for narcotics and other drugs the government considers addictive. As he examined Talley's files, Rauck said, he grew concerned that the small-town doctor was failing to perform adequate physical examinations of patients before prescribing drugs. In case after case -- Patient X, Patient Q, Patient A -- Rauck noted the lack of an exam. "A physical exam to most of us requires a component of a hands-on examination of the patient," Rauck said. Simply watching whether someone appears to have trouble getting up from a chair is not enough. "It's observational." In cross-examination, however, Talley's attorney pressed Rauck to read further into the files. In each instance, the patients had provided Talley with their files and charts from other doctors -- some of them specialists who had conducted exhaustive diagnostic tests to pinpoint the source of patients' ailments. "Isn't it true he had all the information he needed in order to prescribe for the patient?" attorney Robert Clay asked Rauck, referring to the case of a steel worker from Michigan whom Talley was treating with OxyContin. "That's true," Rauck conceded. But Rauck added that all doctors ought to do their own exams on patients -- conditions can change, doctors can miss things. He said all doctors who prescribe narcotics should also monitor their patients carefully for signs of abuse. Urine tests can tell whether patients are taking the drugs they are prescribed, instead of selling them to addicts or swapping them for street drugs. Costs kept low Talley has said such safeguards are unnecessary, and his expert, Hill, agreed. Talley told the medical board earlier that his approach to care was specifically tailored to his patient base. The people who came to see him were often poor or lacked insurance, so he set his fee at $55 and didn't order up procedures he deemed redundant, wasteful and expensive. Instead, he told the board, he relied on observations, discussions with family members and gut reactions about how well his patients were doing. In testimony Friday, Hill said Talley offered a worthy public service to his patients. Trust or verify? What's more, Hill said, Talley was right to dismiss the validity of urine tests and other measures designed to weed out drug abusers. People who divert their narcotic prescriptions by selling them on the street are smart enough to pop a pill before going to the doctor for a urine test. Similarly, if someone is addicted to the narcotics and taking too many, no urine test can determine the amount of drug in the system. Hill said such tests compromise the trust inherent in doctor-patient relationships. "I'm concerned about the attitude in North Carolina," Hill said, "where patients are considered suspects." Testimony is expected to end today. At some point afterward -- hours or perhaps days -- the board will render its decision. - --- MAP posted-by: Keith Brilhart