The POLICE STATE of MEDICINE -- Part II
By Dr. Hurwitz - 9/21/02



On August 31, 2002, I announced my decision to phase out my pain practice by the end of this year unless the persecution of physicians devoted to the treatment of chronic pain with opioid medications is brought under the control of competent medical authorities.[1] I have made this decision in response to a prosecutorial approach that targets physicians based on the misbehavior of a small percentage of their patients who may be involved in illegal behavior. In this article, I want to elaborate on the context of my decision and on the kinds of policies that would allow the medical profession to be more responsive to the mostly hidden epidemic of untreated and inadequately treated pain.

The Evolving Context of Pain Practice

Over the last decade, the prevalence and severity of chronic pain in the U.S. has been increasingly appreciated.[2] According to a recent survey,[3] 9% of US adult population (25 million people) suffer from moderate to severe pain, two thirds of whom (16 million) have had their pain for more than five years. The majority of those with the most severe pain do not have it under control and suffer substantially in their enjoyment of life, their social relations, and their economic productivity.

Beginning in the mid 1980's, there was a reconsideration of the previous rejection of opioid therapy for non-malignant pain.[4] Encouraging clinical experience with chronic opioid administration to cancer patients and to methadone-maintained addicts dispelled fears of this therapeutic modality and led to refinements in terminology that distinguished physical dependence (provocation of an abstinence syndrome upon discontinuation) and tolerance (increased dose required to maintain physiological effects) from addiction (compulsive use for non-medical purpose despite harm). Early research indicated that patients without a prior history of addiction ran little risk of becoming addicted through pain treatment with opioids.[5] A small pilot study in 1990 suggested that addicts with chronic pain could be safely treated and that treatment diminished illicit drug use and improved functional status.[6] In 1997, the American Society of Addiction Medicine affirmed that physicians are obligated to relieve pain and suffering in their patients, including those with concurrent addictive disorders.[7] A study published in 1998 reviewing the relationship between the prescription of opioid analgesics and indicators of drug abuse from 1990 to 1996 concluded that while opioid prescription had increased substantially, opioid abuse represented a declining proportion of drug abuse during this period.[8]

The acceptance by professional bodies of opioid therapy for chronic, non-malignant pain continued throughout the 1990's, as indicated by the passage of Intractable Pain Acts in a number of states, the approval by the American Pain Society and the American Academy of Pain Medicine of The Use of Opioids for the Treatment of Chronic Pain: A consensus statement from American Academy of Pain Medicine and American Pain Society in 1996, and the adoption by the Federation of State Medical Boards of Model Guidelines for Regulating the Use of Controlled Substances in the Treatment of Pain in May, 1998.

In spite of the increasing expert support for opioid therapy, physicians have received mixed signals regarding the acceptability of this treatment. Over the last couple of years public attention has been focused on OxyContin with stories of overdose deaths, pharmacy robberies, and allegedly corrupt doctors. State medical boards have not uniformly accepted expert professional opinion.[9] But a more ominous development is the increasing pace of state and federal criminal prosecution of physicians engaged in pain practice.[10] This is apparently part of a federally coordinated strategy to stop the diversion of OxyContin and other prescription medications at the source--by targeting doctors whose practices focus on medical pain management. [11] This strategy, however, appears to contradict the stated policy of the Drug Enforcement Administration (DEA) that preventing drug abuse "should not hinder patients' ability to receive the care they need and deserve."[12] In his talk before the American Pain Society on March 14, 2002, Asa Hutchinson, the Director of the DEA stated:

"I'm here to tell you that we trust your judgment. You know your patients. The DEA does not intend to play the role of doctor. Only a physician has the information and knowledge necessary to decide what is appropriate for the management of pain in a particular situation. The DEA is not here to dictate that to you. We do not intend to restrict legitimate use of OxyContin or other similar drugs. We will not prevent practitioners acting in the usual course of their medical practice from prescribing OxyContin for patients with legitimate medical needs. We never want to deny deserving patients access to drugs that relieve suffering and improve the quality of life."

Mr. Hutchinson's words, however, have provided scant assurance to the many physicians who shun patients for fear that prescribing opioids will bring unwelcome police attention, nor have they had much impact on the behavior of his agents, who continue to conduct a reign of intimidation. The DEA and its state counterpart agents are embarked on a program of harassment of pain patients through repeated investigations, seizures, and arrests without charges or followed by dropping unsubstantiated charges. Similarly, they pay intimidating "visits" to pharmacists and physicians to "advise" them on how to practice their professions. This type of law enforcement by intimidation has not been seen in the Western world since before the Second World War, and, so far as I am aware, has never been seen in the United States of America. So, we already are perilously close to a situation in which the police agencies simply will not allow medicine to be practiced by honest and ethical standards. The fact that this approach so far has only targeted practitioners of pain medicine should be no source of comfort to physicians in other fields. If police disruption is permitted to displace medical judgment in this field, then it can do the same elsewhere. "Divide and conquer" is the oldest strategy of tyranny.

