Caught in pain's vicious cycle

Emaliss: Hello Dr. Hurwitz. Thank you for talking with me about what happened to you. The story in the USNews & World Report mentioned that the distance between you and some of your patients was part of the reason for your licence revocation and not necessarily the 'over-perscription' of narcotic painkillers. This made me wonder about the motives of the medical board; that perhaps they worried about a back- lash from chronic pain patients. What do you think about this idea?

Dr. Hurwitz: I think that the Board simply had no idea of the barriers to effective treatment that chronic pain patients confront. I don't believe that the Board was worried about a back-lash. Rather, they were insufficiently worried about lack of access to care and the stigmatizing effect of its action against me.

Emaliss: What are the laws for perscribing narcotics?

Dr. Hurwitz: There are federal and state laws governing the prescribing of controlled substances. These laws are designed to prevent diversion and abuse by patients and health care professionals, while providing access to pain medication for those who have medical need of them. Virginia passed an "Intractable Pain Act" which specifically authorized physicians to prescribe controlled substances "in excess of recommended doses" for patients with documented intractable pain.

Emaliss: You felt that you couldn't turn patients away out of concern for yourself, as you understood that these patients truly needed help. What were your thoughts about the possibility of getting into problems?

Dr. Huwitz: I assumed that both the DEA and the state regulatory authorities were fully aware of my practice and would be monitoring me to assure themselves of my competence and honesty. I was not afraid of such scrutiny and, in fact, invited these agencies to meet my patients and to review my therapeutic approach, as I had nothing to hide. I was confident that my patients deserved treatment and that my approach to treatment was rationally based on the published scientific literature.

Emaliss: During the investigation, were any of your patients questioned, and if so do you know how they responded?

Dr. Hurwitz: The DEA interviewed a number of my patients prior to and during the hearing. Patients reported to me that the investigators inquired about how I conducted my practice, and about the patients' medical circumstances. My understanding is that my patients were uniformly appreciative of my efforts on their behalf and happy with the care I provided.

Emaliss: Have you recieved much support from patients, and if so, in what way?

Dr. Hurwitz: A large number of my patients came to the hearings in Richmond, both to express their support and to testify on my behalf. A number of patients made financial contributions to my legal defense.

Emaliss: Have you had much support from the general medical community, and if so, in what way? If not, do you have any ideas about why?

Dr. Hurwitz: Many individual doctors and nurses have expressed their support. The medical professional organizations have not. There silence is understandable. Although there is general agreement that pain should be adequately treated, it is hard for outsiders to determine whether I am a good doctor or not. The mere fact of the Board's action has had a stigmatizing effect, and the organizations are reluctant to stick their necks out with so much uncertainty.

Emaliss: The story also indicates that the medical board was concerned that some patients might be either abusing their narcotics or even selling them. What are your feelings about this?

Dr. Hurwitz: This is the most complicated policy issue in the treatment of chronic pain patients. For doctors to treat their patients as if they are always under a cloud of suspicion of diversion or abuse undermines the doctor-patient relationship. If doctors act like cops, patients will be less candid. The result may be more dishonesty and less effective treatment.

To hold a doctor liable for being deceived places an intolerable risk on the doctor. The only rational response to this risk is to avoid treating patients with pain. Nobody should be expected to meet a standard that requires perfection. Just as we tolerated errors in other areas of medicine without presuming that the doctor is incompetent or corrupt, we should accept human fallibility in this area.

Emaliss: I hear often from people who are told by their doctors that they cannot have narcotic pain medicine because of the possibilities of addiction. But I've also seen many studies which have shown that when narcotics are used for chronic pain (as opposed to being used for 'recreational' purposes) the chances of dependancy is low. Why do you think there is still such a resistance among the medical community and why do you think they do not seem to accept these findings?

Dr. Hurwitz: Fear. The research doesn't really tell the doctor how to deal with uncertainty regarding who to treat and how to treat. The risk to the doctor's career is simply too great for any bad outcome.

Emaliss: What do you think has been the biggest influence resulting in such a change of attitude in both the medical community and the public about the use of narcotic pain medicine for chronic pain patients?

Dr. Hurwitz: I don't know that the attitude toward narcotics has really changed that much among the public. People still confuse "addiction" with "tolerance" to high doses and physical dependence (the risk of withdrawal reactions). Most people think these medications are bad or excessively dangerous. People are suspicious of people who take these medications.

Expert opinion has changed somewhat in response to a series of scientific studies. But the majority of community based physicians have not changed their prescribing practices.

Emaliss: Do you think doctors are more concerned with addiction or about being prosecuted?

Dr. Hurwitz: Both. Different doctors have different concerns.

Emaliss: What kind of impact have you seen on patients lives when they are forced to suffer from chronic pain over a long period of time?

Dr. Hurwitz: Patients become prisoners of pain--their activities and their lives restricted to a bare minimum. Their relationships suffer. They become demoralized, angry, and depressed.

Emaliss: Do you see any hope for chronic pain patients in regards to ever getting proper treatment and relief of pain, or a change in attitude by the medical community?

Dr. Hurwitz: I think that the shift in expert opinion will eventually transform the attitudes of most doctors, most importantly---those of members of boards of medicine. I think that the disenfranchisement of patients through managed care is leading to a political back-lash, and that when the dust settles, patient rights to effective treatment will be more securely established.

Emaliss: What can patients do to help:
a. Change the attitude in the public and the medical community?

Dr. Hurwitz: Patients should complain to the powers-that-be when their medical complaints go unattended. They should join grass-roots organizations that advocate on their behalf. They should make access to treatment a political issue.

Emaliss: b. Get the laws changed to protect doctors from getting the type of discipline you've had?

Dr. Hurwitz: Changing the law isn't critical. Making medical boards legally and politically accountable is what's important. The answer to oppressive medical boards is adequate money for legal defense and political mobilization of adversely affected patients.

Emaliss: I've always felt that the only people who have been affected by Nancy Reagan's "War on Drugs" have been doctors who must write triplicates when perscribing narcotics and the patients who need it, not the real criminals who import and sell illegal drugs. What do you think about that theory?

Dr. Hurwitz: The intimidation and control of doctors is what really hurts patients.

Emaliss: Thank you again Dr. Hurwitz for talking about your experience. I'm sure it will give insight to patients as to why getting pain care is so difficult.

Dr. Hurwitz: Thanks again for your interest.