'Dr. Hurwitz Is Always Concerned'

Jacob Sullum | November 16, 2004

Prosecutors argue that McLean, Virginia, pain doctor William Hurwitz, who is on trial at the federal courthouse in Alexandria, knowingly supplied OxyContin and other narcotics to patients who sold them on the black market. Hurwitz, who faces a possible life sentence, is charged with 62 offenses, including drug trafficking and health care fraud. "A self-proclaimed healer, he crossed the line to dealer," Assistant U.S. Attorney Mark Lytle said in his opening statement. "He thought he could hide behind the pain he treated." Prosecutors have likened Hurwitz to "a street-corner crack dealer."

But certain details of the government's case do not fit this picture. For instance, prosecutors cite Hurwitz's detailed medical records to support their allegation that "he prescribed incredibly large amounts of narcotics, well outside the boundaries of proper medicine." But as Patrick Hallinan, one of Hurwitz's attorneys, noted, "These medical records are written in stone. You think someone involved in a scam of selling pills will document this?"

A former patient called as a prosecution witness testified that "I had a lot of pain, but I exaggerated it, trying to get the drugs." On cross-examination, he added that he had "played a lot of doctors" over the years. He characterized Hurwitz as naive, saying: "He was concerned about me and my wife. Dr. Hurwitz is always concerned."

Such testimony does not make Hurwitz look like a drug trafficker. It makes him look like a sincere healer duped by tricky patients, as his lawyers portray him. By prosecuting him for trusting his patients too much, the government is criminalizing the sort of mistake that doctors already are so keen to avoid that they routinely err in the other direction, turning away or undertreating patients whose suffering could be alleviated by opioids.

Russell Portenoy, a prominent pain expert, warns that a conviction in this case would have a "strong chilling effect" on pain treatment. "I have a very profound concern," he told The Washingtion Post "that the appropriate way to deal with these issues is not through criminal prosecution but through an evaluation of medical practice."

Comments

|11.16.04 @ 11:12AM|#

My hope is that Dr. Hurwitz will be exonerated and that the Prosecution will be prosecuted and then found guilty of errant mischief.

CodeMonkeySteve|11.16.04 @ 12:02PM|#

"he prescribed incredibly large amounts of narcotics, well outside the boundaries of proper medicine."

Except that there is no "boundaries" for narcotics: a dose which barely takes the edge off for one patient may kill another. It's entirely patient-specific.

|11.16.04 @ 12:08PM|#

Ugh...

It's hilarious how established medications, opioids and... well, anything schedule 2 (or 3, less often, I suppose), can still be snubbed by patients and doctors while they're pulling COX-2 inhibitors like Vioxx right and left.

Not that Vioxx was particularly dangerous, but compare the ~16,500k deaths from NSAIDS (incl. COX-2 related meds or not, unsure) to the number of deaths from opioids (I recall something like 3200, but that may be something else entirely, so plz correct if wrong. Bit short on time here or I'd check myself) and consider the clinical data in any real, significant death, I'd say one of the better ways to assure one good health is the consumption of opioid based meds. That is, as opposed to what else is offered for pain. Besides what I mentioned, I recall that off the top off my head as including yr basic tricyclics in adjunct pharm-thearpy (i.e. Nortriptyline still seems pretty common), lidocaine and such topical things for, well, topical injuries, and a handful of muscle relaxers which are sometimes, but not often, benzos. More often they're antihistamine-style muscle relaxers, along the lines of Flexeril (cyclobenzaprine; tizanidine also, I think). Oh, and there's Neurontin, but it's a lot of bunk so far, it seems.

The point is, does it work and is it safe (not necessarily in that order)? If those are the questions, then they're all yes, but with certain considerations. Opioids having the least of them, and the most clinical data to support that. They are superior meds and likely will continue to be for some time.

Also, consider:

-They're as old as the hills, and still fucking used for numerous rather very, very good reasons. As I said, they come with an assload of experience and clinical data which make them trustworthy to the bone.

-They produce results that, almost universally, are incredibly superior to those of any competition. You will never, ever, ever find a paramedic who vouches for the analgesic capacity of, say, Toradol (common injectable NSAID) over morphine, demerol, or fentanyl.

-The [medical] addiction rate, despite the hype, is all of a big, whopping %8 (sorry, Jacob and such folks, I know you know this -- and probably most of everything else in this comment -- already. A small remind, if you will. :> ).

-There is, at least what I consider, pretty neat-o research into partial agonist opioids and their applications outside pain management; I.E.- Back to use as psychotropic meds. This is where they should be getting another fair go around in sporadic use, much in the same way stimulants have proven safe, highly effective meds for psychotropic uses, and could, vice versa, have incredible, far reaching potential in PM. Anyone who denies that Amphetamines lack their own, distinct analgesic capacity, especially in adjunct use with a dose of opioids, has certainly NOT done their homework on the topic, nor tried the combo (or singular Adderall consumption regimen) themselves.

Oh, and...

RE: Amphetamines and Opioids-
An entirely safe combination, though not in use by doctors like my own (whom would probably sooner just "euthanize" me with their bare hands than increase the piddly-ass dose of Oxy currently dispensed, which I've cut down on anyway now that -- thanks to significant, organized, and in all honesty, incredibly enjoyable, street drug consumption -- my pain has diminished considerably). Like usual, ditch the hype on this particular issue. Plenty of research indicates safety and viability of concurrent use of stimulants and narcotics, perhaps with the exception of cocaine (this combo, in a medical context, may itself yet be safe for some kind of short term use. Perhaps the patient has suffered brain damage or a genetic oddity resulting in few to nil Mu, Kappa and or Delta opioid receptors and are naturally in horrific pain, no thanks to aforementioned deformity.)