Principles of Pain Management

Pain specialists broadly agree on the following general principles of opioid use in pain management.

  1. Treatment is to be individualized according to patient response, with upward titration of dose until adequate relief is provided or intolerable side effects develop. This principle is referred to as "titration to effect." Individuals vary in their response to different medications, both with respect to the efficacy of analgesia and with respect to the pattern of side effects. A corollary to this principle is that doctors must rely upon their patients' reports of pain, relief, and side effects to provide effective treatment. Although pain in many clinical circumstances correlates with visible pathology, for many patients it does not.
  2. Opioid medications are not all equivalent. They vary in their analgesic efficacy, their pharmacokinetic characteristics, and in their side effect profiles. Oxycodone, for example, the active ingredient in OxyContin, tends to be less sedating than morphine or methadone, and it may have a more pronounced antidepressant effect.
  3. There is no ceiling to opioid analgesic effect. Doses may range from less than 100 mg per day of morphine or its analgesic equivalent to more than 10,000 mg per day. Given the small size of many opioid formulations, patients on high doses may require hundreds of tablets daily.
  4. The discontinuation of opioid therapy is clinically problematic. Although there are medications to mitigate acute withdrawal symptoms, even gradual dose reduction entails increased pain, which may persist for weeks or months. Rapid reduction from high doses may provoke severe, possibly life-threatening withdrawal symptoms in medically unstable patients. Physicians must take these consequences of withdrawal into consideration with their patients when deciding whether and how to terminate a patient's opioid treatment.

Policy Considerations

The current scientific understanding of pain, addiction, and opioid pharmacology is in tension with the laws, legal doctrines, and attitudes that evolved in response to the earlier (and persistent) conception that equates physical dependence and opioid tolerance with addiction. To implement the DEA's avowed intention to arrive at a balanced policy, it should avail itself of specialized experts in pain medicine, addiction, and epidemiology. The issues raised in the attempt to achieve an optimal balance that maximizes access to effective pain control with a minimum of diversion and abuse are complex. There is little data to guide policy development. Current technologies for evaluating pain, monitoring treatment, and tracking diversion are crude. There is great variation in the level of expertise in pain management among physicians and also a severe shortage of clinicians skilled and experienced in the use of opioids. The uncertainties, ambiguities, and conflicts that abound in the world of pain, addiction, and drug control cannot be papered over with a consensus statement. There is much work to be done to lay the groundwork for a balanced drug policy.

The enforcement policy that has emerged is anything but balanced. The use of criminal prosecution as a primary means of enforcement eventually will eliminate most honest and competent physicians from chronic pain practice, thus deepening the national health care crisis of under-treated pain. Given the enormous criminal penalties imposed for controlled substance offenses, even the smallest risk of erroneous conviction drives most physicians out of pain practice. Those few remaining come under ever-increasing pressure, both from patient demand and enforcement scrutiny, and they have fewer colleagues to come to their defense.

The policy of targeting physicians based on patient misbehavior establishes a standard of perfection in selecting patients that no doctor could live up to. It forces doctors who try to treat pain to act like police, reinforcing a perverse medical paternalism that subverts the ethical imperatives designed to protect patient autonomy and dignity. This distortion of the doctor patient relationship stigmatizes patients and erodes their trust. At the same time, it assigns doctors a function that they are not well-qualified for or well-equipped to perform.

Diversion of lawful prescription drugs by patients should be approached as the law enforcement problem that it is. It is misbehavior of a type that physicians alone cannot detect or deter effectively. Physicians usually can screen out the wholly fraudulent patient without a pain syndrome at all, but current medical technology includes neither a pain "meter" nor other objective test to ensure against other forms of deception or medication misuse by patients. Therefore, law enforcement agencies must take the primary role in enforcement, as they have the tools and the training to do so effectively. Pain physicians should be viewed primarily as the ally of criminal law enforcement and not its targets. Pain physicians can assist law enforcement by providing information on patients and medications, and cooperation in law enforcement investigations.

Conclusion

While difficult, the problems of diversion and abuse are not insoluble, given good will and cooperation among physicians, professional regulators, and criminal law enforcers. The main impediment to progress at the moment appears to be the attitudes of criminal law enforcement agents and prosecutors, who insist upon treating the "upstream" segments of lawful drug distribution as "suspects" rather than the victims of patient dishonesty and the potential allies of law enforcement. The pattern of investigation and prosecution proceeds with no apparent reference to the professional regulatory guidelines that have been developed in recent years. Police should do the policing, doctors should do the doctoring, and professional regulators should develop and review professional standards, while each should cooperate with the others.

