Pubdate: Mon, 25 Jul 2005
Source: Time Magazine (US)
Section: U.S. Edition; Science/Medicine; Pg. 56
Copyright: 2005 Time Inc
Author: Margot Roosevelt
Bookmark: (Chronic Pain)
Bookmark: (Oxycontin/Oxycodone)
Bookmark: (Rockefeller Drug Laws)


The Feds Are Cracking Down On Pain Specialists, And Doctors--And 
Their Patients--Are Crying Foul

On a cold morning last April, in the shadow of Montana's Beartooth 
Mountain range, five agents from the federal Drug Enforcement 
Administration (DEA) walked into the office of Dr. Richard Nelson, a 
Billings neurologist. For six hours, they combed through his records, 
seizing 72 patient charts and confiscating his drug-dispensing 
permit. The charge?

None so far, but the assumption is that he is suspected of improperly 
prescribing narcotic drugs.

Despite a distinguished professional record spanning more than four 
decades, Nelson has had to spend $20,000 on lawyers, fearing that the 
government will indict him if it turns out that one of his patients 
has misused his medicine. "My practice is sunk," says the 73-year-old 
physician, who specializes in chronic-pain treatment. "I can't even 
write a prescription for Tylenol 3 if someone has a migraine."

The DEA, for its part, says it was acting on tips from "several 
individuals in the community and pharmacies ... regarding suspicious 
prescriptions," according to a spokesman, who declined to elaborate.

It's a messy situation.

No one is denying that federal and state officials, under pressure to 
combat a spike in pain-killer abuse, are waging an escalating war on 
drugs that is spilling into the waiting rooms of neighborhood doctors.

Over the past six years, more than 5,600 physicians from Alaska to 
West Virginia have been investigated on suspicion of "drug 
diversion." Some doctors allegedly prescribed narcotics too freely, 
while others issued them to patients who turned out to be dealers or addicts.

More than 450 doctors have been prosecuted on charges ranging from 
illegal prescribing and drug trafficking to manslaughter and murder.

But in the government's new crackdown, legitimate physicians and 
patients may be getting caught in the net. "Fifty million Americans 
are in severe pain from arthritis, back injuries, cancer and other 
disabilities," says Dr. Scott Fishman, president of the American 
Academy of Pain Medicine. "But the government is sending a message to 
avoid prescribing strong pain-killers."

Ultimately, it may be the patients who get hurt most, because a 
growing number of doctors, frightened of government scrutiny, are 
avoiding the use of powerful narcotics such as OxyContin, Vicodin, 
Percocet and Dilaudid. "It is impossible to be sure that a patient is 
not diverting any of his medication," says Dr. Thomas Stinson, a 
Medford, Mass., anesthesiologist who is closing his 20-year practice 
to new pain patients. "I fear I might be targeted."

In the past year, hundreds of sufferers have contacted the 
Baltimore-based American Pain Foundation. "They've gone to every 
physician within hundreds of miles and can't get someone to prescribe 
to them," says executive director Will Rowe. In some cases, patients 
with high-dosage prescriptions are turned away by drug stores, which 
are also subject to DEA investigations. "It's demeaning," says Mary 
Vargas, a Maryland attorney whose spine was injured in an auto 
accident. "Pharmacists tell me they don't have the medication, only 
to recant and dispense it when I persist with the manager."

The pain wars escalated last April when Virginia internist Dr. 
William Hurwitz was sentenced to 25 years in federal prison after 16 
former patients testified against him and a jury found that the death 
of another patient was caused by an overdose.

Hurwitz's assets were seized, and now he is appealing his conviction 
with the help of the pain foundation and the Association of American 
Physicians and Surgeons. Hurwitz defenders acknowledge that he may 
have practiced overly aggressive medicine and allowed addicts to 
snooker him, but insist he never profited from drug sales and was not 
a criminal. "Maybe his license should have been suspended," says Dr. 
Russell Portenoy, chairman of the Department of Pain Medicine and 
Palliative Care at Manhattan's Beth Israel Medical Center. "But there 
was no evidence that his patients were not in pain."

That's not how DEA administrator Karen Tandy sees it. "Dr. Hurwitz 
was no different from a cocaine or heroin dealer peddling poison on 
the street corner," she told reporters after his sentencing. 
Prosecutors said Hurwitz prescribed "obscene" amounts of medicine to 
patients he knew were addicted to cocaine and other drugs.

As for the DEA's other investigations and prosecutions, "We're not on 
a witch hunt," Tandy told TIME. "We are very careful in our 
investigations. More than 600,000 doctors are registered to prescribe 
controlled substances. There are a very small number of bad apples." 
Her agency, she says, has stepped up its investigations because of an 
"explosion" of illegal-prescription-drug abuse. "People are dying out there."

The use of opioids--medicine originally derived from poppies--dates 
back thousands of years.

