Alexander DeLuca, M.D.
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References and Resources: War on Doctors
Peer-reviewed /Academic-quality Literature Collection, Official Reports, and Legal Documents
Compiled by Alexander DeLuca: 1998 - 2007.  
 Latest additions to archive: New! - 2007-08-16 - New!
See also these related Collections: 
Drug War Journalism and Advocacy collection // Pain and Opioid Therapy collection // Classics in the War on Doctors  //
The WAR ON PAIN SUFFERERS collections - Index
// The DeLuca collection

War on Doctors and Pain Crisis Weekly
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Chronic Pain in Veterans - a Brief Review
Testimony: House Subcommittee on Crme; Alex DeLuca; PRN; 2007-07-12. 16. [PDF available]
"A continuous flow of pain signals into the pain mediating pathways of the dorsal horn of the spinal cord alters those pathways... 
The end result is the disease of chronic pain in which a damaged nervous system becomes the pain source generator dissociated from whatever the initial pain source was.
[So,] delaying aggressive opioid therapy in favor of trying everything else first is not rational and is therefore not the standard of care."

See also:

A Boundless Field of Power - PRN Amicus for Dr. McIver - Reynolds, Fisher, DeLuca; PRN; 2007

The Bounds of Medical Practice, and the Standard of Care - DeLuca; PRN; 2007-04-22
PRN's Reynolds' Senate Testimony Re: Oxycontin Settlement
Testimony of Siobhan Reynolds, PRN, to Senate Committee on the Judiciary: "Evaluating the Propriety and Adequacy of the Oxycontin Criminal Settlement;" 2007-07-31.
"Many people in severe pain, especially those with high dose requirements, have been maimed or killed as a result of this department's campaign against pain management. But we haven't, as of yet, seen Senate Judiciary Committee hearings about that ongoing atrocity."
See also:
When Pain is Chronic - Reynolds, LTE, NYTimes; 2007
Red Flags, and the Standard of Care - DeLuca; 2007
Red Flags - the CME Course! - DeLuca; War on Docs/Pain Crisis; 2007-08-13
-- and --

Substance Use Disorders in Primary Care Chronic Opioid Therapy

Fleming, et al.; Journal of Pain; 8(7): 573-582; July 2007
Interesting study purporting to link aberrant drug-related behaviors (red flags) with addiction.
Major Finding:
"frequency of opioid use disorders was 4 times higher in patients receiving opioid therapy compared with general population samples (3.8% vs 0.9%). "
A Major Flaw:
adequacy of the opioid therapy, whether or not patients were undertreated, is ignored.
See also:
Red Flags Uber Alles - DeLuca;  2007-08-06 blog post about this study with good discussion taking place in the Comments thread.
Red Flags and the Standard of Care; DeLuca; 2007
Interpretation of Aberrant Drug-Related Behaviors; Frank Fisher; 2004
Cannabinoids In Medicine: Review Of Their Therapeutic Potential - M.B. Amar; J.Ethnopharmacology, 2006
"Cannabinoids present therapeutic potential as antiemetics, appetite stimulants, analgesics, treatment of MS, spinal cord injuries, Tourette's syndrome, epilepsy and glaucoma."
See also:
Pot Smoking NOT Linked to Lung Cancer - Salynn Boyles; WebMD; 2006-05-23
The Brain's Own Marijuana - Nicoll and Alger; Scientific American; 2004
MJ Smoking and Head & Neck Cancer - Hashibe et al; J. Clin. Pharm; 2002
Taking a Leaf from 'Pot Docs' - Bailey, '04
Decreased Depression in MJ Users - - Densona and Earleywine, 2005
Residual Neuropsychological Effects of Cannabis Use - Gonzalez; 2002
Endogenous Cannabinoid System Protects Against Colonic Inflammation - Massai et al.; J Clin. Investigation; 2004
Medical Marijuana: 2000-2006 collection
Wanted: Public Health Approach to Prescription Opioid Abuse and Diversion (PDF)
Joranson and Gilson; Pharmacoepi.Drug Safety; 2006
"[Efforts] to reduce mortality from opioids must be [targeted] at those who cause the problem while not impeding... patient care. However, targeting interventions requires information about why prescription drugs are misused, how they are diverted, and who diverts them. This area continues to be ripe for a public health examination."
Comment (DeLuca):
Joranson, in response to Paulozzi (below) describes a basic public health approach to the 'drug abuse crisis.' One wonders whether the combined brain power of the NIH, CDC and FDA would not have accomplished this, except for the imperatives of the drug war.