Physicians, under the supervision of professional regulatory agencies such as medical boards, should be permitted to exercise medical judgment without fear of criminal prosecution. Federal and state controlled substance prohibitions should be amended to clarify the intent of current law that there be a safe harbor protecting honest medical judgment from criminal charges. This step is necessary to restore the traditional balance in drug enforcement policy, and to protect the relative competencies of federal versus state authorities and professional regulators versus police personnel.

The oppression and intimidation of doctors by the DEA and state boards of medicine has a long history. The fears provoked by this history will not quickly fade. Furthermore, there is at least some indication that our current state of relative ignorance concerning the drug diversion problem has been perpetuated by the police agencies themselves. Bringing out the truth of this situation will help the honest and dedicated health professionals who are trying to reduce the toll of human suffering, and it will only hurt those public officials who truly do wish to create a police state of medicine. For the moment, let us take the DEA's leader at his word. But his word must be implemented by decisive and comprehensive action. Talk is cheap, and actions speak louder than words.

Dramatic action is needed now if doctors are to feel free to treat their patients' pain. I suggest the following:

  1. Re-affirm and implement the principles that were articulated in the consensus document of October 2001, and in the speech by Asa Hutchinson, Director of the DEA, before the American Pain Society in March of 2002 with visible changes in training, procedure, and administration that makes all official participants in the process-- from Mr. Hutchinson, to local U.S. Attorneys and their assistants, to field agents-- fully and publicly accountable for the government's adherence to its declared policy. As the regulated physicians and pharmacists are working in the open, then so also should all government agencies and their employees. Without transparency, there will never be accountability by public servants.
  2. Suspend current prosecutions against physicians who treat pain unless and until a review by a panel of nationally recognized experts in medical pain management has found that there is an absence of good faith by the physician. If only the physician's adherence to standards of care can be questioned, then the case is not an appropriate one for the criminal process, and should be referred to the professional regulatory authorities.
  3. Design a mechanism to ensure that physicians who treat pain in good faith will have safe harbor protection from criminal prosecution, and a mechanism to improve the skills, techniques, and performance of those whose good faith performance is found wanting in professional sophistication. Forbid the DEA and other police agencies from paying visits to physicians and pharmacists to provide "advice" on how to practice medicine or pharmacy.
  4. Work with the acknowledged professional experts to develop and refine effective mechanisms to deter or apprehend those who would divert prescribed medications without substantial adverse effect on legitimate pain patients.
  5. Fund new research in several critical areas:

(a) new medical treatments that hold out the potential for responsibly reducing opioid dosages, such as the co-administration of opioid antagonists;

(b) new medical technologies that hold out the potential for more objective assessment of patient symptoms;

(c) epidemiological research to more precisely determine the incidence and causes of controlled substance diversion from medical practices as opposed to other sources, such as pharmaceutical thefts or embezzlements, or international smuggling.

  1. My announcement may be read at www.drhurwtiz.com.
  2. The highlights of pain surveys from 1996 to the present reviewing the impact of pain on American society and the roadblocks to relief are available on the website of the American Pain Foundation at www.painfoundation.org under Media Resources.
  3. Chronic Pain in America: Roadblocks to Relief, Roper Starch Worldwide Inc. for the American Pain Society, the American Academy of Pain Medicine, and Janssen Pharmaceutica, 1998
  4. Portenoy RK and Foley KM, Chronic use of opioid analgesics in non-malignant pain: report of 38 cases Pain 1986 May;25(2):171-86; Morgan JP, American opiophobia: customary underutilization of opioid analgesics, Adv Alcohol Subst Abuse 1985; 5(1-2): 163-173.
  5. Porter and Jick, "Addiction Rare in Patients Treated with Narcotics." NEJM 1980, 302; 123.
  6. Kennedy JA, Crowley TJ.Chronic pain and substance abuse: a pilot study of opioid maintenance. J Subst Abuse Treat 1990;7(4):233-8
  7. Rights and Responsibilities of Physicians in the use of Opioids for the Treatment of Pain, Adopted by the ASAM Board of Directors, April 1997
  8. Joranson DE, Ryan KM, Gilson AM, Dahl JL. Trends in medical use and abuse of opioid analgesics. JAMA. 2000;283(13):1710-1714.
  9. Joranson DE, Gilson AM, Dahl JL, Haddox JD. Pain management, controlled substances, and state medical board policy: a decade of change. J Pain Symptom Manage 2002 Feb;23(2):138-47
  10. Wayne Wilson , Shasta trial scheduled in three patient deaths, The state tries to portray a doctor and two pharmacy operators as drug pushers, Sacramento Bee, January 2, 2002 (Frank Fisher, M.D.); Tanya Albert, Florida physician guilty of manslaughter in OxyContin case, As word of the verdict in the OxyContin-related case spreads, experts worry doctors will shy away from pain management., AMNews. March 11, 2002 (James Graves, M.D) Doctor charged with murder for prescribing painkiller, Naples Daily News, Sunday, July 29, 2001 (Denis Deonarine); Lievertz indicted & arrested for dealing OxyContin, http://www.naddi.org/indiana/news.asp (Randolph Lievertz, M.D.); NEWS RELEASE (announcing the indictment of Cecil Knox, M.D.) UNITED STATES ATTORNEY'S OFFICE, WESTERN DISTRICT OF VIRGINIA, February 1, 2002.
  11. Josh White, Pill Probe Focuses On N.Va. Doctors, U.S. Agents Target OxyContin Sources, Washington Post, Sunday, August 4, 2002; Page A01.
  12. Promoting Pain Relief and Preventing Abuse of Pain Medications: A Critical Balancing Act, A Joint Statement from 21 Health Organizations and the Drug Enforcement Administration, Oct 23, 2001