They were widely available in the U.S. until the public, alarmed by 
the growing number of addicts, called for strict anti-narcotics laws 
in the early 20th century.

In the public mind, opioids such as morphine and laudanum, although 
they remained the most effective pain relievers, became associated 
with their illegal cousins--heroin and opium--and doctors often shied 
away from prescribing them.

But opioids made a comeback in the 1980s, after patient groups and 
physicians focused attention on the problem of under-treated pain. 
Research showed that addiction did not necessarily result from 
aggressive, well-managed opioid therapy.

In the 1990s, as the specialty of pain management grew in hospitals 
and universities, opioid use spread from cancer and end-of-life 
patients to the chronic-pain victims of industrial accidents, car 
crashes and conditions such as migraines, diabetes and rheumatoid arthritis.

But as local internists began to prescribe stronger pain-killers for 
regular patients, some of those drugs--no one has reliable 
figures--began to flow into the black market, whether through 
pharmacy and warehouse theft, Internet sales or the scamming of 
legitimate doctors.

When OxyContin, a time-release version of the opioid oxycodone, was 
introduced in 1995, drug addicts learned to grind up the pills to get 
a quick, intense high; in pockets of Appalachia, Maine and Ohio, 
OxyContin became the drug of choice. Meanwhile, celebrity 
abusers--including Rush Limbaugh and Courtney Love--sparked a flurry 
of publicity, leading politicians to push for a crackdown on what was 
being called an epidemic of prescription-drug abuse.

But the dimensions of that epidemic are in dispute--and from 
unexpected quarters.

Last week a spokesman from the White House Office of National Drug 
Control Policy warned TIME that while prescription-drug abuse is a 
serious problem, and growing among teens, the numbers in a highly 
publicized study from Columbia University's National Center on 
Addiction and Substance Abuse are "not a reliable estimate." The 
survey describes a near doubling of prescription-drug abuse from 1992 
to 2003, but because of changes in the way federal statistics were 
gathered in the past decade, no such claim can be made, the spokesman 
said. Last month the libertarian Cato Institute issued a report, 
Treating Doctors as Drug Dealers: The DEA's War on Prescription 
Painkillers, charging that the agency exaggerated reports of 
OxyContin deaths and overdoses.

Nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin and 
ibuprofen, which can lead to intestinal bleeding, cause 35 times more 
deaths a year than OxyContin, the Cato report contended, and are far 
less effective.

The DEA's $154 million drug-diversion campaign is also under attack 
by state officials.

In a stinging 10-page critique issued last March, 32 state attorneys 
general, led by Oklahoma's Drew Edmondson, charged that the agency's 
proposed criteria for investigations would force severely ill 
patients to make frequent, unnecessary doctor visits, thus increasing 
both their hardship and their co-payments. "DEA is creating a climate 
that ... discourages good practice," they wrote. Tandy met with a 
delegation of attorneys general in April to reassure them that "the 
last thing DEA wants to do is to chill the legitimate prescription of 
pain medications," promising that new rules would balance medical and 
legal concerns.

Meanwhile, 25 states are taking the initiative, mounting their own 
electronic systems in pharmacies to catch suspect patients.

As the national debate plays out, Nelson, the Montana neurologist, 
remains under investigation. He describes himself as a cautious 
prescriber. A graduate of Washington University School of Medicine in 
St. Louis, he also trained with the American Academy of Pain 
Medicine. He required that his patients sign a four-page, 21-item 
contract before getting any opioid treatment, pledging, for example, 
that they had never received a diagnosis of substance abuse or been 
involved in drug dealing, that they would not seek to replace lost 
medication or obtain early refills and that they would buy their 
drugs from only one designated pharmacy.

Monthly checkups and extensive tests--including MRIs and 
electromyographic studies--were the norm, Nelson says. Over the 
years, he has dismissed more than 70 patients for not following his rules.

Since the DEA raid, many of Nelson's patients have been unable to find doctors.

Few physicians are trained in the complexities of pain control, and 
fewer still want to risk government second-guessing. Some of Nelson's 
patients have suffered acute narcotic-withdrawal symptoms, as he was 
unable to wean them gradually.

Others, unable to cope with their pain, lost their jobs. They have 
staged demonstrations and press conferences in downtown Billings and 
mounted petition drives.

As one of the few Montana doctors offering opioid therapy, Nelson was 
"like the Mother Teresa of medicine," says Jeannie Huntley, a 
marketing consultant who suffered brain and neck injuries from a car crash.

No one knows yet if any of Nelson's patients may have overdosed or 
illegally sold their meds--and the DEA is keeping mum. But even if he 
is eventually absolved, the Montana native plans to close his 
practice. "We thought we were doing everything just about right," he 
says. "But now a whole bunch of people are sitting out there hurting 
like hell." --With reporting by Pat Dawson/Billings
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