The Police State of Medicine

The Police State of Medicine

Remarks By Dr. William Hurwitz,* MD
BEFORE

The Drug Policy Foundation*
October 18, 1997
NEW ORLEANS, LA

Copyright © 1997 by Dr. William Hurwitz, MD

LINK to The Police State of Medicine

NOTE: Dr Hurwitz was my first real pain doctor... This is his story from 1997 I'm afraid the The Police State of Medicine is coming back, again.

Introduction  — First, I would like to thank the Drug Policy Foundation for the opportunity to speak to you today.  I understand that the rights of patients to effective treatment and the impact of current drug policy on the doctor-patient relationship are very much on your minds, as they are on mine.  I offer my story as a case study of regulatory abuse, as we try to fashion an adequate political and legal response to what I think of as "The Police State of Medicine." I will begin with a review of the legal events in my case.  I will then tell you about my patients and the impact of the legal action against me on them.  Finally, I would like to address two related questions: How does the police-state of medicine affect medical care? and. . . What can we do about it? What Happened to Me? In May of 1996, my license to practice medicine was suspended without a prior hearing by the Commonwealth of Virginia after the deaths of two of my patients were incorrectly attributed to my treatment.  I was charged with having prescribed excessive doses of opioid analgesics in the treatment of 30 patients who, it was acknowledged by the Board of Medicine, had conditions causing intractable pain.  The charges were brought without any apparent reflection by the Board on the applicability of Virginia's Intractable Pain Act, upon which I was relying for legal protection. The hearing might well be characterized as a Kafkaesque inquisition.  This was not anything close to an open-minded search for the truth in which legal adversaries present evidence before an impartial finder-of- fact.  This Board thought it knew from the outset what constituted proper pain management, and it thought it knew that the high doses of medication I prescribed to many of my patients were illegitimate and without clinical rationale.  The number of pills I prescribed was all the evidence the Board or its prosecutors thought they needed.  They had not even bothered to subpoena my medical records! When we pointed out that, under the Virginia Intractable Pain Act, dose alone was an insufficient legal basis for disciplinary action, rather than dismiss the charges, the hearing was turned into a fishing expedition for evidence with which to smear my name and to provide a rationale for the harm they had already caused me and my patients by the summary suspension.  The prosecuting attorney sponsored testimony to the effect that I was taking money under the table for prescriptions — testimony which was subsequently shown to be pure fabrication — without disclosing his witness' prior felony conviction for fraud.  He also presented testimony from an addiction specialist, who, it turned out, had himself been disciplined over a ten year period by this very Board.  He had been an anesthesiologist who was addicted to Fentanyl, a strong opioid used in anesthesia, which he stole from his patients — leaving them to buck in pain on the operating table. My experts — all pain specialists of international repute (one of whom, Dr. C. Stratton Hill, is being honored at this conference) — were harassed by cross-examining Board members.  My patients, many of whom had traveled from distant states, were ignored, ridiculed, insulted, and ultimately condemned to pain and misery. After this caricature of a hearing, my license was revoked.  Although the revocation was stayed and my license was restored after three months, my authority to prescribe the controlled substances necessary to treat my patients was withheld.  The Virginia proceedings set in motion a cascade of legal action against me.  The authorities in the District of Columbia, where I was actually in practice, suspended my license.  This provided the DEA a basis to revoke my registration — although ultimately they agreed to transfer my registration to my Virginia address with restrictions paralleling those imposed by the Virginia Board. After an informal hearing in August of 1997, the Virginia Board restored my ability to prescribe pain medicine and accepted a protocol for treating pain patients that was essentially the same as I had been using prior to my suspension.  By doing so, the Board appears to have accepted the legitimacy of the therapeutic principle that calls for adjustment of medications according to patient response without limit as to dose or combination.  The Virginia Board's action remains, at best, a symbolic gesture without practical consequence, however, unless and until the DEA restores my registration and the Board has an opportunity to demonstrate its good faith. An appeal from the original Board Order of August 1996, in which the Court is called upon to interpret the extent, if any, of the safe-harbor protection afforded by the Virginia Intractable Pain Act, was heard in August of this year (1997).  The Court has not yet issued its opinion.  Nor has the DEA responded to the application I submitted over four months ago for full restoration of my prescribing privileges.  It's not their pain. Only participants can have any idea of the exorbitant personal and professional costs such legal proceedings exact.  But this was nothing, when compared to the impact on my patients. What Happened to My Patients? At the time of the Virginia Board's suspension in May of 1996, I had over 200 patients with intractable pain from all over the United States. Some of their stories are gripping: A young woman whose daily headaches were so bad that she had the nerves to the back of her head cut, only to find that after a brief respite, her pain came back worse than before. A gentleman, now in his 50s whose legs had to be amputated when he was 18 years old.  They had been frozen when he was trapped in his car after an accident in 30-below weather.  He subsequently had the lower portion of his torso removed.  With the benefit of pain medicine, he was able to work and support himself. A physician who had such severe reflex sympathetic dystrophy that his left arm became gangrenous and had to be amputated. A woman in her thirties whose leg had been almost completely severed at the thigh in a motorcycle accident.  The orthopedist who reattached her leg also treated her pain with opioids.  But after he retired, noone would continue her treatment. There were over 200 of these patients with crippling pain from failed backs, arthritis, multiple sclerosis, interstitial cystitis, arachnoiditis, RSD, TMJ, trigeminal neuralgia, and phantom limbs. . . the list goes on and on and on.  Many of them had come to me after years of unsuccessful attempts to obtain relief from a multitude of procedures, doctors, and pain clinics.  They were treated like addicts and criminals. They were stigmatized, insulted, neglected and abandoned.  