Would you ever become a Pain Specialist?

I am on my soapbox---Why in your right mind would you ever
go into this field?-- Very noble- but a Doctor would have to be either completely selfless, or completely out of his mind. For myself, since I have RSD aka CRPS I am beholden to these guys to whatever relief I have managed to achieve.

There will always be bad eggs in any field; but the patients
are caught in the middle of this cat-mouse game the DEA plays.

I have posted before about the Doctor William Hurwitz case
as well as The Strange case of Richard Paey in Florida.
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"Last year, state medical boards took 473 actions against doctors for misdeeds involving prescribing controlled substances. In many cases, their licenses were pulled. Physicians can also lose their D.E.A. registration, and with it the right to prescribe controlled substances. A few dozen do every year, although there is considerable overlap with medical-board actions. Washington is the first state to recommend that only pain specialists handle high-dose opioids; other states are likely to follow.

But such guidelines are futile while there is one pain specialist for, at the very least, every several thousand chronic-pain sufferers nationwide. And even though pain is an exciting new specialty, doctors are not flocking to it. The Federation of State Medical Boards calls "fear among physicians that they will be investigated, or even arrested, for prescribing controlled substances for pain" one of the two most important barriers to pain treatment, alongside lack of understanding. Various surveys of physicians have shown that this fear is widespread. "The bottom line is, doctors say they don't need this," said Heit. "They're in a health care system that wants them to see a patient every 10 to 15 minutes. They don't have time to take a complete history about whether the patient has been addicted. The fear is very real and palpable that if they prescribe Schedule II opioids they will come under the scrutiny of the D.E.A., and they don't need this aggravation."

Proper pain management will always take time, but the D.E.A. can at least ensure that honest doctors need not fear prison. It should use the standard it claims to follow: for a criminal prosecution to occur, a doctor must have broken the link between the opioid and the medical condition. If the evidence is of recklessness alone, then it should be a case for a state medical board, the D.E.A.'s registration examiners or a civil malpractice jury.

Undoubtedly, such a limit will allow a small group of pill-mill doctors to escape prison. But America lives with freeing suspects whose possible crimes are discovered through warrantless searches or torture — and unlike other suspects, doctors who lose their licenses are as incapacitated as those behind bars. For cases without the broken connection, prosecution is too blunt an instrument. It runs too high a risk of condemning innocent physicians to prison and discourages the practice of a medical specialty desperately needed by millions of Americans.
Pain patients are the collateral victims here."
excerpt from NYT article, When is a Pain Doctor a Drug pusher by Tina Rosenberg

July 3, 2007 Findings Juggling Figures, and Justice, in a Doctor's Trial By JOHN TIERNEY

