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"It shows they want to understand what we're trying to do," she said.
Dr. Dunegan said she understands why law enforcement views opioids the way
it does.
"If your job is to protect the public from deleterious effects of drugs,
you begin to hate drugs because that's what you see: the deleterious effects,"
she said. "You don't see people who go back to work. You don't see people who
no longer want to kill themselves.
"We both look at the same picture, but see different things when the law
and medicine butt up against each other."
Nightly character checks
Part of the problem, Dr. Dunegan said, occurs when physicians turn patients
into opioid abusers by abdicating prescribing responsibility. This is done by
giving patients a minimum amount of medication and telling them: "Take it when
you need it, and make it last."
These patients then have nightly "character checks," Dr. Dunegan said,
where they wake up and wait until they cannot take the pain anymore and then
pop some pills. This leads to a sudden rise of opioids in the blood, which
produces euphoria and -- just as patients get used to feeling pain -- they
will get used to feeling euphoria.
"For around-the-clock pain, constant dosing is the key," she said. "You
have to keep a steady level that's just above the patient's threshold for
pain. That way they can function better, and it avoids peaks and valleys."
To avoid problems with both law enforcement and patients who are likely
candidates to abuse opioids, Dr. Dunegan said the key is to keep detailed
records and start off with a written "definition of success."
This definition involves finding out what the patient is looking to
accomplish after their pain has been relieved. This could include going back
to work, being physically active, or being able to return to an activity they
used to enjoy.
Document and follow up
"If you're documenting what you're doing, you're not only protecting
yourself legally, you can track the progress of how well the patient is
doing," she said.
Then there must be follow-through, and for suspect patients this may
include getting permission to call employers and conducting regular blood and
urine drug screens. If a patient is suspected of diverting their medications,
what the drug screen doesn't turn up can be more telling than what it does.
"If you're prescribing opioids and there's none in the blood, the patient
probably sold their prescription," Dr. Dunegan said. "That's a real helpful
test when you get zero."
Dr. Dunegan believes prescription drug monitoring programs are one way
medicine and law enforcement can work together to help stop abuse, explaining
that these programs help physicians by identifying "scammers" who go from
doctor to doctor pursuing fraudulent prescriptions.
Even the most skeptical doctors can get fooled, she said, because "We tend
to believe people when we really shouldn't."
She said the worlds of law enforcement and medicine will continue to
collide over pain medications because there is a certain type of drug abuser
who feels it's safer -- from legal and content standpoints -- to get
prescription narcotics from a doctor rather than street drugs from a dealer.
"If someone finds marijuana in your trunk, you're in the slammer for
years," Dr. Dunegan said. "So they feel a lot better off taking prescription
drugs and -- with more pain medications being prescribed -- there's a lot more
to be diverted and abused."
The war on drugs has created a "pharmacological McCarthyism," said Joel
Hochman, MD, the executive director of the National Foundation for the
Treatment of Pain. The undertreament of pain is an epidemic, he said, because
doctors are becoming afraid to prescribe the right medications.
"Every day, I get 10 to 20 suicidal e-mails from patients, and every week I
get calls from doctors who are scared to death because someone is trying to
take their license away," Dr. Hochman said.
Too much?
Suspicions about overprescribing led Virginia to suspend and then revoke
Dr. Hurwitz's medical license in 1996, but -- since his license was reinstated
four years ago -- Dr. Hurwitz once again has a thriving pain-management
practice.
He admits that a small percentage of his patients are less-than-model
citizens and that there are five in prison now as a result of misbehavior with
prescription drugs.
"That's five out of approximately 400 patients who been to see me in the
last four years," he said.
Dr. Hurwitz believes criminal activity relating to opioid medications has
unjustly tainted the drugs, as well as the physicians who prescribe them.
Rogene Waite, spokeswoman for the U.S. Drug Enforcement Administration,
said the agency is not opposed to the legitimate use of opioids.
"The DEA supports the adequate treatment of pain in the United States and
uses accepted medical practices as a guideline," she said.
Dr. Hochman, however, said the government's actions and its words have very
little in common, because physicians who are following the rules are still
being investigated.
He said the government investigations circumvent professional review and
result in unwarranted indictments of physicians.
"You know what it takes to get an indictment?" he asked. "It takes one
prosecutor and 17 uninformed people."
Costly and damaging, no matter what
Even if eventually cleared, Dr. Hochman called these investigations
"nuclear bombs," explaining that they can cost up to $250,000 to defend
against and, even if no charges result, doctors can have their savings wiped
out and their reputations destroyed.
"We feel the balance has been ruptured and the government has not kept its
commitment" on allowing doctors to practice pain management, he said.
"The playing field is on a 25-degree angle, and guess who has the high
ground? It's not the doctors."
http://www.ama-assn.org/sci-pubs/amnews/pick_02/prsa0923.htm
http://www.drugpolicy.org/docUploads/Bilder_v_Oregon_Stipulated_Order.pdf
Dr Bidler has been cleared and is in
active practice now (2014)
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