The DEA War on Chronic Pain Patients
http://action.painfoundation.org/site/News2?page=NewsArticle&id=5313
The DEA's intimidation tactics against doctors causes billions of dollars of additional healthcare expenses for patients, billions of dollars in lost productivity because of untreated pain, and is actively destroying or severely limiting the quality of life for tens of millions of people in America every single day.
The American Pain Foundation estimates that 50 million U.S. citizens suffer from significant pain daily, but only about a quarter of them are getting adequate treatment.
That's because the DEA campaign against prescription drug abuse has stigmatized patients in need of pain medication. DEA intimidation tactics and sting operations against doctors have created a climate of fear, with the predictable result that many doctors now won't prescribe opiates at all or are only willing to prescribe amounts that are totally inadequate. As a result, many more people die from not having the prescription pain medications they need, than die from the drug abuse the government is trying to prevent. Yes, the DEA is actually killing chronic pain patients by intimidating their doctors.
One of the major causes of those deaths is the overuse of OTC NSAIDS like acetaminophen (Tylenol) and ibuprofen (Advil, Motrin) by people who are desperate for pain relief. The Food and Drug Administration estimates that 200,000 cases of gastric bleeding occur each year, resulting in nearly 20,000 deaths.
In a recent survey, 50% of chronic-pain patients had, at one time or another considered suicide to escape the unrelenting agony of their pain. There are no statistics on the number of suicides attributable to untreated pain, but various studies carried out over the past decade have found that fear of pain is what lies behind the majority of requests for doctor-assisted death.
Untreated pain also raises blood pressure, and researchers have found that every 10mm increase in systolic blood pressure results, on the average, in a 40 percent increase in risk of stroke and a 30 percent increase in risk of heart attack.
http://www.deasucks.com/index.htm
Lynette's story
Saturday, February 18, 2006
http://action.painfoundation.org/site/News2?page=NewsArticle&id=5313
Attitudes concerning pain and pain medicines.
The last 25 years of my life has been spent dealing with pain. Like a lot of people, mine started with car accidents. I hit the windshield of my car with my head and consequently jammed my head into my neck. This happened 2 times. There were no mri's at that time so soft tissue damage could not be determined. The result of those accidents left me with herniated discs in my neck and other back pain as well. Of course, the pain became debilitating and in 1992, I finally found a doctor that diagnosed my problem correctly. The surgeries started in 1992, 1999, and 2003. I now have a plate in my neck stabilizing the area.
In 2001, I started having pains in other areas of my body including my lumbar region. I traveled from doctor to doctor trying to figure out my problem. Finally, I received the diagnosis of fibromyalgia. My worsening lumbar area was diagnosed as degenerative disc disease and more herniations in that area. My upper back (between the shoulders) has arthritis and a scoliosis. I take high strength medication daily and something for breakthrough pain. The doctors also recommended a medtronic pump into my spine. The doctor I am with presently doesn't like pumps. So it's meds. Constantly it seems I have problems with my meds. My doctor has cut back on breakthrough meds. He was prescribing double of what I receive now. Prior authorizations, funny looks, pharmacists that won't dispense (when did pharmacists get to play doctor), attitudes about drugs and addictions. It seems to never end, my husband at times seems unable to comprehend what I need.
Recently, some editorials were written in the NY Times concerning the DEA and interfering in doctor/patient pain situations. I couldn't believe it!!! The DEA and the director of the DEA are now dictating to doctors and what they dispense to patients. This is terribly frightening, because they are comparing pain patients to drug addicts. JUST ANOTHER WEIRDNESS ABOUT PAIN MEDS!!! ANGRY, ANGRY, AND MORE ANGRY.
---
You have to distinguish between the percentage who have abused drugs at some time and those who abuse them regularly.
You also have to distinguish between physical addiction and dependence. Unlike physical addiction, which basically is a medical condition, psychological addiction occurs when the individual user feels or is of the opinion that drugs are necessary for his or her life.
Studies have found the following rates in the general population:
The rate of long-term drug abuse is about 1.4%. The percentage of people who have abused drugs at some time in their lives is 7.7%.
The rate of long-term drug dependence is 0.6%. The percentage dependence of people who have abused drugs at some time in their lives is 2.6%.
A survey by the Substance Abuse and Mental Health Services Administration, who tend to exaggerate, gives a figure of 8.3% for rate of abuse in the past 30 days.
