Drug Policy

The Doctor Is in…for 30 Years

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In the cover story of Sunday's New York Times Magazine, Tina Rosenberg delves into the case of of Ronald McIver, a South Carolina physician who is serving a 30-year sentence for drug trafficking because some of his patients abused or sold painkillers he prescribed. McIver's situation is strikingly similar to that of Virginia pain doctor William Hurwitz, who received a 25-year sentence after his first drug trafficking trial, won an appeal that resulted in a new trial, and is now awaiting sentencing following his conviction on 16 drug-related charges. Both doctors were accused of reckless prescribing that supposedly killed patients whose deaths in all likelihood had nothing to do with the narcotics they received. In both cases, the doctors were too compassionate and too trusting for their own good, were arguably careless in the face of "red flags" suggesting addiction or diversion, but did not deliberately supply the black market or profit from illicit sales. Most of the people for whom they prescribed narcotics were legitimate chronic pain patients who considered themselves lucky to have found a doctor willing to prescribe the medication they needed to make their lives bearable.

Rosenberg treats McIver sympathetically but not uncritically, noting what she considers unwise decisions but arguing that such cases should be addressed through regulatory remedies rather than criminal prosecution. She does a good job of explaining how the war on drugs hurts pain patients, in the process puncturing various myths that contribute to undertreatment. The piece falls short mainly in failing to note that the tension between drug control and pain control is unavoidable: Because pain cannot be objectively verified, making sure that everyone who needs painkillers gets them in adequate doses inevitably means allowing a certain amount of diversion. One of the reforms Rosenberg endorses as an alternative to the DEA's heavy-handed prosecutions, comprehensive electronic monitoring of Schedule II drugs, could well aggravate the problem of inadequate pain treatment by making doctors more fearful of regulatory scrutiny and therefore more reluctant to prescribe narcotics. On the whole, though, Rosenberg's article is an important acknowledgment of the medical fallout from anti-drug hysteria fed by news organizations such as The New York Times.

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  1. Of all the many idiotic aspects of the War on Drugs, this is the idioticest. What the hell is the teaching point here supposed to be? Don’t get an agonizing (or even idioticer, agonizing and terminal) illness or injury because it might lead to a life of drug addiction?

  2. No, the teaching point is that we have such tunnel vision in the WoD that we are unable to discern compassion any longer. That’s what I’ve learned anyway.

  3. This hits close to home. My grandfather was run out of his practice of 40 years because a patient stole his script pad. My grandfather was a dedicated family physician, a WWII vet, a member of the Lions Club and had built several hospitals in our community. None of that mattered a lick. One scumbag takes advantage of him and he’s as good as a drug dealer to the state of Texas. At least they let him retire instead of sending him to jail.

  4. Pain pill users would be wise to travel to mexico and smuggle their drugs home to avoid this whole nonsense, or figure out where they sell heroin in your area. Eventually, we will have three or four million people in jail, five million people in drug court, parole or probation, and hopefully be piss testing 20 million people. Only when we completely abandon self-determination can we be safe from this disease called life.

  5. Every one of these drug warrior bastards should have to live a minimum of a a year preferably two with constant unrelenting chronic insufferable pain before they bring one more of these cases. They have no earthly idea what they’re trying to stop people from treating. It’s not pain like when you stub your toe or break your arm or leg or pain when you’re sick. Pain that continues endlessly, relentlessly that can’t be moderated is something that those who haven’t lived with it for years and even decades can understand. Let them have whatever pills, potions or plants that can ameliorate their suffering and damn those to the depths and tortures of hell that deny it them.

  6. Sure enough, it’s Sullum, but it makes me sad like Balko.

  7. So, can people overdose on OTC stuff? I would imagine so. Could these rulings extend to stores that don’t keep track of / regulate their customers’ headache medicine??

  8. The doctors shouldn’t prescribe pills in massive quantities if they don’t want to go to jail.

  9. Physicians notice this shit. If my wife remotely suspects a drug seeker she won’t prescribe. Pain usually wont kill someone so it makes the decision a bit easier. Too bad.

  10. Sometimes I think these excesses of the drug war show how desperate they are, and that more and more people will soon cry “enough”. Sometimes I think this just goes to show how thoroughly hopeless it is and that they do these things to demonstrate that there are no limits to what they can get away with.

