bBlogBouillabaisse – Pao, pain, po-po

1a. Sam Smith – “We know this isn’t going to end well. The Kings’ Ron Artest sat out Saturday’s loss to the Spurs with a sore back after complaining after the loss in Dallas on Friday he didn’t get the ball enough, didn’t get enough shots and wasn’t sure coach and management are on the same page. Artest told the Sacramento Bee: “We’ve got to find ways to get me the ball. I know that’s kind of selfish, but something has to happen. The organization needs to find out which way it wants to go, you know what I’m saying? I think Coach understands what I can do. It just has to be clear between the organization and coach.” It was Artest’s demands for the ball over Jermaine O’Neal that started all the problems in Indiana…”

1b. Peter Vecsey – “Obviously, 3-9 Memphis is suffering dreadfully without Gasol’s scoring. rebounding and a presence that demands strict defensive attention from two or three opponents. In the final year of his contract and guaranteed not to be re-hired – if for no other reason, the “incoming” owners can’t afford him – Mike Fratello isn’t quite as good a coach without Gasol; funny how that works. Yet, the thrice one-round-and-done playoff team isn’t a big draw in Memphis. Who knows, maybe the franchise has no other choice but to trade him for a squadron of undeveloped, minimum-wage hustlers, the business blueprint (unearthed last week by the Commercial Appeal) of the under-funded group headed by Brian Davis and Christian Laettner. While that may, indeed, be something that could go down once Michael Heisley’s 70 percent is sold, nothing is about to happen at this time. By all accounts, VP Jerry West is forbidden to make a trade no matter how insignificant (or change coaches) until the new group is either approved or disapproved in mid-December, maybe later.

Again, until then, the Celtics, probably the Grizzlies, too, are on their own, while Rivers and Fratello coach from weakness. Should Ainge start to warm up in the bullpen (a la Gregg Popovich replacing Bob Hill when Tim Duncan joined forces with David Robinson), I suspect Boston may be on the brink of acquiring Gasol.”

2a. William E. Hurwitz, M.D., J.D. – “The DEA and its state counterpart agents are embarked on a program of harassment of pain patients through repeated investigations, seizures, and arrests without charges or followed by dropping unsubstantiated charges. Similarly, they pay intimidating “visits” to pharmacists and physicians to “advise” them on how to practice their professions. This type of law enforcement by intimidation has not been seen in the Western world since before the Second World War, and, so far as I am aware, has never been seen in the United States of America. So, we already are perilously close to a situation in which the police agencies simply will not allow medicine to be practiced in conformity with honest and ethical standards.”

Asa Hutchinson, Director of the DEA, 3/14/2002 (in a talk before the American Pain Society): “I’m here to tell you that we trust your judgment. You know your patients. The DEA does not intend to play the role of doctor. Only a physician has the information and knowledge necessary to decide what is appropriate for the management of pain in a particular situation. The DEA is not here to dictate that to you. We do not intend to restrict legitimate use of OxyContin or other similar drugs. We will not prevent practitioners acting in the usual course of their medical practice from prescribing OxyContin for patients with legitimate medical needs. We never want to deny deserving patients access to drugs that relieve suffering and improve the quality of life.”

“The policy of targeting physicians based on patient misbehavior establishes a standard of perfection in selecting patients that no doctor could meet. It forces doctors who try to treat pain to act like police, reinforcing a perverse medical paternalism that subverts the ethical imperatives designed to protect patient autonomy and dignity. This distortion of the patient-physician relationship stigmatizes patients and erodes their trust. At the same time, it assigns doctors a function that they are ill-qualified to perform.”

2b. Laura Cooper, an attorney with multiple sclerosis and a former patient of Hurwitz, moved to Oregon when his practice was shutting down. Her new doctor “is also under the microscope,” she says. “All of these guys are on their way out — if not on their own, the government is on the way to putting them out. Anybody who would treat me the way I need to be treated is not long for American medicine. When my doctor goes down, I don’t know what I’ll do.” Since Cooper lives in Oregon, she notes, “by law I can get drugs to kill myself, but not to treat my pain. The doctor could say, in effect, ‘I’m not trying to treat pain; I’m trying to kill her,’ and that would be more acceptable. Clearly, something’s a little off kilter. My medical needs are less important than their war on drugs.” (Szalavitz, 2004)

2c. Frank Fisher seems to have been targeted based on just this sort of suspicion. At his Northern California clinic, the Harvard Medical School graduate accepted patients on Medicaid and Medi-Cal (California’s health insurance for the poor) that most other physicians refused, and he tried to treat their pain as aggressively as he would treat anyone else’s. In February 1999 state law enforcement agents raided Fisher’s clinic and arrested him for drug dealing, fraud, and murder. His bail was set at $15 million. State prosecutors accused him of “creating a public health epidemic” of OxyContin abuse and death. They implied that he must be a drug dealer because he was the largest prescriber of the drug under Medi-Cal. But in a context where fear of prosecution leads most doctors to under-prescribe, anyone who prescribes what is necessary for severe pain will be a top prescriber. The DEA insists physicians aren’t targeted based on volume alone. But Fisher believes he was. While patients with moderate pain can be treated effectively with low doses of opioids, he explains, severe pain requires that the dose be adjusted (“titrated”) to a level that maximizes pain relief and minimizes side effects. “To get a sense,” he says, “I titrated about two dozen patients, and they ended up taking almost half of the OxyContin 80-milligram pills prescribed in California in 1998. What that tells you is that nobody else titrated.”

Fisher was jailed for five months, during which time the prosecution’s case began to evaporate. First, the murder charges were reduced to manslaughter by the judge, who saw no proof of intent. Then the truth about these “killings” came out. One death involved a passenger who died when her spine was severed in a van accident. Fisher was charged with her “murder” because she had high levels of OxyContin in her blood. Another “victim” had taken drugs stolen from a patient, while a third died of a self-administered overdose two weeks after Fisher was incarcerated. During cross-examination in pretrial hearings, it was revealed that seven attempts by undercover agents to get drugs from Fisher had been rebuffed. “I had a screening process for those who tried to get controlled substances,” he says. “I screened out 60 percent of those, and apparently the agents were amongst them.” In January 2003, four years after Fisher’s arrest, a state judge dismissed all the charges against him because prosecutors had tried repeatedly to delay the trial. (Szalavitz, 2004)