Pain Part III

Handcuffs and Stethoscopes

By JOHN TIERNEY
Published: July 23, 2005
The current zeal for sending doctors to jail for writing painkiller prescriptions may seem baffling, especially to the patients who relied on the doctors for pain relief. But if you consider it from the perspective of the agents raiding the doctors' offices, you can see a certain logic.

During the war on drugs in the 1980's and 1990's, federal and local agents risked their lives going after drug gangs on the streets. As their budgets for drug enforcement soared, they arrested hundreds of thousands of people annually and filled a quarter of American prison cells with drug offenders.

But what did they have to show for it? Drugs remained as available as ever on the streets - and actually got a lot cheaper. The street price of heroin and cocaine dropped by more than half in the last two decades. Dealers just went on dealing, not only lowering their prices but also selling stronger, purer versions of heroin, cocaine and marijuana.

Given this record, and the pressure from Congress to show results, it's understandable that the Drug Enforcement Administration and local police departments hit on a new strategy: defining deviancy up. Federal and local authorities shifted their focus to doctors and the new scourge of OxyContin and similar painkillers, known generally as opioids.

As quarry for D.E.A. agents, doctors offered several advantages over crack dealers. They were not armed. They were listed in the phone book. They kept office hours and records of their transactions. And unlike the typical crack dealer living with his mother, they had valuable assets that could be seized and shared by the federal, state and local agencies fighting the drug war.

I don't mean to suggest that the doctors were all blameless, or that OxyContin wasn't being diverted to the black market and being abused. But the problem wasn't nearly as bad as federal and local authorities made it out to be.

The D.E.A. announced that in two years, there had been 464 OxyContin-related deaths, but most of the victims had taken other drugs, too, so the cause of death was uncertain. Ronald Libby, a political scientist at the University of North Florida, notes that even that figure is a minuscule fraction (0.00008 percent) of the number of OxyContin prescriptions written, and that it's dwarfed by the more than 32,000 people who die in the same period from gastrointestinal bleeding from other painkillers, like aspirin and ibuprofen.

The OxyContin crisis was fanned by sensationalized press coverage and by popular fears that unsuspecting patients getting this painkiller were being turned into dangerous addicts. While it's true that chronic-pain patients taking opioids for a long time require higher and higher doses, the drugs typically don't give them a high or interfere with their lives. Instead, the drugs enable them to function.

Researchers have repeatedly found that very few patients taking opioids have a hard time stopping once their pain goes away. The ones who can't stop - the compulsive addicts - are typically people with a history of abusing alcohol and other drugs.

But many doctors are now afraid to give painkillers to either kind of patient. The D.E.A. tried reassuring them by working with pain-management experts to produce a pamphlet setting out guidelines for doctors who want to avoid investigation. But last fall, the agency said it wasn't bound by the guidelines after all, and could investigate even when it had no reason to suspect a doctor.

That shift prompted a letter from the attorneys general of 30 states, who complained that patients were not getting proper pain relief because the D.E.A. was confusing and scaring doctors.

The state officials warned that "we cannot cast a broad net over all health care practitioners, hoping that a few criminals will be caught while the other cases are thrown out."

If enough doctors are jailed or scared into not writing prescriptions, it's conceivable that this drug war could have more impact than the ones against heroin and cocaine - doctors, after all, are harder to replace than crack dealers. But even if there's less OxyContin on the street, is that worth the suffering of patients who can't get the painkillers they need?

Maybe some OxyContin addicts would be helped, but consider the progress the White House's drug-policy agency found last year in a field survey on drug use in Cincinnati:

"Because diverted OxyContin is more expensive and difficult to purchase," the agency reported, "users have switched to heroin."

Email: tierney@nytimes.com

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For Further Reading:

Treating Doctors as Drug Dealers: The DEA’s War on Prescription Painkillers by Ronald T. Libby. Cato Institute, 28 pp., June 16, 2005.

Saying Yes: In Defense of Drug Use by Jacob Sullum. Jeremy P. Tarcher, 340 pp., May 2003.

“Fisking the DEA” by Radley Balko. The Agitator (blog), May 15, 2005.

Report: Summary of Medical Examiner Reports on Oxycodone-Related Deaths Office of Diversion Control, Drug Enforcement Administration, May 2002.

The Price and Purity of Illicit Drugs: 1981 Through the Second Quarter of 2003. Office of National Drug Control Policy, 109 pp., November 2004.

Letter from state attorneys general to the Drug Enforcement Administration. March 21, 2005.

See? Pain part II

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From the New York Times
July 19, 2005
Punishing Pain
By JOHN TIERNEY
Zephyrhills, Fla.

When I visited Richard Paey here, it quickly became clear that he posed no menace to society in his new home, a high-security Florida state prison near Tampa, where he was serving a 25-year sentence. The fences, topped with razor wire, were more than enough to keep him from escaping because Mr. Paey relies on a wheelchair to get around.

Mr. Paey, who is 46, suffers from multiple sclerosis and chronic pain from an automobile accident two decades ago. It damaged his spinal cord and left him with sharp pains in his legs that got worse after a botched operation. One night he woke up convinced that the room was on fire.

"It felt like my legs were in a vat of molten steel," he told me. "I couldn't move them, and they were burning."

His wife, Linda, an optometrist, supported him and their three children as he tried to find an alternative to opiates. "At first I was mad at him for not being able to get better without the medicines," she said. "But when he's tried every kind of therapy they suggested and he's still curled up in a ball at night crying from pain, what else can he do but take more medicine?"

The problem was getting the medicine from doctors who are afraid of the federal and local crusades against painkillers. Mr. Paey managed to find a doctor willing to give him some relief, but it was a "vegetative dose," in his wife's words.