  11. It’s time to start calling the DEA and its allies by their proper name: The pro-torture lobby.

  12. Physicians notice this shit. If my wife remotely suspects a drug seeker she won’t prescribe. Pain usually wont kill someone so it makes the decision a bit easier. Too bad.

    pigwiggle,

    Wow, you’re a regular Mother Theresa. You obviously have never been on the other side of the issue. I’ve tried to obtain medicine that is on the “controlled substances” list and I’ve been met with only suspicion and unnecessary caution, and I’ve been so far unsuccessful in getting anything other than a short-term prescription for said medicine. My guess is that my doctor is trying to cover her own ass much in the same way your wife is, but at the expense of my comfort. I am capable of responsible and appropriate use, but thanks to doctors like your wife — if she is as uncompassionate as you make her out to be — patients have to deal with an extra (and otherwise unnecessary) obstacle. But pain and suffering is no big deal as long as it’s not you suffering, right?

    Maybe if doctors weren’t criminally prosecuted for their patients’ actions, this wouldn’t be an issue.

  13. Pain usually wont kill someone so it makes the decision a bit easier.

    Pain does kill, as noted in the article. It just happens slowly.

  14. The problem is chronic pain is a squishy diagnosis. Everyone’s pain threshold is different. What one person considers debilitating another considers nagging. It’s hard to tell genuine pain cases from pill seekers because there is no subjective measure. This constantly puts Doctors at risk, because all it takes is one junkie to destroy a career. Because of this my father, who is also a doctor, won’t prescribe anything stronger than Tylenol-3.

    Pain meds can also exacerbate the problem because when someone is doped up they aren’t active, leading to a cascade of issues. My brother-in-law is a chronic pain sufferer. I have no no doubt he is in pain. But I have also watched him further deteriorate because all he can do on meds is sit on the couch and zone. This has lead to muscle atrophy, diabetes as he’s put on weight and a host of other issues I’m convinced have more to do with the meds he’s on than his original condition. I don’t know what the course of treatment should be, but simply killing the pain isn’t serving him well.

  15. Matt J,

    I can agree with the squishy diagnosis part but until we invent the pain-o-meter what do you do? If abusing prescription pain medication is immoral or even dangerous when used improperly then that should be up to the patient to cross that moral or dangerous threshold. Right? Doctors shouldn’t make that distinction with something that is purely subjective. At least that’s my opinion. Maybe I’m an idiot.

  16. Carl,

    I don’t think you’re an idiot. Doctors are just as conflicted on this point. All they really have to guide them is – First do no harm. Addiction isn’t the only consideration when prescribing pain meds. Bowel issues, liver damage and the risk of atrophy leading to worse problems all must be considered. If someone has a broken bone, or cancer then they obviously need pain meds. If someone says “I hurt all over doc” without any obvious cause then what do you do? Just give them what they ask for knowing that there are serious side effects, addiction related and otherwise, that could put that patient in a worse spot than they are now? Granted the draconian drug laws create an atmosphere of risks aversion, but not every doctor that won’t prescribe opiates is doing so out of fear. Some genuinely believe that long term use of pain meds is a cure that is often worse than the disease.

  17. Smacky-

    I am capable of responsible and appropriate use, but thanks to doctors like your wife — if she is as uncompassionate as you make her out to be — patients have to deal with an extra (and otherwise unnecessary) obstacle.

    So wait, wasn’t this thread about a doctor who pulled 30 years for prescribing pain meds? If you are looking to spin this, how about *you* placing your comfort above the very real prospect of jail-time for your physician. My wife didn’t ask to be the gatekeeper of narcotics, it’s just the way it is. In a perfect world you’d get your narcotics OTC, but in this one a physician could go to jail for a very long time over your simple indiscretion. That’s what you need to get worked up about.

  18. “Every one of these drug warrior bastards should have to live a minimum of a a year preferably two with constant unrelenting chronic insufferable pain before they bring one more of these cases. They have no earthly idea what they’re trying to stop people from treating.”

    No, I think most of them sincerely think they’re improving the practice of medicine, and not keeping genuine pain patients from getting treated adequately. Some of them probably even think that some of the same docs undertreat some pain while being reckless with narcotics.

  19. The attitude evinced by pigwiggle’s supposed wife isn’t all that uncommon among general practitioners. As the article noted, the average physician receives virtually no training in pain management and probably has the same conceptions about drugs and addiction as the general public. The physicians with whom I interact almost daily are not pain specialists, and they will always error on the side of caution when doling out narcotics, even if doing so means that people such as yourself do not get adequate relief.

    The problem is with a system that will throw physicians in jail for the actions of their patients- even physicians as sloppy as the article portrays this McIver guy to be shouldn’t face the kind of charges he did for actions of patients beyond his control.

  20. I can agree with the squishy diagnosis part but until we invent the pain-o-meter what do you do?

    How about having the government get the Hell out of the doctor/patient relationship that has served well for over 100 years? But no, some DEA agent (read cop) knows better. This is to be expected in an environment where Bill Frist, a licensed physician, can make a neurological diagnosis via videotape. Compassionate conservatives my ass.