Hurwitz 2005
(see below) is an example of the sort of analyses we should expect, but never get, from our academic and federal patriarchs
See also:

The Challenge of Prescription Drug Misuse: A Review and Commentary - William Hurwitz; Pain Medicine; 2005
Increasing Deaths from Opioid Analgesics in the United States - Paulozzi et al.; Pharmacoepi.Drug Safety; 2006
Dr. Fishman's Response to Paulozzia's 'Increased Deaths from Opioid[s]'
(PDF) - Scott M. Fishman; Pharmacoepi.Drug Safety; 2006
U.S. Painkiller Deaths Up - Miranda Hittite; WebMD; 2006-07-24 
Drug Crime [Not Pain Docs] Source of Abused Pain Meds in the U.S. - Joranson and Gilson, J.Pain and Symptom Manage.; 2005
The War on Drugs, War on Doctors, and the Pain Crisis in America - Alex DeLuca; Columbia University; 2004
Related resources:  
Drug War Journalism and Advocacy archives
The Pathological DEA: Aftermath of the DEA FAQ Debacle -
compiled: DeLuca; War on Pain Sufferers series #11; 2006
Principles of Opioid Management of Pain - Joel Hochman and members of NFTP and PRN listServ; Summer 2006

The Project for Pain and Chemical Dependency:  
'Defining What is Right, Not What is Wrong'
Comment (DeLuca):
A consensus document defining medically correct, ethical, patient-centric, respectful opioid treatment for pain.

Unlike almost every other such effort  promulgated by pain societies or Fed. agencies, Principles does not encourage physicians take on a law enforcement role, and does not discriminate against high-dose patients or non-medical drug users in pain.
See also:
'High Dosage' Opioid Management -
Hochman; Practical Pain Management; 2005
Chronic Pain:
I - A New Disease?  ;  II - The Case for Opiates -
Daniel Brookoff; Hospital Practice; 2000
White Paper on Opioids and Pain: A Pan-European Challenge
- compiled by OPEN Minds; 2005
Dr. Hurwitz Wins Appeal - Gets New Trial -
Drug War Chronicle #450; 2006-08-25
"'The district court effectively deprived the jury of the opportunity to consider Hurwitz's defense.' That was a fatal error. 'We cannot say that no reasonable juror could have concluded that Hurwitz's conduct fell within an objectively-defined good-faith standard,' wrote Judge Traxler."    
See also:
US v Hurwitz Appeal Decision
(PDF) - Widener, Traxler, and Currie; 4th Circuit Appeals Court; 2006-08-22
Brief of Appellant William Eliot Hurwitz (PDF) - Robbins, Russell, & Taaffe; 2005
Billy's Lament  and  The Appeal  - two poems by Dr. Hurwitz; Federal Detention; 2005
The Dr. William Hurwitz Collection - WAR ON PAIN SUFFERERS #4, 2005
Desperate Florida Gov. Candidate Gallagher Strikes Out Unjustly at Dr. Merrill to Distract from Crippled Campaign
John P. Flannery; PRN press release; 2006-07-01
"'Florida,' Flannery said, 'has a policy of intimidating any doctor who would dare to help chronic pain patients and [the prescribing doc] and the patients [are] criminalized.
Gallagher makes great pretense at having 'family values' and yet he has thrown his political weight against those families who value a loved one suffering from chronic pain.'"
Comment (
Drug War prosecutors and pathological liars like Karen Tandy can consider this a warning shot. If you attack a pain doc for selfish and venal political reasons, expect to be held to account in the press by PRN.
I applaud the more aggressive stance PRN is taking - for ex the recent Heberle victory and Paey appeal .

See also:
  Trial Begins for [Dr. Merrill] - Nelson; AP; 2006
Paey Appeal Selected Transcripts: Defense Attorney Flannery Addresses the Court, February 2006
Reply Brief of the Appellant Dr. McIver - J.P. Flannery; Forth Circuit Appeals Court; 2006

War on Doctors and Pain Crisis Weekly - RSS feed:
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The Trials of Dr. Frank Fisher: the Cost of Exoneration

WAR ON PAIN SUFFERERS Collection #7; compiled by DeLuca; 2006-06-23
Nonacute (Residual) Neuropsychological Effects of Cannabis Use: Qualitative Analysis and Systematic Review
Gonzalez, R., et al., J. Clin. Pharm., 2002
"[The] authors review the evidence for persisting effects of nonacute cannabis use on... neuropsychological performance. [They] could not detect consistent evidence for persisting deficits in cannabis users; however, 22 of the 40 studies reported at least some subtle impairments."
See also:
Medical Marijuana, 2000-2006 archives
Cannabinoids In Medicine: Review Of Their Therapeutic Potential -
M.B. Amar; J.Ethnopharmacology, 2006
"Cannabinoids present therapeutic potential as antiemetics, appetite stimulants, analgesics, treatment of MS, spinal cord injuries, Tourette's syndrome, epilepsy and glaucoma."


