The Doctor Is in...for 30 Years
Jacob Sullum | June 19, 2007, 6:33pm
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.
TrappedEastOfTheBigMuddy | June 20, 2007, 2:18pm | #
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.
TrappedEastOfTheBigMuddy | June 20, 2007, 5:33pm | #
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.
