Doctor organization recommends under or non-treatment

Doctors' Group Advises Physicians to Avoid Treating Pain with Opiates, Cites Persecution of Pain Doctors -- Tucson Case Illustrates Point
http://www.drcnet.org/wol/295.shtml#aapshassman

Prompted by an ever-mounting list of physicians charged with over- prescribing opiate painkillers and the indictment of a Tucson physician in March, a Tucson-based medical association representing some 5,000 doctors has warned its colleagues not to prescribe opiates for pain relief and to take elaborate -- and expensive -- precautions if they do. On July 1, the Association of American Physicians and Surgeons (http://www.aapsonline.org), a free market-oriented group, sent out a memorandum titled "Advice to Doctors Re: Pain Management (or What the Government Has Taught Doctors)."

"If you're thinking about getting into pain management using opioids, DON'T," said the AAPS memo. "Forget what you learned in medical school -- drug agents now set medical standards. Until wrongs are righted and procedural changes are made, physicians have little choice other than to be unusually suspicious of new patients, to require unnecessary and expensive tests, to waste time on excessive documentation, or to turn away suffering patients, even if they think the patients may not find anyone else to treat them.

If you are already prescribing opioids," the memo continued:

* "Beware of new patients. If you accept a new patient, do background checks, demand old records before writing the first Rx, obtain urine screens and get them to sign opioid contracts. It is safer to turn them down, explain why, and give them an action item (call their congressman, for example).

* "Do thorough physicals, even if unnecessary and not helpful.

* "Make voluminous notes.

* "Exercise zero tolerance for patient slip-ups (such as losing a prescription).

* "Beware of any patients with a history of drug abuse. Even if now clean and in genuine pain, they might be induced by government zealots to testify against you to save themselves from imprisonment on drug charges.

* "Refer patients early and often to addictionologists, orthopedists, pain specialists, psychologists, regardless of expense or your opinion of helpfulness.

* "Keep a low profile and beware of saying anything that might offend an official of law enforcement, the licensure board, or the state medical society.

* "Never forget that you could be held to a standard of strict liability for any patient misbehavior or for any bad outcomes such as death, no matter the cause and without regard to the culpability of the patient or his associates. Remember, your medical decisions will be reviewed by drug agents who will decide if your actions were medically reasonable.

* "Consider phasing out this part of your practice, giving patients plenty of time to find another doctor."

"We don't really want to give doctors this advice," said Dr. Jane Orient, executive director of the AAPS, "but something has got to be done. A lot of doctors are afraid to prescribe opiates even for desperately ill patients -- it's not worth spending the rest of your life in prison for prescribing pain medications," she told DRCNet.

That's the prospect confronting Tucson pain management specialist Dr. Jeri Hassman (http://www.drhassman.com), who faces a 66-count indictment charging her with prescribing opioid painkillers to six patients without a legitimate medical reason. Those drugs included morphine, methadone, Vicodin and Oxycontin. She is also charged with defrauding TRICARE, a managed health-care group serving US military retirees and their families, and is facing DEA administrative hearings and a state medical board investigation, according to her lawyer, former US Attorney for Arizona Bates Butler. According to the DEA and federal prosecutors, Dr. Hassman's patients included a number of suspected "doctor shoppers," or people who go to multiple doctors seeking to obtain large amounts of controlled substances.

"Why in the sam hell didn't they go to her if they thought some of her patients were doctor-shopping?" fumed Butler. "They didn't inform her of a potential problem, they just sent in an undercover agent claiming he was in pain."

There is a common practice across the country that seems designed more to cripple doctors than to achieve justice, Butler said. "What happens is the DEA suspends the doctor's license to prescribe, then the doctor appeals and the case is set for an administrative hearing. Now the doctor has to reveal to the DEA the specific defense to the charges, which effectively wipes out your Fifth Amendment privilege," he explained. "After the DEA gets a look at your defense, but before the actual administrative hearing, here comes a criminal indictment. Now, the doctor's lawyer is going to tell him to put the administrative appeal on hold because there are more serious matters to deal with. So what we have is the DEA forcing doctors to spend time and money to defend themselves at these administrative hearings, while the DEA uses that process to build a criminal indictment. And, of course, there are also state medical board hearings, so it's a triple whammy, and it's an abuse of civil proceedings by the DEA."

At a press conference June 26 in Tucson, Dr. Hassman told reporters she had spent $100,000 on her defense so far and feared the bill could reach half a million dollars. While Dr. Hassman's practice remains open, her employees have had to take pay cuts, she said. And while Dr. Hassman conceded that there are people who "doctor shop" to seek drugs, she said the DEA should work with doctors to identify them instead of targeting doctors. And, she said, DEA efforts to thwart abuses should not get in the way of legitimate medical needs. "You cannot ignore there are millions of people who suffer severe and chronic pain," she said.

Dr. Hassman feels alone, Butler said, but her case is not unique. According to the AAPS, there have been at least 32 similar prosecutions of pain management specialists in recent years. Nor is Dr. Hassman alone professionally. At least four Tucson-area pain specialists are prepared to testify that Hassman was engaged in legitimate medical practices, including local pain treatment expert Dr. Jennifer Schneider and the immediate past president of the Arizona Medical Association, Dr. Richard Dale.