The National Survey on Drug Use and Health (NSDUH)
http://alcoholism.about.com/od/drugs/a/nsduh_drugs.htm
The percentage of addiction in patients of patients with no history of abuse is only 0.19%. Even if the physician does not pre-screen the patient the addiction rate is only 3.27%.
References
"The incidence of addiction in patients with no history of abuse was only 0.19% compared to 3.27% for non-preselected patients.
If the results of the study are correct, the physician can be relatively certain that use of opioids for treatment of chronic pain will lead to addiction in a low percentage of patients.
Use of opioid analgesic therapy has a place in the treatment of chronic pain. It reduces pain and permits improved function in daily activities. This study provides some reassurance that the incidence of addiction or aberrant behaviors may be low."
http://www.adlergiersch.com/persona...n-the-treatment-of-chronic-pain-how-bad-is-it
From
Opioid Addiction in the Treatment of Chronic Pain: How Bad Is It?
Janet Thoman Green
Ref. Fishbain, et al, Pain Med 2008 May-June; 9(4):444-59
The vast majority of the harm attributed to illegal drugs is actually due to the illegality rather than the drugs themselves. For example, heroin is not particularly harmful in itself. Like all narcotics, it can be taken in a fatal overdose, but the amount required is many times the typical dose (about 50 times by the best estimates). What are reported as heroin overdose deaths are in fact in nearly all cases due to contaminants in street drugs, combinations with alcohol or other drugs, uncertainties in the dosage of street drugs, or combinations of these factors.
In describing the "effects of drugs," prohibitionists typically mingle *possible* effects, correlations that have nothing to do with the drugs themselves, and effects of long-term heavy use, i.e., abuse.
The enormous amount of crime associated with illegal drugs is almost entirely due to the illegality. Gangs of dealers fight turf wars just as bootlegger gangs did in the 1920s. Addicts must steal to get enough money to pay the black market prices of drugs, which are inflated by thousands of percent.
Enforcing the drug laws costs tens of billions of dollars a year. Some estimates run to $75 billion or more, not counting indirect costs. The indirect costs run into the hundreds of billions of dollars.
The vast majority of those who abuse drugs now are people who have a personality disorder that leads them to risky behaviors of all kinds (sexual promiscuity, crimes, etc.)
Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions.
Compton, Wilson M.; Thomas, Yonette F.; Stinson, Frederick S.; Grant, Bridget F.
Archives of General Psychiatry, Vol 64(5), May 2007, 566-576. doi: 10.1001/archpsyc.64.5.566
Prevalences of 12-month and lifetime drug abuse (1.4% and 7.7%, respectively) exceeded rates of drug dependence (0.6% and 2.6%, respectively). Dependence associations with most mood disorders and generalized anxiety disorder also remained significant. Comorbidity of drug use disorders with other substance use disorders and antisocial personality disorder, as well as dependence with mood disorders and generalized anxiety disorder, appears to be due in part to unique factors underlying each pair of these disorders studied.
(PsycINFO Database Record (c) 2010 APA, all rights reserved)
http://psycnet.apa.org/psycinfo/2007-06992-006
Deadly Morals
article By Katherine Eban Finkelstein
Copyright Playboy Magazine, August, 1997
THE DEA IS BUSTING DOCTORS FOR PRESCRIBING DRUGS-AND PATIENTS ARE DYING IN PAIN
DONALD DEWBERRY, 44, a retired aircraft mechanic, went to Dr. John McFadden several years ago after two failed surgeries for degenerative disk disease. ..Dr. McFadden, who is medical director of the Tupelo Pain Clinic in Tupelo, Mississippi, prescribed Dewberry narcotic painkillers known as opioids, which are highly effective and rarely addictive when taken to relieve pain.
Unfortunately for McFadden, he was under surveillance. Federal and state narcotics investigators first went to his red-brick clinic in 1987 on a tip from the Mississippi State Board of Pharmacy that he was overprescribing painkillers. They sifted through his inventory logs for evidence that narcotic medications had been diverted to the street for black-market resale. McFadden claims that only minor record-keeping errors were found. Yet because McFadden specialized in pain treatment (and therefore had prescribed narcotics such as Vicodin and Tylenol #3), he was subject to continuing suspicion. Over the next nine years, agents from the Mississippi State Board of Medical Licensure periodically investigated his prescribing habits.
A new front had been opened in the drug war, and patients in pain were potential enemies. Even though McFadden, the only pain specialist in northern Mississippi, administered legal medications of great benefit, his prescribing of narcotics targeted him as a suspect.