MJ Smoking and Head & Neck Cancer -
Hashibe et al; J.Clin.Pharm; 2002
"[THC has] anti-tumor properties... as well as tumor-promoting properties... However, in a cohort study with 8 years of follow-up, marijuana use was not associated with increased risks of all cancers or smoking-related cancers."
Doctors: New Target in the War On Drugs?
 Wayne Guglielmo; Medical Economics; 2006-05-19
"[DEA] has taken [Title II of the 1970 Drug Control Act] to mean that it can decide when doctors treating pain are practicing legitimate medicine. That interpretation, critics say, is a bold example of the fed overstepping its authority and treading in areas [constitutionally] reserved [to the states]...
[DEA] has hired hundreds of new investigators, [and they] have made clear that quantity alone... can trigger an investigation."

See also:

The Amazing Vanishing DEA Pain FAQ - Drug War Chronicle, #358; 2004-10-15
Assisted-Suicide Ruling May Affect Painkiller Cases -
Marc Kaufman; Washington Post, A04; 2006-01-22
DEA’s 'One-tenth of 1 Percent' Myth - Libby; Cato; 2005
The Dr. William Hurwitz Collection
The War on Doctors and the Pain Crisis in the Aftermath of the DEA FAQ Debacle
Selected articles from the January 2006 issue, Volume 7, Number 1, of Pain Medicine and related documents, compiled by DeLuca; 2006-04-16.

"If those at the top of the DEA hierarchy can be so manifestly indifferent, if not hostile, to the insights and perspectives of such groups [as the NAAG and PPSG], then... we are tilting at windmills when we... beseech the DEA to genuinely embrace the [principle] of balance..." - Ben Rich, Of Smoke and Mirrors and Passive-Aggressive Behaviors, Pain Medicine, 7(1), 2006.

Comment (DeLuca):
Truly Fascinating articles by Heit, Fishman, Passik, and Rowe - who contributed mightily to the FAQ - and by Rich commenting on the ethical-moral disaster in pain medicine. A must-read for serious students of the War on Doctors.

Healthcare Professionals and the DEA: Trying to Get Back in Balance - Howard Heit; Pain Medicine; 7(1): 72-74; 2006.
Pain Management Misstatements: Ceiling Effects, Red and Yellow Flags - Steven D. Passik; Pain Medicine; 7(1): 76-77; 2006. 
Of Smoke, Mirrors, and Passive-Aggressive Behaviors - Ben A. Rich, JD, PhD; Pain Medicine; 7(1): 78-79; 2006.
Pain, the DEA, and the Impact on Patients - Will Rowe, MA; Pain Medicine; 7(1): 86-86; 2006. 
Pain and Politics: DEA, Congress, and the Courts, Oh My! - Scott Fishman; Pain Medicine; 7(1): 87-88; 2006. 

Related Documents:
Now You See It, Now You Don't: The Amazing Vanishing DEA Pain FAQ - Drug War Chronicle, #358; 2004-10-15. 
Drug Crime Is a (Major) Source of Abused Pain Medications in the United States - D.E. Joranson and A.M. Gilson, Journal of Pain and Symptom Management, 30(4): 299-301, 2005. 
An Ethical Analysis of the Barriers to Effective Pain Management - Ben Rich; Cambridge Quarterly of Healthcare Ethics, 2000. 
Comment on Prescribing Controlled Substances for the Treatment of Pain (PDF) - National Association of Attorneys General; 2005-03-21. 
H.R. 3015 (NASPER) Continues War Against Pain Patients and Doctors - Michael Glueck, and Robert Cihak;; 2004-11-23.
The War on Drugs, War on Doctors, and the Pain Crisis in America: Eighty Years of Naked Emperors - Alexander DeLuca; 2002. 
The Dr. William Hurwitz Collection - War on Pain Sufferers #4; compiled by DeLuca; 2005, 2006. 
Introduction and Index to the War on Pain Sufferers Special Resource Collections

The Endogenous Cannabinoid System Protects Against Colonic Inflammation - F. Massai et al.; Journal of  Clinical Investigation; 113(8): 1202-1209; 2004 -- "Our results indicate that the endogenous cannabinoid system represents a promising therapeutic target for the treatment of intestinal disease conditions characterized by excessive inflammatory responses."