Betrayed by the whole medical profession with the refrain, "I would like to help you, but I can't.  I don't want to lose my license."  But who can blame the doctors, who are themselves the victims of the thuggish drug-control police and the heartless and mindless bureaucrats who serve on boards of medicine. When my patients came to see me, they were terrified that I too would reject them, or subject them to more tests, more procedures, more expense and delay.  But my approach was different.  I asked them what had worked in the past, and that was my starting point.  I let their response to medication guide my treatment.  If one medication didn't work, or made them sick, we — the patient and I — tried another.  If a medication became less effective, we increased the dose.  Sooner or later, we found what worked best for each patient. The response to pain relief was dramatic.  People who hadn't worked in years went back to work.  People who could barely get out of bed began to move, even to dance.  Some no longer needed crutches or a cane.  Almost everyone reported that their lives were better.  Many said that I had given them their lives back. When word went out that my license had been suspended, there was panic as patients contemplated what it would mean for the pain to return.  Lives that had been rebuilt on the basis of pain control had lost their foundations.  After I lost my license, the fear was palpable:  pharmacists afraid to fill my prescriptions, doctors afraid to take my patients, and patients desperate for continuity and certainty.  Added to the stigma of taking morphine, methadone, or Dilaudid, was the stigma of being one of "Dr. Hurwitz's" patients. There were a few happy stories.  A few physicians who had known my patients before they came to me and saw their improvement while under my care were willing to continue the treatment.  Pain specialists at some of the academic centers and a few brave doctors in private practice were willing to take my patients.  Some of my patients, those who had saved a reserve supply, were able to obtain a modicum of pain relief and avoid the symptoms of abrupt withdrawal. Some stories were not so happy.  A few patients went through horrible withdrawals — a number who availed themselves of medical help were admitted to psych units and detoxed cold turkey.  Some found doctors who were willing to treat them, but were unwilling to continue what had been successful medication regimens.  Some were exploited by doctors who imposed expensive and risky procedures as a condition for receiving pain medication.  And some just gave up, exhausted by insurmountable obstacles. There were two suicides directly attributable to the prospect of inadequate pain control. How Does The Police-State of Medicine Affect Medical Care? The quasi-criminal liability imposed on physicians distorts clinical information and medical judgment, impedes the development of clinical expertise, undermines the ethical commitments necessary to medical practice, and leads to the abandonment, wasted lives, and deaths of patients with intractable pain.  Holding physicians liable for the misbehavior or dishonesty of their patients turns physicians into policemen and is, in principle, incompatible with effective medical care. In what other context do we sit in judgment of a patient's moral worth to determine his eligibility for treatment?  Is a former addict with AIDS less entitled to medical care than the victim of a contaminated transfusion?  Or less entitled to pain relief with opioid medications? To me, the unequivocal answer is no.  We are not society's policemen, nor should we be.  I am not arguing that we should be indifferent to the use to which our prescriptions are put.  I am arguing that patients deserve the benefit of the doubt, that a Draconian response to the occasional, but inevitable physician error in providing medication to the dishonest patient who may be misusing or diverting medication has the inevitable consequence of denying pain relief and perhaps condemning to death the honest one. Effective medical care requires trust in both directions.  A patient must trust that his physician is acting in the patient's medical interest.  But how is this possible when the physician's career is threatened by doing so?  A physician must trust that his patient is reporting his circumstances and symptoms accurately.  How is this possible when the patient is afraid that the truth will look suspicious, and that merely looking suspicious will prompt abandonment? Under current regulatory policies, distrust governs the treatment of pain and subverts the usual clinical calculus of risk and benefit.  Patients are subjected to a modern version of trial by ordeal, where their credibility as patients is measured by the pain and indignity they are willing to endure and the expense they are willing to incur.  And physicians who are unwilling to impose these indignities as a condition for pain treatment are punished with the destruction of career, reputation, and livelihood. In the end, the only important clinical question should be:  What is best for the patient?  As physicians, we treat individuals for the simple reason that they are fellow human beings, and our treatment must respect their humanity.  Respect requires that patients be afforded the dignity of choice — the freedom to choose or refuse treatments based on their calculus of risk and benefit and cost.  The current regulatory regime effectively denies most patients the dignity and respect that simple humanity requires. What Can We Do About It? The stakes in this battle are too great to leave its outcome to the valiant efforts of the dedicated few.  We need reinforcements in the form of legal help, publicity, and financial support to help make boards of medicine and the DEA legally and politically accountable for the misery they engender.  Intractable pain acts are not enough.  And if boards of medicine were, as a practical matter, legally, ethically and politically accountable, such statutes would not be necessary. Our strategy should be to raise the cost to the regulators of their regulatory tyranny and to lower the cost to physicians, pharmacists, and patients of defending their rights.  We need to destroy the public's naive presumption of the regulators disinterested good faith, to debunk the myth that medicine is being regulated in the public interest, and to reveal the abuse of power for what it is.  Only then will we empower physicians to help their patients, and patients to control their pain. *   Dr. William Hurwitz, MD, is 51-years old and a graduate of Columbia College (1966, BA), Stanford Medical School (1971, MD) and George Mason University School of Law (1996, JD).  Married with two children, Dr. Hurwitz resides and now practices medicine in McLean, Virginia — prior to the revocation of his medical licenses, he practiced in Washington, DC.  Dr. Hurwitz and this issue have been the focus of in-depth reporting by CBS's "60 Minutes," "US News & World Report" and PBS's John McLaughlin.

