Physicians are under intense scrutiny because of concerns
over prescription drug diversion and abuse. At the same time,
they are also under pressure from patients and advocates to prescribe
adequate pain medication. It is a difficult balancing act and sometimes,
overzealous law enforcement can tip the scales.
For more information
The Cato Institute published this tremendous analysis
of pain management policy by Professor Ronald T. Libby of the
University of North Florida. Download a copy of
the full report, and also check out
public service ad which excerpts the Libby report.
A Michigan study confirms what many patients already know:
Pharmacies in minority and low-income areas are less
likely to carry sufficient supplies of pain medications.
Click here to read more about this
study on access to pain medication which was
published in the Journal of Pain in Oct. 2005.
where healthcare and drug control policies intersect.
Click here for more
about pain management, diversion, and related items.
Also check out
this new CSDP
public service ad on the federal war against physicians over
Florida Governor Charlie Crist and his cabinet voted unanimously to grant pain patient Richard Paey a full pardon for his 2004 conviction on drug trafficking and possession charges. For more information, click here.
The re-trial of Doctor William Hurwitz came to an end in July 2007. The doctor's sentence was reduced to less than five years. He was originally given 25 years. For more information,
A federal judge is challenging the plea agreement entered into earlier in 2007 between prosecutors and Purdue Pharma, the manufacturer of OxyContin. For more information, click
The New York Times Magazine featured a cover story on pain management issues in their June 17, 2007 edition.
Click here to read the story in full.
Purdue Pharma, manufacturer of OxyContin, and three current and former executives were allowed to plead guilty in federal court to misleading the public about
Oxy's risks. For more information,
Federal re-trial of pain specialist Dr. William Hurwitz ends some charges dismissed, acquittal on some charges but guilty verdicts on others. For more information
Commutation Urged After Appeal Fails
Chronic pain patient Richard Paey lost in the appeal of his sentence on drug charges and faces a mandatory minimum 25-year-sentence.
For more information
DEA Issues Policy Statement On Pain Management
The US Drug Enforcement Administration has issued a new policy statement on pain management and prescribing practices. For details,
Also, a full copy of the notice as published in the Federal Register is available by clicking
The 4th Federal Circuit Court of Appeals has granted a new trial to Dr. William Hurwitz of Virginia. Dr. Hurwitz had been accused of drug trafficking for prescribing large quantities of narcotics to patients. For more information click here.
Rightwing talkshow host Rush Limbaugh reached a plea deal with prosecutors charges to be dropped in 18 months if he completes treatment, avoids re-arrest. For more info,
One of the first physicians in the nation to be charged with the deaths of patients from narcotics abuse was found guilty of one count of manslaughter and five counts of narcotics trafficking in her retrial in Florida. Dr. Asuncion Luyao faces maximum 30 year prison term
an appeal is planned.
Click here for more info.
First Annual Opioid Certification Program
Presented by the Opioid Management Society & the
Journal of Opioid Management, the conference will be held April 22-23, 2006, at The Conference Center at Harvard Medical, Boston, MA. To register, contact the
Opioid Management Society.
The cover story in Harvard Magazine's Nov-Dec 2005 issue
is "The Science of Hurt," by Kathleen Koman.
Download and read a
PDF copy of this tremendous article.
FDA, doctors win versus DEA on question of
final approval of new painkilling drugs.
Click to read more.
Compulsory "treatment" for drug addiction in some parts of the world is "tantamount to torture or cruel, inhuman or degrading treatment," according to report last month from the UN's special rapporteur on torture and other degrading treatments and punishments. The report was delivered to the Office of the UN High Commissioner for Human Rights in Vienna.
[image:1 align:right caption:true]Authored by Special Rapporteur Juan Mendez, the report takes special aim at forced "rehabilitation centers" for drug users. Such centers are typically found in Southeast Asian states, such as Vietnam and Thailand, as well as in some countries in the former Soviet Union. But the report also decries the lack of opiate substitution therapies in confinement setting and bemoans the lack of access to effective opioid pain treatment in large swathes of the world.