In March 1996 a state medical board investigator arrived at his clinic with a search warrant. "We had been expecting him. We knew he had to do his job, so we were friendly and said, 'You can look at any-thing you want,"' McFadden recalls. The agent seized the medical charts of 36 patients. Several months later McFadden was notified that the medical board had charged him with 11 counts of violating the Mississippi Medical Practice Act, including unprofessional conduct "likely to harm the public."
After two days of administrative hearings and 30 minutes of deliberation, the medical board-whose members are appointed by the governor-suspended McFadden's medical license and prohibited him from prescribing a variety of controlled substances on an outpatient basis. McFadden's censure has had a chilling effect in Mississippi medical circles. To avoid similar repercussions or scrutiny, other area doctors have virtually stopped prescribing narcotics. One doctor in Tupelo posted a notice in his waiting room: DO NOT ASK ME TO REFILL PAIN MEDICATIONS. In a doctor's office 40 miles away in Corinth, a sign read DON'T ASK FOR OPIOIDS.
As a result, pain is grievously undertreated. According to the National Chronic Pain Outreach Association, an estimated 34 million patients suffer chronic pain and lose 50 million workdays a year. Seven million of these patients cannot relieve their pain without opioids, but there are only approximately 4000 doctors in the country willing to prescribe them. A recent New England Journal of Medicine editorial noted that 56 percent of cancer outpatients and 82 percent of AIDS outpatients received inadequate pain treatment. Fifty percent of hospitalized patients with a range of illnesses also received inadequate pain treatment.
Our drug war has overshadowed our pain crisis because the former is fought by politicians, while the latter is lived by patients who are often confined to bed. In the absence of an effective pain lobby, politicians have been able to whip the public into an opiophobic frenzy. "All you have to do is scream about the drug hysteria, then everyone tucks his tail and runs," says Dr. Stratton Hill, a Houston pain specialist. "No politician wants the charge that he's soft on drugs." Late last year the Clinton administration challenged referenda in Arizona and California that would legalize the medical use of marijuana for easing the pain and nausea that are related to cancer and its treatment. This past March the president emerged from knee surgery declaring that he would not medicate his pain with narcotics.
Enforcers could pronounce guilt and revoke a registration simply by declaring that the public interest had been threatened. Suddenly, prescribing that was determined to be against the "public interest" was being used as prima facie evidence of diversion. The government had effectively criminalized narcotic pain treatment and had begun to practice medicine.
It was charged with ensuring the availability of pharmaceutical drugs for legitimate needs and preventing their diversion for illegitimate sale and use. But the 1984 drug bill changed everything. Despite limited data on the origins or amount of diversion, the agency targeted doctors and patients, performing search and-seizure operations in the offices of baffled clinicians.
This new system encouraged doctors to suspect the motives of their patients. "As doctors, we believe in people, but the government expects each of us to be an FBI unit. We're supposed to trust no one," explains Dr. Frank McNiel, a family practitioner in Knoxville, Tennessee.
Federal and state arsenals are now bristling with weaponry. The DEA performs long-range computer surveillance with the Automated Reports and Consolidated Orders System. This database logs every transaction between manufacturers and distributors of controlled substances. If a large quantity of barbiturates, for example, were distributed in a certain city, it could mean that an organized group had diverted the medication. Law enforcement authorities would launch an investigation.
States use their own monitoring apparatuses to track the prescriptions of individual doctors and their patients' habits. Some states require doctors to report even their terminal cancer patients as addicts if they are prescribed opioids for a certain period of time. In eight states, including California and New York, doctors who want to prescribe from Schedule II must order registered prescription forms that have multiple copies: The doctor retains one, the pharmacist keeps one and the third copy is sent to state health or narcotics-control agencies. Studies show that doctors in these states have decreased the amounts of Schedule II drugs they prescribe by 40 percent to 60 percent. Possibly, some of the drugs had been diverted and the crackdown was actually successful. But studies also have shown that doctors in these states increased their prescribing of less-regulated painkillers by almost the same percentages. These alternative drugs are often less effective in treating pain and can also be more dangerous to patients than are Schedule II drugs.
The scrutiny has led doctors to ration pain medicine and ignore pain --
necessary restraint in a world of diversion, enforcers would have us believe. "Even if you treat a patient with a terminal malignancy, it's irresponsible to write a prescription for 500 Dilaudid tablets," says Dr. James Winn, executive vice president of the Federation of State Medical Boards. "If the patient dies three days later, in a legitimate family the rest should be flushed down the commode. But sometimes a family member picks them up. We have a major drug problem in this country, and a lot of it comes from doctors."