On April 14, 2005, the day Dr. William E. Hurwitz was sentenced to 25 years in prison, Karen Tandy called a news conference to celebrate the sentence and reassure other doctors. Ms. Tandy, head of the Drug Enforcement Administration, held up a plastic bag containing 1,600 opioid pills. "Dr. Hurwitz prescribed 1,600 pills to one person to take in a single day," she announced. This bag showed that he was "no different from a cocaine or heroin dealer peddling poison on the street corner," she said, and made it "immediately apparent" that he was not a legitimate doctor. "To the million doctors who legitimately prescribe narcotics to relieve patients' pain and suffering," Ms. Tandy said, "you have nothing to fear from Dr. Hurwitz's prosecution." Next week, Ms. Tandy will have another photo opportunity, when Dr. Hurwitz is again sentenced in federal court, after the reversal of his conviction and a retrial this year. But this time, Ms. Tandy may want to skip the show-and-tell. Counting pills is a prosecutor's trick, not a proper gauge of medical practice, and the trick didn't even work at the retrial. Dr. Hurwitz was cleared of most of the charges on which he was previously convicted, including the one involving the patient who received the prescription brandished by Ms. Tandy. The defense successfully argued that the patient was not a drug dealer and that Dr. Hurwitz never intended to give him 1,600 pills a day - that number was the result of a clerical error, not a plot to sell drugs. None of the jurors I interviewed considered Dr. Hurwitz anything like a street drug dealer, and they were appalled to learn after the trial that he had already served more time in prison than some of his patients who were caught reselling the drugs. The only lesson for doctors I can see in Ms. Tandy's bag of pills is, "Be afraid." No matter what you have learned in medical school, if you are prescribing opioids in doses that seems high to narcotics agents and prosecutors, you are at risk of a trial. And once you enter the courtroom, anything can happen. At the first trial, Dr. Hurwitz was convicted of writing prescriptions that caused bodily injury, crimes that carried a mandatory minimum sentence of 20 years. At the retrial, the judge dismissed the charges for the very good reason that there was no proof the prescriptions actually caused the injuries. At the first trial, the 1,600-pill argument carried the day with the jury. The foreman cited that number in explaining to The Washington Post why, even though he was "not an expert," he was sure Dr. Hurwitz was not a "legitimate" doctor, because the number of pills went "beyond the bounds of reason." In Dr. Hurwitz's retrial, the prosecution tried the same strategy by repeatedly mentioning the 1,600 pills and other high- dosage prescriptions. The defense presented reams of expert testimony that there was no recognized upper limit on the level of opioids that should be prescribed. Some chronic-pain patients need enormous amounts because they develop a tolerance. One of those patients was Patrick Snowden, the man who was prescribed the 1,600 pills. His mother wrote Dr. Hurwitz a letter praising him for giving her son his life back by enabling him to deal with the pain of a foot injured so badly that he had undergone nine operations and been advised to amputate it. There was no evidence that Mr. Snowden resold any of the pills prescribed by Dr. Hurwitz, including the famous 1,600 pills. According to the defense, that scary number was a one-time fluke resulting from a clerical error when Mr. Snowden was given two new prescriptions for pills of a lower strength because his pharmacy had run out of the usual pills. The defense maintained that Dr. Hurwitz never intended Mr. Snowden to take 1,600 pills in one day and that Mr. Snowden never did take them because he realized what his proper dosage was. The prosecution fixated on the pill counts of other patients, too, often to baffling effect, because the only thing that seemed to matter was the number of pills, not their strength. When an F.B.I. agent, Aaron Weeter, prepared an elaborate chart listing the number of pills received by Dr. Hurwitz's patients, he was questioned about its usefulness by Larry Robbins, a defense lawyer. "Would you agree that, standing alone, we can learn nothing very important from the pill count alone?" Mr. Robbins asked. "I'm not qualified to answer the question," Mr. Weeter replied. Mr. Robbins tried working through the math with him. Wouldn't two 40-milligram pills be no more potent than a single 80-milligram pill? But the agent stood by his pill-count charts. After the trial, the jurors told me that the defense had persuaded them to ignore the pill counts. I suppose that this could be counted as a victory for science, but it is an isolated one, because the pill-count prosecution strategy has repeatedly worked in other cases. Richard Paey, a chronic-pain patient in Florida who uses a wheelchair, was sent to prison for drug trafficking after a prosecutor argued that he could not possibly have been taking 25 pills a day himself. Most other doctors could not hope to do as well in court as Dr. Hurwitz, who had unusual advantages at his second trial thanks to his prominence and the outrage over his conviction. He was supported by some of the leading pain experts and received a pro bono defense from two top criminal lawyers in Washington who led a legal team with more than 20 members. Paying for a defense like his would probably cost at least $3 million, beyond the means of most doctors in drug cases, because their assets are normally seized long before trial. Even though Dr. Hurwitz's defense cleared him of most of the charges, the jurors still convicted him of drug trafficking in some cases because they decided that he had ignored signs that the patients were reselling the drugs. I think that the jurors wrongly interpreted the law and the facts of the case, but I can also understand why they had a hard time figuring out what constitutes legal medical practice. They were asked to render verdicts on dozens of prescriptions given to 19 patients - the equivalent of 19 different malpractice cases involving the treatment of pain and addiction, two of the most controversial areas of medicine. The jurors did not have the time or the expertise to sort through all the complexities. After the trial, when they learned more about the pain- medicine debate and found out that Dr. Hurwitz might still be sentenced to 10 or more years in prison, several jurors expressed regret to me. They said they hoped that he was sentenced to the two and a half years that he had already served. Even if Dr. Hurwitz does walk free next week, I wouldn't take much solace in his victory if I were a doctor treating pain patients. I wouldn't feel safe until doctors' prescribing practices are judged by state medical boards, as they were until the D.E.A. and federal prosecutors started using criminal courts to regulate medicine. The members of those state medical boards don't always make the right judgment, but at least they know that there is more to their job than counting pills.