See also:
Medical Marijuana: 2000-2006 collection


Reynolds (PRN) Comments on Luyao Conviction (PDF) -
Siobhan Reynolds; Pain Relief Network listServ; 2006-03-07 -- "This isn't an odd verdict. What's odd is that the lawyers continue to enjoy the game when it's long since become clear that the doctors don’t stand a chance. Look at how emotionalism dominated the debate, how irrationality was the defining characteristic of the verdicts. Look at how that patient's relative apparently thought that the doctor needed to go to prison in order to be stopped from being a doctor any more"

See also:
Jurors: Deciding Dr. Luyao's Fate was 'Difficult, Emotional' - Simmonsen;; 2006-03-09
Luyao [Trials] Part of Wider Debate - Simmonsen;; 2006-03-12

Drug Crime Is a Source of Abused Pain Medications in the U.S. - Joranson and Gilson, J.Pain Symptom Manage., 2005 -- "[Theft] is an important source of prescription opioids diverted into the illicit market... If we accept uncritically that drug diversion stems only from prescriptions, we risk distorting our view of the medical profession and patients... which further weakens physicians' desire to treat pain and worsens patient access to pain care."

See also:
Commentary by Dr. Stephen Passik -
Trends in Medical Use and Abuse of Opioid Analgesics: A Revisit
- Novak et al.; Pain Medicine; 2004

Evidence for Controlled Heroin Use? -- Shewan and Dalgarno, British .J. Health Psych. 2005

Comment  (DeLuca):
In this study, subjects had occupational and educational status comparable to that of general UK pop. Ongoing problems were rare; heroin was not a significant predictor. Use frequency data suggests importance psych factors. The pharmacological properties of opioids, per se, do not inevitably lead to harmful use patterns.
See also:
Occasional and Controlled Heroin Use - Not a Problem? -
Warburton et al., Rowntree Foundation, 2005
Some Eminent Narcotics Addicts  ;  The Heroin Overdose Mystery - Edward Brecher; Chapter 5;12, "Licit and Illicit Drugs"; 1972
How Bad is Heroin Withdrawal? - Jara Krivanek; Chapter in "Heroin, Myths and Realities"; Allen & Unwin, Publishers; 1988

An Evaluation of Fitness-for-Duty Testing -
Debra R. Comer; 103rd Ann. APA  Meeting., 1995
Comment (DeLuca):
Excellent, important, review of fitness-for-duty testing of employees - a field not rich in well-designed, clear-cut research. Document greatly revised, 2006, including addition of interactive Table of Contents

See also:
A Critical Assessment of Workplace Drug Testing - DeLuca, 2002

Drugs and Drug Policy - Bill Marcus, Deputy AG, California, Retired; Narc Officer, 6(5), 23-29, 1989 -- "If we fail to distinguish between [drug use and] abuse, we risk perpetuating unreasoning fear and inadequate treatment as well as inhibiting legitimate research. Little is accomplished if a patient in real need is denied legitimate, marketed controlled substances due to unreasoning fear-on the part of the prescriber, dispenser or patient-exacerbated by ill-considered propaganda (or laws)."

 The Big Chill - Inserting the DEA into End-of-Life Care - Timothy E. Quill and Diane E. Meier; New England Journal of Medicine; 345(1); 1-3; 2006-01-06
"A finding in favor of the Justice Dept  [in Gonzalez v. Oregon] would not only nullify the Death with Dignity Act, permitting the DEA to penalize physicians for providing medications to hasten the deaths of terminally ill patients, but also have a chilling effect on physicians' willingness to treat patients' terminal symptoms."
See also:
Let's Get Serious About Chronic Pain (PDF) - Jane Brody; New York Times; 2006-01-10

U.S.A. vs. Ronald A. McIver, D.O.  Appellant's Brief, Case No. 8:04-75 - Eli D. Stutsman and C.Rauch Wise; Filed: 2005-12-2005 

From the Introduction to the case by Siobhan Reynolds, President, Pain Relief Network:
"Whenever I approach attorneys with the top law firms asking if they would be interested in working on one of these cases pro bono, they always have the same requirement: find them a doctor with no "bad facts" and maybe they will help...
So here is the doctor with no bad facts. None at all. This is a guy [Ronald McIver, D.O.] who was convicted of prescribing high doses of pain medicine to people in pain. NOT A CRIME."

Revised! (2005-12-28)
How Bad is Heroin Withdrawal?
Jara A. Krivanek; Chapter in: "Heroin, Myths and Realities"; Allen & Unwin, Publishers; 1988.Posted 2001-10-09. Modified: 2005-12-28.