The DEA provides no detailed record of the amount of diverted prescription drugs it recovers each year. The agency also lacks comprehensive data on the origin of the medication it seizes. Thus, despite Dr. Winn's assessment, there is little evidence to suggest that the narcotics which originate in doctors' offices are the same drugs which wind up on the street. In fact, DEA officials concede that the majority of black-market narcotics originate from crime rings in foreign countries, where the drugs are manufactured illegally.
In February ODC director Gene Haislip retired after 17 years, leaving behind an agency known for its intimidation tactics. Haislip maintains that legitimate prescribing has not been deterred at all by his policies. "I don't believe doctors would not prescribe because of there being a government report any more than they would not make money because they have to report it on their income tax," he claimed confidently in a speech that outraged doctors.
Despite this shaky analogy, the IRS doesn't destroy your livelihood, it simply takes a portion of it. A DEA fine, or even a protracted state medical board investigation, can threaten your medical practice, your income and the wellbeing of your patients. A state board ruling nearly ruined Dr. McNiel's life. A family practitioner who ran an outpatient clinic in Mosheim, Tennessee, McNiel vividly remembers the day he was first targeted. "In 1992 an investigator with a badge walked into my office and said I was under investigation. She had a list of patients and said she wanted to look at charts. She dug around for a few days, then disappeared." As McNiel puts it, her visit "encased the office in ice."
Working for 15 years as a missionary doctor in Honduras and Nicaragua, McNiel had witnessed all kinds of injustices. But nothing could have prepared him for what happened next. More than a year later, he received an official envelope that contained a long list of charges: "The only thing it didn't include was rape because they didn't think of it. They make you out to be the scum of the earth. This is devastating to a person's self-esteem." The medical board brought charges against McNiel of nontherapeutic prescribing in the cases of ten patients, in addition to mentioning, without any explanation, "other cases too numerous to count." The board, seemingly making no effort to conceal its arbitrary methods, also proposed more than $20,000 in fines.
National data suggest that such administrative intimidation is widespread. In 1994 state medical boards took action against 434 physicians for prescribing in violation of state medical practice acts, according to the Federation of State Medical Boards. However, the DEA, which often works with state medical boards, pursued only six criminal cases against doctors in 1994, according to information obtained from a database of justice Department files. Of these, only one doctor, from Puerto Rico, was found guilty.
The data from 1995 are similar. State medical boards took 392 actions against doctors for prescription violations. Only 11 cases were pursued by the feds that year, but there were no criminal findings. Two of the cases were dismissed because of minimal federal interest. The picture is the same at the state level. Last year in New York, the Bureau of Controlled Substances adjudicated 36 cases against doctors. However, 14 were civil cases, 14 had no charges issued and there was a smattering of warnings. Only one case was criminal.
Though these numbers seem small, each doctor works in a close-knit community. The flash of a badge can send shock waves through a hospital, or a state, and indelibly change prescribing habits. Some doctors in New York still shudder when they think of Dr. Ronald Blum, former deputy director of the Kaplan Cancer Center at New York University. In 1987 two state drug agents with guns and badges arrived at Dr. Blum's office. Though Blum was not arrested, the agents threatened to slap him with three record-keeping violations. Eighteen months later, he received a letter of warning and the investigation against him was dismissed. Nonetheless, Blum's "case" was used to bolster the statistics on state drug crackdowns.
The DEA, for its part, is quick to point out that its drop-ins on doctors are not arrests. An agency spokesperson explains: "It is important for people to realize that just because the DEA initiates an action, that doesn't mean there's criminal activity." Which is just the point.
A lawyer in Austin, Texas who has defended numerous doctors from overprescribing charges describes the agency's numbers game: "The DEA agents show up like a blitz, unannounced, in their little black jackets. They'll scare the you-know-what out of a doctor and get him to surrender his DEA registration. They get instant results for their own data, and they make a quick bunch of money for the government, a $25,000 fine. But the doctor is screwed, because he doesn't have his DEA number and can't reapply for a year. When he does, the medical board says, 'You gave up your DEA number. You must have done something wrong."' It is a rare doctor who, when threatened with these sorts of grave charges, will refuse to surrender his registration.
