Saturday, June 16, 2007

"Doctor or drug pusher" in the NY Times

This week's New York Times Sunday Magazine cover story is on criminal prosecutions of pain doctors for prescribing opioids. It is a long article which mostly focuses on a single case of a physician who certainly recklessly prescribed opioids for chronic pain - but for whom there's no evidence that he did it with any sort of intent other than to relieve pain (he wasn't running a prescription mill, conspiring to divert or otherwise distribute opioids, nor was he profiting from people misusing his prescriptions). The journalist more or less accuses the DEA/the Feds of reassuring physicians they won't be prosecuted unless they prescribe with criminal intent - knowingly prescribing opioids to be diverted or abused etc. (and not just recklessly but with analgesic intent which would be a matter for civil litigation/malpractice/etc.); then refusing to define what proper medical prescribing is (because, after all, the DEA shouldn't be telling docs how to practice medicine); then going ahead and prosecuting docs anyway for prescribing recklessly but with analgesic intent.

"But the agency is defining issues of medical practice in dramatic fashion — by jailing doctors who step over the line. It would not seem to be bothering, however, to draw the line first."

"Proper pain management will always take time, but the D.E.A. can at least ensure that honest doctors need not fear prison. It should use the standard it claims to follow: for a criminal prosecution to occur, a doctor must have broken the link between the opioid and the medical condition. If the evidence is of recklessness alone, then it should be a case for a state medical board, the D.E.A.’s registration examiners or a civil malpractice jury."

The article closes with the story of one of the imprisoned pain doc's patients who had been on gram doses of oxycodone daily, apparently doing really well - working, etc. - whose life was dramatically worsened when the doc was arrested and he couldn't find anyone to prescribe him analgesic doses anymore...

'With Ben’s permission I talked to his current doctor, who said Ben was a good patient but had been taking way too much. “I thought Ben made an error,” he said. “He had been taking five or six times the recommended dosage. There are well-recognized levels, and you don’t step across the line. You may have to live with some pain.”'

Recommended dosage? Well-recognized levels? The line? No wonder physicians are being imprisoned if their colleagues (and therefore DA's, judges, and juries) believe this.... While I'm sure our chronic pain colleagues are worried I also wonder if this trend continues if there will be spill-over into the cancer pain world.

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