"Compulsory detention for drug users is common in so-called rehabilitation centers," Mendez wrote. "Sometimes referred to as drug treatment centers or 'reeducation through labor' centers or camps, these are institutions commonly run by military or paramilitary, police or security forces, or private companies. Persons who use, or are suspected of using, drugs and who do not voluntarily opt for drug treatment and rehabilitation are confined in such centers and compelled to undergo diverse interventions."
The victims of such interventions face not only drug withdrawal without medical assistance, but also "state-sanctioned beatings, caning or whipping, forced labor, sexual abuse, and intentional humiliation," as well as "flogging therapy," "bread and water therapy," and forced electroshock treatments, all in the name of rehabilitation.
As Mendez notes, both the World Health Organization (WHO) and the UN Office on Drug Control (UNODC) have determined that "neither detention nor forced labor have been recognized by science as treatment for drug use disorders." Such forced detentions, often with no legal or medical evaluation or recourse, thus "violate international human rights law and are illegitimate substitutes for evidence-based measures, such as substitution therapy, psychological interventions and other forms of treatment given with full, informed consent."
Such centers continue to operate despite calls to close them from organizations including the WHO, the UNODC, and the UN Commission on Narcotic Drugs. And they are often operating with "direct or indirect support and assistance from international donors without adequate human rights oversight."
Drug users are "a highly stigmatized and criminalized population" who suffer numerous abuses, including denial of treatment for HIV, deprivation of child custody, and inclusion in drug registries where their civil rights are curtailed. One form of ill-treatment and "possibly torture of drug users" is the denial of opiate substitute therapy, "including as a way of eliciting criminal confessions through inducing painful withdrawal symptoms."
The denial of such treatments in jails and prisons is "a violation of the right to be free from torture and ill-treatment," Mendez noted, and should be considered a violation in non-custodial settings as well. "By denying effective drug treatment, state drug policies intentionally subject a large group of people to severe physical pain, suffering and humiliation, effectively punishing them for using drugs and trying to coerce them into abstinence, in complete disregard of the chronic nature of dependency and of the scientific evidence pointing to the ineffectiveness of punitive measures."
The rapporteur also noted with chagrin that 5.5 billion people, or 83% of the planet's population, live in areas "with low or no access to controlled medicines and have no access to treatment for moderate to severe pain." While most of Mendez' concern is directed at the developing world, he also notes that "in the United States, over a third of patients are not adequately treated for pain."
Mendez identified obstacles to the availability of opioid pain medications as "overly restrictive drug control regulations," as well as misinterpretation of those regulations, deficiencies in supply management, lack of concern about palliative care, and "ingrained prejudices" about using such medications.
Prominent pain patient advocate and Pain Relief Network founder Siobhan Reynolds, 50, was killed in a plane crash on Christmas Eve day. She was one of three people aboard a small private plane attempting to land at an Ohio airport that afternoon. The plane missed the runway and instead crashed on a parallel road, killing all aboard.
[image:1 align:left]For the last decade, Reynolds had been a fierce advocate for patients suffering chronic pain and the doctors who attempted to treat them with high-dose opioid pain medication protocols. She came to be an advocate through personal tragedy -- her husband, a chronic pain patient, died as the family moved cross-country seeking effective relief for him.
But Reynolds turned her personal tragedy into activism of the highest sort, founding the Pain Relief Network to advocate for an effective response to the under-treatment of pain in this county. She was present for the trial of Northern Virginia pain management pioneer Dr. William Hurwitz, a trial I attended and where we first met. Hurwitz was convicted of being a drug dealer and imprisoned, an injustice that only deepened Reynolds' fire for justice.
She and the Pain Relief Network played a central role in winning freedom for Richard Paey, the wheelchair-bound pain patient sentenced to 25 years in state prison, and that was just one of her many interventions in the DEA's war pain doctors. Where the DEA saw only "pill mills" and Dr. Feelgoods, Reynolds saw the effectiveness with which high-dose opioid theory brought relief to suffering people.
Her feisty and tireless advocacy brought her into direct conflict with the DEA and federal prosecutors, most notably in the case of Kansas pain clinic owner Dr. Steven Scheider, who was charged with over-prescribing pain pills, and his wife, Linda, a nurse who was charged along with him. When Reynolds set up shop in Kansas to publicize the case and the issues and lend support to the Schneiders, Assistant US Attorney Tanya Treadway opened a criminal investigation into Reynolds and the Pain Relief Network, seeking, among other things, all of Reynolds' email, phone records, and other communications with doctors, patients, and attorneys.
