If the patient is telling the truth, the doctor committed perjury and was presumably doing so to cover up illegal prescription practices. If the patient is not telling the truth, the patient forged prescriptions. No matter how you slice it, somebody broke the law. It isn’t necessary to break the law in order to provide effective pain management.

When they say that he was caught with more than 28 grams of medications such as Percocet, does that mean 28 grams of Percocet? (Am I right that the typical pill would be 10 mg, in which case that’s 2,800 pills? Which is about two months worth of pills for a hard core addict?)

Given the lengths I have seen some doctors go to in order to provide effective pain management, I am a bit perplexed that the person didn’t receive a prescription for an implantable morphine pump before he got into trouble. If regulations say “No, you must prescribe pills, which can be easily diverted, over an effective alternative which makes diversion unlikely”, well, that’s nuts.

It is a shame that Tierney doesn’t take on the big issue here – this story is not about pain management, but an out-of-control “war on drugs”. Even if I accept the prosecutor’s case, that this guy forged prescriptions for controlled substances, the sentence is insane. Attempting to blame the defendant for the consequences of a bad law, even if he could have accepted a plea bargain to avoid jail time, doesn’t change the fact that it is a bad law.

I greatly appreciate that you posted this article. The standoff between the doctor and the patient in Tierney’s report reflects 2 very difficult and opposed forces, both of which are subject to insufficient policy responses.

On the one hand, the patient was like many (or so the data show)…ie in severe pain that was insufficiently treated. Physicians are imperfectly-trained in managing this very common problem, and they are frightened by the legal implications (see below).

The other side of the equation is the rise of prescription drug misuse. National survey data (generally collected through standardized surveys like the National Survey on Drug Use and Health) document a massive increase in nonmedical use of prescription painkillers in the last 5 years. It is not clear that this self-reported prescription opiate abuse consistently involves full-fledged dependence/abuse, but the number of persons who self-report using these pills for nonmedical purposes (on government surveys) has risen extraordinarily.

This latter problem will be difficult to address, but the current policy response has been influenced by the DEA’s selective and harsh prosecutions, the effect of which is to chill physicians’ willingness to treat pain. One physician, Dr. Hurwitz, was put away in federal prison for 25 years.

This week’s Time describes the investigation of a neurologist specializing in pain management. The feds have carted out his records and he says his practice is basically sunk. If the article is correct, his prescribing practices included stringent requirements of patients, actually more stringent than those recommended by the main organization of state medical boards. He prescribed only to patients who signed a 21-item, 4-page contract, and over the years he had enforced that contract through dismissal of over 70 patients for not following the contract provisions which included items such as “no early refills”, etc. At this point he is out of business.

I infer that the DEA’s attention is drawn principally by the volume of prescriptions or the size of individual prescriptions (they specifically de-endorsed a guideline document last year because it asserted that “number of pills prescribed” would NOT be considered presumptive indication of abuse or diversion)…Since some patients really do require large numbers of pills, it is hard to believe that criminal prosecutions and investigations of this nature will lead physicians to engage in more rational prescribing practices tightly honed to patient needs.

Stef

You can read the Time article at http://www.time.com/time/magazine/article/0,9171,1083911,00.html

Correspondence between the University of Wisconsin Pain & Policy Studies Group and the DEA, including their recommendations to the DEA, are online at:

http://www.medsch.wisc.edu/painpolicy/DEA/