Top three Bill Clinton misstatements, in no particular order: 1) I never had sex with that woman
2) The era of big government is over
3) I feel your pain.
One of the most obvious facts about pain is that it's subjective. It can't be shared. At one time there were attempts to provide reproducible pain for drug studies. For example, a black spot would be painted on a subject's forehead, and a bright light focused on the spot until the pain caused a reaction. This would be done, first without any pain relievers, and then with various analgesics. There was a scientific logic to the studies, but when the results were translated to the real world, treatment of cancer pain, the results were simply wrong. With all the medical instrumentation in the world, pain assessment remains a subjective report by the patient, and the observation of a nurse or physician. Accuracy is not guaranteed.
The Drug Enforcement Administra-tion, a division of the Department of Justice, not only expects accuracy, but also compliance with the DEA's expectations. That's why, on the DEA website, there's still a picture of Administrator Karen Tandy holding a bag of 1,600 oral solid dosage forms (the text calls them "pills" -- the word "pill" is commonly misused to refer to tablets or capsules, and most modern people have never even seen a pill in the technical sense of the word. Don't worry. The DEA is allowed to make mistakes. No one else is.) The picture, which shows Administrator Tandy posing like Perseus with the head of Medusa, was dated April 14, 2005, after the successful prosecution of Dr. William Hurwitz, a Virginia pain management specialist who, according to reports, made a sincere effort to treat pain. Dr. Hurwitz's original conviction was overturned, and while his retrial resulted in some convictions, it too seems to have been marred by prosecutorial zeal. John Tierney of the New York Times has provided excellent coverage of the tribulations of Dr. Hurwitz, and, in part, focused on the DEA's use of those 1,600 doses -- which turned out to be a transcription error, and the prescriptions were never even filled.
While most of the reporting on Dr. Hurwitz's two trials shows bias one way or the other, it seems incontrovertible that Dr. Hurwitz prescribed large quantities of narcotic drugs for his patients, and the DEA is anxious to have him convicted of something. When the Commonwealth of Virginia Board of Medicine reviewed Dr. Hurwitz's case, they found him guilty of negligence in three cases, but there were no charges of drug trafficking. The penalty was that Dr. Hurwitz, who had already closed his pain management practice, was required to practice medicine only in a setting approved by the Board and would be subject to unannounced inspections.
Unfortunately, anyone with a license to practice a profession is as likely to be guilty of negligence at some point in their career as anyone with a license to drive is likely to be guilty of speeding. But, a look at the records of pain management specialists is as sure of success as quail hunting on the Armstrong Ranch. In spite of all the progress in medicine, some people experience severe pain which can only be treated with narcotic analgesics. However, narcotics are enzyme inducers -- continued use produces more liver enzymes which metabolize the drug, so that increased, sometimes dramatically increased, amounts are needed to provide basic pain relief. While there are undoubtedly physicians who are dealing in improper prescriptions, some of the most highly publicized cases seem to be presented not on the basis of evidence of criminality, but simply because of high prescription volume. The DEA had approved and even, in August 2004, published pain management guidelines which might have served as a defense for prescribers, but in November 2004 they removed the advisory, leaving the decision on what's medically necessary to a legal staff looking for wins.
In 1950, a University of Rochester study demonstrated that pain was being routinely undertreated, and subsequent studies have shown no improvement. According to the Pain Relief Network, in Florida, Richard Paey, wheelchair bound with spinal cord injuries, was sentenced to 25 years in prison for possession of large quantities of narcotics, even though they were needed for his own treatment and he had no intention of selling the drugs or offering them for sale. In the Virgin Islands, Dr. Paul Maynard's attorney scored the minor victory of having the doctor's sentence based on the amount of narcotics prescribed, not total tablet weight (a tablet of Percocet might contain 5 milligrams of oxycodone, and 300 of acetaminophen. The original sentence included jail time for the full tablet weight -- never mind that acetaminophen or aspirin are included in these formulations to reduce the chances of drug abuse.)
The era of big government is back -- bigger and badder than ever. But instead of setting rules, publishing a treatment algorithm, this agency works through uncertainty -- and since there's no way of knowing what the DEA will allow physicians are afraid to provide adequate analgesia. Those physicians who try to provide adequate pain relief get caught in a cycle, because they attract patients in increasingly severe pain, who require more analgesia. Uncertainty can be a more potent force than clear treatment guidelines. And for those patients in intractable pain who can't get help, the message is simple: take two aspirin, but don't bother to call, because nobody feels your pain.
Sam Uretsky is a writer and pharmacist living on Long Island, N.Y.
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