Caught in pain's vicious cycle Dr William Hurwitz

Caught in pain's vicious cycle

He helped his patients---and lost his license.
A talk with Dr. William Hurwitz

Emaliss: Hello Dr. Hurwitz. Thank you for talking with me about what happened to you. The story in the USNews & World Report mentioned that the distance between you and some of your patients was part of the reason for your licence revocation and not necessarily the 'over-perscription' of narcotic painkillers. This made me wonder about the motives of the medical board; that perhaps they worried about a back- lash from chronic pain patients. What do you think about this idea? Dr. Hurwitz: I think that the Board simply had no idea of the barriers to effective treatment that chronic pain patients confront. I don't believe that the Board was worried about a back-lash. Rather, they were insufficiently worried about lack of access to care and the stigmatizing effect of its action against me. Emaliss: What are the laws for perscribing narcotics? Dr. Hurwitz: There are federal and state laws governing the prescribing of controlled substances. These laws are designed to prevent diversion and abuse by patients and health care professionals, while providing access to pain medication for those who have medical need of them. Virginia passed an "Intractable Pain Act" which specifically authorized physicians to prescribe controlled substances "in excess of recommended doses" for patients with documented intractable pain. Emaliss: You felt that you couldn't turn patients away out of concern for yourself, as you understood that these patients truly needed help. What were your thoughts about the possibility of getting into problems? Dr. Huwitz: I assumed that both the DEA and the state regulatory authorities were fully aware of my practice and would be monitoring me to assure themselves of my competence and honesty. I was not afraid of such scrutiny and, in fact, invited these agencies to meet my patients and to review my therapeutic approach, as I had nothing to hide. I was confident that my patients deserved treatment and that my approach to treatment was rationally based on the published scientific literature. Emaliss: During the investigation, were any of your patients questioned, and if so do you know how they responded? Dr. Hurwitz: The DEA interviewed a number of my patients prior to and during the hearing. Patients reported to me that the investigators inquired about how I conducted my practice, and about the patients' medical circumstances. My understanding is that my patients were uniformly appreciative of my efforts on their behalf and happy with the care I provided. Emaliss: Have you recieved much support from patients, and if so, in what way? Dr. Hurwitz: A large number of my patients came to the hearings in Richmond, both to express their support and to testify on my behalf. A number of patients made financial contributions to my legal defense. Emaliss: Have you had much support from the general medical community, and if so, in what way? If not, do you have any ideas about why? Dr. Hurwitz: Many individual doctors and nurses have expressed their support. The medical professional organizations have not. There silence is understandable. Although there is general agreement that pain should be adequately treated, it is hard for outsiders to determine whether I am a good doctor or not. The mere fact of the Board's action has had a stigmatizing effect, and the organizations are reluctant to stick their necks out with so much uncertainty. Emaliss: The story also indicates that the medical board was concerned that some patients might be either abusing their narcotics or even selling them. What are your feelings about this? Dr. Hurwitz: This is the most complicated policy issue in the treatment of chronic pain patients. For doctors to treat their patients as if they are always under a cloud of suspicion of diversion or abuse undermines the doctor-patient relationship. If doctors act like cops, patients will be less candid. The result may be more dishonesty and less effective treatment. To hold a doctor liable for being deceived places an intolerable risk on the doctor. The only rational response to this risk is to avoid treating patients with pain. Nobody should be expected to meet a standard that requires perfection. Just as we tolerated errors in other areas of medicine without presuming that the doctor is incompetent or corrupt, we should accept human fallibility in this area. Emaliss: I hear often from people who are told by their doctors that they cannot have narcotic pain medicine because of the possibilities of addiction. But I've also seen many studies which have shown that when narcotics are used for chronic pain (as opposed to being used for 'recreational' purposes) the chances of dependancy is low. Why do you think there is still such a resistance among the medical community and why do you think they do not seem to accept these findings? Dr. Hurwitz: Fear. The research doesn't really tell the doctor how to deal with uncertainty regarding who to treat and how to treat. The risk to the doctor's career is simply too great for any bad outcome. Emaliss: What do you think has been the biggest influence resulting in such a change of attitude in both the medical community and the public about the use of narcotic pain medicine for chronic pain patients? Dr. Hurwitz: I don't know that the attitude toward narcotics has really changed that much among the public. People still confuse "addiction" with "tolerance" to high doses and physical dependence (the risk of withdrawal reactions). Most people think these medications are bad or excessively dangerous. People are suspicious of people who take these medications. Expert opinion has changed somewhat in response to a series of scientific studies. But the majority of community based physicians have not changed their prescribing practices. Emaliss: Do you think doctors are more concerned with addiction or about being prosecuted? Dr. Hurwitz: Both. Different doctors have different concerns. Emaliss: What kind of impact have you seen on patients lives when they are forced to suffer from chronic pain over a long period of time? Dr. Hurwitz: Patients become prisoners of pain--their activities and their lives restricted to a bare minimum. Their relationships suffer. They become demoralized, angry, and depressed. Emaliss: Do you see any hope for chronic pain patients in regards to ever getting proper treatment and relief of pain, or a change in attitude by the medical community? Dr. Hurwitz: I think that the shift in expert opinion will eventually transform the attitudes of most doctors, most importantly---those of members of boards of medicine. I think that the disenfranchisement of patients through managed care is leading to a political back-lash, and that when the dust settles, patient rights to effective treatment will be more securely established. Emaliss: What can patients do to help: a. Change the attitude in the public and the medical community? Dr. Hurwitz: Patients should complain to the powers-that-be when their medical complaints go unattended. They should join grass-roots organizations that advocate on their behalf. They should make access to treatment a political issue. Emaliss: b. Get the laws changed to protect doctors from getting the type of discipline you've had? Dr. Hurwitz: Changing the law isn't critical. Making medical boards legally and politically accountable is what's important. The answer to oppressive medical boards is adequate money for legal defense and political mobilization of adversely affected patients. Emaliss: I've always felt that the only people who have been affected by Nancy Reagan's "War on Drugs" have been doctors who must write triplicates when perscribing narcotics and the patients who need it, not the real criminals who import and sell illegal drugs. What do you think about that theory? Dr. Hurwitz: The intimidation and control of doctors is what really hurts patients. Emaliss: Thank you again Dr. Hurwitz for talking about your experience. I'm sure it will give insight to patients as to why getting pain care is so difficult. Dr. Hurwitz: Thanks again for your interest.

Marijuana Prices & Costs and the Black Market

I've been a speaker for LEAP (Law Enforcement Against Prohibition) now called Law Enforcement Action Partnership for YEARS???

I told many people at Kiwanis, Lions, and Rotary clubs over the years that if we legalized marijuana the prices would drop dramatically and the bad guys would go away.

A study by H. Guyford Stever a Professor of Operations Research at Carnegie Mellon University Heinz College & Qatar Campus and the RAND Drug Policy Research Center called the Estimated Cost of Production for Legalized Cannabis.

