March 4, 1998

Dear Dr. T:

I could not agree with you more. I am looking forward to reading your articles as soon as the library locates them. There is little argument that extensive research has demonstrated that there is a large group (estimated by the AMA to number 15 million) of selected, chronic, intractable pain patients for whom continuing use of opiate-derived medication is the only remaining alternative. The problem is neither scientific or medical, but regulatory. The DEA, in cooperation with State Medical Boards, has steadily pursued an unspoken and perhaps even idiosyncratic, nation-wide policy of pursuing and prosecuting practitioners who attempt to provide appropriate care to these patients. In 1995, 385 physicians lost their licenses from such prosecutions. In a recent press release of testimony before Congress, a representative of the DEA bragged that his agency had revoked the licenses of 700 physicians in the last two years for prescribing to pain patients! I have been in contact with many of these unfortunate targets, on behalf of the National Foundation for the Treatment of Pain, and found them to be sincere, legitimate and caring doctors. Their lives have been filled with tragedy as a consequence of the actions brought against them.

To defend themselves costs, on the average, between $150,000 and $200,000, for which few doctors are prepared. It frequently takes two years, during which the emotional and professional stresses are enormous. And even, when successful, they wear a "scarlet letter" for the rest of their professional lives. It is truly terrible. In many instances the DEA simply targets the doctors and feeds information to the State Medical Board, which then prosecutes. Typically undercover agents pose as phony patients, reciting carefully rehearsed complaints, medical histories and requests for help. The challenge seems to be whether they can dupe the physician into complying with their requests. In at least one instance in which I have been involved as a consultant, the informants simply perjured themselves with concocted "evidence" presented to a Federal Grand Jury to win an indictment. This seems incredible, but we have all recently seen in the Clinton matter that the use of concocted evidence, perjured testimony and skillful "leaks" and disinformation, is now commonplace in government and prosecution. The objective is clearly to succeed in prosecution, not to win justice.

It is equally surprising to discover that in response to direct polling of all the members of State Boards of Medical Examiners, fully 25% still believe that the on-going prescription of opiate-derived medication for intractable cancer pain is injudicious prescription and should be prosecuted! 86% of the same respondents stated they would prosecute doctors who prescribe on-going pain medication for intractable, chronic, non-malignant pain sufferers. There is no sound medical or scientific basis for this view, as you well know. It is simply the product of dogma and cant. Relatedly, the medical literature strongly supports the finding that chronic pain patients do not suffer addiction. If acceleration in dosage occurs it is most often a result of inadequate medication in the first place, or lack of treatment of co-morbid conditions, such as serious depression, which is universal among chronic pain patients. Similarly, diversion of legitimate medication is well-known to be an insignificant factor in the availability of illegal drugs, which is the product of professional, international criminal activity.

Positively, the risk of prosecution is significantly less for doctors practicing in groups, for physicians who routinely use independent medical consultation to confirm the lack of alternatives to opiate-derived treatment, and for doctors who combine intensive rehabilitative and anesthesia-based interventional treatments with pain medication. But even here, there are no absolute safeguards from policy-based prosecution. Even clinicians at Sloan-Kettering and Mt. Sinai hospitals have been the target of prosecution. The goal does not seem to be rational or scientific, but simply to generate anxiety and intimidation as a means of categorically discouraging the use of Opioid-derived pain relief.

Few doctors have been able to acknowledge their own anxieties regarding the fear of prosecution. Instead the common psychological defense has been to "identify with the aggressor", and become judgmental, stereotypic and enforcement-minded about the "risk of addiction". Consider the prior discussant who categorically pronounced that "the use of opiates has no place in the treatment of chronic pain" (above). It is easier to practice stereotypy than to confront one’s own fears.

This situation will change through education, litigation, administrative and/or legislative intervention into the "drug war on doctors", and most importantly, through the universal insistence by doctors of a scientific basis for medical practices. Also, the unfearful defense by a majority of doctors, of legitimate pain treatment practices, will go far to stopping these terrible offenses to both physicians and chronic pain patients. Recall the data that reflect that as many as 90% of Dr. Kervorkian’s patients are sufferers of unrelieved, intractable pain. The problem has even drawn the attention of the AMA, which on July 17, 1997, released a press kit describing the under-treatment of chronic pain as one of the most serious issues in American Medicine, today.

Forgive me for the length of this reply, but this issue continues to be an unabated disgrace to American medicine. Besides courage in the face of ignorance, it will also be effective to support the American Academy of Pain Medicine, the International Association for the Study of Pain, and the National Foundation for the Treatment of Pain. All seek to gain support for the rational practice of medicine and the safeguarding of the prerogative of physicians to prescribe appropriately, without regulatory intimidation.

Posted for the National Foundation for the Treatment of Pain