Fw: [DrugWar] US: Prisoners of Pain

Preston Peet ptpeet at nyc.rr.com
Sun Aug 28 16:19:21 EDT 2005

----- Original Message ----- 
From: "Richard Lake" <rlake at mapinc.org>
To: <drugwar at mindvox.com>; <drctalk at drcnet.org>; <harmred at drcnet.org>; 
<DPFT-L at listserv.tamu.edu>
Sent: Sunday, August 28, 2005 2:14 PM
Subject: [DrugWar] US: Prisoners of Pain

> Pubdate: Thu, 1 Sep 2005
> Source: AARP The Magazine (US)
> Copyright: 2005 AARP
> Issue: September/October
> Page: 54
> Contact: aarpmagazine at aarp.org
> Website: http://www.aarpmagazine.org/
> Details: http://www.mapinc.org/media/3683
> Note: LTEs printed are short, under 100 words
> Author: Barry Yeoman
> Cited: Drug Enforcement Administration http://www.dea.gov
> Cited: American Academy of Pain Medicine http://www.painmed.org
> Cited: American Pain Society http://www.ampainsoc.org
> Cited: Compassion & Choices http://www.compassionandchoices.org/
> Bookmark: http://www.mapinc.org/find?232 (Chronic Pain)
> Bookmark: http://www.mapinc.org/topics/morphine
> Bookmark: http://www.mapinc.org/oxycontin.htm (Oxycontin/Oxycodone)
> Bookmark: http://www.mapinc.org/find?136 (Methadone)
> Bookmark: http://www.mapinc.org/people/Russell+Portenoy
> Bookmark: http://www.mapinc.org/people/Jeri+Hassman
> Bookmark: http://www.mapinc.org/people/William+Hurwitz
> Why Are Millions Of Suffering Americans Deing Denied The Prescription Drug 
> Relief They Need?
> Deborah Hamalainen was feeling more and more agitated by the minute. 
> Waiting to see her neurologist, she was silently rehearsing a 
> confrontation that had been building for months. She planned to look the 
> doctor directly in the eyes and demand that he treat the chronic pain that 
> had invaded her life.
> In the two decades since doctors diagnosed her with multiple sclerosis, 
> Hamalainen learned to tolerate numb extremities, tingling sensations, even 
> the weakness that causes her left foot to drag. And it wasn't like her to 
> be confrontational. "I'm much happier in denial," admits the soft-spoken 
> 52-year-old sculptor.
> Some physicians fear that if they deliver humane pain care, they'll face 
> prosecution by the DEA.
> The symptoms she couldn't ignore, though, were the intense shooting pains 
> that raced across her shoulder blades and down her limbs. By the time she 
> arrived for this doctor's appointment, they were a 24-hour presence. 
> Hamalainen barely slept anymore. Rolling over was an ordeal. When the 
> Medford, New Jersey, resident awoke, stiff and exhausted, she braced her 
> shoulders so they wouldn't move as she rose. Sometimes, her husband had to 
> pull her upright from the bed.
> Every three months for three years, Hamalainen saw this neurologist. Each 
> time, she mentioned the pain. Each time, the doctor deftly changed the 
> subject. Each time, she left in pain.
> But this time would be different.
> Hamalainen waited quietly as nurses wandered in and out of the examination 
> room, taking her vital signs. Finally, she lost it. "My pain is real," she 
> said frantically to one of the nurses. "I need relief. Why does he keep 
> refusing to talk to me about it? What do I have to do?"
> The nurse turned to her conspiratorially and lowered her voice. "I should 
> not tell you this," she said. "But he doesn't want to treat your pain 
> because the treatment that works is opioids, and he's afraid to prescribe 
> them."
> With that conversation, Hamalainen joined legions of patients who are the 
> victims of a troubling and all-too-common medical practice: the 
> undertreatment of significant and debilitating pain. An estimated 75 
> million Americans suffer from chronic pain, according to the American 
> Medical Association, and numerous studies have shown that patients often 
> don't receive the medication that could provide relief. Undertreatment 
> runs as high as 50 percent among advanced-stage cancer patients and 85 
> percent among older Americans living in long-term care facilities.
> Much of this suffering is preventable. Experts do know how to reduce pain 
> safely. In particular, physicians now know that opioid analgesics, 
> medicines such as morphine and oxycodone, provide relief for a wide 
> spectrum of pain problems, with relatively few side effects when taken as 
> prescribed. "We can't cure everybody who is in pain, but we can make 
> almost everyone feel better," says Scott Fishman, chief of the division of 
> pain medicine at the University of California, Davis, and president of the 
> American Academy of Pain Medicine. "Becoming a prisoner of pain is not an 
> inevitability."