Newshawk: chip
Pubdate: 1 Oct 2003
Source: Times-Dispatch (VA)
Author: BILL MCKELWAY

Conditions for doctor's bond set
Charges involve pain medication
BY BILL MCKELWAY
TIMES-DISPATCH STAFF WRITER
Oct 1, 2003

ALEXANDRIA- A federal magistrate opened the way yesterday for the release on bond of a well-known doctor whose arrest last week on drug and prescription-fraud charges has raised protests among patients with intractable pain.

But U.S. Magistrate Barry R. Poretz stayed provisions of a strict bond regimen that would essentially place Dr. William E. Hurwitz under house arrest.

Poretz gave federal prosecutors until tomorrow to decide if they will appeal the ruling, which could make family members and supporters of Hurwitz liable for $1 million in bond money if he flees.

"He would wipe out the family finances if he flees," said Poretz, noting that he was "spreading the risk" among Hurwitz' 22-year-old daughter, his 86-year-old mother, a brother, his former wife and her husband.

Each of them must guarantee the bond. In addition, Hurwitz would be under 24-hour electronic surveillance and would be obligated to stay in the Washington area. He could not practice medicine or give medical advice.

Referring to Hurwitz as "mister" rather than "doctor," assistant U.S. Attorney Mark Lytle described Hurwitz as a man who has minimal ties to the Northern Virginia community, has sold his home and is unemployed.

He questioned if any set of conditions would prevent him from fleeing.

Hurwitz, 57, faces a life sentence if convicted of charges issued in a 49-count indictment last week that followed a two-year federal investigation.

The indictment alleges Hurwitz conspired with patients to prescribe large doses of addictive drugs that were then sold on the street. Three patients listed in the indictment died; some were not properly assessed by him; Hurwitz allegedly knew some were drug dealers; and, he failed to consult with other doctors, according to the indictment.

Lytle has described Hurwitz as a man whose white coat and pen served as a license to deal drugs; he has sought to distance the doctor's prosecution from the notion that this is merely a malpractice case or a matter of bad judgment.

But the executive director of a national organization focused on drug issues and medical care said yesterday that Hurwitz's prescription methods and patient care have always been closely monitored by the Virginia Board of Medicine.

"If he was doing something so wrong, they could have yanked his license and stopped him instantly," said Dr. Jane Orient, of the Arizona-based Association of American Physicians and Surgeons.

When the state medical board took up many of the same issues in May that are now addressed in the federal indictment, the board put Hurwitz on probation and set up provisions he needed to meet to re-open his office.

Hurwitz had closed his practice in McLean last year in August after a raid by federal agents. He learned he was the target of a federal criminal investigation in February last year.

Orient described Hurwitz as "a national leader at the vanguard" of offering treatments for people suffering unbearable pain; she blasted the federal government's efforts to prosecute Hurwitz and other doctors around the country involved in heavy-dosage medication.

"We're getting calls every day from doctors who see what's happening to Bill Hurwitz and are scared to proceed with their own patients," Orient said.

Hurwitz's lawyer, James Hundley, said yesterday that Hurwitz treated each of his patients with care and concern and said that patient conduct that was illegal was beyond his control.

But the indictment alleges Hurwitz clearly knew of the illicit activities carried out by some of his patients and he continued prescribing medicines for them.

Outside the federal courthouse yesterday, Leigh Anne Franklin, a Hurwitz supporter who traveled to Alexandria from North Carolina, described Hurwitz, dressed yesterday in a black-and-white striped jail uniform, as a saint.

"He saved my life and my sister's life when doctor after doctor had turned us down," she said, describing her severe pain from kidney stones and a sister's back problems.

"Now that he's been arrested, my doctors back home are really having doubts about what to do. They're terrified."