Marijuana Indoor Grow Costs
The study says it costs $225 per pound to grow marijuana indoors. $75 per pound for electricity and the remaining $150 per pound for other factors. Those costs work out to be quite consistent with those described in a Dutch case study described by Cervantes (2006, p.148). The Cervantes study goes on to say cost could be $116 per pound as equipment has been paid for. The study goes on to says the Outdoor Costs to Grow Marijuana is around $8.00 per pound.

I was very disappointed when in many states the non-profit medical marijuana dispensaries continued to charge black market prices for medical marijuana, around $8,000 per pound. In Arizona to add insult to injury it cost the disabled and patients with medical conditions requiring medical marijuana to pay a physician $150 for a certification good for one year. Then pay the state $150 for the right to pay $8,000 a pound for your medicine.

I did like the fact that Mexican marijuana prices have dropped. In 2016 a story on PRI.org "Loosened US pot laws have sent Mexican weed prices plunging". They reported that "marijuana has gone from selling for about $100 per kilo to about $30 a kilo and that's a change that's been happening over the last two or three years".

The current black market can undercut the legal taxed marijuana prices for many years to come as long as $8.00 a pound marijuana sells for $8,000 a pound. We need to stop charging patients $300 a year for the right to use and purchase the medicine they need...


LINK Estimated Cost of Production for Legalized Cannabis 

Beware, Pain-Sufferers Jeff Sessions Is Coming for Your Doctor

Beware, Pain-Sufferers Jeff Sessions Is Coming for Your Doctor

A new push to imprison those who prescribe too many opioids

This article from Reason Magazine says Today Sessions announced a new task force devoted to fighting opioid overdoses by going after doctors who overprescribe the drugs. He's not even trying to sugarcoat it—he wants to put doctors in prison cells.

The bad news is patients and physicians will suffer. The good news is apparently Arizona doesn't have an opioid problem as it's not included in the Arizona U.S. Attorney's District.

In Sessions speech he said: "This sort of data analytics team can tell us important information about prescription opioids—like which physicians are writing opioid prescriptions at a rate that far exceeds their peers; how many of a doctor's patients died within 60 days of an opioid prescription; the average age of the patients receiving these prescriptions; pharmacies that are dispensing disproportionately large amounts of opioids; and regional hot spots for opioid issues"

The problem comes when primary care physicians and pain management specialists are considered peers. Obviously pain management specialists will write opioid prescriptions at a rate that far exceeds a primary care physician.

Lets face the facts, there aren't a lot of pain management specialists so pharmacies that are dispensing disproportionately large amounts of opioids may simply be close to a pain management specialists.

The following districts have been selected to participate in the program:

1. Middle District of Florida,
2. Eastern District of Michigan,
3. Northern District of Alabama,
4. Eastern District of Tennessee,
5. District of Nevada,
6. Eastern District of Kentucky,
7. District of Maryland,
8. Western District of Pennsylvania,
9. Southern District of Ohio,
10. Eastern District of California,
11. Middle District of North Carolina, and
12. Southern District of West Virginia.

Suicide and Pain: The Silent Epidemic

I've been saying the opioid crisis is becoming a pain crisis for many pain patients. I fear like back in the 1990's we are going to have more pain patients giving up the fight.

Article in Pain Medicine News Suicide and Pain: The Silent Epidemic

PLEASE contact the suicide prevention hotline should you be considering harming yourself. The help is free and confidential. Call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).

There Really are Good Pain Doctors Here's Some Great Information on Pain from Dr Forest Tennant

 There are good pain management physicians who really care about their patients and stand up for them.

One of these physicians is Dr Forest Tennant one of the nations leading pain management specialists.

These links below have great information on pain management for both pain patients and pain management physicians. They contain what self care patients can do, and what to do while looking for a pain management physician.

Here's a recent article in Reason Magazine Meet the Doctor Who Refuses to Stop Prescribing Opioids to Pain Patients

This is a list of articles in Pain Journals from Dr Tennant 

Dr Tennant's Patient Instruction Guides

Hormones and Pain Care A great page for patients and physicians on why pain patients need hormone testing.

The Doctor Patient Relationship is one of the most important relationships in your life.....

The doctor patient relationship is one of the most important relationships in your life. Your life literally depends on the doctor you choose. Medical errors by physicians is the 3rd leading cause of death in the US

The doctor patient relationship depends on trust. Your doctor needs to trust the things you tell them about your medical problems are the truth. You need to trust that your doctor tells you the truth about your medical problems. This is especially important in the doctor patient relationship as apposed to other relationships in life.

If a banker stock broker or even your wife lie to you it can cost you money and break your heart, but a broken heart will heal in time. If your doctor lies to you about your condition or medications, it can end your life.

You need to not only trust your doctor has the medical knowledge and experience to care for your medical needs, but will always tell you the truth and make decisions in your best interest. All medications prescribed should be judged by the same standard. 

Any medication, procedure, or surgery must be medically The physician also needs to explain the risk vs the benefits to the patient, NOT the risk vs the benefits to the physician.

Recently many pain management physicians are telling patients about a nonexistent DEA mandate to lower pain medication doses.

The problem is they have no medical justification for lowering the dose. They tell patients they received a letter from DEA mandating lowering opioid doses, or that DEA came by the office and told them to lower doses. 

This is a flat out lie, DEA investigations in Washington tells me that DEA does NOT tell physicians what or haw to prescribe medications, and would NEVER stop by a physicians office and tell them what to prescribe.

Educated Pain Patient or Drug Seeker?

How do physicians tell the difference between a patient with chronic pain and a drug seeking patient? It's difficult even for experienced pain management physicians. Some of DEA's recommendations on spotting drug seekers make it difficult for patients who have dealt with pain for many years and know what works and what doesn't. SEE Recognizing the Drug Abuser below

A patient that's suffered chronic pain for many years has been through it all with doctors, tests, and medications. Usually when a patient goes to a new primary care physician they tell them what medications they take and why.

If a pain patient knows what medications they've used in the past or are currently taking that work, the physician looks at the DEA Drug Abuser Profile it says "May show unusual knowledge of controlled substances". In other words tell the physician they take opioids and you're an instant suspect.

