May 1, 2007

Managing Pain: Dr. Feelgood's Hard Time

A jury in Alexandria VA recently found Dr. William Hurwitz guilty of 16 counts of drug trafficking, determining that he prescribed massive quantities of medicine to patients in chronic pain. The 12-member jury acquitted Hurwitz on 17 other trafficking counts, but Hurwitz faces up to 20 years in prison for each count on which he was convicted. He will be sentenced July 13.

This was the second trial for Dr. Hurwitz. In the first, the judge improperly told jurors that they could not consider whether Hurwitz acted in "good faith" when he prescribed the large doses of medicine. So whether he acted in good faith or not, the good doctor is going where drugs are readily available, but prescriptions are never needed.

Hurwitz is a trusting soul who has become a lightening rod for the issue of pain management. He defines pain in a very simple manner: "Ultimately, pain is what the patient says it is..." In other words, as a doctor, he does not put himself in a position to question his patients. If they say they are in pain, he provides the strongest available medications. In large quantities. Repeatedly. If his patient "loses" the prescription, he immediately provides another.

During the four-week retrial, prosecutors argued that Hurwitz was a common drug dealer whose McLean waiting room was filled with sleeping and incoherent patients with track marks on their arms. The prosecution presented 41 witnesses, including 12 former patients who had been convicted of drug crimes.

"He crossed the line from a healer to a dealer," Assistant U.S. Attorney Gene Rossi told the jury in closing arguments April 18.

Dealer as Healer
In an article by New York Times reporter John Tierney, we read of a compelling incident in support of Dr. Hurwitz:

It occurred...during the appearance of a hostile witness, Dr. Robin Hamill-Ruth, one of the experts who was paid by the federal prosecutors to analyze Dr. Hurwitz’s prescriptions for OxyContin and other opioids.

Dr. Hamill-Ruth, who noted that she never prescribed the highest-strength OxyContin tablet, said some of Dr. Hurwitz’s actions were “illegal and immoral” because he prescribed high doses despite warning signs in patient behavior that the opioids were being resold or misused.

Then, during cross-examination by the defense, Dr. Hamill-Ruth was shown records of a patient who had switched to Dr. Hurwitz after being under her care at the University of Virginia Pain Management Center. This patient, Kathleen Lohrey, an occupational therapist living in Charlottesville, Va., complained of migraine headaches so severe that she stayed in bed most days.

Mrs. Lohrey had frequently gone to emergency rooms and had once been taken in handcuffs to a mental-health facility because she was suicidal. In 2001, after five years of headaches and an assortment of doctors, tests, therapies and medicines, she went to Dr. Hamill-Ruth’s clinic and said that the only relief she had ever gotten was by taking Percocet and Vicodin, which contain opioids.

Mrs. Lohrey was informed that the clinic’s philosophy “includes avoidance of all opioids in chronic headache management,” according to the clinic’s record. The clinic offered an injection to anesthetize a nerve in her forehead, but noted that “the patient is not eager to pursue this option.” Mrs. Lohrey was referred to a psychologist and given a prescription for BuSpar, a drug to treat anxiety, not pain.

“You gave her BuSpar and told her to come back in two and a half months?” Richard Sauber, Dr. Hurwitz’s lawyer, asked Dr. Hamill-Ruth. Dr. Hamill-Ruth replied that unfortunately, the clinic was too short-staffed at that point to see Mrs. Lohrey sooner. Under further questioning Dr. Hamill-Ruth said that she was not aware that BuSpar’s side effects included headaches.

Mrs. Lohrey looked elsewhere for help. Having seen Dr. Hurwitz on television _ — “60 Minutes” and other programs had featured his controversial high-dose opioid treatments — she sent him a letter describing her pain and the accompanying nausea and vertigo.