No Drug War Activist
Email: [email protected]
http://action.painfoundation.org/site/News2?page=NewsArticle&id=5313
The DEA's intimidation tactics against doctors causes billions of dollars of additional healthcare expenses for patients, billions of dollars in lost productivity because of untreated pain, and is actively destroying or severely limiting the quality of life for tens of millions of people in America every single day.
The American Pain Foundation estimates that 50 million U.S. citizens suffer from significant pain daily, but only about a quarter of them are getting adequate treatment.
That's because the DEA campaign against prescription drug abuse has stigmatized patients in need of pain medication. DEA intimidation tactics and sting operations against doctors have created a climate of fear, with the predictable result that many doctors now won't prescribe opiates at all or are only willing to prescribe amounts that are totally inadequate. As a result, many more people die from not having the prescription pain medications they need, than die from the drug abuse the government is trying to prevent. Yes, the DEA is actually killing chronic pain patients by intimidating their doctors.
One of the major causes of those deaths is the overuse of OTC NSAIDS like acetaminophen (Tylenol) and ibuprofen (Advil, Motrin) by people who are desperate for pain relief. The Food and Drug Administration estimates that 200,000 cases of gastric bleeding occur each year, resulting in nearly 20,000 deaths.
In a recent survey, 50% of chronic-pain patients had, at one time or another considered suicide to escape the unrelenting agony of their pain. There are no statistics on the number of suicides attributable to untreated pain, but various studies carried out over the past decade have found that fear of pain is what lies behind the majority of requests for doctor-assisted death.
Untreated pain also raises blood pressure, and researchers have found that every 10mm increase in systolic blood pressure results, on the average, in a 40 percent increase in risk of stroke and a 30 percent increase in risk of heart attack.
http://www.deasucks.com/index.htm
Lynette's story
Saturday, February 18, 2006
http://action.painfoundation.org/site/News2?page=NewsArticle&id=5313
Attitudes concerning pain and pain medicines.
The last 25 years of my life has been spent dealing with pain. Like a lot of people, mine started with car accidents. I hit the windshield of my car with my head and consequently jammed my head into my neck. This happened 2 times. There were no mri's at that time so soft tissue damage could not be determined. The result of those accidents left me with herniated discs in my neck and other back pain as well. Of course, the pain became debilitating and in 1992, I finally found a doctor that diagnosed my problem correctly. The surgeries started in 1992, 1999, and 2003. I now have a plate in my neck stabilizing the area.
In 2001, I started having pains in other areas of my body including my lumbar region. I traveled from doctor to doctor trying to figure out my problem. Finally, I received the diagnosis of fibromyalgia. My worsening lumbar area was diagnosed as degenerative disc disease and more herniations in that area. My upper back (between the shoulders) has arthritis and a scoliosis. I take high strength medication daily and something for breakthrough pain. The doctors also recommended a medtronic pump into my spine. The doctor I am with presently doesn't like pumps. So it's meds. Constantly it seems I have problems with my meds. My doctor has cut back on breakthrough meds. He was prescribing double of what I receive now. Prior authorizations, funny looks, pharmacists that won't dispense (when did pharmacists get to play doctor), attitudes about drugs and addictions. It seems to never end, my husband at times seems unable to comprehend what I need.
Recently, some editorials were written in the NY Times concerning the DEA and interfering in doctor/patient pain situations. I couldn't believe it!!! The DEA and the director of the DEA are now dictating to doctors and what they dispense to patients. This is terribly frightening, because they are comparing pain patients to drug addicts. JUST ANOTHER WEIRDNESS ABOUT PAIN MEDS!!! ANGRY, ANGRY, AND MORE ANGRY.
---
You have to distinguish between the percentage who have abused drugs at some time and those who abuse them regularly.
You also have to distinguish between physical addiction and dependence. Unlike physical addiction, which basically is a medical condition, psychological addiction occurs when the individual user feels or is of the opinion that drugs are necessary for his or her life.
Studies have found the following rates in the general population:
The rate of long-term drug abuse is about 1.4%. The percentage of people who have abused drugs at some time in their lives is 7.7%.
The rate of long-term drug dependence is 0.6%. The percentage dependence of people who have abused drugs at some time in their lives is 2.6%.
A survey by the Substance Abuse and Mental Health Services Administration, who tend to exaggerate, gives a figure of 8.3% for rate of abuse in the past 30 days.
