Pubdate: Sat, 26 Mar 2005
Source: New York Times (NY)
Column: Editorial Observer
Copyright: 2005 The New York Times Company
Contact:  http://www.nytimes.com/
Details: http://www.mapinc.org/media/298
Author: Tina Rosenberg
Bookmark: http://www.mapinc.org/people/Hurwitz
Bookmark: http://www.mapinc.org/find?232 (Chronic Pain)
Bookmark: http://www.mapinc.org/oxycontin.htm (Oxycontin/Oxycodone)
Bookmark: http://www.mapinc.org/rehab.htm (Treatment)

WEIGHING THE DIFFERENCE BETWEEN TREATING PAIN AND DEALING DRUGS

Federal prosecutors in Virginia want Dr. William Hurwitz, recently 
convicted on 50 counts of distributing narcotics, to go to prison for life 
without parole when he is sentenced in mid-April.

For the 50 million or so Americans who suffer from chronic pain, the fate 
of Dr. Hurwitz should be of some interest. He is a prominent doctor 
committed to aggressive treatment of pain. His behavior in some cases was 
inexcusable. Patients for whom he freely provided large prescriptions 
should, at the very minimum, have been given more close supervision. But 
malpractice should be cause for loss of license.

Instead, Dr. Hurwitz has been prosecuted as a drug kingpin because some 
patients sold their pills, although prosecutors never claimed he made a 
penny from it. That sends a chilling message to doctors who treat people 
with extreme pain.

Dr. Hurwitz's case involved prescriptions for opioids like OxyContin or 
Vicodin. Abuse of those drugs can be a lethal problem, but the new 
consensus among pain doctors is that very high doses are appropriate in 
some chronic pain cases. The Drug Enforcement Administration apparently 
disagrees. The Hurwitz case shows that increasingly it is the D.E.A., not 
doctors, that decides what is appropriate therapy.

Last August the D.E.A. published policies to guide doctors in treating 
pain. The document said the amount or duration of pain medicine prescribed 
was a physician's decision and would not by itself spark a criminal 
investigation. Dr. Hurwitz's lawyers filed to introduce it as evidence. 
Mysteriously, it suddenly disappeared from the D.E.A. Web site. The agency 
then announced it contained "misstatements." In November, the agency 
published new guidelines that said doctors who prescribe high dosages of 
opioids for long stretches are subject to investigation.

Pain is already undertreated in America. Although pain experts estimate 
that perhaps one in 10 people who suffer from chronic pain could benefit 
from opioids, the vast majority will never find this out. Many doctors 
won't prescribe opioids, especially in high doses. Opioids are safe and 
nonaddictive if used correctly, but addictive and deadly if crushed and 
injected or snorted, which defeats their time-release mechanism.

Abuse of narcotics like OxyContin is a serious problem and has devastated 
many communities. But a huge amount of OxyContin on the street is stolen 
from pharmacies - 1.5 million tablets from 2001 to 2003, according to the 
D.E.A.

Diversion of prescriptions may account for only a small part of the abuse, 
but it has brought a sadly disproportionate response from authorities. For 
example, Richard Paey, who has used a wheelchair since a car accident in 
1985 and also developed multiple sclerosis, is serving a 25-year prison 
sentence in Florida for fraudulently obtaining prescriptions for Percocet 
even though prosecutors acknowledged he consumed all the pills himself.

Dozens of doctors have been charged with drug trafficking because the 
D.E.A. felt they were prescribing too many pills. The Association of 
American Physicians and Surgeons warns doctors to think twice before 
treating pain. "Discuss the risks with your family," it says.

One California doctor who prescribed opioids, Frank Fisher, was charged 
with five counts of murder - including that of a patient who died as a 
passenger in a car accident. All charges were dropped. A doctor in Florida, 
James Graves, is serving 63 years for four counts of manslaughter involving 
overdoses by people who either abused their prescriptions or mixed their 
prescribed medicines with other drugs.

Dr. Hurwitz, a crusader for aggressive pain treatment, had a controversial 
practice. More than 90 percent of his patients were genuine, and many say 
he was the only doctor who quieted their chronic pain. But his willingness 
to treat patients other doctors shunned, including drug addicts, also 
attracted scammers. It is legal to prescribe to addicts who are in pain, 
and many respected pain doctors believe that in some cases, addiction is 
caused by untreated pain and ends when the pain is controlled.

Dr. Hurwitz, who was disciplined by medical boards several times, testified 
that he did dismiss 17 patients he concluded were abusing their 
prescriptions and was tapering down the dosage for others. But he also said 
he felt that cutting off patients was tantamount to torture, and he did not 
do so without strong evidence of bad behavior.

Many of Dr. Hurwitz's colleagues believe that he was far too slow to accept 
such evidence and that he should not have been practicing medicine. But 
while he was blind to his patients' deceptions, there has never been any 
evidence that he was part of their conspiracy. In the prosecutors' 
post-trial motions, they argue that the conviction should stand even if Dr. 
Hurwitz believed he was prescribing for a legitimate medical purpose.

His prosecution seems inexplicable except as a signal to other doctors that 
they can go to prison for life for being duped by their patients. That 
signal is being heard - the exodus from aggressive treatment of pain is 
increasing. This might marginally reduce the amount of opioids on the 
street, but in the process it will sentence hundreds of thousands of people 
to suffer needlessly. 
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MAP posted-by: Richard Lake