Jewish World Review May 14, 2004 /23 Iyar 5764
Drs. Michael A. Glueck & Robert J. Cihak
Death from painful medical myths
Pain makes people miserable, unproductive, depressed and worse. And not only
patients feel badly. The doctors who dare prescribe pain medications are now
risking their careers - because at any moment government prosecutors may
decide to target their practices.
The government permits doctors a zero percent error rate in prescribing
medicines. No mistakes allowed. Even one prescription judged unlawful can
lead to a conviction that labels the doctor a felon, and triggers other laws
resulting in loss of medical license and the ability to make a living as a
Compare this zero tolerance with the much more lenient policy applied to
insurance companies under contract to process Medicare claims. For these
companies, the government allows a seven percent error rate.
In the past, we've described how over-zealous government agents target
doctors. But behind this zeal are other factors.
One is the prohibitionist attitude towards some pain-killing medicines, such
as morphine and other opiates. Until the 1920s, narcotics users were under
medical treatment or largely ignored by government agents. However, Congress
created a Narcotics Division of the Treasury Department which succeeded in
creating a very large criminal class for itself to police, but has not
"solved" the narcotics problem to this day.
Another factor is that pain management is a judgment call; there are no
objective tests to measure pain.
Yet another is the remarkable advances in pain-relief medications that have
become available over the past decade. In the 1990s, new drug forms such as
Duragesic and Oxy-Contin markedly advanced the art and science of pain
treatment. They do not cure the condition causing pain. Patients often
become dependent on these drugs just as people taking replacement thyroid
hormones become dependent. Note well: the patients are not "legally"
addicted, according to the definition below. They are dependent, meaning the
patient requires the medicine to ameliorate the pain and get on with life
just as some patients require replacement thyroid hormone to function
The Drug Enforcement Administration (DEA) defines addicts as "individuals
who habitually use any narcotic drug that endangers the public morals,
health, safety, or welfare" [21 USC Sec. 802 (1)]. This leads some to the
mistaken belief that chronic non-cancerous pain patients taking large
amounts of legally-prescribed narcotics are addicts and that physicians who
treat them are conspirators in the illegal drug trade. This ignores the
medical fact that less than one percent of chronic pain patients are
addicted in this sense.
However, the DEA takes the non-medical and non-scientific position that
narcotics such as OxyContin should be the medicine of "last resort for
chronic pain," disregarding the dangers of other non-narcotic and
less-effective medicines. Obviously, determining whether a pain patient is
also an "addict" and whether OxyContin is "medically necessary" in treating
chronic pain is clearly beyond the ability of DEA agents who are rarely
physicians and who never actually have a patient-doctor relationship with
the people they accuse of being addicts.
A drug addict seeking new thrills or transitory highs is a very different
person from a patient whose chronic pain is relieved by pain medicines.
Unfortunately, the police and news media often conflate the two categories.
The drug police get reports of pain medicine prescriptions from pharmacies.
They investigate, arrest and prosecute doctors prescribing what these police
think is too much of these medicines. Other doctors hear about these arrests
and understandably become more reluctant to prescribe the doses many
Says Dr. Jane Orient, Clinical Lecturer in Internal Medicine at the
University of Arizona College of Medicine and Executive Director of the
Association of American Physicians and Surgeons "The needs of patients, and
the need of society to combat the social pathology of substance abuse, can
be met only if physicians are treated by law enforcement as allies rather
than adversaries, and the rights of both patients and physicians are
respected. Zero tolerance for error will result in zero access to
desperately needed treatment for many patients."
Fortunately, patients and physicians are organizing to combat these
misinterpretations of law and medical practice. They are presenting model
policy and legislative proposals to policymakers around the country,
including Washington DC, with positive changes already enacted in many
In pain treatment, half a loaf can be as bad as no loaf at all; inadequate
treatment leaves the patient still suffering. Too many people are paying a
painful price because their doctors rightly fear being charged with a crime
for helping them.
Maybe people in chronic pain should go directly to vice squad agents for
medical services - since they've taken on the ultimate responsibility for
determining what's "medically necessary".
Editor's Note: Robert J. Cihak wrote this week's column.
Michael Arnold Glueck, M.D., is a multiple award winning writer who comments
on medical-legal issues. Robert J. Cihak, M.D., is a Discovery Institute
Senior Fellow and a past president of the Association of American Physicians
and Surgeons. Both JWR contributors are Harvard trained diagnostic radiologists.
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