The National Survey on Drug Use and Health (NSDUH)
http://alcoholism.about.com/od/drugs/a/nsduh_drugs.htm
The percentage of addiction in patients of patients with no history of abuse is only 0.19%. Even if the physician does not pre-screen the patient the addiction rate is only 3.27%.
References
"The incidence of addiction in patients with no history of abuse was only 0.19% compared to 3.27% for non-preselected patients.
If the results of the study are correct, the physician can be relatively certain that use of opioids for treatment of chronic pain will lead to addiction in a low percentage of patients.
Use of opioid analgesic therapy has a place in the treatment of chronic pain. It reduces pain and permits improved function in daily activities. This study provides some reassurance that the incidence of addiction or aberrant behaviors may be low."
http://www.adlergiersch.com/persona...n-the-treatment-of-chronic-pain-how-bad-is-it
From
Opioid Addiction in the Treatment of Chronic Pain: How Bad Is It?
Janet Thoman Green
Ref. Fishbain, et al, Pain Med 2008 May-June; 9(4):444-59
The vast majority of the harm attributed to illegal drugs is actually due to the illegality rather than the drugs themselves. For example, heroin is not particularly harmful in itself. Like all narcotics, it can be taken in a fatal overdose, but the amount required is many times the typical dose (about 50 times by the best estimates). What are reported as heroin overdose deaths are in fact in nearly all cases due to contaminants in street drugs, combinations with alcohol or other drugs, uncertainties in the dosage of street drugs, or combinations of these factors.
In describing the "effects of drugs," prohibitionists typically mingle *possible* effects, correlations that have nothing to do with the drugs themselves, and effects of long-term heavy use, i.e., abuse.
The enormous amount of crime associated with illegal drugs is almost entirely due to the illegality. Gangs of dealers fight turf wars just as bootlegger gangs did in the 1920s. Addicts must steal to get enough money to pay the black market prices of drugs, which are inflated by thousands of percent.
Enforcing the drug laws costs tens of billions of dollars a year. Some estimates run to $75 billion or more, not counting indirect costs. The indirect costs run into the hundreds of billions of dollars.
The vast majority of those who abuse drugs now are people who have a personality disorder that leads them to risky behaviors of all kinds (sexual promiscuity, crimes, etc.)
Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions.
Compton, Wilson M.; Thomas, Yonette F.; Stinson, Frederick S.; Grant, Bridget F.
Archives of General Psychiatry, Vol 64(5), May 2007, 566-576. doi: 10.1001/archpsyc.64.5.566
Prevalences of 12-month and lifetime drug abuse (1.4% and 7.7%, respectively) exceeded rates of drug dependence (0.6% and 2.6%, respectively). Dependence associations with most mood disorders and generalized anxiety disorder also remained significant. Comorbidity of drug use disorders with other substance use disorders and antisocial personality disorder, as well as dependence with mood disorders and generalized anxiety disorder, appears to be due in part to unique factors underlying each pair of these disorders studied.
(PsycINFO Database Record (c) 2010 APA, all rights reserved)
http://psycnet.apa.org/psycinfo/2007-06992-006
Deadly Morals
article By Katherine Eban Finkelstein
Copyright Playboy Magazine, August, 1997
THE DEA IS BUSTING DOCTORS FOR PRESCRIBING DRUGS-AND PATIENTS ARE DYING IN PAIN
DONALD DEWBERRY, 44, a retired aircraft mechanic, went to Dr. John McFadden several years ago after two failed surgeries for degenerative disk disease. ..Dr. McFadden, who is medical director of the Tupelo Pain Clinic in Tupelo, Mississippi, prescribed Dewberry narcotic painkillers known as opioids, which are highly effective and rarely addictive when taken to relieve pain.
Unfortunately for McFadden, he was under surveillance. Federal and state narcotics investigators first went to his red-brick clinic in 1987 on a tip from the Mississippi State Board of Pharmacy that he was overprescribing painkillers. They sifted through his inventory logs for evidence that narcotic medications had been diverted to the street for black-market resale. McFadden claims that only minor record-keeping errors were found. Yet because McFadden specialized in pain treatment (and therefore had prescribed narcotics such as Vicodin and Tylenol #3), he was subject to continuing suspicion. Over the next nine years, agents from the Mississippi State Board of Medical Licensure periodically investigated his prescribing habits.
A new front had been opened in the drug war, and patients in pain were potential enemies. Even though McFadden, the only pain specialist in northern Mississippi, administered legal medications of great benefit, his prescribing of narcotics targeted him as a suspect.