“I have lost hope of retrieving my life as it was,” she wrote, because she could find no doctor to take her seriously. “I currently have a physician who has said that I am psychologically manufacturing my headaches, and that I am addicted to narcotic pain relief. This of course is not the first time that I have been treated as a ‘nut’ or a ‘junkie.’ "

While I normally would lean toward Dr. Hamill-Ruth's approach to pain management - minimizing the use of opiates - she clearly was no help to Mrs. Lohrey and may have exacerbated her condition (by prescribing a medication with a headache side-effect). Her cavalier approach may have been even less helpful than Dr. Hurwitz's.

What is Pain?
There are no objective tests to validate or measure pain. It's a very complicated issue, with extraordinary ramifications in the workers comp system (where Oxycontin is all-too-frequently prescribed - see our prior post here).

As Dr. Hurwitz says, pain is what the patient says it is. Ah, but patients can lie, especially those who are addicts, who will do anything and say anything to secure their next dose. Hurwitz, if nothing else, was phenominally naive. His "good faith" was trumped by his poor judgment. If pain is what the patient says it is, then we'd best have a very close look at the patient. That's where good Dr. Hurwitz morphed into Dr. Feelgood. He was so focused on making the pain go away, he routinely prescribed pain relievers that all-too-quickly become problems unto themselves. And now he pays a price well out of proportion to his crime. In the matter of pain and pain management, there is very little middle ground.



Looks like there is at least one additional US Attorney that President Bush should have canned. This is a matter for the medical licensing board if anyone at all.

I worked with an anesthesiologist in the late 80's who eventually lost his license behind too many drugs and some other incidents but the drugs is what got him. There is still a thin line behind healing and dealing and what I have discovered in the 15 plus years of working with chronic pain patients, is that no matter what, you have to be in control of the pain med route. Some of those patients were manipulative and those were the same patients that testified against him. How many times do you lose an entire bottle of Norco #120? How do you misplace and entire box of Duragesic 50mcg? I had one patient seriously explain to me that his German Shepard, again, ate up all 300 of his 30 mg MS Contin. Guess what? The doctor refilled his prescription. While I am on the phone his dog is barking! One patient explained how her vacuum cleaner kept eating up her Vicodin! And she kept getting refills. It is when you get STUPID with the prescibing of the meds that get you in trouble. The pharmacies would call him on the multiple doctors and rx's the patients would bring in and he would get so cocky. In fact he got turned into the board because he prescribed to a suicidal patient, 700 10 mg Methadone tablets. When they found her unconscious, (she od'd on Melaril) her sister who was an RN called this doctor to ask why he prescribed that amount to her sister (he knew she was under care for her depression), he just went off on her! I knew then he was done, I was listening when she told him she would report him. Prior to that I repeatedly told him how to keep track of the "repeat offenders" but he refused to listen. Pain is hard to gauge but you still have to use some common sense when treating these patients. A junkie is a junkie, plain and simple! We had patients remove their medication from their infusion pumps just so they could shoot up or sell the actual med to someone. One of those patients got a massive infection of the pump pocket behind that! When a patient refuses to try any other modalities that should be a red flag to any doctor! When a patient constantly comes in early for his or her medication...another red flag. I worked with another pain doctor who I convinced to do routine blood and urine screens on his patients. You would be surprised as to how many patients either had other drugs in their system (such as cocaine), or when you did the blood screen they had none of the prescribed medication in their system, even though they had just obtained another "early" refill! Why? They weren't using the drugs they were selling them for extra income! Common sense and documentation will keep the doctor out of trouble!


Submit your email to be notified when this site is updated

Need help with your workers' comp program?

Monthly Archives

About this Entry

This page contains a single entry by Jon Coppelman published on May 1, 2007 11:04 AM.

News roundup: workplace cancers, medical costs, SC reform, ergonomics, photo of the week was the previous entry in this blog.

Keeping up with RIMS from the sidelines is the next entry in this blog.

Find recent content on the main index or look in the archives to find all content.

OpenID accepted here Learn more about OpenID