Contact Bill McKelway at (804) 649-6601 or [email protected]



Doctor Hurwitz Indicted In OxyContin Scheme


By Josh White
Washington Post Staff Writer
Friday, September 26, 2003

A McLean pain doctor was indicted by a federal grand jury yesterday on charges that he led a broad conspiracy to illegally distribute prescription narcotics across the nation, resulting in the deaths of at least three patients.

In a 49-count indictment, William E. Hurwitz, 57, was charged with drug trafficking resulting in death and serious injury, engaging in a criminal enterprise, conspiracy and health care fraud. Hurwitz was arrested yesterday morning at his ex-wife's home and was ordered held without bond until a hearing Monday. Should Hurwitz be convicted of the most serious charges, he faces life in prison.

The indictment in U.S. District Court in Alexandria grew out of a wide-ranging federal investigation into doctors, pharmacists and patients suspected of selling potent and addictive painkillers on a lucrative black market. More than 40 people have been convicted in the ongoing probe.

Hurwitz's attorney, James Hundley, said the charges come from overaggressive prosecutors trying to scare doctors from prescribing painkillers. Hundley said Hurwitz says he was practicing good medicine.

"Dr. Hurwitz is a legitimate medical doctor with expertise in the area of the management of intractable chronic pain," Hundley said. "He was doing nothing but providing appropriate medical care. The government has come in and taken a medical issue and attempted to apply horribly twisted logic to it through criminal statutes."

The indictment signals an aggressive push by federal prosecutors to hold doctors accountable for what happens to the drugs they prescribe. It also highlights the complexities of proving criminal culpability in cases of licensed and reputable physicians prescribing a legal painkiller. Hurwitz is one of a few doctors across the country who have been indicted on charges of over-prescribing drugs, and he is among the first to be charged with orchestrating a widespread conspiracy.

The illegal sale of OxyContin and drugs such as methadone and Dilaudid has fueled an epidemic of abuse that has affected small towns throughout Appalachia, authorities said. Over the past few years, the abuse and sales have crept into suburban and urban areas, bringing associated crimes such as theft, fraud and homicide, authorities said.

OxyContin is a government-approved pill that releases its main ingredient, oxycodone, slowly over time to patients who need strong levels of pain relief. It is hailed as a miracle drug by cancer patients and others with intractable pain, but it is decried by local, state and federal authorities for its potential for abuse and lethal overdose.

"The indictment and arrests in Virginia demonstrate our commitment to bring to justice all those who traffic in this very dangerous drug," Attorney General John D. Ashcroft said. "We will continue to pursue vigorously physicians, patients and others who are responsible for turning OxyContin from a legitimate painkiller to a vehicle of addiction and death."

Patient advocates have said the prosecutions are troubling for those who need help for pain but are finding it increasingly difficult to convince doctors to treat them. "It's a terrifying turn of events that the medical community ought to look at carefully," Hundley said.

U.S. Attorney Paul J. McNulty said yesterday that Hurwitz was a "major and deadly drug dealer" who used the cover of medical pain management to dispense "misery and sometimes death."

According to the indictment, Hurwitz's Northern Virginia pain practice was at the heart of a conspiracy to distribute the painkillers for profit. The grand jury alleges that Hurwitz prescribed "countless prescriptions for excessive doses" of controlled drugs with the goal of hooking his patients, getting them to pay him a monthly fee and encouraging illegal sales.

Assistant U.S. Attorneys Gene Rossi and Mark Lytle alleged that Hurwitz wanted "to make as much money as possible" and wanted the drugs to be resold throughout Northern Virginia, southwest Virginia, Tennessee and Kentucky.

The most serious charges -- that the conspiracy caused fatal overdoses -- focus on patients Rennie Buras Sr. of Louisiana, who died on Oct. 9, 1999, and Linda Lalmond, who died in Fairfax County on June 1, 2000.

Bryan Slaughter, a Charlottesville lawyer, represented Lalmond's family in a civil lawsuit against Hurwitz that was settled earlier this year in Fairfax. He said Lalmond died days after first meeting Hurwitz and taking high doses of morphine. "Dr. Hurwitz's treatment was so far outside accepted medical practice that the result was certainly foreseeable in Linda's case," Slaughter said.

The indictment also mentions the death of Mary Nye in Prince William County on Nov. 4. Hurwitz is charged with causing Nye serious bodily injury by prescribing her large amounts of OxyContin and methadone.

"Dr. Hurwitz got her hooked on narcotics and took advantage of her," said Manassas attorney Amy Ashworth, who represents Nye's widower, Paul.