Physicians are taught (since the very beginning of medical school) that any patient requesting pain medication is to be Scrutinized" and to be "Wary" of them especially if they tell you they can't take anti-inflammatory drugs, that is a sure "SIGN" of addiction.

NSAID's are also what put me in the emergency room throwing up blood. Then there's the fact that NSAID's kill 17,000 people a year in the hospital, and we don't know how many from OTC NSAID's. As an EMT we could diagnose a GI bleed from the front door, it's not something anyone should go through.  

And God help you if you have nerve damage at L5 S1 like I do. When a pain patient tells a physician that their big toe and the next one is numb, or the outside three toes are numb and edge of your foot gets shooting pains. DEA says these are textbook symptoms, and something to watch out for.

In 1996 the Kingman neurologist who did my nerve conduction study spent half an hour lecturing me and telling me nobody in Kingman would give me opioid pain medications. 

Then he did the nerve conduction study. He said "it was textbook" for L5 S1 nerve root damage, and gave me a prescription for opioid pain medications...... Wow... Now medical textbooks are wrong, or right?

No wonder pain management physicians are confused...




If the article below wasn't true, it would be funny.....

D.E.A. Defines Drug Seeking – Try not to Laugh

This is from http://recoveryrocks.bangordailynews.com/2013/09/03/addiction/d-e-a-defines-drug-seeking-try-not-to-laugh/

September 3, 2013Addiction

By Jim LaPierre

Recognizing the Drug Abuser

• Unusual behavior in the waiting room;
• Assertive personality, often demanding immediate action;
• Unusual appearance – extremes of either slovenliness or being over-dressed;
• May show unusual knowledge of controlled substances and/or gives medical history with textbook symptoms OR gives evasive or vague answers to questions regarding medical history;
• Reluctant or unwilling to provide reference information. Usually has no regular doctor and often no health insurance;
• Will often request a specific controlled drug and is reluctant to try a different drug;
• Generally has no interest in diagnosis – fails to keep appointments for further diagnostic tests or refuses to see another practitioner for consultation;
• May exaggerate medical problems and/or simulate symptoms;
• May exhibit mood disturbances, suicidal thoughts, lack of impulse control, thought disorders, and/or sexual dysfunction;
• Cutaneous signs of drug abuse – skin tracks and related scars on the neck, axilla, forearm, wrist, foot and ankle. Such marks are usually multiple, hyper-pigmented and linear. New lesions may be inflamed. Shows signs of “pop” scars from subcutaneous injections.

Now, for all that the D.E.A may be on top of, one thing is certain:  grammar is not their specialty. I cut and pasted the bizarre number of semicolons directly from their site.  

Given the D.E.A’s antiquated and stereotypical findings, how are we to convey our needs to prescribing physicians and clinicians without creating the appearance of drug seeking?

Jim’s Corresponding Do’s and Don’t’s for Reporting Pain & Ensuring DEA compliance:

·         Ok – nobody knows for sure what “unusual behavior” is so everybody be cool and ACT NORMAL! (while experiencing high levels of pain)

·         It seems assertiveness is bad. Please stop advocating for yourself just do what they say....

·         Ok – let’s not look bad when we’re in excruciating pain and don’t go showing up at the ER wearing your Sunday best.

·         Stop reading WebMD immediately. You might learn too much about your health conditions and appear sketchy

·         Ok – bad news: being poor and not having a PCP or health insurance just became suspicious.(Wow, really?)

·         If you have a chronic pain condition – something really scandalous like being an above the knee amputee, don’t explain that you know which meds work for you and which do not. It’s important that the doctor do trial and error each time.

·         Feign interest in the medical terminology your doctor lodges at you. Don’t just take the discharge papers home and call the medical professional you’re distantly related to from home. Hang on every word your doctor rapidly spews as though it’s fascinating.

·         No exaggerating! Describe your high pain levels in um, reasonable ways…

·         Mood disturbances are bad – no mood swings as you sit in the ER for 4-6 hours. If you’re feeling suicidal, don’t tell anyone. If you’re having sexual dysfunction get online and order meds like everyone else.

·         Ok. I concede the final point. If you’re showing up with track marks; it’s beyond time to get help.

Someone Asked Me What It Was Like To Have Chronic Pain

Unless you have chronic pain most people just don't understand chronic pain. Yep God made us that way. You see God was pretty smart when he us made humans. We can remember something hurt, but not the actual pain. If we could I'm pretty sure there would be a lot more single child family's.

We all have pain from time to time, but that's acute pain. It hurts, but it only last a few minutes to a few weeks and it's gone. The pain it's self fades and over time and the memory of the pain fades until you say, ya getting thrown from that 2000 bull did hurt, but it wasn't that bad.

Chronic pain on the other hand go on day after day, you go to bed with it, and you wake up to it. It affects aspect of your life you can't even imagine. Little things like being able to pick up your grand kids to fixing simple things around your home others think nothing about.


If you're one of those people who think someone with chronic pain can just buck up and get over it, give this a try. 

Take two small vice grip pliers, clamp one on the side of your foot behind your little toe. Now take the other vice grip and hook them on your foot near your heal. Make sure they're nice and tight, now keep them on for a week. Let me know how that goes, oh wait.

You need to understand neuropathic pain too. So take a cord from a lamp about 6' long and cut it off. Split the wires and hook one side to one of the vice grips, and the other side to the other vice grip. Now plug it into 110v for 2 to 5 seconds every 5-10 minutes during the day, all day, every day. Now you understand....

Most people won't tell you these things, because the first thing you learn about pain, is that nobody really want's to hear you hurt.

When you hurt all the time it wears on you, you just get tired of hurting. When you add fighting with pain doctors who listen to rumors and fake news rather than the CDC, FDA, or DEA.

Then there's the pharmacists who look at everyone on pain medications as drug addicts or junkies.... One pharmacist at Safeway told me all pain management doctors should be locked up..... 