An excerpt from the book:  "Heroin, Myths and Reality." Discussion of withdrawal, with particulate reference to the harm that stems from the illegal status of the drug. These include shared paraphernalia, the 'heroin lifestyle' and it's accompanying violence, desperation, poverty, malnutrition and poor hygiene, adulterated drug, and overdose.
See also:
Some Eminent Narcotics Addicts - Edward Brecher; Chapter 5, "Licit and Illicit Drugs"; 1972
Occasional and Controlled Heroin Use - Not a problem? - Warburton, Turnbull and Hough; Joseph Rowntree Foundation; 2005
The Heroin Overdose Mystery and Other Occupational Hazards of Addiction - Edward Brecher; Chapter 12, "Licit and Illicit Drugs"; 1972

Occasional and Controlled Heroin Use - Not a problem? -
Hamish Warburton, Paul J. Turnbull and Mike Hough; Joseph Rowntree Foundation; 2005 -- "The study describes how this largely hidden population maintained stable and controlled patterns of heroin use. It examines reasons for starting to use heroin, previous and current patterns of use, mechanisms and factors that helped to control use, and why this group saw their use as fairly problem-free."

See also:
Some Eminent Narcotics Addicts -
Edward Brecher; Chapter 5, "Licit and Illicit Drugs"; 1972
How Bad is Heroin Withdrawal? - Jara Krivanek; Chapter in "Heroin, Myths and Realities"; Allen & Unwin, Publishers; 1988
The Heroin Overdose Mystery and Other Occupational Hazards of Addiction - Edward Brecher; Chapter 12, "Licit and Illicit Drugs"; 1972

Opioid Rotation in Patients with Cancer Pain - Bruera et al.; Cancer; 78(4); 852-857;  1996
"The dose ratio between morphine and hydromorphone was 5.33... However, the hydromorphone / methadone ratio was found to be 5 to10 times higher than expected [given methadone's equipotence with morphine]."
See also:
Opiate Rotation, Incomplete Cross-Tolerance, and Hyperalgesic Metabolites
DeLuca; 2001
Psychostimulants as Adjuvant Analgesics -
Bruera and Watanabe; J Pain Symptom Manage.; 1994
New! - High-Dose Ketamine in Neuropathic Pain -
Tarumi et al.; J Pain Symptom Manage.; 2000

High-Dose Ketamine in Neuropathic Pain -
Tarumi, Y.; Watanabe, S.; Bruera, E.; Ishitani, K.; Journal of Pain and Symptom Management; 19(6); 2000. Posted: 2005-12-04 -- "Neuronal hyperactivity is at least partially mediated by N-methyl-D-aspartate (NMDA) receptors and agonists. Clinical evidence has reported that NMDA receptor antagonists reduce pain caused by nerve injury. Ketamine is one of the commercially available NMDA antagonists. We report a case in which ketamine was successfully used to treat severe neuropathic pain."

Opioids in Pain Management - Henry McQuay; Lancet; 353; 2229-2232;1999-06-26 -- "Opioids are our most powerful analgesics, but politics, prejudice, and our continuing ignorance still impede optimum prescribing... The restriction of opioid availability to protect society and the individual continues in many countries. In this review I focus on chronic and cancer pain, but many of the principles apply in acute pain. The justification for this focus is that patients with chronic pain may suffer longer and unnecessarily if we prescribe and legislate badly."

Antidepressant-Like Activity and Modulation of Brain Monoaminergic Transmission by Blockade of Anandamide [Endocannabinoid] Hydrolysis - G. Gobbi, F. R. Bambico, et al;  Proceedings of the National Academy of Sciences (PNAS); 2005; 102(51); 18620-18625 -- "Here, we show that URB597, a selective inhibitor of the enzyme... which catalyzes the intracellular hydrolysis of the endocannabinoid anandamide, exerts potent antidepressant-like effects in [testing on mice]. Moreover, URB597 increases firing activity of serotonergic neurons in the dorsal raphe nucleus and noradrenergic neurons in the nucleus locus ceruleus. These actions are prevented by the CB1 antagonist rimonabant, [and] are accompanied by increased brain anandamide levels... The findings support a role for anandamide in mood regulation and point to fatty-acid amide hydrolase as a previously uncharacterized target for antidepressant drugs."

DEA's Opioid Policy Discussed [in Montana] - Diane Cochran; Billings Gazette; 2005-12-03 -- "Doctors avoid prescribing [opioids] to people who need them because they are afraid of being investigated by the federal government... said Dr. John Oakley, medical director of the Northern Rockies Regional Pain Center. 'The ability to discern who is an addict and who is not an addict is difficult to do, and treating an addict can be seen as a violation of the law'... and he said doctors are often uncertain what is legitimate and what is not."