Hurwitz has been under scrutiny before. He lost his medical license for over-prescribing painkillers and was most recently placed on probation in Virginia in May. His marketing practices, authorities said, allowed him to keep patients in all parts of the country and Canada. The indictment alleges that Hurwitz prescribed medications in as many as 39 states, issuing the prescriptions with little or no physical examination and sometimes over the phone, fax, or the Internet.

Prosecutors allege that Hurwitz made large profits by charging an initiation fee of $1,000 for each patient and then $250 a month for maintenance. They said Hurwitz had about 470 patients in his clinic over the past five years, accounting for millions of dollars in profit.

Hurwitz shut his offices last year because he feared an indictment and wanted to give his patients time to find new doctors.



'OxyContin Network Believed Extensive Federal Probe Nets 41 Convictions'


Note: OxyContin Network (link above) by Josh White (Post) prompted Ms. Reynolds of the Pain Relief Network to comment:


"This guy, Josh White, at the (Washington) Post is trying to make a reputation in this Oxycontin area. I have spoken with him, and have been in e-mail communication with him on many ocassions, attempting to show him that his work is killing people, to no avail. He is half-bright and an easy gull for Rossi and the DEA.

I and others have pointed out that this Oxycontin firestorm was started by DEA, that the "deaths" have been debunked, etc. that these charges are disingenuous (the DEA and Justice know perfectly well that Drs. Hurwitz and Statkus were practicing medicine in good faith) and that this is essentially a campaign for funding, cynically run by DEA. White is having too much fun presently, playing reporter. The man is dangerous.

This sort of thing indicates that Statukus and Hurwitz may indeeed be put through a show trial like the Comprehensive Care case in South Carolina. Fortunately, they don't appear to have the equivalant of a Dr. Woodward in Northern Virgina so they will have to rely on the razzle dazzle of having patients say they lied to the doctors and using this as proof that the doctors were in bad faith.

I know its hard to understand how jurors would fall for such a thing but they do. Such a hysteria has been drummed up around opioids that even intelligent doctors such as Dr. Define, for example, can be manipulated into pointing the finger at a medication she knows has no special chemical properties or an added evil molecule. And yet, we see her saying here that it's bad because of what it has "done" to people. Clearly, confusion reigns. And it does so because the government is actively inciting riot of this kind. And the press, unfortunately, has been cooperating.

The story is lurid. It's man bites dog, so why not! It's easy for a guy like Josh White to pretend to be a reporter when he covers such a "dramatic" story in this way. There is nothing we can do about people like Josh White. The time will come when we will need to denounce him but we have a lot of hard work to do in the meantime.

The government is inciting a mob reaction against the pain profession, pointing to the doctors as though they were some kind of vampires and telling the mob that the doctors are the evil ones. Of course the mob can be counted on to gather round, torches blazing. I don't know about all of you, but I find the situation extremely dangerous.

This will not confine itself to "little guys" like the fifty or so doctors around the country facing this. Dr. Hurwitz is high profile. It could happen to any one.

Dr. Bordeaux was the test case to see if they could prosecute a totally innocent doctor and keep her collegues from running to her defense. It worked, so on they went.

I and my collegues have formed PRN to actively oppose what's happening here. We have been working on this thing full time since South Carolina.. We will soon be announcing our mission and outlining our essential plan."

All The Best,
Siobhan Reynolds
Executive Director
PRN Painreliefnetwork.org




BELOW IS HOW YOU CAN HELP DR. HURWITZ







Dear Patients and Friends,


The Virginia Board of Medicine has issued charges challenging my care of a number of patients and the way I conducted my practice. I am preparing to defend my practice and hope, through these efforts, to make the practice of pain medicine safer for both doctors and patients. My lawyers, who are working pro bono, have advised me that I will need money (which I don't have) for litigation related expenses, such as expert fees, a court reporter, and the costs of copying documents.

Since I have suspended my pain practice, I have been unable to find consistent work, nor do I have any substantial savings to cover the cost of litigation. The resources of my family have already been stretched to the limit, and I simply can't carry on the fight alone.

It would be terrible if I were unable to present the best case possible for lack of funds. With adequate resources, I think there is a chance that I can have a beneficial effect on the legal climate in which pain is treated. If I succeed, we will all be the beneficiaries.

To carry on the fight, I need your help. Please send your contribution to:

Hurwitz Legal Defense Fund
c/o Tate & Bywater
2740 Chain Bridge Road
Vienna, VA 22181

With much appreciation for any contribution you can make,

William Hurwitz, MD
Cell: 703-625-6158

4/03











11/6/02 DRUG ENFORCEMENT AGENCY
RETURNS TO DR. HURWITZ'S


The DEA executed search warrants on Dr. Hurwitz's Office and on his home on Wenesday Nov. 6th. Among other things, they took patient files, financial records, his cell phone and other misc. items. All hard drives on all the computers were confiscated, as well as the server.

