War on Drugs—War on Pain Management

Posted on Friday, December the 28th at 7:02pm

By Dr. Stephen F. Grinstead, LMFT, ACRPS, CADC-II

On February 12, 2004 United States Representative Ron Paul, MD from Texas spoke before the US House of Representatives on what he called “Rush Limbaugh and the Sick Federal War on Pain Relief.” Please see the following table for several excerpts taken from his address.

In 1999 Dr. Frank Fisher, who is considered a pioneer in the field of pain management, was charged with over-prescribing medications that resulted in the deaths of five people. California prosecutors charged Fisher and the co-owners of a pharmacy with five counts of murder. Dr. Fisher claimed he prescribed heavy doses of painkillers to ease the suffering of chronically ill patients. He said his arrest represents a misunderstanding of his work. “I feel like I'm being punished for behaving with good conscience and doing the right thing,” he said. “I don't think the attorney general's office understands the issue of chronic pain or how you treat it.”

A Shasta County judge later reduced the charges against Dr. Fisher and the pharmacy owners to involuntary manslaughter. The judge ruled there was insufficient evidence for murder charges. Under California's Intractable Pain Act of 1990, physicians are allowed to prescribe any level of medication they think is needed as long as an increase in dosages is gradual. Dr. Fisher’s original trial was October 9, 2001, but the case was not resolved until February 2, 2005, six years after state agents raided his medical clinic in Anderson, California. Dr. Fisher's legal problems now appear to have ended with the quiet dismissal of the last of four wrongful death suits against him.

Unfortunately, because of cases like this doctors are becoming afraid to prescribe and their patients are suffering. Because law enforcement agencies and the DEA (Drug Enforcement Agency) are not content with fighting the failing war on "street" drugs, they are focusing considerable attention on pain medication and the physicians and pharmacists who make it available to millions of suffering Americans. The DEA is expanding the "War on Drugs" to a "War on Pain Management." Much of the DEA’s attention has been on the drug OxyContin, a powerful time-released version of oxycodone, the same opiod used in Percocet and Percodan.

Medical science has significantly improved our quality of life with many new pharmaceutical products resulting in successful treatment of diseases and other medical conditions that historically have caused so much pain and suffering.  The down side is that yes some of these medications are being abused. Some of the most abused pain management drugs include; Hydrocodone (Vicodin, Loratab, Norco, etc.), OxyContin, Demerol, Morphine, Methadone, Dilaudid, Soma, and the Benzodiazepines; Valium,^® Librium,^® Xanax,^® and Klonopin.^®  However, one of the major contributing factors to prescription drug abuse is ineffective or inappropriate chronic pain management. People don’t want to be in pain. 

Ironically, one of the drugs that tends to get the most media attention is OxyContin. While it is true that there have been numerous reports in the media about OxyContin, the reality is that someone misusing over-the-counter Tylenol is much more likely to end up in an emergency room than someone taking OxyContin. In the year 2000, 200 people died from the purposeful abuse of Oxycodone, the active ingredient of OxyContin, but to this day there have been no documented deaths from patients when they are using this medication as prescribed. Statistically the number of deaths (200 in one year) is incredibly small considering the number of chronic pain patients using opioid pain medications (about 10 million in the year 2000).

These ongoing reports of widespread misuse of OxyContin are making physicians even more fearful of prescribing opioids. However, according to the American Academy of Pain Management, the public-health problem represented by misuse of prescription opioids like OxyContin is minuscule in comparison with that of untreated and unrelenting pain.

It is true that some very insightful addicts have figured out how to abuse this legitimate medication, but law enforcement and the DEA’s response has been disproportional to the problem. It is also true that like any other powerful pain management medication this drug can be dangerous—in fact it is completely contraindicated for many mild to moderate pain conditions.

Many physicians are afraid of professional sanctions or criminal charges if their patients become addicted. However, pain medication can be prescribed safely to people with severe chronic pain when doctors complete a thorough medical history and physical examination before developing a written treatment plan with diagnostic evidence to support that plan. They also need to conduct a periodic review of the treatment course, paying close attention to patients who are at risk for misusing their medication as well as documenting patient education and medication management contracts/agreements with their patients.

Researchers at the University of Wisconsin Medical School wanted to determine if the use of narcotics for medicinal pain resulted in a higher level of abuse compared to other drugs. They found some abuse of opioid pain relievers but noted, “Compared with the abuse of other drugs, illicit drugs in particular, the abuse of opioid analgesics appears to be relatively low.”

The report they published in the New England Journal of Medicine recommended that, “To maintain this trend, manufacturers, pharmacies, clinicians and patients should continue their efforts to improve pain management while exercising care so that the diversion of opioid medications for non-medical use is minimized.” People with a legitimate pain condition should be entitled to adequate pain management.

In June of 2001 a California jury ruled in favor of the family of an 85-year-old man who claimed his doctor under-treated his pain. The Alameda County jury awarded $1.5 million to the family of William Bergman, a retired railroad worker who died in 1998. Jurors agreed with the family’s argument that Dr. Wing Chin failed to prescribe sufficient pain medication to alleviate Bergman's pain associated with his lung cancer.

Cases like these set important precedents of holding physicians accountable for appropriate pain management, but the doctors are in a double-bind situation. If doctors are afraid to get in trouble with the DEA and under-prescribe they could be sued, but if they try to be compassionate and go for effective pain management they could be arrested, lose their license and even go to jail.

This “war on pain management” must stop. Too much is at stake. In 1999 there were about 247.2 million adults in the United States and about 86 million of those people suffered from moderate to severe chronic pain caused by back injuries, arthritis, and other non-cancer conditions. By 2003 the numbers had increased to approximately 117 million American adults suffering with chronic pain conditions. If the DEA policies continue, or worsen, it could mean that many of these people might not receive adequate pain management.

When I talk about this problem at trainings the common response is “sure this isn’t right, but what can we do?” For starters we can become better educated about this problem and then start talking about it with our friends and colleagues, as well as writing to our elected officials telling them that we want this war on pain management stopped.

I also agree with Representative Paul that “Congress should take action to rein in overzealous prosecutors and law enforcement officials, and stop the harassment of legitimate physicians who act in good faith when prescribing opioids for relief from chronic pain.” The united message that we need to send should emphasize that trained medical professionals, not law enforcement agencies, are the ones who should determine pain management protocols.