Many times the last straw is when the pharmacy tells you time and time again, sorry your medicine won't be in until next week....

A Letter To Governor Ducey on Opioids Problem

Governor Ducey June 30^th 2017

I fear the violence we saw at the Las Vegas pain clinic on Thursday will be coming to Arizona soon. What physicians are doing to thousands of pain patients is wrong and will cause more pain and suffering, and I’m sure more suicides and violence will follow.

Physicians like Dr Benjamin Venger are reducing patient’s medications based on fake news and without medical justification leaving patients to turn to the street for illegal drugs, or end the pain like the patient Thursday.

At my last visit May 26^th with my pain management physician Dr Benjamin Venger in Fort Mohave he tried to reduce my medications again like he has to all his patients, again I told him DEA didn't do it.

I told Dr Venger that I had spoke to DEA in Washington D.C., and the agent said DEA does not tell physicians what or how much medications to prescribe, and “that any change to a patient medication must be based on medical necessity and not on policy”.

When I told Dr Venger that the 2016 CDC pain treatment guidelines were for primary care physicians, not pain specialists, I was stunned by his answer. Dr Venger said “I know, but its gone social now”.

I have no idea what a subject “going social” has to do with the medical treatment of patients. When I told people at DEA, the FDA, and the CDC that physicians were lowering patient doses because of “social media” and not medical necessary many were speechless.

The Director of the CDC’s National Center for Injury Prevention and Control Dr Debra Houry said in her response that the CDC “believes patients deserve safe and effective pain management. The Guideline also helps providers and patients—together—assess the benefits and risks of opioid use”

Dr Hourly went on to say “the recommendation to taper or reduce dosage is only for when patient harm outweighs patient benefit of opioid therapy”. 

Reducing the dose of opioids without regard for tolerance, dependence or medical necessity as individual patient is NOT in line with the 2016 CDC pain guideline.

As the benefits of opioid therapy outweigh the risks for many individual patients’ physicians must document the medical necessity of any dose reductions or they need to face disciplinary action when patients harm themselves or others because of lack of pain control.

It’s sad when someone abuses opioids and overdoses.

It’s tragic when a pain patient must take their life for lack of proper pain management.

Jay Fleming, Speaker

Dolan Springs Arizona

Law Enforcement Action Partnership

Advancing Justice and Public Safety Solutions

LawEnforcementActionPartnership.org

Overdoses Will Continue to Rise Along With Pain Patient Suicides in 2017

As physicians reduce the doses without medical justification for long time opioid patients who have built a tolerance over years patients will be forced to the street or worse, give up the fight. 

We need to monitor the death of any patient who has been under the care of a pain management physician within the previous year. 

It's to easy to write off a pain patients who overdoses as an abuser, when the real reason is they were not given enough medication to control their pain, so they save enough to end the pain.

Pain management physicians like the one I see are reducing patients doses even thought it goes against recommendations in the FDA 2016 Pain Guidelines.

When I told my pain management physician that DEA had no mandate to reduce medications, and what he was referring to was a 2016 CDC pain guideline for family practitioners, not pain specialists. He said that "he knew, but now its gone social”.

Like somehow what DEA and the FDA were saying meant nothing and social media was telling physicians what and how to prescribe medications.

First it's fake news and now physicians are ruled by social media rather than medical boards the FDA and DEA. 

The United States has a little over 300,000,000 people, 100,000,000 suffer chronic pain on a daily basis, and we're getting older. Most people I talk to are not afraid to die, they are afraid to die in pain.

Do You Know the Difference Between Addiction Tolerance and Dependence? Some Physicians Don't

It's important the public understands these two things about opioid use.

First that anyone who takes opioid medications for over a week or so will develop tolerance and physical dependence. 

The second thing is that tolerance and physical dependence alone does't mean someone is addicted. 

It's critical that physician's not confuse tolerance and physical dependence in pain patients with addiction. Many physicians either don't understand this fact, or choose not to treating many pain patients like drug addicts.

Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

Physical Dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. 


Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.

Pain Patient vs Abuse
What's the difference between a pain patient and someone who abuses the medications their pain management physician provides?

The pain patient uses their medications to reduce their pain be more active and improve their quality of life.

Someone who abuses the medications will use a months prescription in a couple weeks, leaving to turn to the street for additional drugs, or become very sick for several days. This type of lifestyle causes harm to the person using as well as family, friends.

PAIN HELPED HIM PULL THE TRIGGER

We will see a lot of pain and death from the new pain guidelines

Please Read and Share

Pain Helped Him Pull the Trigger

If someone abuses their medications, that's sad.

If someone takes their life because of under treated pain, thats tragic 

Male Patients Chemically Castrated by Pain Doctors with NO Warning

If you’re a male pain patient and your physician has prescribed pain medications for you including Codeine, Fentanyl, Lora Tab, Norco, Vicodin, Dilaudid, Demerol, Morphine, Oxycodone, Oxycontin, or any other medication containing opioids, your physician has basically castrated you with no warning.

Symptoms low testosterone is reduced desire for sex, fewer erections, infertility, muscle loss, depression, low energy, and sleep disturbance.

Physical changes from Opioid-Induced Androgen Deficiency include increased body fat, decreased strength/mass of muscles, fragile bones, decreased body hair, swelling/tenderness in the breast tissue, hot flashes, night sweats, increased fatigue, and effects on cholesterol metabolism.

The Problems Pain Meds Cause…….

Imagine a 30 something male that gets injured at work. The patient goes to the ER and the problem is diagnosed as a herniated a disc and the patient is given opioid medications, and his primary care physician continues the pain medications.

Within a couple weeks he notices a loss of energy, but thinks it’s just the injury. His wife notices her husband no longer has any interest in making love to her.

The patient doesn’t notice the problem because for the guy it’s like when you were 8 years old, girls aren’t icky, you just have no interest in playing with them. As time goes on the wife and intimacy and making love gets worse. The wife begins to think her husband doesn’t love her any longer or he’s cheating on her. This isn’t good for the relationship and creates problems.