In March 1996 a state medical board investigator arrived at his clinic with a search warrant. "We had been expecting him. We knew he had to do his job, so we were friendly and said, 'You can look at any-thing you want,"' McFadden recalls. The agent seized the medical charts of 36 patients. Several months later McFadden was notified that the medical board had charged him with 11 counts of violating the Mississippi Medical Practice Act, including unprofessional conduct "likely to harm the public."
After two days of administrative hearings and 30 minutes of deliberation, the medical board-whose members are appointed by the governor-suspended McFadden's medical license and prohibited him from prescribing a variety of controlled substances on an outpatient basis. McFadden's censure has had a chilling effect in Mississippi medical circles. To avoid similar repercussions or scrutiny, other area doctors have virtually stopped prescribing narcotics. One doctor in Tupelo posted a notice in his waiting room: DO NOT ASK ME TO REFILL PAIN MEDICATIONS. In a doctor's office 40 miles away in Corinth, a sign read DON'T ASK FOR OPIOIDS.
As a result, pain is grievously undertreated. According to the National Chronic Pain Outreach Association, an estimated 34 million patients suffer chronic pain and lose 50 million workdays a year. Seven million of these patients cannot relieve their pain without opioids, but there are only approximately 4000 doctors in the country willing to prescribe them. A recent New England Journal of Medicine editorial noted that 56 percent of cancer outpatients and 82 percent of AIDS outpatients received inadequate pain treatment. Fifty percent of hospitalized patients with a range of illnesses also received inadequate pain treatment.
Our drug war has overshadowed our pain crisis because the former is fought by politicians, while the latter is lived by patients who are often confined to bed. In the absence of an effective pain lobby, politicians have been able to whip the public into an opiophobic frenzy. "All you have to do is scream about the drug hysteria, then everyone tucks his tail and runs," says Dr. Stratton Hill, a Houston pain specialist. "No politician wants the charge that he's soft on drugs." Late last year the Clinton administration challenged referenda in Arizona and California that would legalize the medical use of marijuana for easing the pain and nausea that are related to cancer and its treatment. This past March the president emerged from knee surgery declaring that he would not medicate his pain with narcotics.
Enforcers could pronounce guilt and revoke a registration simply by declaring that the public interest had been threatened. Suddenly, prescribing that was determined to be against the "public interest" was being used as prima facie evidence of diversion. The government had effectively criminalized narcotic pain treatment and had begun to practice medicine.
It was charged with ensuring the availability of pharmaceutical drugs for legitimate needs and preventing their diversion for illegitimate sale and use. But the 1984 drug bill changed everything. Despite limited data on the origins or amount of diversion, the agency targeted doctors and patients, performing search and-seizure operations in the offices of baffled clinicians.
This new system encouraged doctors to suspect the motives of their patients. "As doctors, we believe in people, but the government expects each of us to be an FBI unit. We're supposed to trust no one," explains Dr. Frank McNiel, a family practitioner in Knoxville, Tennessee.
Federal and state arsenals are now bristling with weaponry. The DEA performs long-range computer surveillance with the Automated Reports and Consolidated Orders System. This database logs every transaction between manufacturers and distributors of controlled substances. If a large quantity of barbiturates, for example, were distributed in a certain city, it could mean that an organized group had diverted the medication. Law enforcement authorities would launch an investigation.
States use their own monitoring apparatuses to track the prescriptions of individual doctors and their patients' habits. Some states require doctors to report even their terminal cancer patients as addicts if they are prescribed opioids for a certain period of time. In eight states, including California and New York, doctors who want to prescribe from Schedule II must order registered prescription forms that have multiple copies: The doctor retains one, the pharmacist keeps one and the third copy is sent to state health or narcotics-control agencies. Studies show that doctors in these states have decreased the amounts of Schedule II drugs they prescribe by 40 percent to 60 percent. Possibly, some of the drugs had been diverted and the crackdown was actually successful. But studies also have shown that doctors in these states increased their prescribing of less-regulated painkillers by almost the same percentages. These alternative drugs are often less effective in treating pain and can also be more dangerous to patients than are Schedule II drugs.
The scrutiny has led doctors to ration pain medicine and ignore pain --
necessary restraint in a world of diversion, enforcers would have us believe. "Even if you treat a patient with a terminal malignancy, it's irresponsible to write a prescription for 500 Dilaudid tablets," says Dr. James Winn, executive vice president of the Federation of State Medical Boards. "If the patient dies three days later, in a legitimate family the rest should be flushed down the commode. But sometimes a family member picks them up. We have a major drug problem in this country, and a lot of it comes from doctors."