The execution of this warrant represents a new phase in the on-going and what seems to be never-ending investigation of the doctor and his practice.

Dr. Hurwitz would like it known that some of his patients have been unable to identify other physicians to carry on their pain treatment and would appreciate any offers from any of his fellow colleagues.

He has patients in Vermont, Massachusetts, Maine, Connecticut, West Virginia, Virginia, Kentucky, Tennessee, North and Sourth Carolina, and Florida for whom possible referrals are needed.

Contact Information
Office: 703-790-8007
Fax: 703-790-1973
1350 Beverly Road Suite 104
McLean, Virginia 22101
[email protected]







Dr. Hurwitz Again

Mr. Josh White
Washington Post
[email protected]

Dear Mr.White:

Regarding Doctor Hurwitz's case:

Your paper has published several articles about the DEA's investigation of Washington area pain practitioner Dr. William Hurwitz. Dr. Hurwitz announced that he would close his practice rather than subject his patients to further harassment and the risk of abandonment were he arrested.

My practice also consists of treating patients with chronic, intractable pain. In fact, I am the Executive Director of the National Foundation for the Treatment of Pain (www.paincare.org)

A number of Dr. Hurwitz's former patients have come to me. All were legitimately and correctly diagnosed. All believed his treatment regimen to have been effective and were thoroughly satisfied with his care. All described marked improvement in functionality under his care. None presented any credible reason to doubt their reliability and legitimacy.

All were accompanied by more than competent and adequate medical records that clearly established conditions which medically justified chronic and long-term opioid therapy. His clinical notes are extensive and highly organized. The records show that he carefully and appropriately adjusted medications to the effective level. Upon reaching stable treatment, doses did not accelerate, tolerance did not develop and no adverse medical or behavioral changes occurred. No addictive behaviors or symptoms occurred. None of the patients appeared likely to engage in, nor was there any history or evidence of, diversion.

I have continued the long term opioid therapies. Medications were in some cases revised, and adjustments in doses made. Several patients were transitioned to different, sustained release medications. The changes reflected legitimate and ordinary differences in professional practice and preferences. All the patients have continued to do well and improve. In short, there is nothing in these patient's treatment that indicates any malpractice or criminal intent.

What should we make of the case of Doctor Hurwitz? Is he the poster child for a DEA campaign to deter all high dose opioid treatment? How many other physicians, including myself, can expect to be among the next targets?

The ethics of medicine require compassionate care. Chronic pain is a scourge in this country that disables millions and blights the lives of patients and their families. Medical standards and regulatory guidelines support and encourage effective pain management. Despite this, most doctors are afraid to treat pain aggressively. The chilling effect of the Hurwitz investigation will step up this trend. Sadly, it also stigmatizes pain patients, and particularly those who have been attended by Dr. Hurwitz. No doctor can consider helping them without wondering if investigations, notoriety and financial catastrophe will come with them. The situation is horrific for all.

Judging the legitimacy, appropriateness and effectiveness of medical care is not the business of prosecutors, Grand Juries or law enforcement. Professional mechanisms for such review are universally available. Why are they being circumvented?

J.S. Hochman MD

----------------------------------------------------

I think it would be enightening for the members to write Mr. White - to express the feelings of intractable pain patients about this matter.

Dr..H.

Write to:
Mr. Josh White
Washington Post
[email protected]









8/2002 With federal prosecutors driven to a frenzy by Oxycontin mania, a nationwide federal investigation of doctors who prescribe large amounts of painkilling drugs underway, and other pain doctors being arrested, prosecuted, and even imprisoned over their pain management practices, one of the nation's most prominent pain management physicians has decided it is unsafe for both himself and his patients for his practice to continue. McLean, Virginia, physician Dr. William Hurwitz will shut down his practice at year's end, he told DRCNet this week.

Hurwitz and fellow Virginia physician Joseph Statkus have been publicly identified by federal prosecutors as the primary targets in a criminal investigation targeting doctors whom the feds believe have been selling Oxycontin and other potent painkillers that have been diverted from legitimate medical uses. For more than a year, a dozen federal agencies and numerous state and local officials have been attempting to build cases against Hurwitz, Statkus and other pain management physicians.

"The growing national plague of Oxy addictions, overdoses and deaths caused by the illegal activity of some doctors, pharmacists, and patients has been focused on like a laser beam by this office and other US Attorney's offices," Alexandria, Virginia, federal prosecutor Gene Rossi told the Washington Post earlier this month. "If any person falls into one of those three categories, our office will try our best to root out that person like the Taliban. Stay tuned," he blustered.

Hurwitz told DRCNet he was doing nothing illegal, but that he was a target nonetheless. He owed it to his patients to close up shop in a responsible manner, he said. "My feeling is that if they're targeting me for criminal prosecution and the risk of summary shutdown of my practice, I don't want the horror show of 300 patients suddenly cut off from all support," said Hurwitz. "I will shut down in December; I have decided to announce this now so my patients have due notice to either taper off or try to find another doctor to take care of them."