See also:
WAR ON PAIN SUFFERERS #1 - Montana 2005, a War on Sick People


APPELLANTS' PETITION FOR REHEARING AND PETITION FOR REHEARING EN BANC  - Eli D. Stutsman (Attorney for Dr. Bordeaux); U.S. State Court of Appeals, Fourth Circuit; USA vs. Drs Alerre, Bordeaux, and Jackson; Filed: 2005-12-15 -- "The prosecution's theory of criminal culpability, expressed on this record as the 'standard of care,' 'medical necessity,' and 'legitimate medicine,' is wrong as a matter of law"

See also:
Decision in Appeal of Drs' Alerre, Bordeaux, and Jackson: Convictions Affirmed; Sentences Vacated; Remanded for Resentencing
King; 2005-12-01. And,
WAR ON PAIN SUFFERERS #6-The Myrtle Beach Massacre


Constitutional Claim on Behalf of Americans In Pain - PRN Seeks to Enjoin DEA from Enforcing CSA Against Physicians - Siobhan Reynolds; Pain Relief Network; 2005-12-01 -- "The Controlled Substances Act... criminalizes pain patient and physician, requiring both to prove their conduct is authorized. [It] denies people in pain the traditional presumption of innocence... and lifts the burden of proof off of the government and puts it squarely on citizens in pain and [their docs]."

Comment (DeLuca):
A brilliant and very important initiative by Reynolds and PRN. We urgently need to bring this case NOW! We need support NOW!
Please contact: Siobhan Reynolds.


Decision in Appeal of Drs' Alerre, Bordeaux, and Jackson: Convictions Affirmed; Sentences Vacated; Remanded for Resentencing - Written by circuit court justice King, affirmed by judges Michael, and Motz. 2005-12-01 -- "The defendants [contended that] their lawyers were constitutionally ineffective and the prosecutors engaged in prejudicial misconduct [and] that the trial evidence was insufficient to support their money-laundering conspiracy convictions." 

Decreased Depression in Marijuana Users - Densona and Earleywineb; Addictive Behavior; In Press - Corrected Proof; 2005 -- "[Those] who used once per week or less had less depressed mood, more positive affect, and fewer somatic complaints than non-users. Daily users reported less depressed mood and more positive affect than non-users... [and] medical users reported more depressed mood and more somatic complaints than recreational users..."

The Thin Green Line: Employers and Medical Marijuana - Paula Barran, Atty.; MedfordNews; 2005 --"Ore gon permits certain individuals to use marijuana medically for conditions that defy other legal treatment. Although not intended to stand workplace substance abuse policies on their heads, that has happened."

What Research Tells Us About the Treatment of Adolescent Substance Use Disorders - Titus and Godley; IL Gov. Report; 1999 -- "These statistics reveal a disturbing and challenging fact: adolescents with substance use disorders presenting for treatment are typically involved with the criminal justice system and often have co-occurring emotional and other problems."

See also:
The Challenge of Prescription Drug Misuse" - Hurwitz; Pain Med.; 2005

Substance Abuse / Dependence in Metro and Non-Metro Areas: 2004 Update - NSDUH Report; OAS / SAMHSA; 2005-10-07 -- "Rates of past year substance abuse or dependence changed little between 2002, 2003, and 2004 in either metropolitan or non-metropolitan areas"

The data also shows little change for 1) adolescent drug use, and 2) prescription drug abuse at any age, BTW. So where is the prescription drug crisis that justifies a federal policy of restricting access to opioid analgesics to legitimate pain patients?

Marijuana and Multiple Sclerosis by Goodin; Lancet Neurology; 3(2); 2004 -- "Zajicek and colleagues recently reported the results of a large, randomised, placebo-controlled trial of marijuana for the treatment of spasticity in MS."

See also:
WAR ON PAIN SUFFERERS #6:  Medical Marijuana - 2000-2005


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Comment on Prescribing Controlled Substances for the Treatment of Pain (PDF) - National Association; 2005-03-21 -- "We are concerned that recent DEA actions send mixed messages to the medical community and are likely to discourage appropriate prescribing for the management of pain." [emphasis in the original]

Ah, that would be the Chilling Effect that the DEA denies exists.

