HTTP/1.0 200 OK Content-Type: text/html Trafficker or Healer? And Who's the Victim?
Pubdate: Tue, 27 Mar 2007
Source: New York Times (NY)
Copyright: 2007 The New York Times Company
Author: John Tierney
Cited: Pain Relief Network
Bookmark: (Doctor Hurwitz)
Bookmark: (Chronic Pain)


ALEXANDRIA, Va. -- The case of the United States v. William Eliot 
Hurwitz, which began in federal court here on Monday, is about much 
more than one physician. It's a battle over who sets the rules for 
treating patients who are in pain: narcotics agents and prosecutors, 
or doctors and scientists.

Dr. Hurwitz, depending on which side you listen to, is either the 
most infamous doctor-turned-drug-trafficker in America or a 
compassionate physician being persecuted because a few patients duped him.

When Dr. Hurwitz, who is now 62, was sent to prison in 2004 for 25 
years on drug trafficking and other charges, the United States 
attorney for Eastern Virginia, Paul J. McNulty, called the conviction 
"a major achievement in the government's efforts to rid the pain 
management community of the tiny percentage of doctors who fail to 
follow the law and prescribe to known drug dealers and abusers."

Siobhan Reynold, the president of an advocacy group called the Pain 
Relief Network, hailed Dr. Hurwitz's singular dedication and compared 
his plight to Galileo's. Some of the country's foremost researchers 
in pain treatment and addiction supported his appeal for a retrial, 
which was ordered because the jury in the first case was improperly 
instructed to ignore whether Dr. Hurwitz had acted in "good faith." 
These scientists say they are upset by how their research has been 
distorted by prosecutors in this case, and suppressed by the Drug 
Enforcement Administration in its campaign against the misuse of 
OxyContin and other opioid painkillers.

In the first trial, the prosecution accused Dr. Hurwitz of crossing 
the line from doctor to trafficker by prescribing irresponsibly high 
doses of painkillers to his patients in the Virginia suburbs of 
Washington. He was accused of ignoring blatant "red flags" or signs 
that some patients were misusing or selling the drugs. That is an 
emotionally powerful argument for a jury: warning signs can seem 
perfectly clear with the benefit of hindsight.

But to researchers who study deceptive patients, there is no such 
thing as a blatant red flag. Deception is notoriously difficult to 
spot, as Dr. Beth F. Jung and Dr. Marcus M. Reidenberg of Cornell 
University document in a new survey of the literature. They note, for 
starters, an experiment showing that even police officers and judges 
- -- ostensibly experts at detecting fraud -- do no better than chance 
at detecting lying.

Doctors are especially gullible because they have a truth bias: they 
are trained to treat patients by trusting what they say. Doctors are 
not good at detecting liars even when they have been warned, during 
experiments, that they will be visited at some point by an actor 
faking some condition (like back pain, arthritis or vascular 
headaches). In six studies reviewed by the Cornell researchers, 
doctors typically detected the bogus patient no more than 10 percent 
of the time, and the doctors were liable to mistakenly identify the 
real patients as fakes.

When treating people with chronic pain, doctors have to rely on what 
patients tell them because there is no proven way to diagnose or 
measure it. Also, there is no standard dosage of medicine: A 
prescription for opioids that would incapacitate or kill one patient 
might be barely enough to alleviate the pain of another.

During the first trial, the prosecution argued that it was beyond the 
"bounds of medicine" for Dr. Hurwitz to prescribe more than 195 
milligrams of morphine per day, but dosages more than 60 times that 
level are considered acceptable in a medical textbook. The 
prosecution's supposedly expert testimony on dosage levels and proper 
pain treatment for drug addicts was called "factually wrong" and 
"without foundation in the medical literature" in a joint statement 
by Dr. Russell K. Portenoy and five other past presidents of the 
American Pain Society.

Dr. Portenoy, the chairman of the pain medicine department at Beth 
Israel Medical Center, was one of the researchers who worked with the 
D.E.A. four years ago to draw up guidelines on pain medication for 
doctors and law enforcement officials. The guidelines assured doctors 
that they would be safe unless they "knowingly and intentionally" 
prescribed drugs for illegitimate reasons, and cautioned narcotics 
agents not to investigate doctors just because they prescribed large 

The D.E.A. published the guidelines, and then abruptly withdrew them 
on the eve of Dr. Hurwitz's trial, just after his defense had 
indicated that it planned to use the document at the trial. The 
D.E.A., which said the document had not been properly vetted, went on 
to repudiate some of the guidelines and warned that it intended to 
keep targeting doctors deemed suspicious because they prescribed 
large quantities and ignored certain red flags.

Dr. Portenoy, who is to be a witness for Dr. Hurwitz at the retrial, 
has been one of the pioneers in identifying the risks of prescribing 
opioids. He says the warning signs that seem so obvious to 
prosecutors rarely offer clear guidance to doctors. When a patient 
keeps asking for refills because he runs out of his pills early, does 
that mean that he is a dealer or that he is not getting enough 
medication? If a urine test shows the presence of cocaine or other 
illegal drugs -- as it did in some of Dr. Hurwitz's patients -- 
should a doctor automatically cut him off? That's what some 
prosecutors and narcotics agents demand, but doctors realize that 
there are plenty of illegal drug users who also need pain relief.

"Half of pain patients would have to stop taking their medicine if 
the rule went out that every so-called red-flag behavior meant you 
couldn't prescribe," Dr. Portenoy says. He and researchers like Dr. 
Steven D. Passik, a psychologist at the Memorial Sloan-Kettering 
Cancer Center, have found that about half of pain patients exhibit at 
least a couple of the warning signs, and that even veteran physicians 
cannot agree on which signs are the most important to look for.

In a pretrial motion, Dr. Hurwitz's lawyer, Richard A. Sauber, asked 
the court to bar the prosecution's expert witnesses from using the 
red-flag argument because "it defies reason that any expert could 
testify" about something without "scientific support." That motion 
was denied, however, so the flags may well be waving during the trial.

Even Dr. Hurwitz's supporters acknowledge that he is not the ideal 
doctor to be the representative for the cause of pain patients. 
Although his expertise in pain medicine is well respected, some say 
he was gullible and reckless to the point of incompetence. But the 
traditional punishments for such mistakes are malpractice settlements 
and the loss of a state medical license, not a federal investigation 
and 25 years in prison.

"Doctors are trained to treat patients, not to be detectives," says 
Dr. James N. Campbell, a Johns Hopkins University neurosurgeon 
specializing in pain, who will be another witness for Dr. Hurwitz. He 
says that doctors have already reacted to the D.E.A. crackdown by 
changing the way they deal with the many Americans -- at least 50 
million, by several estimates -- who suffer from chronic pain.

"Opioids were a revolution in pain treatment during the 1990s, but 
doctors are now more reluctant to use them," Dr. Campbell says. "If a 
doctor perceives there's a 1 in 5,000 chance that a prescription will 
lead to a D.E.A. inquiry -- just an inquiry, not even an arrest -- 
he's not going to take the chance. So the victims are the patients." 
- ---
MAP posted-by: Richard Lake