Actually, it's (among SANE doctors who do their research) quasi-routinely used now for those who experience severe drowsiness with a long term narcotic regimen.

As far as anyone's further concerns about how this related to the "speedball" combination: That combo involves cocaine and diacetylmorphine (or, for the non-pharma-geek types like me aorund here, heroin. I always liked "smack" myself; Name and drug). Not to say other things haven't adapted the same name here and there, for whatever dumb as hell reason (thank the crooked rehab industry, AA/NA, NARCANON, so on and so fourth, for tainting street lore with a colorful variety of dangerous absurdities).

In any case, there is an ocean of differences between amphetamines and cocaine(s). Amphetamines are most certainly not similar to tropinines in any way that would be useful to making our judgement about this particular question (tropinines being, among others like the "stimulant" category, one of the categories cocaine primarily falls into. More a chemistry-type category, but when you're distinguishing for a pharmacology related purpose, I find it helps illustrate a wide difference in methods of action and such things).

And if "ya'll" don't feel like readin 'bout no tropinines by hittin' up Google or Wikipedia -- No worries! The methyl face feels ya, but not in a bad, Catholic kind of way!

Just dig yrself some lil' moleculizzlez:
http://www.erowid.org/cgi-bin/chem_compare/chem_compare.cgi?LM=_ch_cocaine_ia_cocaine_3d_mid.jpg&RM=_ch_amphetamines_ia_amphetamine_3d_mid.jpg

That should make things pretty self-explanatory (...like the ulcerations resulting from consumption of anti-inflammatories, a rapping white boy like myself might be prone to add).

======

Well, with all that said, and having gone (as is standard) totally off topic, still with so much else to add that is yet further off topic....

Alas, my time has run short on me.

Point and case: OPIATES+OPIOIDS = TIME TESTED SUPERIOR MEDICATIONS. Their yet still massive potential is being shunned in favor of what is often complete bullshit, and even worse, for purely political reasons. They're certainly not any more expensive than further research in your run of the mill COX-2 inhibitors. Probably millions of millions less (currently uninvestigated, but if nothing else, narcotics are routinely cheaper for the patient).

But of course, leave it to government to stamp out sanity in whatever lovely pockets of it there are of it still around. Pharmacology and medicine, in this era. I am, somehow, totally unsurprised. (Note: Subtle Orwell refernce, teehee!...)

Ok, folks, digest that while I vacuum and walk the dog... At the same time! :)

|11.16.04 @ 12:21PM|#

Sorry bout the link.

It was way too long anyway. =

|11.16.04 @ 2:51PM|#

Turley doesn't sound like a dupe; he sounds like an idiot. But he shouldn't be prosecuted under the drug laws; he should be drummed out of medicine by the AMA, with a license revocation. And no, I don't disagree that opiates are sometimes necessary. I do think that he should be suspicious of people claiming excess pain without some kind of evidence.

Never mind the drug laws; handing out oxycontin to possible drug dealers certainly violates the Hyppocratic oath.

|11.16.04 @ 3:30PM|#

mac, you're nuts. Law enforcement should not be able to look over the shoulder of legitimate doctors and tell them they're over-presribing medicine.

"Handing-out" oxycontin to drug dealers? Nice hyperbole there.

|11.16.04 @ 8:11PM|#

While it's anathema to true believers like Jacob Sullum, the answer here is that the AMA needs to step up to the plate and police its own. This requires telling the drug warriors where they can stick it, but it also involves telling the "there's no such thing as addiction" crowd that they can stick it, too.

|11.17.04 @ 9:07AM|#

The AMA exists for the sole purpose of maintaining and protecting the various medical professions' monopolies. They have no interest in "policing their own", at least when it comes to something like painkillers.

|11.17.04 @ 10:24AM|#

"...but it also involves telling the "there's no such thing as addiction" crowd that they can stick it, too."

Oh please. There is no such crowd that denies addiction. There is, however, a wide number of people with varying degress of rather serious and legitimate criticism, with regards to the currently accepted mainstream addiction model.

My main beef with it: Those who would just attribute all their problems and errors in life to a chemical, and then expect the rest of us to conform to their "lessons" which too often make upon the aforementioned model. If not make it up, the individuals who exploit such vague concepts too often find support within it.

It's worth mentioning that this is only problematic where healthcare is tightly regulated.

I guess all I'm saying is... When was the last time you saw a privately run heroin (and or methadone) maintenance clinic in the US (or Europe)?

|11.26.04 @ 1:12PM|#

Be suspicious of someone complaining of exessive pain without documentation??? For years I had severe migraine type headaches and other related neurologic disturbances (over a decade of problems). I took heavy pain meds on 10-12 occasions through a typical year - not much. But damn if I wasnt in severe pain. Turns out I had a significant case of chronic mercury poisoning. Once diagnosed, the cure took effect almost overnight. No problem since and no pain meds needed or desired either. Doctors like Hurwitz should be more careful with screening to be as certain as possible their meds aren't being diverted, but he and doctors like him are angels to a lot of people who really do live in "undocumented" agony.