> The problem is that the most effective medications cause skittishness 
> among many physicians. Poor medical-school training has left them unaware 
> of the tools at their disposal and even the importance of treating pain. 
> Many harbor the false impression that opioids frequently lead to addiction 
> or unmanageable side effects, even when used correctly for a legitimate 
> medical need. 'Becoming a prisoner of pain is not an inevitability.'
> The problem is that the most effective medications cause skittishness 
> among many physicians. Poor medical-school training has left them unaware 
> of the tools at their disposal and even the importance of treating pain. 
> Many harbor the false impression that opioids frequently lead to addiction 
> or unmanageable side effects, even when used correctly for a legitimate 
> medical need.
> Worse, some physicians fear that if they deliver humane pain care, they'll 
> face prosecution by the federal Drug Enforcement Administration (DEA) or 
> state medical boards. In recent years, a number of respected doctors have 
> been investigated and even prosecuted after prescribing large amounts of 
> opioids. The result, according to experts, is an environment that scares 
> doctors away from practicing good medicine.
> "I've had prominent physicians call me up and say, 'I have patients doing 
> well, taking opioids for otherwise treatable pain, but I'm going to stop 
> writing prescriptions because I don't want the DEA coming into my office 
> and putting handcuffs on me,' " says James Campbell, a neurosurgeon at 
> Johns Hopkins University. "Five years ago, we were actually doing a better 
> job at handling pain patients. Now we've seen a backslide, and patients 
> are definitely the victims. They're suffering."
> On his first day as a licensed physician, Russell Portenoy had a troubling 
> experience that would influence the course of his career. At the New York 
> City hospital where he was interning, a nurse summoned him to a room where 
> a cancer patient was moaning with abdominal pain. Portenoy knew the woman 
> would benefit from opioids, but he was new at doctoring, so he first 
> phoned the resident in charge to clear his decision.
> "I have a patient here. She's 60 years old, she's got metastatic ovarian 
> cancer, and she's in bad pain," Portenoy told his supervisor.
> "What do you want to do?" the resident asked.
> "Well, I thought we should give her some pain medicine."
> "What do you want to give her?"
> "Morphine."
> There was silence on the other end of the line. It was 1980: even 
> physicians who endorsed opioids for terminally ill patients believed that 
> morphine was too potent and too dangerous. Finally, the resident said, 
> "Look, you're the doctor. You want to give her morphine, give her 
> morphine." After further consultation, Portenoy wrote an order for a 3 mg 
> injection, less than one third of what he would likely give her today. He 
> never checked back to see if the medication worked.
> The patient was still on Portenoy's mind the following year when he 
> decided to specialize in pain medicine. "I'd given somebody with severe 
> cancer pain a dose that didn't have a prayer of providing any benefit," he 
> says. "My hope is that there was such a profound placebo effect that she 
> didn't scream the rest of the night."
> Portenoy joined a coterie of pioneers who encouraged their colleagues to 
> become bolder in treating patients' suffering. They argued that pain is 
> more than a symptom; it's a disease by itself that can trigger a cascade 
> of other health problems from a weakened immune system to obesity if left 
> untended.
> At Memorial Sloan-Kettering Cancer Center, where he launched his career as 
> a researcher and pain physician, Portenoy initially concentrated on cancer 
> pain. Eventually he discovered that opioid medicines routinely prescribed 
> in advanced-cancer cases also worked for patients without terminal 
> illnesses. They relieved the symptoms without fogging patients' brains or 
> turning them into addicts. The only major ongoing side effect, 
> constipation, was manageable with other drugs. But when Portenoy shared 
> the news in a 1986 journal article, he received excoriating criticism from 
> his colleagues.
> Slowly, time has proven Portenoy correct. In 1996 two leading professional 
> groups declared opioids "an essential part of a pain-management plan." 
> Five years later, the DEA and 21 health organizations agreed that opioids 
> are often "the most effective way to treat pain and often the only 
> treatment option that provides significant relief."
> Across the United States, hospitals are starting to take the issue 
> seriously, creating programs specializing in pain management. Portenoy's 
> own department, at New York City's Beth Israel Medical Center, has 14 
> physicians, a team of researchers, and training programs for doctors and 
> others. Using opioids and other therapies, these programs have restored 
> normalcy to many lives.
