COMPASSIONATE HEALTHCARE NETWORK
C H N
The Drug Enforcement Administration
DEA Withdraws Its Support Of Guidelines on Painkillers
Leaving Patients in Pain
D.E.A. DICTATES DOCTOR CONFUSION
DOCTOR IN VA. DRUG-TRAFFICKING CASE GRANTED NEW TRIAL
By Marc Kaufman
Washington Post Staff Writer
Thursday, October 21, 2004; Page A03
The Drug Enforcement Administration has reversed its support for a set of negotiated guidelines designed to end a controversy over the arrests of hundreds of pain specialists who prescribed powerful narcotics for their patients. The agency took the document off its Web site earlier this month, less than two months after announcing it with great fanfare.
In rescinding its endorsement, the DEA wrote on its Web site that the 31-page document "contained misstatements" and "was not approved as an official statement of the agency." The agency declined to give any more specifics, saying that it hoped to issue a statement "in one or two weeks."
Worried doctors who had worked on crafting the "consensus" document -- written over the past year by DEA officials and prominent pain management specialists -- criticized the agency's unannounced decision to disavow it. They said they were given no explanation or told whether the agency had changed its position on the contentious question of when and how doctors can prescribe the popular painkillers without risking prosecution.
Advocates for aggressive pain management said the DEA's decision appears to have been triggered when defense lawyers tried to introduce the guidelines in the upcoming drug-trafficking trial of William Hurwitz, a McLean physician.
In late September, Hurwitz's defense team sought to introduce them as evidence. Several weeks later, the DEA took the document off its Web site and said it was not official policy.
Twelve days after that, U.S. Attorney Paul J. McNulty, who is prosecuting Hurwitz, filed a motion in the case asking that the guidelines be excluded as evidence, again saying that they do "not have the force and effect of law."
"It seems pretty clear that they felt they had to try to get rid of the guidelines because they supported so many parts of our case," said Hurwitz's defense attorney, Patrick Hallinan. "If the Justice Department followed the guidelines, there would be no reason to arrest and charge Dr. Hurwitz." The case is scheduled for trial Nov. 3.
DEA spokesman Ed Childress said the agency intends to rework the guidelines and publish them again. He said he could not comment on whether the decision to remove them had anything to do with any legal case.
The guidelines, which were published in August in the form of a "Frequently Asked Questions" feature prominently displayed on the DEA Web site, were described at the time as an effort to codify the "balance" that both the DEA and the pain management community have long said they are seeking.
The DEA has complained in the past that irresponsible, and possibly criminal, doctors prescribed narcotic painkillers too frequently and without enough care -- letting the valuable drugs get into the hands of people who sell them, abuse them and sometimes are harmed by them.
But many pain specialists have watched with dismay as scores of colleagues were arrested on criminal charges based on what many believe was sometimes good, aggressive treatment or, at worst, negligent prescribing practices. Many of the cases triggered mandatory sentencing guidelines that can send convicted drug dealers to prison for decades.
The introduction of long-lasting prescription opioids such as OxyContin revolutionized the treatment of pain, which doctors say is greatly under-treated in the United States.
Researchers say a small percentage of patients become addicted, but most people in pain do not. However, OxyContin and other powerful drugs became popular with drug abusers in the late 1990s, especially in rural and southern areas, and it has been linked to numerous hospitalizations and some deaths.
The consensus document was the product of more than a year of work by Russell K. Portenoy, a leading pain expert with New York's Beth Israel Medical Center, University of Wisconsin pain specialist David E. Joranson, professionals involved in the care of dying patients, and two top officials of the DEA.
When the guidelines were made public, DEA Administrator Karen P. Tandy embraced them and said in a statement: "The medical and law enforcement communities continue to work together to carefully balance the needs of legitimate patients for pain medications against the equally compelling need to protect the public from the risk of addiction and even possible death from these medications. . . . The DEA is committed to assisting the overwhelming majority of health care providers who successfully strike that balance every day, as well as the law enforcement officers investigating diversion and abuse of pain medications."
Portenoy said the group worked closely with the DEA, responding to many of its concerns and revising drafts many times to accommodate the agency. Portenoy said agency officials were active in the entire process, and he said he strongly believed that there had been "complete buy-in from the upper echelon" of the DEA regarding the guidelines.
Since word went out the guidelines had been withdrawn, he has received many calls and e-mails from worried and upset doctors, Portenoy said.
"There was a real feeling that we had made significant progress, but now we have to wonder whether that progress is all gone," Portenoy said. "If they don't fix whatever problems they might have and put the document back up, that would speak very clearly that the goal of the DEA is not to collaborate with the medical community or to reassure doctors about the proper role and use of prescription opioids in pain management."