And while the Arizona Medical Association was reluctant to comment directly on Dr. Hassman's case, the group's executive director, Chic Older, told DRCNet the issue of legitimate pain treatment was becoming increasingly important. "We are watching to see what will happen," Older said. "Our medical association is on record saying we feel physicians ought to be able to act in the best interests of their patients. We don't think physicians should have to worry about losing their license for treating a dying patient in intractable pain. Sometimes there are cases whose outcome really sets a marker, and this could be one of them," he said.

Regardless of the outcome in this particular case, said Older, prosecutions like this one can deter physicians from properly treating pain. "This is part of the criminalization of medicine," he said, "and that has a chilling, chilling effect on physicians' willingness to prescribe necessary medications. The whole notion of the enforcement and judicial arms of government overseeing physicians and looking for criminal intent is becoming a very significant issue in this country," Older said.

Also attending Dr. Hassman's press conference were about a dozen of her former patients, who passionately defended her. One of them, Don Hayden, 48, told reporters he had been bedridden with chronic pain for years before finding Dr. Hassman. "She prescribed the proper pain medication to make me a functioning member of this society," Hayden said. Other patients said they were having trouble getting the medications they need since Dr. Hassman's certificate to prescribe was suspended by the DEA.

"The DEA says the justification for these arrests of doctors is the public health," Bates said, "but Dr. Hassman had over 200 patients who were receiving controlled substances for pain relief. What about the public health when 200 patients can't go to their doctor? What makes this even more frustrating is that of those patients of Dr. Hassman who have managed to find another doctor, 97% of those we can find are now on the same or higher doses of controlled substances."

"This is a serious problem," said AAPS' Dr. Orient. "We have physicians being prosecuted like drug kingpins. We need real legal reforms so that a doctor who gets taken in by an undercover agent or a talented actor does not face life in prison. We need a nationwide educational program about the difficulty patients are already having getting pain medications. It's only going to get worse," she said. "Doctors need to be seen as allies in the war against drug diversion, not the enemy. Doctors are not cops, they don't have lie detectors. If law enforcement was seriously interested in stopping drug diversion, it would work with doctors, not target them."

"They've already lost the war on drugs," said Bates, who spent a career prosecuting drug cases as US Attorney. "Now they want to turn it into a war on doctors. There's a certain amount of ego gratification in this for prosecutors," he said. "It's much more exciting to take down a doctor, a lawyer, or some other professional than just to prosecute another kid caught coming across the border with a backpack full of dope."

 

The War on Drugs claims even more innocent victims, this time it is dying patients suffering intractable pain and the doctors that show enough compassion to treat these patients.

In a system where healthcare and education govern drug policy, it would be possible to manage these patients where in a criminal justice based system, they are just casualties.

How many innocent victims does the DEA want to torture (which is what they are doing by denying those patients access to pain medications) and kill?

How long will we have to put up with the injustices and untruths before we wake up and move to a rational drug policy?

Can anyone justify the position the DEA has taken on this one?

 

This is just a DEA thing, but it is definitely spurred on by Ashcroft's influence. The DEA recently tried to have hemp foods reclassified to ban them, they have been raiding medical mar1juana providers in California (where the voters approved medical MJ), and they even cracked down on shops that sold parephernalia over the 'net recently.

The DEA specifically and the drug war in general drain our tax money, invade our privacy, and are trying to run our doctors now.

Doctors need to do the prescribing, not the DEA.

Is there even a single DEA agent as well educated as your average doctor?

 

It meant that Californians want their drug policy to be based on science rather than politics. It also indicated that the citizens want their doctors to be able to use their best judgement when deciding on a course of treatment for their patients.

It might be meaningless to you and the DEA, but it was not meaningless to Californians, to caregivers in the state, or to suffering patients.

BTW, do you have any comment on the article? You can't justify what the DEA is doing to patients? I guess that shouldn't be a surprise.

Cynthia Ryan is the general counsel (a lawyer) for the DEA, not an agent. I'm quite sure that the CFO has a postgraduate degree too, but I wouldn't call that as educated as someone who went through pre-med, med school, and residency, especially about the topic of pain management with opioids.

Are you actually trying to make the argument that the DEA's people are better educated about pain medication than doctors who deal with it every day?

You really are deluded about this issue.

 

I wouldn't call deputized city agents "pot dealers."

No weight except for the will of Californians, which the federal government does seem to be ignoring, which is my point. The federal government continues to ignore scientists, doctors, and the will of the voters to pursue its unproductive, destructive policy.

No matter how much you claim that DEA agents are well educated (I know a couple that are definitively NOT), I will continue to maintain that the people who should be deciding about medicine (ALL medicine, not just what the government wants to admit is medicine) are doctors and scientists, not politicians.

I DO get worked up when the federal government oversteps its bounds. I see this as a states rights issue and I believe that if Californians (or the people of any state) want to experiment with their drug policy, the feds should butt out.

It is currently the law, but so was slavery once. This policy is as wrongheaded as slavery ever was and has actually created a new slave trade: prisoners for hire by the for-profit prison industry. There is BIG money in prohibition, which is why it has lasted as long as it has, and is also why it is a racist policy that punishes poor, brown, and black people for behavior that people of all colors and socioeconomic levels engage in.