As always, Reynolds fought back against the feds, and, in a shameful episode in American jurisprudence, she lost -- and worse. Not only was she forced to comply with Treadway's subpoena, but Treadway and the federal courts conspired to hide the whole sordid episode from public view. The ruling in the case has never been published, nor are the briefs available for scrutiny. Reynolds was even barred from sharing the briefs she submitted with the press.
That ruling was the last straw for the Pain Relief Network, which Reynolds announced was being dissolved a year ago. But not for Reynolds. I spoke with her earlier this year, and she was planning to form another pain advocacy organization. It is our loss that she never got the chance.
Siobhan Reynolds wasn't always easy to work with because she was a true believer in her issue. She was impatient with potential allies who were not willing to go as far as she was, whether they were physicians groups or academics or drug reformers. She wanted the Controlled Substances Act abolished as an abomination, and if you weren't ready to go there, she didn't really want to waste her time with you. But sometimes a movement needs a determined, fiery-eyed idealist. Siobhan Reynolds was that person for the movement against the under-treatment of chronic pain.
[image:1 align:right caption:true]My friend and colleague Siobhan Reynolds, founder of the Pain Relief Network (PRN), died in a p
The Power of the Poppy: Harnessing Nature's Most Dangerous Plant Ally, by Kenaz Filan (2011, Park Street Press, 312 pp, $18.95 PB)
[image:1 align:right]Kenaz Filan thinks that Poppy (always capitalized in the book) is a sentient being. Before you roll your eyes as you recall the fervent mushroom cultists who say the same sort of thing, recall also that more mainstream authors, such as foodie Michael Pollan, have been known to talk like that, too, posing similar questions about what plants want. I'm not personally convinced about the sentience of plants, but I find that adherents of such a position definitely bring something of value to the table: respect for their subjects.
The opium poppy certainly deserves our respect. It can bring miraculous surcease from suffering through the pain-relieving alkaloids within, but those same alkaloids can also bring addiction, oblivion, and death. Our "most dangerous plant ally" can be both kindness and curse, boon and bane. Only by respecting Poppy, writes Filan, can we learn how best to manage our relationship with her.
The Power of the Poppy is part historical treatment, part cultural essay, part pharmacopeia, part practical guide. As such, positions on plant consciousness notwithstanding, it's a fascinating and illuminating treatment of the poppy and its derivatives. Filan traces the history of man's relationship with poppy from 6,000-year-old archeological digs in Europe, through early uses in the Roman empire and the Islamic world, and on to the current era of the war on drugs.
While Filan addresses the war on drugs and finds it stupid, this is not mainly a book about drug policy, and he dismisses the issue in short order. "Our war on drugs has been a one-sided rout," he writes in the introduction. "We keep saying 'no' to drugs, but they refuse to listen."
In his few pages devoted to the past century of opium prohibition, he reiterates the futility of trying to stamp out poppy even as its cultivation spreads. "Poppy is happy to fulfill our needs as long as we propagate her species," he writes. "To her, our 'war' is like locust invasions and droughts -- an annoyance, but hardly something that will endanger the continued existence of her children."
From there, Filan turns to the chemistry and pharmacology of opium and its derivatives and synthetics. He traces the isolation of morphine, codeine, heroin, thebaine (from which is derived hydromorphone [Dilaudid], oxymorphone [Opana], hydrocodone [Vicodin], and oxycodone [Oxycontin]), kompot (East European homebrew heroin), methadone, and fentanyl. Along the way, Filan touches on such topics as the lack of pain-relieving poppy products in the developing world, the development of Oxycontin and the rapid spread of "hillbilly heroin," and controversies over needle exchanges, safe injection sites, and methadone maintenance therapies.
In nearly every case of the development of a new opiate or opioid drug, researchers were hoping to find a substance that maintains poppy's analgesic qualities while eliminating or at least reducing its addictive ones. No such luck. "Despite the best efforts of our chemical minds," Filan writes, "Poppy still demands her bargain…Even as we go to war with Poppy, we are forced to do business with her."
