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Painful Rift Unnerves Doctors

The clash over the use of opioids to treat patients intensifies. Where law enforcement officials see a drug pusher, many in medicine see a pioneer.

October 20, 2003|Ralph Vartabedian | Times Staff Writer

Federal prosecutors launched one of their highest-profile and most controversial assaults in the war against prescription drug abuse recently when they indicted Dr. William E. Hurwitz, a 57-year-old Virginia pain treatment specialist.

Hurwitz, a Stanford University medical graduate who also has a law degree, was depicted as a "street-corner crack dealer" by federal officials during a court hearing last month. He remains in a Virginia jail, unable to post bail set at $2 million.

Although medical boards have suspended Hurwitz's license three times in the last decade and federal officials have depicted him as corrupt, the case has evoked unexpected support from medical groups.

Hurwitz is regarded as a pioneer in pain treatment by many doctors, academicians and medical groups, who have decried his prosecution. The case, along with other prominent criminal prosecutions, is putting a chill on legitimate pain treatment by doctors who fear prosecution, they say.

The Hurwitz case has exposed a deepening rift between law enforcement and the medical community over the use of opioids in modern pain treatment. These powerful drugs, including OxyContin, Vicodin and Dilaudid, are based on natural or synthetic opium.

Over the last decade, a revolution in medical thinking has discarded the idea that people should just cope with profound long-term pain, and instead holds that they should be helped with high doses of opioids. Without such treatment, the victims of serious disease and injury are often bedridden, unemployable and depressed, and in some cases suicidal, doctors say.

At the same time, abuse of these drugs has soared. An estimated 6.4 million Americans illegally used opium-based painkillers in 2001, more than the 4.1 million who used cocaine, according to the Substance Abuse and Mental Health Services Administration. OxyContin, introduced seven years ago and hailed as a breakthrough drug, has become the most abused pain pill in the nation.

Illegal use of opioids has been going up 27% annually, according to surveys. Among the most recent high-profile cases is that of talk show host Rush Limbaugh, who recently admitted he is a pain-pill addict.

Despite such abuse, national health organizations argue that serious pain is undertreated and have criticized the Justice Department and local law enforcement agencies for causing widespread fear among doctors that they can not prescribe opioid painkillers, particularly OxyContin, without risking prosecution.

"There is no question that doctors now fear being held liable if they prescribe painkillers," said Dr. Michael Fleming, a practicing Louisiana doctor and president of the 94,000-member American Academy of Family Physicians. "We have let our members know what is going on. There is a heightened awareness by the Drug Enforcement Administration."

A broad range of experts, including pain specialists, directors of hospice facilities, academicians and the pharmaceutical industry, have come to the same conclusion. Even law enforcement officials agree that legitimate doctors are spooked, although officers have sought to assure them that they have nothing to worry about.

"What happens typically is that 99% of the physicians, who are good, decent people, can become paranoid," said John Burke, head of a drug enforcement task force in Ohio and vice president of the National Assn. of Drug Diversion Investigators. "This is a very touchy issue. We do not want to impact legitimate pain patients or their physicians."

Prosecutors and investigators say doctors violate the law when they prescribe pain pills to patients who they know -- or reasonably should know -- are selling or abusing the drugs. The most flagrant cases involve doctors who spend little time with patients, write them identical pain-pill prescriptions and ignore repeated signs that they are attracting addicts to their office. A patient overdose death, not evidence on its own of illegal prescribing of pain pills, often attracts close scrutiny.

The medical use of marijuana, which received a favorable ruling last week from the Supreme Court, is another issue on which federal prosecutors are clashing with doctors. But with official estimates that 75 million Americans suffer from persistent pain, opioids have a vastly more important and accepted role in medicine.

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Trying to Curb Abuse

The DEA, which regulates controlled drugs such as opioids, denies that it has ramped up prosecutions or adopted tougher investigation tactics, but rather says it is trying to hold the line on the abuse of pain medications, which has caused serious social and economic problems.

Pat Good, a senior official at the DEA's office of diversion control, said the agency was focusing on doctors who ran "prescription mills" or whose entire practices involved pain medications diverted to illegal uses. And allegations that the agency is putting a chill on pain treatment are not new, she said.

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