Example

A friend of ours was taking pain medications for a back injury. He’s a big biker guy about 6’2” 275 pounds. One day my wife was at their house and he came home early from work crying.

She asked what was wrong and he said, they called me a sniveling little bitch at work and sent me home because I was crying about my dog being sick.

My wife asked how his energy was, he said not very well. She asked about his sex life, he said what sex life. She explained that opioids deplete testosterone and to have his testosterone level checked. A few weeks later he felt better, and his wife understood he wasn't cheating on her.

If your pain management physician is not testing your testosterone levels please file a complaint with the Arizona Medical Board.

Any physician who treats pain should know this information, if not there's a problem.

This is a link to AZ Medical Board complaint page https://www.azmd.gov/Regulation/Regulation#

For more information please read my blog Pain Crisis in America……… http://paincrisisinamerica.blogspot.com

PLEASE READ These Articles

Article in the Pain Physician Journal on Opioid-Induced Hypogonadism: Why and How to Treat It

http://www.painphysicianjournal.com/current/pdf?article=MTcwOQ%3D%3D&journal=68

Article from Pain Physician Journal on Opioid-Induced Androgen Deficiency

http://www.painphysicianjournal.com/current/pdf?article=MTcxMg%3D%3D&journal=68

Article Politics of Pain in Kingman Daily Miner

The Kingman Daily Miner interviewed me for an article on pain medications....

The Politics of Pain 

There Are NO New DEA Rules Requiring Physicians to Reduce Patient's Opioid Doses

When I saw my pain management physician he told me a new DEA rule said it was mandatory that he had to cut my pain medications in half. I contacted the DEA diversion unit and was told there are no new DEA rules on prescribing opioid medications, and DEA does not tell physicians what or how to prescribe medications.

I don’t know where he gets his legal advice, but I found what he was referring to. It’s not a new DEA rule, but a 2016 CDC Guideline for Prescribing Opioids for Chronic Pain that was not meant for pain management physicians.

On the CDC’s web page the CDC Guideline for Prescribing Opioids for Chronic Pain summary says “This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care”.

The guidelines are not meant for pain specialists, in fact in it tells primary care physicians to seek “recommendations based on consultation with pain specialists” when doses are over 90mg’s.

The guidelines are for new patients, not patients who have taken opioids for years, are not problem patients, and don’t agree with reduction in medications due to tolerance and withdrawal issues.

The CDC Guidelines say this about established patients, "Established patients already taking high dosages of opioids, as well as patients transferring from other providers, might consider the possibility of opioid dosage reduction to be anxiety-provoking, and tapering opioids can be especially challenging after years on high dosages because of physical and psychological dependence… For patients who agree to taper opioids to lower dosages, providers should collaborate with the patient on a tapering plan. Experts noted that patients tapering opioids after taking them for years might require very slow opioid tapers as well as pauses in the taper to allow gradual accommodation to lower opioid dosages."

Forcing patients who have used opioid medications for years and have both a tolerance and dependence on those medications is cruel and can cause serious medical problems.

The attached letter from the CDC Director says “Specifically, the Guidelines Includes a recommendation to taper or reduce dosage only when patient harm outweighs patient benefit of opioid therapy”.

If you have been a good patient for many years, and have never abused your medications. Then reducing your dose will cause for more harm than continuing the opioid therapy.

Ask your  pain management physician to restore your medications to a workable dose, or explain to the medical board how the harm outweighs the benefits of continuing my  opioid therapy.

It seems DEA is always looking at physicians for over prescribing opioids. My hero pain doc, Dr William Hurwitz told me treating pain patients was as much about being a psychiatrist as a physician.

For a hundred years we've know stimulants potentiate pain medicine from aspirin to opioids. Anacin has had caffeine for many years.

Some physicians use stimulants like Dextrostat to potentiate opioids and reduce the opioid dose by as much as half.

Dextrostat also helps patients who have problems with being lethargic on opioids.

There are numerous studies on this but most pain physicians don't know how to treat pain. Most have little training in pain management, and fail to listen to patients.

One in a hundred pain physicians understand pain, its finding the one in a hundred.

Jay

What Does A Physician Have To Do To Get In Trouble?

I contacted the Arizona Medical Board about my complaint the lady basically said I lost it was waiting for the director to sign off that the doctor followed the guidelines.

I will appeal, then get an attorney. This guy needs to listen to his patients.

Every guideline except listen to the patient, and if the patient isn't symptomatic, its probably not the problem.

I don't care if a patients heart rate is 140, if they're not symptomatic, don't Shock them.

Still Waiting for Arizona Medical Board Investigation Results

In January this year I had a bad experience at Kingman Regional Medical Center in Kingman Arizona.

I filed a complaint with the Arizona Medical Board who initiated an investigation into the actions of Dr Saadeh Saadeh, a cardiologist who scared the Hell out of my wife.

The doctor should listen to what the patient says the symptoms are, not tell the patient hat the symptoms are.

If you tell the doctor, "I'm not short of breath" in a clear voice, then you're not short of breath.

It's been over seven months now, I recently sent a couple emails asking the outcome of the investigation. When I hear something I'll post the results. I don't know how they can justify scaring my wife and I thinking I was having a heart attack when it was herniated disc's. Then there's the $45,000 bill I'm still paying on.....

Things Getting Better

Sorry I haven't poster for a while. Our fire district went broke, so I've been fighting to get better emergency services for the area.

Anyway, it looks like things are getting a little better. Patients have told me they don't have to go from pharmacy to pharmacy so much. It looks like all the calls, letters, and emails sent to government officials did some good. If anyone hears differn't please let me know.

As far as doctors telling patients it's all DEA's fault, that's still a problem. If your doctor tells you they can't do something because of new DEA rules, call the DEA diversion unit near you and ask them. Get the agent's name, and if your doctor has any questions when you tell him it's not DEA's fault. Give him the DEA agent's name and number, ask him to cal them and ask.

Have a pain free day
Jay

TAKE ACTION Congress Does Listen to Patients H.R.471 - Ensuring Patient Access and Effective Drug Enforcement Act of 2015

H.R.471 - Ensuring Patient Access and Effective Drug Enforcement Act of 2015

Congress has heard patients, and is moving to make sure patients have access to medications.