See also:
WAR ON PAIN SUFFERERS #4 - The Dr. Hurwitz Collection

NAAG to DEA Re: Vanishing DEA Pain FAQ; 2005-01-19

WAR ON PAIN SUFFERERS - Special Resource Collection #4: The Doctor William Hurwitz Collection
compiled by Alexander DeLuca, M.D., MPH
The trial of William Hurwitz was (wrongly) about the particulars of his medical practice. The appeal is about the viability of pain medicine and addiction medicine as ethical professional disciplines. [DeLuca, 2004]
See also:
Index & Intro to the WAR ON PAIN SUFFERERS Collections


Medical Marijuana, Federalism, and the Supreme Court  by Gostin; JAMA; 2005; 294(7); 842-844 -- "[M]arijuana may offer respite for some patients—a position supported by patient experiences and physician opinions. The "drug war" metaphor does not justify an ideology that removes hope from patients when they are most vulnerable and in need."

See also:
War on Pain Sufferers #3: - Medical MJ


White Paper on Opioids and Pain: A Pan-European Challenge Compiled by OPEN Minds; 2005-06 -- "The reputation of opioids has been damaged by a singular 'war on drugs' emphasis aimed only at their potential for abuse... [What] is required... is a straightforward process of updating the numerous rules and regulations that are identified in this White Paper."

Characterizations of Long-term Oxycodone / Acetaminophen Prescriptions in Veterans by J.A. Hermos et al.; Arch. Internal Med.; 2004

They went looking for abuse and escalating doses, and found mostly stable patients.
Unfortunately, the authors fail to measure the clinical adequacy or inadequacy of the opioid therapy provided. The average VA dose for the "long term management of chronic pain" is apparently four Vicodin daily - a shockingly LOW dose for anything other than the mildest chronic pain.

Treating Doctors as Drug Dealers - The DEA's War on Prescription Painkillers by Ronald T. Libby, Cato Policy Analysis #545; 2005-06-16 -- "The government is waging an aggressive, intemperate, unjustified war on pain doctors [which] bears a remarkable resemblance to the [Reign of Terror] against docs under the Harrison Act of 1914, which made it a [federal crime] for physicians to prescribe [opioids] to addicts."

Scholarly, thorough, in-depth analysis - excellent work! Especially strong examination of DEA's vindictive media manipulation tactics.

The Challenge of Prescription Drug Misuse: A Review and Commentary by William Hurwitz; Pain Medicine; 6(2); March '05 -- "This article presents an analysis of... illicit use [and suggests] that a... policy focused on physicians is unlikely to reduce the overall use of illicit drugs, but that it is likely to have an adverse impact on [medical ethics and] pain treatment."

Vintage Hurwitz - carefully constructed and complex analysis and a unique view on the data. Explains exactly why seeking 'Balance' & 'Aberrant behaviors' & 'Appeasement' will always fail. Brilliant, important work!

Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain by Gourlay et al.; Pain Medicine; March 2005
"All patients [need to be assessed] in a biopsychosocial model, including past and present aberrant behaviors... and by applying careful and reasonably set limits in the clinician-patient relationship, it is possible to triage chronic pain patients into three categories according to risk.

Peer-reviewed journal article proposing 'universal precautions' by applied to pain patients and potential addicts - sort of like they had a fatal, highly infectious disease (which neither pain nor addiction are). This is NOT a prescription for stigma-reduction, BTW.
It's official: Pain Medicine has Jumped the Shark.

Methadone for Pain States by Toombs & Kraal; Amer.Fam.Physician; 4/1/2005 -- "Methadone's unique pharmacokinetics and pharmacodynamics make it a valuable option in the management of... chronic pain, including neuropathic pain states. It may be an appropriate replacement for [other] opioids when side effects have limited further dosage escalation."

Brief but pretty good review of the pharmacology of methadone and principles of it's use for the treatment of chronic pain.

"High Dosage" Opioid Management - Considerations in Treating Intractable Pain by J.S. Hochman, MD, Executive Director NFTP; Practical Pain Management; March 2005 -- "When titrated carefully to effectiveness, patients achieve dramatic improvement in pain levels and function, with no evidence of adverse effects, medical complications or addiction... Addiction is non-existent in our most recent series of 204 patients followed for four years."

The Challenge of Prescription Drug Misuse: A Review and Commentary by William Hurwitz; Pain Medicine; 6(2); March '05 --  "How can there be a balanced policy without a scale to measure all the relevant outcomes?"

Risk of Disciplinary Action by State Medical Boards Against Physicians Prescribing Opioids by Richards & Reidenberg;  Journal of Pain & Symptom Managament; 29(2); 206-221; February 2005. -- "Most physicians disciplined had multiple violations in addition to overprescribing controlled substances."

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Opioid Use in Orthopedic Spine Clinic Mahowald et al.; Arthritis & Rheum.; Jan. 2005 -- This study provides evidence to support [opioid therapy by] docs treating chronic musculoskeletal diseases [and protect them] from regulatory agencies. [It]will benefit patients by [easing access] to these effective, safe medications.