The guidelines were also on many Web sites for pain clinics and programs. The DEA called at least one of them, the Pain & Policy Studies Group of the University of Wisconsin, and asked it to remove the document.
Patients in Pain
Saturday, October 30, 2004; Page A18
"DEA Withdraws Its Support of Guidelines on Painkillers" [news story, Oct. 21] described the arduous consensus-building undertaken by Drug Enforcement Administration officials and the medical establishment in developing pain-management guidelines. What was missing from the article -- and from the decision making -- was the effect that the DEA's renunciation of its consensus document has had on patients experiencing pain related to life-limiting illness.
The DEA decision has turned the clock back on years of work by oncologists, ethicists and patient advocates seeking reasonable, responsible and humane remedies for pain. A 2003 Institute of Medicine report targeted pain control in advanced cancer as one of 20 priority areas that could transform health care in America. The report said, "Twenty percent of Americans die from cancer, often after months of painful progressive illness. Effective programs have shown that this pain typically can be controlled enough to give patients a satisfactory level of comfort."
The DEA promises to revisit this issue, but the government's retreat from its pain-management guidelines is an affront to patients and those who care for them.
ELLEN L. STOVALL
President and CEO
Member, Board of Directors
National Coalition for Cancer Survivorship
© 2004 The Washington Post Company
D.E.A. DICTATES DOCTOR CONFUSION
PLEASE COPY AND DISTRIBUTE
DrugSense FOCUS Alert #296 Monday, 25 Oct 2004
This past week, the Drug Enforcement Administration removed from its website a document titled 'PRESCRIPTION PAIN MEDICATIONS: Frequently Asked Questions and Answers for Health Care Professionals and Law Enforcement Personnel.' saying it contained misstatements. See http://www.deadiversion.usdoj.gov/faq/pain_meds_faqs.htm
While most websites have removed the document, a web search today still finds copies, like the one at http://headaches.about.com/library/meds/pain_meds_faqs.pdf
Pain control advocates blasted the move, saying the document was needed guidance for physicians who feared prosecution in prescribing the powerful drugs.
The dispute is the latest chapter in a long running battle between groups that promote appropriate use of pain medication and the DEA.
Effective medical pain treatment SHOULD be a human right. In fact, allowing people to suffer pain untreated is equal in many ways to physical torture. Under treatment of pain is a fact and the DEA owns much of the responsibility for it.
Decisions on proper levels of pain medications should be a private matter between patients and their physicians. Leaving the DEA as final arbiter of the line where responsible use ends and illegal diversion begins is a bad idea. Even when such guidelines exist -- as they did for a few days until the DEA removed them from their website -- the idea that law enforcement should be making medical decisions is ludicrous.
Please consider writing a letter to the editor of the Washington Post, and to your local newspapers. The problems caused by the DEA and law enforcement for pain specialists and their patients has had much press over the past months. Thus a letter about the short lived DEA guidelines may be well received by any newspaper. You may find letter to the editor contacts for your local newspapers at: http://www.mapinc.org/media.htm
Many chronic pain related news clippings may be found at this link http://www.mapinc.org/find?232
If you support a defined set of guidelines, express your demand that the DEA produce such a list immediately so as to reduce doctor confusion and to lower the chances that either a patient or doctor will be unduly charged as drug criminals. If you believe the DEA should not have such overall power to intrude on doctor/patient relationships using pre-set guidelines, express your demand that the DEA desist from charging either doctors or patients as drug criminals without first having direct evidence of illegal diversion by one or both parties.
Thanks for your effort and support.
It's not what others do it's what YOU do
Note: This is a sample only. Please write your own letter! Newspaper
editors are well aware attempts to have many people send them form letters for publication, and reject those attempts. See, for example, this article on letter writing published yesterday: http://www.oregonlive.com/search/index.ssf?/base/editorial/1098533049109381.xml
The Drug Enforcement Administration continues to delay the release of guidelines for use by medical doctors who prescribe pain medications. Every day that passes without those guidelines being well-defined and available to all MDs is another day that doctors are put at risk of being arrested by DEA agents and charged with one or more drug crimes. Without well defined rules for prescribing opiates, such arrests can occur even though the doctor is following established medical procedures and has no intent to either over-prescribe pain medicine or to see them be illegally diverted to unqualified users.
Considering the harsh and punitive legal sanctions that can be levied against any American convicted of a federal drug crime, not having an accepted set of federal guidelines from the DEA also puts patients' legitimate medical needs at risk. Doctors confused by constantly changing and/or non-existent federal rules will likely lean to minimizing dosage levels in order to protect their own liberty even when they might know the patient could benefit from a different level of care.
It's time for the DEA to settle the confusion for all concerned. If they continue to delay, the health of patients and the liberty of both patients and doctors are both at undue risk.