Read H.R. 471 and contact your representives and tell them your story.

https://www.congress.gov/bill/114th-congress/house-bill/471/text

CVS Health’s bogus ad campaign

CVS Health has a lot of nerve running TV commercial's that talk about how CVS Health has programs and tools to help patients stay on the medications their physicians prescribe.

This must mean only the medications CVS wants to keep in stock. I find it hard to believe CVS is serious about making sure patients take their medications as prescribed. CVS itself puts quotas on how many pain medications (opioids) each of their pharmacies can receive in a month. This causes patients to go without medications and suffer withdrawals.

CVS pharmacists regularly tell patients they don't have the medication they need. If that wasn't bad enough, they tell the patients they might have their medication in the next shipment, which can be a few days to a week away.

Chronic pain affects all aspects of the patient’s life. Many can no longer work. Pain affects their relationship and so many things most of us take for granted, like playing with their kids. The last thing they need is to run out of medications because CVS put quotas on the medication the patient needs. That's why I don't believe CVS when they say they have programs and tools to help patients stay on their medications.

Arizona Marijuana Legalization ,,, Off Topic but Important

Arizona has a medical marijuana law, but citizens and legislators are considering legalizing marijuana for recreational use for adults. That's good because it will free law enforcement resources currently wasted on marijuana enforcement.

Today there are more important issues law enforcement needs to be concerned with:

Like keeping track of sex offenders every day, not once a year in a publicized roundup on TV, but every day of the year.

Like having the resources to return felons wanted for crimes, such as burglary, theft and assault. When police stop wanted felons in other states, you think they would be arrested and returned to face trial and punishment, but dispatchers have to grit their teeth, and tell their officer the originating agency won't extradite. They just let the wanted felon go.

Like identity theft, cybercrime is one of the fastest growing crime categories. Attacks happen daily against the computers of individuals, corporations and government agencies. These attacks are done by high school kids, and by highly organized and funded attacks by foreign governments.

Smart Arizona legislators realize that if passed a voter initiative takes a 3/4 vote of the House and the Senate to make changes.  So if legislators want to have any say on how the new law is written, they need to pass it themselves.

There are some things legislators just don't get. If lawmakers don't listen, they're going to write a law that will allow criminals and cartels to continue making millions of dollars for many years.


Legislators need to understand marijuana is cheap to grow. If they place too high a tax, like the $50 an ounce tax one Arizona legislator recently proposed, the black market will continue to prosper for years to come.

The Estimated Cost of Production for Legalized Cannabis (1) says that not counting labor, it costs $25 per POUND, or about $1.50 an ounce to grow high quality marijuana indoors, or about $8 per pound, or 50 cents per ounce outdoors without labor.

Black market U.S. sellers and marijuana grown outdoors in the U.S. by Mexican cartels could sell their marijuana for $50 an ounce and still make a nice profit.

Currently, Mexican marijuana sells for about $800 per pound in Phoenix. You need to consider the cartels have expenses on each pound they sell.

They need to pay someone to grow the marijuana, someone to harvest, dry, and guard the marijuana. Then they need someone to transport it to the border and someone to smuggle it across the border. Now they need someone to store the marijuana in the U.S. until it's sold by someone else.

Still, after all those expenses Mexican marijuana sells for around $800 per pound. It doesn't cost a lot to grow marijuana. U.S. growers don't have those expenses, so prices will drop rapidly as more marijuana is grown. Setting a flat per ounce tax won't work. The tax needs to be a percentage like most other taxes.

The only way to get criminals and cartels out of the marijuana business is for legislators to stop expecting black market prices to continue once marijuana is legal. Somehow when we passed our state non-profit medical marijuana laws, the price stayed at black market prices.

(1)  The Estimated Cost of Production for Legalized Cannabis
http://www.rand.org/pubs/working_papers/WR764.html

No Fellowship for Pain Physicians

Pain is the number one reason people see a physician. Yet pain management is not a recognized medical speciality, it's a sub-speciality of several other medical specialities, but there's no fellowship for physicians to learn how to treat pain. 

Any physician can hang out a shingle and treat pain. Most give out pills, but don't ask patients the right questions, or treat the side effects of the opioid's they prescribe.

An old adage says, the physician who writes the narcotic should write the prophylactic for constipation. Physicians should ask patients each visit about constipation, excess sweating, changes in energy levels, sleep, depression, changes in sex drive, or relationship problems.

Almost every patient taking opioids will suffer from constipation. Problems from acid reflux to colon cancer can be caused by chronic constipation.

Opioids can cause excessive sweating. This can be a problem anywhere, but here in Arizona where temperatures can reach 120 degrees, it can be deadly. Excessive sweating can cause the loss of electrolytes like salt and potassium. My wife had a life-threatening heart arrhythmia because her potassium was too low.

Changes in energy levels, depression, changes in sex drive, can point to low testosterone. This isn’t just a sex hormone, it controls muscle growth, mood, energy and so much more in male patients. 

Yesterday at the imaging center while I was getting an MRI, my wife Jean was talking to a young mother of three. She told Jean she thought her husband was cheating on her because he wasn't as close as used to be.

Jean ask her if he got teary eyed at some movies, had less energy, and no interest in making love anymore? When she said yes, Jean smiled, then explained about our relationship and testosterone. She said his family doctor had just tested his testosterone levels because of a family history, not his opioids. Jean told her once he gets his testosterone levels back up to normal, she should have her husband back. 

Relationship problems can be a precursor to a patient abusing or selling their medications. Physicians need to be as much a psychiatrist as a medical doctor if they treat pain.

This brings us back to testosterone. When a guy’s testosterone is very low, it's like when he was 8 years old. He doesn't think girls are icky, he just has no interest in playing with them. Like the young wife above, the spouse either thinks the guy is cheating or he doesn't love her anymore.

Neither one is good for the relationship, and can be a precursor for abusing their medications. Physicians who treat pain need to listen their patients, and learn from each other.