> "It's a miracle," says 55-year-old Michele Ferreri, a Staten Island, New 
> York, woman who suffers from a painful nerve condition that appeared in 
> the aftermath of shingles. Once unable to get out of bed because of her 
> burning headaches, she started taking extended-release morphine and other 
> medications after seeing Portenoy at Beth Israel. Now she lives an active 
> life, taking her mother shopping, doing laundry, and attending social 
> functions with her husband, a hospital CEO. "I can smile now," she says. 
> "I can smile and greet people."
> Until recently, there was no legal incentive for doctors to take pain 
> seriously. That's starting to change. In 2001 a California jury awarded 
> $1.5 million to the family of a lung-cancer patient who lay undermedicated 
> and dying in a hospital near San Francisco. (The award was later reduced 
> in keeping with state law.) Two years later, the California Medical Board 
> reprimanded a physician in a similar case involving a nursing home. These 
> decisions "sound a resounding wake-up call to all health care providers 
> that failure to treat pain attentively will result in accountability," 
> says Kathryn Tucker, attorney for Compassion & Choices, which litigated 
> the cases.
> But the wake-up call hasn't stirred everyone. Millions of Americans still 
> don't receive the therapy they need. "The odds of your getting good pain 
> management are, at best, 50-50," says UC Davis bioethicist Ben Rich.
> Studies bear Rich out. One survey of Oregon families, published in 2004, 
> showed that almost half of terminally ill patients were in significant 
> pain or distress during the last week of their lives. In a study of 
> nursing homes in 11 states, Brown University researchers found that two 
> thirds of the residents initially found to be in daily pain were still 
> suffering two to six months later.
> But even when treatment is available, patients often reject it because of 
> widely held misconceptions. Popular media play up addiction be it on the 
> TV series ER, where Noah Wyle portrayed a young physician addicted to 
> prescription painkillers, or in tabloid newspapers, which devoted 
> voluminous ink to Rush Limbaugh's struggle with pain pills in late 2003. 
> Indeed, Limbaugh's alleged drug of choice, OxyContin (a form of 
> oxycodone), has become popular among rural drug abusers, who chew the 
> pills to destroy their time-release mechanism and get a heroinlike rush.
> In reality, for those using opioids as prescribed, the likelihood of 
> addiction is extremely low, according to research. "It's really an 
> unwarranted fear," says Christine Miaskowski, former president of the 
> American Pain Society. Many patients do become physiologically dependent, 
> meaning they'd go through withdrawal syndrome if they quit cold turkey but 
> this is a normal condition that can be managed by tapering down the 
> dosage. It's not the same as addiction, which requires psychological 
> dependence. Experts say patients with a history of drug abuse can safely 
> use opioids too, as long as they are carefully monitored by their 
> physicians to avoid a recurrence of their abusive behaviors.
> These reassurances don't convince everyone. "There is a 
> just-say-no-to-drugs attitude in the United States," says Diane Meier, a 
> geriatric and palliative-care specialist at New York City's Mount Sinai 
> Medical Center. "Even my own family will say, 'I don't want to be doped up 
> on those drugs.' "
> Patients aren't alone in their misinformation. Physicians, trained to 
> suspect there's an abuser lurking behind every painkiller request and, to 
> be fair, there sometimes is still confuse addiction with physical 
> dependence. The facts don't dissuade them: although Ferreri has become 
> functional on morphine, her family doctor still "talks to my husband all 
> the time about the amount of medication I'm on, how dangerous it is. He 
> really makes me feel that I'm a drug addict."
> Worse, some physicians simply don't understand the importance of treating 
> pain at all. Miaskowski, a professor in the physiological nursing 
> department at the University of California, San Francisco, recently 
> completed a study of cancer patients. "We had one patient whose primary 
> care physician told her, 'Don't take your pain medicine. Let the pain kill 
> the cancer.' " Was this advice offered years before recent advances in 
> pain management? No, she says. "This was 2001."
> There's another, more ominous reason some doctors don't treat pain 
> aggressively: they don't want to end up like Arizona physician Jeri 
> Hassman.
> Hassman, a physical medicine and rehabilitation specialist licensed in 
> 1986, opened a solo practice in 1999 to focus on nonsurgical treatments 
> for injured patients. Working with physical therapists and chiropractors, 
> she developed a comprehensive program that includes massage, electrical 
> stimulation, muscle injections, and even posture lessons. She also 
> prescribed painkillers. "Medications are important," she says. "If you 
> decrease pain, you get better compliance with exercise and other 
> rehabilitation." Until 2002, she says, "I wasn't afraid of prescribing 
> strong pain medicines alongside the available therapies."