Hurwitz told DRCNet he had attempted to reach an agreement on acceptable practices with the DEA to no avail. "We have offered to have open discussions with the DEA and prosecutors about problematic areas of this practice, but have been spurned," he said. That attitude contributed to his decision to end his practice, he said.

"That's terrible," said Skip Baker, director of the American Society for Action on Pain (http://www.actiononpain.org). "Bill Hurwitz has saved so many lives, yet they've intimidated him so much that he feels he has to go out of business," he told DRCNet. "This is a real disaster. Dr. Hurwitz was the last chance for so many patients in intractable pain. What a sad day it will be when he is gone."

One of Hurwitz's patients, who asked to be identified only as a Pennsylvania resident named Marianne, agreed that Hurwitz' imminent departure was a disaster. "I have degenerative joint disease -- every one of my discs and joints is affected -- and the only thing that worked for me was opioids," she told DRCNet. "I tried acupuncture, biofeedback, physical therapy, you name it. After my last physician refused to prescribe me any more opioids, I was about ready to do myself in. Dr. Hurwitz was a godsend. He agreed to see me quickly, and within five days of titrating [adjusting the dosage for] me, I was walking and working again," she said. "Dr. Hurwitz is a brilliant, dedicated man. I am heart broken that he is closing his practice. I feel like he saved my life, and I appreciate that."

Jim Klimek, a Hurwitz patient from Kentucky who lost all his body beneath the waist in a truck accident, feels betrayed -- not by Hurwitz but by the federal government. "I just don't understand their thinking," he told DRCNet. "There are people bombing us. Don't they have better things to do than shutting down a bunch of doctors? I don't know what to think about this country anymore," he said.

Neither does Klimek know where to turn for help. "I don't know what I'll do now," he said. "I'll just have to try to find another doctor, but it's hard to find one here who will prescribe adequate medications. I'll just have to go at it day by day," he said.

Hurwitz told DRCNet he recognized there are legitimate concerns about diversion of pain medicines for recreational use, but argued that the federal government is unable or unwilling to engage in a process of working with doctors to address those concerns. "Anyone would recognize there is a problem with leakage from legitimate prescribing," he said, "but there are certainly different instrumentalities other than prosecuting pain doctors that would minimize that problem. Unfortunately, they don't want to talk to us. The attitude of the prosecutors is that I'm a drug pusher with a license."

"Dr. Hurwitz is no Dr. Feelgood," said Marianne. "There are doctors who are operating pill mills, and I say it's great when they get shut down, but Hurwitz isn't one of those. He may get deceived occasionally because he gives the benefit of the doubt to patients. But people like me aren't taking these drugs to get high or abuse them; they are my lifeline."

But for doctors, it may be becoming too dangerous to extend that lifeline. "The real problem is as long as this police regime continues," said Hurwitz, "no one should be doing what I was doing. It's not safe. Not for patients, not for doctors. We have a bunch of nave doctors who were conned by patients and now they're spending time in jail or facing the threat of prosecution. This is a horrible, draconian response; it is a pseudo-solution to a real problem foisted on the American public. A handful of doctors have become scapegoats for the sins of our society."

And support from either the medical establishment or the pharmaceutical companies that profit from the sale of opioid pain medications has been nil, said Hurwitz. "I'm waiting for support," Hurwitz laughed grimly. "I would call upon the leaders of the Academy of Pain Medicine and other groups to convene an urgent summit with their counterparts in government to review the impact of present policy on the ability of pain patients to get access to their medicine," he said. "Asa Hutchinson said they were only going after a few bad apples, but it ain't so," he said. As for the drug companies, "those guys have avoided any backing," said Hurwitz. "They don't want to be contaminated by the possibility of a guilty doctor."

Hurwitz told DRCNet that doctors in pain management needed a legal defense fund to come to their aid. As for himself, "I've engaged counsel." And the patients are out of luck.

See our October 1996 report on Dr. Hurwitz's major battle with the Virginia medical board and the patients who rallied to his defense -- http://www.drcnet.org/guide10-96/pain.html -- includes photographs.


To write to the Governor of Virginia:

Virginia Governor
Governor Mark R. Warner - Commonwealth of Virginia
Office of the Governor
State Capitol, 3rd Floor
Richmond, Virginia 23219
Phone: (804) 786-2211
Fax: (804) 371-6351
TTY/TDD (For the Hearing Impaired): (804) 371-8015

Online e-mail form: www.governor.state.va.us/..._form.html
General WebSite: www.governor.state.va.us/
Virginia's Senators www.visi.com/juan/congres...i?state=va








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