  21. Pain usually wont kill someone so it makes the decision a bit easier.

    A friend of my father got late onset cluster headaches before the advent of sumatriptan (aka Imitrex) and related drugs.

    I get cluster headaches too, but with the newer drugs they are a lot more livable and I usually only get one cluster a year that lasts for about two months. My first cluster was so horrible I that my doctor ended up prescribing percocet. It didn’t stop the pain, it just stopped me from caring about anything.

    My father’s friend used ergotamine but it didn’t really help. His first and only cluster went on for over nine months before he ate a bullet.

    I know exactly why he pulled the trigger.

    I had thought about it too.

  22. piggly-wiggly,

    I think smacky’s point flew far over your head. The presumption of indiscretion is a harsh one to make. From what you say about you wife’s point-of-view, everybody is a potential abuser, and therefore nobody gets any pain relief. I can believe that because I know physicians who think like that, but that sort of black-and-white thinking and lack of compassion misses the forest for the trees. Making patients suffer because of a broken system that punishes physicians for criminal patients is unconscionable.

  23. Jim Bob-

    What I wrote …

    If my wife remotely suspects a drug seeker she won’t prescribe.

    So …

    From what you say about you wife’s point-of-view, everybody is a potential abuser, … correct … and therefore nobody gets any pain relief. … don’t know where you got that, you know, other than it makes for a nice rhetorical springboard.

    So, I put myself in her place – there is no way in hell I’m taking that kind of risk. I confine my philanthropy to blood donations and writing checks for the Human Society. Do your own jail time … and I’ll do my part by getting all indignant on blogs and voting for sympathetic pols.

  24. And JimBob-

    It’s not so fine a distinction, but I’ll point out that everyone is a potential abuser – just like everyone is a potential bearded lady or astronaut. It’s all about the likelihood, which is where your “presumption of indiscretion” comes in. Assuming a potential for abuse doesn’t necessarily assume indiscretion, rather it recognizes the the *potential* for indiscretion. See?

  25. How about having the government get the Hell out of the doctor/patient relationship that has served well for over 100 years? But no, some DEA agent (read cop) knows better.

    Because we need the government to prevent people from abusing drugs. The DEA is trained more on addiction than doctors.

    In a perfect world you’d get your narcotics OTC,

    In a perfect world you would only get them in daily dose amounts at a clinic you would visit every day.

    but in this one a physician could go to jail for a very long time over your simple indiscretion. That’s what you need to get worked up about.

    Too bad, it is a strict liability crime.

    We should probably make all meds with addiction potential illegal. There are other safer alternatives to narotics, such as aspirin, NSAIDs and acetominophen.

  26. Ladies and Gentlemen (and I use the terms loosely), for your viewing entertainment, from the deep dark depths of the sweltering forests of despair, The Perfect Troll, Juanitaaaaaaa!

    Wow, you basically hit every point with that post. Well played and I give you a +1 for consistency.

  27. I feel strongly about this, so I will be as gentle as possible

    The problem is chronic pain is a squishy diagnosis. Everyone’s pain threshold is different. What one person considers debilitating another considers nagging.

    Correct. Pain happens in the mind of the sufferer. It is subjective.

    The doctor can not quantify it.
    The AMA can not quantify it.
    The FDA can not quantify it.
    The DOJ can not quantify it.

    So, who are they to say how much relief is enough.

    It’s hard to tell genuine pain cases from pill seekers because there is no subjective measure. This constantly puts Doctors at risk, because all it takes is one junkie to destroy a career.

    You’re framing this incorrectly.

    The junkie doesn’t destroy a carreer. It takes a bureaucracy to do that…

    This distinction is important.

    Assigning the blame to the junkie strengthens the WOD. Placing the blame where it belongs suggests the right policy.

    Pain meds can also exacerbate the problem because when someone is doped up they aren’t active, leading to a cascade of issues.

    The is a chronic pain patient in my life. Call him/her Robin.

    Robin spent four years trying a least a dozen cocktails of weak and medium strength pain meds under the supervision of three different doctors. Any combination which wouyld suppress the pain left Robin lethargic and dopey. Robin grew steadly weeker, more deeply deconditioned, more overwieght.

    Then the last of these doctors—a neurologist, the best of the lot, and a genuine Good Man—started getting suggestive inquiries from insurance companies. He decided to stop treating pain.

    Panic.

    Robin got lucky and found an anesteseologist in the area who would take on pain patients, and before the last perscriptions ran out.

    The new guy took Robin off all the half measures and perscribed an opiod. The right does supressed the pain without undue side effects. Robin became more active, got stronger, converted fat to muscle, got stronger still.

    Then came a cross-country move.

    It was hard to find doctors willing to perscribe the right stuff.

