David Covillion finally got relief from his pain with the help of Jack Kevorkian. The pain came from neck and back injuries Covillion had suffered in April 1987, when his station wagon was broadsided by a school bus at an intersection in Hillside, New Jersey. The crash compounded damage already caused by an on-the-job injury and a bicycle accident. Covillion, a former police officer living in upstate New York, underwent surgery that fall, but it only made the pain worse. Along with a muscle relaxant and an anti-inflammatory drug, his doctor prescribed Percocet, a combination of acetaminophen and the narcotic oxycodone, for the pain.
The doctor was uneasy about the Percocet prescriptions. In New York, as in eight other states, physicians have to write prescriptions for Schedule II drugs--a category that includes most narcotics--on special multiple-copy forms. The doctor keeps one copy, the patient takes the original to the pharmacy, and another copy goes to the state. After a year or so, Covillion recalled in an interview, his doctor started saying, "I've got to get you off these drugs. It's raising red flags." Covillion continued to demand painkiller, and eventually the doctor accused him of harassment and terminated their relationship.
"Then the nightmare really began," Covillion said. "As I ran out of medication, I was confined to my bed totally, because it hurt to move....At times I'd have liked to just take an ax and chop my arm right off, because the pain got so bad, but I would have had to take half of my neck with it." He started going from doctor to doctor. Many said they did not write narcotic prescriptions. Others would initially prescribe pain medication for him, but soon they would get nervous. "I'd find a doctor who would treat me for a little while," he said. "Then he'd make up an excuse to get rid of me." Eventually, Covillion went through all the doctors in the phone book. That's when he decided to call Kevorkian.
The retired Michigan pathologist, who has helped more than 40 patients end their lives, was reluctant to add Covillion to the list. At Kevorkian's insistence, Covillion sought help from various pain treatment centers, without success. He called Kevorkian back and told him: "I'm done. I have no more energy now. I just don't have the fight. If you don't want to help me, then I'll do it here myself." Kevorkian urged him to try one more possibility: the National Chronic Pain Outreach Association, which referred him to Dr. William E. Hurwitz, an internist in Washington, D.C., who serves as the group's president.
The day he called Hurwitz, Covillion was planning his death. "I had everything laid out," he said. "I got a few hoses and made it so it would be a tight fit around the exhaust pipe of my car. I taped them up to one of those giant leaf bags, and I put a little hole in the end of the bag. All I had to do was start the car up, and it would have filled the bag right up, pushed whatever air was in there out, and it would have filled the bag up with carbon monoxide. Same thing as what Dr. Kevorkian uses. And then I had a snorkel, and I made it so I could run a hose from the bag full of gas and hook it up to that snorkel, and all I had to do was put it in my mouth, close my eyes, and go to sleep. And that would have been it. I would have been gone that Friday."
But on Thursday afternoon, Covillion talked to Hurwitz, who promised to help and asked him to send his medical records by Federal Express. After reviewing the records, Hurwitz saw Covillion at his office in Washington and began treating him. "The last three years I've been all right," he said in a July interview. "I have a life." Yet Covillion was worried that his life would be taken away once again. On May 14 the Virginia Board of Medicine had suspended Hurwitz's license, charging him with excessive prescribing and inadequate supervision of his patients. At the time Hurwitz was treating about 220 people for chronic pain. Some had been injured in accidents, failed surgery, or both; others had degenerative conditions or severe headaches. Most lived outside the Washington area and had come to Hurwitz because, like Covillion, they could not find anyone nearby to help them.
In July, after the case was covered by The Washington Post and CBS News, the Pennsylvania pharmaceutical warehouse that had been supplying Covillion with painkillers stopped filling Hurwitz's prescriptions, even though he was still licensed to practice in D.C. The pharmacist who informed Covillion of this decision (in a telephone conversation that Covillion recorded) suggested that Hurwitz had prescribed "excessively high amounts." At the same time, he recommended that Covillion "find another doctor" to continue the prescriptions. Covillion's reply was angry and anguished: "There is no other doctor!"
Hurwitz may not be the only physician in the country who is willing to prescribe narcotics for chronic pain, but there are few enough that patients travel hundreds of miles to see them. "I call it the Painful Underground Railroad," says Dr. Harvey L. Rose, a Carmichael, California, family practitioner who, like Hurwitz, once battled state regulators who accused him of excessive prescribing. "These are people who are hurting, who have to go out of state in order to find a doctor. We still get calls from all over the country: 'My doctor won't give me any pain medicine.' Or, 'My doctor died, and the new doctor won't touch me.' These people are desperate."