The DEA provides no detailed record of the amount of diverted prescription drugs it recovers each year. The agency also lacks comprehensive data on the origin of the medication it seizes. Thus, despite Dr. Winn's assessment, there is little evidence to suggest that the narcotics which originate in doctors' offices are the same drugs which wind up on the street. In fact, DEA officials concede that the majority of black-market narcotics originate from crime rings in foreign countries, where the drugs are manufactured illegally.
In February ODC director Gene Haislip retired after 17 years, leaving behind an agency known for its intimidation tactics. Haislip maintains that legitimate prescribing has not been deterred at all by his policies. "I don't believe doctors would not prescribe because of there being a government report any more than they would not make money because they have to report it on their income tax," he claimed confidently in a speech that outraged doctors.
Despite this shaky analogy, the IRS doesn't destroy your livelihood, it simply takes a portion of it. A DEA fine, or even a protracted state medical board investigation, can threaten your medical practice, your income and the wellbeing of your patients. A state board ruling nearly ruined Dr. McNiel's life. A family practitioner who ran an outpatient clinic in Mosheim, Tennessee, McNiel vividly remembers the day he was first targeted. "In 1992 an investigator with a badge walked into my office and said I was under investigation. She had a list of patients and said she wanted to look at charts. She dug around for a few days, then disappeared." As McNiel puts it, her visit "encased the office in ice."
Working for 15 years as a missionary doctor in Honduras and Nicaragua, McNiel had witnessed all kinds of injustices. But nothing could have prepared him for what happened next. More than a year later, he received an official envelope that contained a long list of charges: "The only thing it didn't include was rape because they didn't think of it. They make you out to be the scum of the earth. This is devastating to a person's self-esteem." The medical board brought charges against McNiel of nontherapeutic prescribing in the cases of ten patients, in addition to mentioning, without any explanation, "other cases too numerous to count." The board, seemingly making no effort to conceal its arbitrary methods, also proposed more than $20,000 in fines.
National data suggest that such administrative intimidation is widespread. In 1994 state medical boards took action against 434 physicians for prescribing in violation of state medical practice acts, according to the Federation of State Medical Boards. However, the DEA, which often works with state medical boards, pursued only six criminal cases against doctors in 1994, according to information obtained from a database of justice Department files. Of these, only one doctor, from Puerto Rico, was found guilty.
The data from 1995 are similar. State medical boards took 392 actions against doctors for prescription violations. Only 11 cases were pursued by the feds that year, but there were no criminal findings. Two of the cases were dismissed because of minimal federal interest. The picture is the same at the state level. Last year in New York, the Bureau of Controlled Substances adjudicated 36 cases against doctors. However, 14 were civil cases, 14 had no charges issued and there was a smattering of warnings. Only one case was criminal.
Though these numbers seem small, each doctor works in a close-knit community. The flash of a badge can send shock waves through a hospital, or a state, and indelibly change prescribing habits. Some doctors in New York still shudder when they think of Dr. Ronald Blum, former deputy director of the Kaplan Cancer Center at New York University. In 1987 two state drug agents with guns and badges arrived at Dr. Blum's office. Though Blum was not arrested, the agents threatened to slap him with three record-keeping violations. Eighteen months later, he received a letter of warning and the investigation against him was dismissed. Nonetheless, Blum's "case" was used to bolster the statistics on state drug crackdowns.
The DEA, for its part, is quick to point out that its drop-ins on doctors are not arrests. An agency spokesperson explains: "It is important for people to realize that just because the DEA initiates an action, that doesn't mean there's criminal activity." Which is just the point.
A lawyer in Austin, Texas who has defended numerous doctors from overprescribing charges describes the agency's numbers game: "The DEA agents show up like a blitz, unannounced, in their little black jackets. They'll scare the you-know-what out of a doctor and get him to surrender his DEA registration. They get instant results for their own data, and they make a quick bunch of money for the government, a $25,000 fine. But the doctor is screwed, because he doesn't have his DEA number and can't reapply for a year. When he does, the medical board says, 'You gave up your DEA number. You must have done something wrong."' It is a rare doctor who, when threatened with these sorts of grave charges, will refuse to surrender his registration.
No Drug War Activist
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