In his next section, demonstrates the bargain poppy extracts as he profiles 11 famous users, including Confessions of an Opium Eater author Thomas de Quincy, Samuel Taylor Coleridge, William Burroughs, Lou Reed (whose Velvet Underground-era Heroin and Waiting for My Man put the 1960s New York junkie experience to music), and DJ Screw, whom I must confess I never heard of until reading The Power of the Poppy. Mr. Screw, whose real name, it turns out, was Robert Earl Davis, was a Houston DJ who rose to hip-hop fame after smoking Mexican weed and accidentally hitting the pitch button as he mixed tapes. The ensuing distorted vocals and slowed down beats became known as "screwed down" and Davis picked up the moniker DJ Screw.
Among the favorite topics of Screw and his crew was "purple drank," a concoction of soda pop, codeine cough syrup, and Jolly Ranchers candy, that created a warm, relaxed high. Screwed down music was the perfect accompaniment for a drank-fueled evening. While DJ Screw died young, in part because of his fondness for drank, he was also an overweight, fried-food loving smoker. While drank may have helped make DJ Screw, as always, poppy exacted her part of the bargain.
In the final segment of the book, Filan gets practical. He describes how to grow your own (from papaver somniferum seeds widely available at gardening stores) and how to extract the raw opium. He describes poppy tea brewing recipes, as well as how to use poppy in pill, tablet, or capsule form; as well as eating smoking, snorting, and shooting it. And he doesn't stint on explaining the dangerous path one is on when one embraces the poppy. Although I don't recall Filan ever using the words harm reduction, he is all about it as he cautions about overdose, dependency, and addiction.
The Power of the Poppy elucidates the many ways the histories of man and poppy are intertwined, and it's full of interesting tidbits along the way. Who knew that the use of "dope" to mean drugs came from Dutch sailors mixing opium and tobacco off China in the 17th Century? They called the mixture "doep," like a greasy stew they ate. Or that calling seedy establishments "dives" derived from scandalized descriptions of California opium dens, with the patrons reclining on divans? Or that the scientific name for snorting is "insufflation"?
If you have an interest in opium and its role in human affairs, The Power of the Poppy will be both entertaining and enlightening. And -- who knows? -- maybe you'll start treating that plant and its derivatives with the respect they deserve.
More than eight out of 10 of the world's inhabitants have little or no access to opioid pain medications, the International Narcotics Control Board (INCB) said Wednesday. The finding came as the INCB released both its Annual Report 2010 and a special report on the global availability of pain medications.
[image:1 align:right caption:true]People in many countries in Africa, Asia, and parts of the Americas had little or no access to opioid pain medications and psychotropic substances for medical purposes, the INCB found. Opioids include both narcotics, such as morphine and oxycodone, and synthetic opiates, such as fentanyl. Psychotropic medicines include depressants, antidepressants, and antipsychotics.
"Ninety percent of the licit drugs are consumed by 10% of the world's population in the United States, Australia, Canada, New Zealand and some European countries," Hamid Ghodse, the INCB's president, said in a briefing on the release of the reports. "It has to be recognized that the availability of narcotics and psychotropic medicines is indispensable to medical practice," Ghodse told reporters.
The US is by far the world's leading consumer of opioid pain medications. According to INCB figures, for every pain pill consumed per capita in Asia, Africa, or Latin America, 50 are consumed in Europe, and 300 in North America. The US alone, with 5% of the world population, consumed 56% of the world's pain pills. [Editor's Note: This does not mean that US patients who need opioids can always get prescriptions for them.]
The special report on the availability of pain medicines found that while the global supply of raw opium for licit needs is adequate, there are a number of obstacles blocking their availability in large parts of the world. The INCB identified the obstacles in descending order as concerns about addiction, reluctance to stock or prescribe, lack of training of professionals, restrictive laws, administrative problems, cost, distribution problems, lack of supply, and absence of policies around the prescribing of the drugs for pain treatment.
Lack of supply was near the bottom of the list. The INCB said opiate raw materials, including opium, poppy straw, and poppy straw concentrate were sufficient to outstrip consumption. "There is no problem whatsoever with the availability of raw materials," Ghodse said.
Ghodse called on governments to analyze the problem, identify barriers to adequate availability, and take action to reduce or remove them. The report called on governments to collect data on licit drug requirements, legislation, education and training, national drug control systems, and steps to combat misuse.
