Chronic pain and the physician (2008)

Chronic pain and the physician (2008)

by Fred Lane, PhD
Medical practitioners, generally, are poorly trained in the management of chronic pain. The USA has many physicians who do not keep up with the complex and frequently frustrating task of pain management. However, it also has a very few others who stand out as world leaders in pain research and treatment. Unfortunately, this field has many grey areas and traps, even for the experts. Remember this when you are asking your physician for more medication to treat your chronic pain.

World leader

One of those in the forefront of chronic pain interventions, William Eliot Hurwitz MD, was a highly respected 58-years old researcher and practitioner. In 2002 he had a prosperous surgery in the very fashionable Washington suburb of McLean, Virginia. He charged assessment fees of US$1000 and maintenance fees of US$250 a month, cash in advance. His work had been profiled on the American TV program 60 Minutes. He says that pain must be treated aggressively, sometimes by prescribing massive doses of analgesics, including opiate-based analgesics, for long periods.

This brought him into conflict with the American Drug Enforcement Administration (DEA) who initially worked with Hurwitz, in that he opened his patient records to their inspectors. He received feedback that a small proportion of his patients might not be true pain sufferers but drug dealers who might be converting his prescriptions into drugs for sale to others and making vast profits.

Hurwitz dismissed 17 of these patients and reduced the amount of medication in others, but found that his surgery consultations failed to confirm many of these accusations. If the police wanted to arrest his patients, that was their prerogative; he would not stand in their way. On the other hand, drug dealers could feel as much chronic pain as non-dealers. Therefore he felt he was sometimes obliged to prescribe large doses of strong analgesics like acetaminophen hydrocodone (Vicodin) and oxycodone (OxyContin), even to proven drug dealers, if he perceived them to be in genuine pain.

Detecting duplicity

He admitted that he might not be able to detect a patient skilled in duplicity any better than any other physician. He was not alone. A 2007 Cornell University study found that representative samples of police officers and judges, who should be experts in the field, could detect lying at no better than chance rates (Jung and Reidenberg, 2007). Hurwitz said he was not a policeman, but a physician bound by very clear medical ethics. Hurwitz also pointed out, correctly, that there was no objective test in the world that could determine the amount of pain felt by any individual. Finally, after years of discussion, there was no accepted guideline that said how much was too much when it came to long-term opiates treatment. If in doubt, he was obliged to treat the patient (vide amicus curiae brief, 6 September 2005.)

This brought him into conflict once more with the DEA who were instrumental in shutting down his practice in 2002 and prosecuting Hurwitz in 2004. After a 44-day trial with 76 witnesses, he was found guilty on 50 counts and received four sentences of 25 years and 46 of 15 years, concurrent, in prison. He appealed this sentence and was granted a retrial in 2007. That retrial found him not guilty of the major charges related to narcotics trafficking but guilty of 16 others and reduced his sentence to 57 months, less the 30 months he had served in prison. The judge at this trial said that although she thought initially that the Hurwitz medication regimes were “crazy”, defence witnesses persuaded her that there was “an increasing body of respectable medical literature and expertise” that supported Hurwitz.

Two of his patients subsequently committed suicide saying they could not get adequate pain relief elsewhere.

In Australia, in 1999-2000, there were about 8750 “known abusers” obtaining more than a quarter of a million codeine compound prescriptions, sometimes from 15 different doctors. In America, there are about 50 million with chronic pain, many of whom would qualify as “known abusers” under DEA policy.

DEA Guidelines withdrawn in 2002

Unfortunately, there is no objective guideline on exactly how much is too much when it comes to prescription pain medication. The DEA worked with researchers over many years to publish guidelines around 2002, but abruptly withdrew them just before the first Hurwitz trial. Perhaps the withdrawal was sparked by the notice that the defence intended to quote from those guidelines that the amount or duration of pain medication prescribed was a “physician’s decision” and of itself “should not spark a criminal investigation.”

The prosecution, instead, argued in his first trial that a Hurwitz prescription of 195 mg of morphine a day was “beyond the bounds of medicine.” On the other hand, a dosage of more than 60 times that level is considered acceptable in at least one medical textbook. Furthermore, the president, Dr R.K. Portenoy and seven past presidents of the highly regarded American Pain Society criticised the prosecution’s chief “medical expert” witness for being “factually wrong” and aspects of his evidence “without foundation in the medical literature … in fact absurd,” (Portenoy et al letter 10 December 2004). New DEA guidelines suggest that doctors who prescribe high doses of opioids for long periods are subject to investigation. Unfortunately, they do not specify how much is “too much” nor how long is “too long”.

All this raises the question as to who sets the bar for the “too much, too long” objective standard. The medical profession strongly asserts that it is not the province of the DEA or any other government organ, but the medical profession itself. For the time being, there is no convincing data that will resolve the question. Hurwitz might well have been a little more conservative in prescribing pills, but should that not result in the loss of his licence to practice, not prison as a drug trafficker?< p/>

Bottom line

Modern research suggests the bottom line for pain patients remains unchanged. Don’t put up with pain. Ask, nay demand, more and more intervention until the pain is reliably controlled, even for brief periods, then gradually extend the time of these pain-free periods, through distraction, exercise, self hypnosis, acupuncture etc., whatever works, as the medication is gradually reduced. Too little medication certainly risks more severe and more lasting chronic pain.

References:

Amicus curiae brief: Docket 05-4474 US Court of Appeals, Fourth Circuit, The Association of American Physicians and Surgeons in support of William Eliot Hurwitz, 6 September 2005.
Jung, B. and M.M. Reidenberg, Physicians being deceived: Whose responsibility? Pain Medicine, Vol 8/5, pp. 433-437, July 2007.
Portenoy R.K. et al, letter to Marvin D. Miller, 10 December 2004.

(Google “William Eliot Hurwitz” for updates.)