> Then, in May of that year, federal agents stormed her Tucson office in 
> full view of her patients. They spent eight hours questioning her staff, 
> seizing patient files and appointment logs, and copying the hard drives 
> off her computers. According to a government brief, the DEA had been 
> contacted by pharmacists "concerned about the large amounts of narcotic 
> drugs that were being prescribed for Dr. Hassman's patients, plus the 
> frequency with which they were returning for refills." The druggists were 
> also concerned that some medicines had fallen into the hands of 
> nonpatients, the brief said. Hassman was arrested and charged with 320 
> counts of illegally distributing narcotics and 41 counts of health care 
> fraud.
> Just before the case was scheduled for trial, federal prosecutors offered 
> Hassman a plea agreement, allowing her to plead guilty to four counts of 
> failing to report prescription abuse. Unwilling to risk a jury trial, 
> Hassman accepted the offer. She was sentenced to two years' probation and 
> agreed to surrender her DEA license to prescribe controlled substances.
> Hassman was relatively lucky. This April, Virginia pain specialist William 
> Hurwitz was sentenced to 25 years in prison for drug trafficking after 
> prescribing large doses of painkillers such as OxyContin, morphine, and 
> methadone to his patients. One of his patients died after taking a very 
> high dose of morphine. DEA officials likened Hurwitz to a heroin dealer. 
> Others, though, testified that Hurwitz provided them with the only 
> effective relief they had ever received for debilitating pain.
> Though the DEA wouldn't comment for this article, it has previously 
> insisted that it only goes after bad apples. "Our focus is not on pain 
> doctors. Our focus is on people who divert drugs," agency official 
> Patricia Good said during a 2004 teleconference. But physician groups and 
> patient advocates point to a growing list of respected pain doctors who 
> have been prosecuted by the DEA and by state medical boards. They say that 
> while the DEA has a legitimate interest in preventing the diversion of 
> harmful drugs, the agency's adversarial zeal has grown in the past four or 
> five years.
> For its part, the DEA notes that it arrests fewer than 100 doctors a year 
> on drug-diversion charges, hardly a full-scale attack on the profession. 
> The numbers hardly matter, though, because the arrests, and the publicity 
> surrounding them, have created a chilling effect. "Every time a physician 
> picks up a newspaper or hears an account of some physician who has been 
> accused of inappropriately prescribing controlled substances, it 
> reinforces the proposition bad things can happen to you when you attempt 
> to manage patients' pain aggressively but appropriately," says bioethicist 
> Ben Rich. "Doctors don't say, 'I'll be more judicious and that won't 
> happen to me.' Their reaction is, 'I don't need this.' "
> It took Deborah Hamalainen another year, plus the encouragement of a 
> friend, to find effective treatment for her pain. Early one morning, the 
> two women took an 80-mile bus trip to New York City, then took a taxi 
> downtown to Beth Israel Medical Center. There, Hamalainen met with pain 
> specialist Russell Portenoy, who found her story credible. Portenoy 
> explained to Hamalainen that he couldn't cure her multiple sclerosis, but 
> he could control her symptoms. "The goal is to focus on the pain itself, 
> to get you comfortable, and to help you function," he told her.
> After monitoring several medications for side effects, Portenoy and 
> Hamalainen settled on fentanyl, a synthetic opioid delivered through an 
> adhesive patch worn on her lower back. She uses oxycodone as a "rescue" 
> drug when the fentanyl isn't effective.
> As Portenoy predicted, the medicine hasn't eliminated the source of 
> Hamalainen's pain. In fact, the multiple sclerosis has progressed. She's 
> been losing feeling in her hands and feet, dropping objects, and tripping. 
> She relies on a pair of canes to get around. Still, with the pain under 
> control, Hamalainen has been able to return to her art. She recently had a 
> mixed-media exhibition at the gallery where she used to work. In one 
> sculpture, she took old canes, including the ones her father used after he 
> lost a leg to diabetes, and smashed them with an ax, then enclosed them in 
> a clear plastic exhibition box.
> When the pain was at its worst, Hamalainen contemplated suicide. Now, with 
> opioids to relieve the symptoms, Hamalainen can envision a productive 
> artistic future. "Being able to be creative again has been thrilling," she 
> says. "It's like having a new life."
> - ---
> MAP posted-by: Larry Seguin
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