For the INCB, the flip side of barriers to adequate pain pill access in large swathes of the world is excess availability, which it said can lead to abuse and drug dependence. While the number of single doses of opioid pain medications consumed has increased four-fold in the last 20 years, driven largely by increases in synthetic opioid production, consumption in the US, for example, has increased six-fold. The US now sees more people dying of prescription drug overdoses than from illegal drugs.
[image:2 align:left caption:true]"In countries with excessive availability, the non-medical use of pain relievers, tranquillizers, stimulants or sedatives has become the fastest growing drug problem," the report said.
That is a theme repeated from last year's INCB report, when the monitoring body reported that the abuse of prescription drugs was increasingly markedly worldwide. More people were taking prescription drugs for non-medical reasons than were using heroin, cocaine, and ecstasy combined, that report said.
Another major theme for the INCB in this year's report was increasing concern over the emergence of new synthetic drugs, or what it called designer drugs. The INCB said the development of such drugs is escalating so rapidly that governments need to adopt generic bans on new substances.
The report cited 4-methyl-methcathinone, or mephedrone, which has effects similar to cocaine or amphetamines and is being marketed as bath salts under names like Ivory Wave. The drug is currently the cause of ongoing concern in the US, where it has been banned in at least four states, and in Europe, where it has been banned by the European Union.
"Mephedrone has now become a problem drug of abuse in Europe, North America, Southeast Asia and in Australia and New Zealand," the INCB report said. But mephedrone is just "one example of a large number of designer drugs that are being abused."
The European Union, for example, is monitoring 15 other methcathinone analogues alone, while Japan recently placed 51 designer drugs under control. The INCB is recommending generic bans on such substances.
"Given the health risks posed by the abuse of designer drugs, we urge governments to adopt national control measures to prevent the manufacture, trafficking in and abuse of these substances," said Ghodse.
The INCB's schizophrenic report -- increase access to licit opioid pain medications, continue to ban new drugs -- reflects its bifurcated mission. At the same time it is charged with ensuring an adequate supply of medicines to the world, it is also charged with preventing non-medical use and diversion.
The Drug Enforcement Administration worked with pain
management specialists to develop pain prescription guidelines
so that law enforcement could do its job and physicians could
do theirs. A month later,
DEA pulled the guidelines.
In a letter, 30 state attorneys general take DEA to task
over withdrawal of pain management prescription guidelines.
Check out this
public service ad
on the letter.
OxyContin has been the center of controversy
as pain management has moved to the front of
the public consciousness. Much of what's been
reported is exaggerated.
Click here for more news and information about
Oxy and pain management issues.
"By demonizing physicians as drug dealers and
exaggerating the health risk of pain management,
the federal government has made
physicians scapegoats for the failed drug war.
Even worse, the Drug Enforcement
Administration's renewed war on pain
doctors has frightened many physicians out of
pain management altogether, exacerbating an
already serious health crisis - the widespread
undertreatment of intractable pain."
"Experts agree that tens of millions of Americans
suffer from undertreated or untreated
pain ... According to one 1999 survey, just
one in four pain patients received treatment
adequate to alleviate suffering."
"The medical evidence overwhelmingly
indicates that when administered properly,
opioid therapy rarely, if ever, results in 'accidental
addiction' or opioid abuse."
"Pain specialists make an important distinction
between patients who depend on opiates to
function normally - to get out of bed, tend to
household chores, and hold down jobs - and
addicts who take drugs for euphoria, and
whose lifestyles deteriorate as a result of taking
opiates, instead of improving. The DEA
makes no such distinction."
"The relationship between a doctor and his
patient is crucial to the proper assessment and
treatment of the patient's condition. The
DEA's aggressive investigative procedure
poisons the doctor-patient relationship from
"The DEA continues to lower its evidentiary
standards, making it nearly impossible for many
doctors to determine what is and isnít permitted."
"Large quantities of narcotics routinely go
missing en route from manufacturers to wholesalers
and from wholesalers to retailers. The
DEA itself acknowledges this problem.
Given the poor job the DEA is doing of
monitoring the narcotics it's charged with
overseeing ... DEA's attempt to blame physicians
for the drugs' street availability seems
arbitrary, unjustified, and capricious."