    Months of half-measures. More leathargy and weekening. Finally another pain doc. Back on the opiods. Activity and health return.

    The lesson here is: Give the patient the right meds.

    The second lesson is: Fucking around with the wrong meds to satisfy governmental shitheads is immoral. The obvious corallary of this is: Interfering with the doctor–patient relationship for political gain is also immoral.

    My best guess on where to apply pressure: the AMA. If the doctors put their collective feet down, we can see some action. I am not optimistic.

  28. I’m presuming that wasn’t really Juanita, The Perfect Troll, but a cheap imitation. I mean, she really was too perfect. There is no way any human being could have written her words without cracking a smile.

    Nice try, pseudo-Juanita.

  29. piggy,

    Strange you’re chomping at the bit to put yourself in your wife’s place, but the people suffering from chronic pain don’t appear on your radar.

    Everyone is a potential abuser, huh? And a bearded lady and an astronaut too? Okay, sure, I’ll play along. Everyone is a potential amoeba, a potential South Park character, potentially Darth Vader, has the potential to be a writer, and is potentially full of shit.

    There is no difference between assuming the “potential” for indiscretion and assuming actual indiscretion if the action taken in either case- in this context, withholding pain meds- is the same.

  30. There is no difference between assuming the “potential” for indiscretion and assuming actual indiscretion if the action taken in either case- in this context, withholding pain meds- is the same.

    Well, maybe. But I didn’t say the actions were the same, did I? Read more carefully – parsing this minutia for you is tedious, asking for it is weak. And if you are just looking to argue, well then, pound sand troll.

  31. The junkie doesn’t destroy a carreer. It takes a bureaucracy to do that…

    Does it matter who destroys it? Destroyed is destroyed is destroyed. It’s easy to take a principled stance when it’s someone else’s freedom and livelihood on the line. But I guess rich doctors don’t have families they need to take care of. Fuck em. They’re doctors. And everyone knows doctors are heartless pricks that got into healthcare for the money.

  32. pignuts,

    Despite overwhelming evidence to the contrary, I refuse to believe you are that stupid. Show me on the doll where the bad words hurt you and I’ll see about not giving you any meds for the pain because you might be an addict.

  33. The junkie doesn’t destroy a carreer. It takes a bureaucracy to do that…

    Does it matter who destroys it? Destroyed is destroyed is destroyed. It’s easy to take a principled stance when it’s someone else’s freedom and livelihood on the line. But I guess rich doctors don’t have families they need to take care of. Fuck em. They’re doctors. And everyone knows doctors are heartless pricks that got into healthcare for the money.

    It matters where you put the blame.

    It really does.

    Every doctor who won’t perscribe strong pain meds or won’t perscribe enough out of fear of the government is acting rationally. They have no obligation to suffer humilation, bankruptcy, and/or incarceration to make a point, and no blame attaches to them.

    Robin and I felt nothing but sympathy for that neurologist when he decided to get out of pain care. How could we blame him? He could hear the footsteps of a giant coming to destroy him, and there was no one who both could and would stand up for him.

    But it still matters where you put the blame.

    It doesn’t belong to the junkie: he’s just looking for a fix.

    It doesn’t belong to the doctor: he’s just trying to help.

    But the stuffed shirt holding the press conference brings the threat of lethal viloence to the table to get his way when he is ignorant of the facts of the case and innocent of the expertese to evaluate them if he had them. Without the shadow of armed men dictating treatment to a doctor gets you told to fuck off, and well it should.

    The blame belongs to the meddling bureaucrat or politician. Make sure they get it, or be prepared for their meddling to continue without end.

    On reading again what I wrote above, I can see how you got the impression that I blamed Robin’s doctors. Or individual doctors in general. I appologise for that impression, it is not representative of what I was thinking.

    I did warn you I feel strongly on this issue.

    Please allow me to clarify myself.

    No doctor, acting on his or her own can make the least dent in this murderous machine, but their professional societies are another matter. They are the best source of pressure to correct this asinine policy.

  34. But it still matters where you put the blame.

    It doesn’t belong to the junkie: he’s just looking for a fix.

    It doesn’t belong to the doctor: he’s just trying to help.

    Point clarified and taken. I’ve got people on both sides of the issue so I too feel strongly. Physician and patient. The situation for both is untenable.

    But, just as chronic pain is real so is the junkie. The one that took my grandad’s script pad wasn’t invented by a WOD propagandist. The government isn’t the only thing that makes docs gun shy about prescribing pain pills. Bitter experience plays a big part.

    I’m glad your Robin has found something that works for him/her. I hope things continue to work out.

  35. Jim Bob-

    Yeah, I should have caught on trolling sooner – bully for you. Stroke yourself all you want, I’m done.

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