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Prepared by: Stephen Heath, MAP Media Activism Facilitator
= Please help us help reform. Send drug-related news to firstname.lastname@example.org
Medical groups are hailing a
federal appeals court's decision to grant a new trial to a Virginia doctor
accused of drug trafficking for prescribing large quantities of narcotics to his
The 4th Circuit Court of Appeals ruled Tuesday that jurors at the 2004 trial of Dr. William Hurwitz of McLean, Va., were improperly prevented from considering whether he acted in good faith. He was convicted on 50 counts and sentenced to 25 years in prison.
An appeals court judge, William Traxler Jr., wrote that the jury should have been told that Dr. Hurwitz committed no crime if he had a reasonable, good-faith belief that the prescriptions were appropriate medical care. "A doctor's good faith in treating his patients is relevant to the jury's determination of whether the doctor acted beyond the bounds of legitimate medical practice," Judge Traxler said. "The district court effectively deprived the jury of the opportunity to consider Hurwitz's defense."
The case attracted the attention of physicians and patients' advocates who said the tough punishment could discourage doctors from providing adequate medication to those with severe pain.
Prosecutors argued that Dr. Hurwitz wildly overprescribed pain-killing drugs such as OxyContin and Dilaudid, giving one patient prescriptions for more than half a million pills over a 40-month period. The government also said there was evidence the physician suspected that some of his patients were selling a portion of their prescribed medicines.
Defense attorneys contended that Dr. Hurwitz acted within professional standards and that patients suffering from long-term pain can require extremely high doses of narcotics because smaller doses often become ineffective over time. The defense acknowledged that Dr. Hurwitz had been disciplined by state medical boards, but said those agencies "were back in the Stone Age."
A past president of the American Academy of Pain Medicine, Dr. Scott Fishman, said his group has not formally endorsed or rejected Dr. Hurwitz's methods, but filed an amicus brief because the court proceedings put all doctors in jeopardy. "On the surface, this is a case that appears to be an issue around a doctor who is at the extreme of practice, if not over the line," Dr. Fishman, a professor at the University of California at Davis, said. "It was about whether he got a fair trial. We felt if we didn't stand up in this case, future legitimate appropriately prescribing physicians could be prosecuted as drug dealers. We're trying to protect patients."
A libertarian-oriented physicians group, the American Association of Physicians and Surgeons, offered a more robust defense of Dr. Hurwitz. "Billy Hurwitz is an accomplished physician at the cutting edge of medicine, trying to help his patients," a lawyer for the group, Andrew Schlafly of Far Hills, N.J., said. "This guy published articles in medical journals. He had a medical approach."
Mr. Schlafly said federal prosecutors overreached by using the criminal justice system to control doctors. "The federal government has no business mischaracterizing a doctor as a drug dealer and interfering in the states' regulation of the practice of medicine," the lawyer said.
Mr. Schlafly said the defense victory was remarkable because the 4th Circuit is considered the most pro-government of the federal appeals courts. "This was a rarity, really," he said.
An attorney for Dr. Hurwitz, Lawrence Robbins, said he was "delighted" with the decision. He said overzealous prosecutors had "chilled the availability of legitimate and legal pain management."
Prosecutors said through a spokesman that they were considering their options, which include asking the full bench of the 4th Circuit to rehear the case.
While the appeals court panel was unanimous in granting Dr. Hurwitz a new trial, they differed over precisely what jurors should have been told. Judge Traxler and another judge, Cameron Currie, favored telling jurors that the doctor's belief he was acting appropriately had to be both in good faith and objectively reasonable. However, the third judge on the panel, Hiram Widener Jr., dissented, saying that made little sense. "The two terms are contradictory, it seems to me," he wrote.
Liebeskind's lab remained in the forefront of the field for more than twenty
years. In the 1980s, he and his team demonstrated that pain repressed the
body's immune system and could indirectly promote tumor growth, or in
Liebeskind's stark phrase, "Pain can kill!"
Liebeskind's editorial in Pain (1990) was a forceful expression of his
lifelong view that the ultimate purpose of pain research was to provide better
care for pain patients and to ensure that no patient should have to suffer the
debilitating and dangerous condition of chronic pain.
1998 symposium on
"Pain and Suffering in History–
Narratives of Science, Medicine and Culture," The index is on this page:
Dr. Hurwitz Appeal: http://www.csdp.org/news/news/054474p.pdf
NEW DEA STATEMENT HAS PAIN DOCTORS MORE FEARFUL by Marc Kaufman, Washington Post Staff Writer, 30 Nov 2004 Washington Post
Common Sense for Drug Policy is a nonprofit 501(c)(3) organization dedicated to reforming drug policy and expanding harm reduction. http://www.csdp.org/news/news/oxycontin.htm
AMERICAN PAIN SOCIETY
When Morphine Fails to Kill By GINA KOLATA
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