Outside View: Jailed doc, tortured patient

By JANE M. ORIENT, M.D., Outside View Commentator

TUCSON, Jan. 5 (UPI) -- No, there is nothing in the U.S. penal code that provides for torture as a sentence for any crime, no matter how heinous. Even executions are supposed to be carried out in a humane manner. The possibility that the United States might accede to the torture of enemy combatants to obtain critical information provokes outrage, no matter how many innocent people might be spared a violent death thereby.

Nonetheless, the U.S. government has adopted a policy that will result in subjecting human beings to torture, without limit as to degree or duration, and without the necessity of proving them guilty (or even suspecting them ) of any crime.


This is not its stated intent, of course. There is no deliberate application of thumbscrews, the rack or the Iron Maiden. The pain is a matter of happenstance: an accident, a disease, failed surgery. It's just that once the pain occurs, it may be illegal for a physician to prescribe a substance controlled by the U.S. Drug Enforcement Administration to relieve it.


It also might not be illegal. But if a physician can't tell with 100 percent certainty that it isn't he runs the risk of having the same fate befall him as Dr. William Hurwitz, who was recently convicted of conspiracy to traffic in drugs, and dozens of other physicians, some of whom will almost certainly die in prison.

If you have an operation or an acute injury, chances are that your doctor will order adequate pain medication, perhaps even in a patient-controlled intravenous infusion. If you're dying of cancer, you will probably get plenty of pain medicine, even at the risk of hastening your death. But if you're one of the millions of people in the United States with chronic, intractable so-called benign pain, you may be told to learn to live with it -- and for many years.

Opinion about drugs like morphine and the new synthetic equivalents --called opioids -- has changed dramatically since I was in medical school in the early 1970s. We were very stingy with pain-relievers, even in post-operative patients, because we were afraid of turning them into drug addicts. Patients with cancer frequently died in agony because doctors believed that nothing was worse than being an addict.


Some change had occurred by the late 1970s, when one of my patients at the Veterans Administration Hospital got lucky. He got cancer of the esophagus. Amazingly, it was the best thing that had happened to him in decades. Doctors became willing to prescribe enough medicine for the stump pain that had tormented him since his leg got blown off above the knee. He eventually took what we thought were huge doses: three shots of the largest dose of morphine available (10 mg) every three hours.

People were so suspicious of him -- he was now buzzing down South Sixth Avenue in his wheelchair wheeling and dealing instead of moaning in his room -- that I had the nurse give him his medicine in the emergency room one day. We had the crash cart handy and the antidote drawn up, in case he should stop breathing.

We watched him for some time. He remained alert, said "Thank you," and wheeled himself off to the pharmacy.

A few months later, he died. In the hospital. Of cancer, not an overdose. I remember him vividly, as one of my most important teachers. I wrote up the story for the Southern Medical Journal.


Today, there is considerable evidence that patients rarely, if ever, become junkies because of using opioids for pain relief -- even though they are as dependent on the drugs as heart patients may be on their heart medicine. We also know that many patients, who had tried everything else that modern medicine offers without relief, have been restored to a productive, relatively normal life by opioids, even in doses that could knock out an opioid-naïve horse. The drugs have been literally lifesaving in countless patients who might otherwise administered a gunshot wound to their head or suffered a fatal one-car accident.

Some physicians contest this. Most of the general public that makes up the jury pool might not believe it either. And a number of overzealous, ambitious prosecutors portray themselves as crusaders against the supposed scourge of medically caused addiction.

The DEA repeatedly denies that it has any intention of suppressing the appropriate or legitimate prescription of opioids to patients who need them. But then it withdrew a set of "Frequently Asked Questions" worked out with pain specialists, which were supposed to be reassuring to doctors. This prevented the FAQ from being introduced into evidence by Hurwitz's defense.

The official explanation makes it clear that it is law enforcement that will define what is legitimate-after the fact.


Physicians know that they will make mistakes if they prescribe opioids: denying them to some patients who should have them, and writing them for phony patients who will dupe the trusting physician, and then sell the drugs, abuse them, or transmit to law enforcement the evidence that the physician prescribed inappropriately for a lying undercover agent.

Doctors also know they will face ethical dilemmas: should they prescribe for a patient with a history of drug abuse, who now has genuine pain, thereby risking prosecution -- or act as judge and executioner in adding unrelieved torture to whatever punishment the law metes out to users who defy the drug laws?

All drugs, in fact, are dangerous. High-dose opioids, used properly, are relatively safe. Unlike acetaminophen (Tylenol), which causes liver failure in overdose, there is no upper limit to the safe dose of opioids in a tolerant patient. Unlike the nonsteroidal antiinflammatory drugs (such as ibuprofen and naprosyn), they don't cause sudden fatal internal bleeding.

Opioids, however, are unique in the risk they pose to the physician: prosecution for drug dealing -- or even for murder should a patient die while using the drugs. (One prosecutor even indicted a doctor for murder after his patient died as a passenger in a fatal car crash).


The prudent decision is to avoid chronic pain patients. Physicians are quietly dropping out of this field, one at a time. But we need to ask, will this protect the public from the scourge of prescription drug abuse? Hurwitz was accused of being responsible for an epidemic of drug abuse in Virginia and many other states. Now that he's been shackled and carted off to prison, possibly for life, prosecutors may be popping champagne corks and preparing new indictments.

The effect on the illegal prescription-drug traffic in Virginia because he has been convicted will be precisely zilch. This is known with absolute certainty: the last prescription Hurwitz wrote was in December 2002 when he voluntarily closed his practice.

We won't know how many patients will suffer torture because of the deterrent effect on other doctors. But it's not the DEA's problem. It did its duty. A message has been sent, in the interest of protecting the public health from demon drugs.

Shouldn't all patients be willing to be sacrificed for such a noble objective?


(Dr. Jane M. Orient is an internist who no longer treats chronic pain. She is executive director of the Association of American Physicians and Surgeons.)



(United Press International's "Outside View" commentaries are written by outside contributors who specialize in a variety of issues. The views expressed do not necessarily reflect those of United Press International. In the interests of creating an open forum, original submissions are invited.)

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