So desperate that, like Covillion, many contemplate or attempt suicide. In an unpublished paper, Rose tells the stories of several such patients. A 28-year-old man who underwent lumbar disk surgery after an accident at work was left with persistent pain in one leg. His doctor refused to prescribe a strong painkiller, giving him an antidepressant instead. After seeking relief from alcohol and street drugs, the man hanged himself in his garage. A 37-year-old woman who suffered from severe migraines and muscle pain unsuccessfully sought Percocet, the only drug that seemed to work, from several physicians. At one point the pain was so bad that she put a gun to her head and pulled the trigger, unaware that her husband had recently removed the bullets. A 78- year-old woman with degenerative cervical disk disease suffered from chronic back pain after undergoing surgery. A series of physicians gave her small amounts of narcotics, but not enough to relieve her pain. She tried to kill herself four times--slashing her wrists, taking overdoses of Valium and heart medication, and getting into a bathtub with an electric mixer--before she became one of Rose's patients and started getting sufficient doses of painkiller.
Patients who cannot manage suicide on their own often turn to others for help. "We frequently see patients referred to our Pain Clinic who have considered suicide as an option, or who request physician-assisted suicide because of uncontrolled pain," writes Dr. Kathleen M. Foley, chief of the pain service at Memorial Sloan-Kettering Cancer Center, in the Journal of Pain and Symptom Management. But as she recently told TheNew York Times Magazine, "those asking for assisted suicide almost always change their mind once we have their pain under control."
One thing that supporters and opponents of assisted suicide seem to agree on is the need for better pain management. Concern about pain was an important motivation for two 1996 decisions by federal appeals courts that overturned laws against assisted suicide in New York and Washington. In the New York case, the U.S. Court of Appeals for the Second Circuit asked, "What business is it of the state to require the continuation of agony when the result is imminent and inevitable?" With the U.S. Supreme Court scheduled to hear a combined appeal of those decisions during its current term, the persistent problem of inadequate pain treatment is sure to be cited once again.
In medical journals and textbooks, the cause of this misery has a name: opiophobia. Doctors are leery of the drugs derived from opium and the synthetics that resemble them, substances like morphine and codeine, hydromorphone (Dilaudid) and meperidine (Demerol). They are leery despite the fact that, compared to other pharmaceuticals, opioids are remarkably safe: The most serious side effect of long-term use is usually constipation, whereas over-the-counter analgesics can cause stomach, kidney, and liver damage. They are leery because opioids have a double identity: They can be used to get relief or to get high, to ease physical pain or to soothe emotional distress.
Doctors are afraid of the drugs themselves, of their potency and addictiveness. And they are afraid of what might happen if they prescribe opioids to the wrong people, for the wrong reasons, or in the wrong quantities. Attracting the attention of state regulators or the Drug Enforcement Administration could mean anything from inconvenience and embarrassment to loss of their licenses and livelihoods. In the legal and cultural climate created by the eight-decade war on drugs, these two fears reinforce each other: Beliefs about the hazards of narcotics justify efforts to prevent diversion of opioids, while those efforts help sustain the beliefs. The result is untold suffering. Dr. Sidney Schnoll, a pain and addiction specialist who chairs the Division of Substance Abuse Medicine at the Medical College of Virginia, observes: "We will go to great lengths to stop addiction--which, though certainly a problem, is dwarfed by the number of people who do not get adequate pain relief. So we will cause countless people to suffer in an effort to stop a few cases of addiction. I find that appalling."
Because pain is hard to verify objectively, the conflict between drug control and pain relief is inevitable. It can be alleviated through regulatory reform, but it can never be eliminated. A system that completely prevented nonmedical use of prescription drugs would also leave millions of patients in agony. Conversely, a system that enabled every patient with treatable pain to get relief would also allow some fakers to obtain narcotics for their own use or for sale to others. In deciding how to resolve this dilemma, it's important to keep in mind that people who use prescription drugs to get high do so voluntarily, while patients who suffer because of inadequate pain treatment have no choice in the matter.
A woman who recently served as a chaplain at a New York City hospital encountered many patients in severe pain. "You let them squeeze your hand as hard as they want to, and cry, scream, express their frustration," she says. "It's horrible being in pain. It's really debilitating. It kills the spirit." She found that nurses were reluctant to give patients more medication. "If a patient seemed to really be in agony, I would go to a nurse," she says. "They were concerned about giving them too much." She recalls one patient who was in "terrible pain" following surgery. "They only had him on Tylenol," she says. "He complained about it, but then he said, 'Well I suppose they know best. They don't want me to get addicted to anything.'"