William E. Hurwitz spent much of last year trying to find new doctors for his patients. It wasn't easy, since physicians often are reluctant to treat chronic pain. They worry that repeated prescriptions for large doses of narcotic painkillers will attract unwanted attention from the government. That anxiety was the main reason Hurwitz had ended up treating so many people for pain -- about 300 patients suffering from cancer, rheumatoid arthritis, degenerative disc disease, diabetic complications, and other painful conditions. Some of them had searched for months or years, growing increasingly desperate, before finding him. Many lived hundreds of miles from his Northern Virginia office.
Hurwitz's retirement was not exactly voluntary. A veteran of battles with state regulators and the Drug Enforcement Administration (DEA), the 57-year-old internist saw more trouble on the horizon. After learning that he had been targeted by a federal grand jury investigation of prescription drug diversion, he decided to gradually transfer his patients rather than put them at risk of suddenly losing access to pain medication.
Hurwitz was still working to match patients with new doctors in November, when the DEA raided his home and office. "There are patients in Vermont, Massachusetts, Maine, Connecticut, West Virginia, Virginia, Kentucky, Tennessee, North and South Carolina, and Florida for whom possible referrals are needed," he said in a written statement. In the raid, DEA agents "took patient files, financial and other records, my cell phone, and miscellaneous items. They also copied the hard drives on many of my computers and took my server, as they did not have the equipment to copy this in the office. Fortunately, I had backup files and was able to re-establish my computer network and resume patient care."
But the raid reinforced Hurwitz's concern about his patients' future. "The stigma that these people suffer, both as pain patients on opioid medications in general and as former patients of accused doctors in particular, tends to foreclose most opportunities for effective continuing care," he said last August in a written statement that announced he would be closing his practice. Last summer one of his patients told The Washington Post, "If I go to a doctor and mention [Hurwitz's] name, they won't even touch me. All I'm concerned about is getting rid of this excruciating pain." Another said: "I don't know what I'm going to do. While the criminals who are diverting the drugs get jailed, the innocent patients get the death penalty."
Facing the prospect of criminal prosecution after two regulatory actions against him, Hurwitz certainly understood why doctors are leery of pain patients. Hurwitz lost his state medical license and his federal prescribing privileges in 1996 after the Virginia Board of Medicine and the DEA accused him of excessive prescribing. (See "No Relief in Sight," January 1997.) More than 50 of his patients testified on his behalf at the board's hearing, and pain experts came to his defense, describing the large doses of narcotics he prescribed as reasonable and appropriate. His Virginia license was restored in 1997, and in 1998 he resumed his practice after the DEA reinstated the registration that allows doctors to prescribe controlled substances.
Four years later, however, Hurwitz was giving up. "These aggressive and ill-informed prosecutions convey a message of intimidation to doctors and indifference to the plight of patients in pain," he said in his August statement. "Not even the most honest and competent doctors can practice pain medicine with any assurance of safety for themselves or continuity of care for their patients."
The OxyContin "Epidemic"
The focus of the investigation that finally convinced Hurwitz to stop practicing medicine was OxyContin, a drug that in recent years has been portrayed as a seductive, deadly menace. The news media have advertised its "heroin-like high," generating interest among drug users and alarm among politicians. U.S. Rep. James Greenwood (R-Pa.), who held hearings on the subject in August 2001, asserted that "OxyContin is to prescription drug pain relievers what jet fuel is to unleaded gasoline." That year the Food and Drug Administration (FDA) slapped a "black box warning" onto OxyContin declaring that it has "an abuse potential similar to morphine." The DEA has identified OxyContin as "a major drug of concern," putting it alongside Ecstasy, cocaine, heroin, methamphetamine, and marijuana. Attention from the government has triggered more press coverage, which in turn has egged on drug warriors who are convinced we are in the midst of an "OxyContin epidemic."
For Hurwitz's former patients and other people in pain, OxyContin is not an agent of a metaphorical disease; it is a medication that helps relieve the suffering caused by their all-too-real illnesses and injuries. Introduced by Purdue Pharma in 1995, OxyContin is a 12-hour, timed-release form of oxycodone, a synthetic opioid that has long been available in products such as Percocet, Percodan, and Tylox. OxyContin quickly became the most prescribed narcotic on Schedule II of the Controlled Substances Act (the most tightly regulated category of medication), with about 7.2 million prescriptions in 2001. It was a godsend for patients suffering from moderate to severe chronic pain, who could use it to get steady relief throughout the day.
Because some versions of OxyContin contained large doses of oxycodone (up to 160 milligrams), unmixed with analgesics such as acetaminophen or aspirin, it appealed to drug users looking for a handy way to get high. They discovered they could get all the oxycodone at once by crushing the tablets and snorting the powder or mixing it with water and injecting it. The crackdown triggered by such nonmedical use has made doctors wary of OxyContin. "While complete data for 2002 [are] not available," Purdue Pharma reports, "the growth in the number of prescriptions written has dropped compared to 2001." The government's response to OxyContin abuse also has increased doctors' apprehension about prescribing narcotics in general. The upshot is unnecessary suffering by patients who have trouble getting adequate pain treatment.
The consequences of an unreasonable aversion to narcotics, which pain experts call "opiophobia," can be severe, even deadly. In a May 2001 report to the American Society for Action on Pain (ASAP), a Kentucky physician said a former patient, a paraplegic with severe chronic pain, had killed himself. The man's new doctor, alarmed by official warnings about OxyContin, had drastically reduced his dose, leaving him in agony.
Skip Baker, ASAP's president, has collected petition signatures from thousands of pain patients concerned about the loss of effective treatment. "Many of them mention that they were taken off OxyContin because of the 'bad press' about it after having been on it for years," says Baker, who suffers from chronic pain caused by ankylosing spondylitis and fibromyalgia. "It has really been a crisis for us. Even my good pain doctor will not prescribe OxyContin, even though he knows it's the best pain medicine ever made. He admits that it's all because of how law enforcement's efforts have made it look so bad that doctors dare not prescribe it."
Looking Over Doctors' Shoulders
The negative publicity surrounding OxyContin has aggravated a longstanding problem. Beginning in the 1970s, studies repeatedly have found that pain is undertreated even in hospitals and nursing homes, even with patients on the verge of death. Last July an expert panel convened by the National Institutes of Health (NIH) confirmed that people with cancer still suffer needlessly from pain.
One member of the NIH panel, Dr. Paul Frame of Rochester University's School of Medicine, said restrictions aimed at preventing nonmedical use were partly to blame for the undertreatment of pain. "Sometimes doctors don't want to go to the hassle of prescribing a triplicate drug," he said at a press conference, referring to the special forms required by some states for strong painkillers. "They may decide to use something less effective instead."