"It was enough for him to lay in bed," Mrs. Paey said. "But if he tried to sit through dinner or use the computer or go to the kids' recital, it would set off a crisis, and we'd be in the emergency room. We kept going back for more medicine because he wasn't getting enough."

As he took more pills, Mr. Paey came under surveillance by police officers who had been monitoring the prescriptions. Although they found no evidence that he'd sold any of the drugs, they raided his home and arrested him.

What followed was a legal saga pitting Mr. Paey against his longtime doctor (and a former friend of the Paeys), who denied at the trial that he had given Mr. Paey some of the prescriptions. Mr. Paey maintains that the doctor did approve the disputed prescriptions, and several pharmacists backed him up at the trial. Mr. Paey was convicted of forging prescriptions.

He was subject to a 25-year minimum penalty because he illegally possessed Percocet and other pills weighing more than 28 grams, enough to classify him as a drug trafficker under Florida's draconian law (which treats even a few dozen pain pills as the equivalent of a large stash of cocaine).

Scott Andringa, the prosecutor in the case, acknowledged that the 25-year mandatory penalty was harsh, but he said Mr. Paey was to blame for refusing a plea bargain that would have kept him out of jail.

Mr. Paey said he had refused the deal partly out of principle - "I didn't want to plead guilty to something that I didn't do" - and partly because he feared he'd be in pain the rest of his life because doctors would be afraid to write prescriptions for anyone with a drug conviction.

If you think that sounds paranoid, you haven't talked to other chronic-pain patients who've become victims of the government campaigns against prescription drugs. Whether these efforts have done any good is debatable (and a topic for another column), but the harm is clear to the millions of patients who aren't getting enough medicine for their pain.

Mr. Paey is merely the most outrageous example of the problem as he contemplates spending the rest of his life on a three-inch foam mattress on a steel prison bed. He told me he tried not to do anything to aggravate his condition because going to the emergency room required an excruciating four-hour trip sitting in a wheelchair with his arms and legs in chains.

The odd thing, he said, is that he's actually getting better medication than he did at the time of his arrest because the State of Florida is now supplying him with a morphine pump, which gives him more pain relief than the pills that triggered so much suspicion. The illogic struck him as utterly normal.

"We've become mad in our pursuit of drug-law violations," he said. "Generations to come will look back and scarcely believe what we've done to sick people."


E-mail: tierney@nytimes.com

For Further Reading:

For more information on Richard Paey's case and others like it, visit the Pain Relief Network.
Treating Doctors as Drug Dealers: The DEA’s War on Prescription Painkillers (pdf) by Ronald T. Libby. Cato Institute, 28 pp., June 2005.


Cartoons by Richard Paey
Copyright 2005 The New York Times Company

This is How My Boss Makes Me Feel

Repeat after me

"I am not confused. I am just well mixed."

"I am rich in never-ending unrest."

Two quotes from my horoscope this week. Ai dios mio. If I could only believe them. If I could only put that positive spin on the utter confusion and emotional exhaustion I feel.... If I could "embrace the confusion" of stepmotherhood instead of feeling sick to my stomach over the confusion.... If only I knew what I was doing.... If only if only

Pain

As someone with crohn's disease, pain is an every day part of my life. Most of the time, I hardly remember what being "normal", or pain free feels like. It's just something you deal with. And the pain changes: in intensity, location, what type of pain, how it effects you life, your mind, thoughts, actions, relationships. but who really wants to hear about your pain? noone. why would they? I certainly don't want to hear about anyone else's pain that I can't do anything about. what do you say but "sorry"?
I can completely understand that, which is why I try my damndest to keep quiet about how I feel. I dread being concidered sickly or weak or delicate or a whiner or WHATEVER. And even if people don't think those things, they eventually will come to some judgement on who I am based on the status of my health. And most will just run for the hills. Fine. Whatever. Fuck them. To ME, it takes a hell of a lot of strength, fortitude and courage to continue through life with a smile AND bleeding guts, beat up spine, whatever. Most of those who pass judgement will never have to try to deal with a life blanketed wtih pain, and I use that knowledge as salve on my aching ego when they do judge.
But there comes a time when you have to confide in someone, namely healthcare professionals who, from time to time, have the power to actually help out. When the pain snaps you to attention and you are left panting and unable to think about a single thing except the exact moment that you are living; when you can no longer be stoic or thoughtful, or helpful, or anything except THERE; you have no choice but to reach out for some help.
So I've had a couple of those moments recently from some nerve pain, which can be slightly masked by pharmaceuticals, so I broke down and asked for some pain relief (with the crohns, most over the counter pain relievers are big no-nos) from my doc's office. I don't know if its my age or WHAT, but when I make these calls (very very very rare), I can be sure that I will be greeted with the attitude that I'm some sort of addict. More judgement. From the one person that I must share my personal and extreme feelings with. I'm reduced by the pain to having no quality of life, because what life can you realistically have when you can't even think? Then I have to be reduced to a beggar, trying to explain why I need the relief, and that I promise i won't call again anytime soon, and please can't they do something? It makes me feel awful. Its like you know they think you are lying or exaggerating. I'm like "Hello!! I know pain, I know how to meditate and breath it away to the point that I can function. I know how to deal with it, I know I know I know, but THIS TIME I CAN'T" And besides, don't they say that pain is a vital sign? So would they ignore my other vitals? Would they judge me based on them? Why pain? why do even health care folks pass judgement based on the pain that a person feels? It's ridiculous, and it makes me feel desparate to be someone else. Ahhhh, life.