The Brain's Own Marijuana by Nicoll & Alger; Scientific American, 12/2004; pages 69-75. -- "Research into natural chemicals that mimic marijuana's effects in the brain could help to explain--and suggest treatments for--pain, anxiety, eating disorders, phobias and other conditions"

See also: "Marijuana Research"
An editorial from this same December 2004 issue of Scientific American blasting federal drug policy for outdated regulations and attitudes that thwart legitimate research (in PDF format).


Modulating effects of a cold water stimulus on opioid effects in volunteers by Conley , er al.; Psychopharmacology; 131(4); 1997. -- "Several of the subjective effects of morphine were attenuated either during or in between cold-water immersions, including visual analog scale ratings of... "high,""sleepy,"and "lightheaded".

US v. Deborah Bordeaux, M.D. Legal Background by Eli Stutsman, Attorney appealing  her federal conviction under the CSA; 2004. -- "... Dr. Bordeaux was prosecuted under the medical malpractice standard familiar... as the 'standard of care.' The correct legal standard in a criminal proceeding under the CSA is, however, the 'course of professional practice,' not the civil standard of care."

Eli Stutsman, a lawyer with Death with Dignity, who also represents physicians charged by the DEA, sued John Ashcroft (Complaint (1.21 MB)) and the DEA in federal district court on behalf of a physician and pharmacist, setting important precedents in the process.
See also:
DEA Called Unqualified to Set Standards On Pain-Killing Drugs"

Marijuana Research (PDF) Editorial: Scientific American; pg 8; December 2004. -- "[O]utdated regulations and attitudes thwart legitimate research with marijuana... a so-called Schedule 1 drug...  defined as being potentially addictive and having no medical use, which... becomes a self-fulfilling prophecy."

This issue of SA may be worth buying for the Medical  Marijuana policy wonk or doc in the family. Has a feature article entitled: "The Brain's Own Marijuana" by Nicoll & Alger with a wild lead-in picture.


Oxycodone involvement in drug abuse deaths:  DAWN-based classification scheme applied to oxycodone postmortem database containing over 1000 cases by Cone et al.; J.Analytical Toxicology; 27(2); 2003. - "Only 3.3% of the drug abuse cases involved oxycodone as the single... entity; of these, 12 cases had OxyContin identified as a source of oxycodone. 96.7% were... deaths in which there was at least one other plausible contributory drug in addition to oxycodone."  

How the Drug War in Afghanistan Undermines America’s War on Terror by Ted Carpenter; Cato Foreign Policy Briefing; # 84; 11/2004. -- "There is a growing tension between... the eradication of the remaining Al Qaeda and Taliban forces in [Afghanistan]... and the eradication of Afghanistan’s drug trade. The antidrug efforts may fatally undermine the far more important anti-terrorism campaign."

Dispensing Controlled Substances for Pain - DEA Interim Policy Statement [Re: the Amazing, Vanishing FAQ]
by M. Leonhart, Deputy Administrator,  DOJ,  11/12/04. -- "This.. statement explains how some of the statements in the FAQ were erroneous... [and] how DEA plans to address... the issue of dispensing controlled substances for the treatment of pain." 

Mostly parses the finer & dumber requirements of the CSA, which is what the DEA does best. An outrageous document - note they plan to address the issue of pain. <sheesh!>
They also indulge in their usual "Outcome Obfuscation" with the tired old: "nonmedical use" non-issue.  
America, wouldn't you rather have docs controlling how pain and substance abuse are treated?   ..alex...

Pain clinicians' rankings of aberrant drug-taking behaviors by Passik, et al. J Pain Palliat.Care Pharmacotherapy; 2002
-- "This survey suggests that an experienced group of pain clinicians does not view aberrant drug related behaviors uniformly. Average rankings suggest clinicians seem to view illegal behavior as the most worrisome."

Clinical Guidelines, Public Policy, and the Regulation of Opioids by R. Gallagher; Pain Medicine; 5(3); 2004. "The DEA letters (see "Dear DEA") clearly answer our questions about DEA policy... and should reassure those wishing to practice... pain medicine."

This is very dangerous, bad, almost negligent advice from the Editor-in-Chief of Pain Medicine.
 To any MD's considering practicing opioid therapy: Do Not Be Reassured; Be Afraid of the DEA; Be Very Afraid.
See also: "AAPS Correspondence with DEA" for a sense of reality about the real relationship of DEA and pain docs.


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Dear DEA by Heit, Covington & Good; Pain Med. 5(3); 2004. -- "[This article] is a series of 5 clinical vignettes intended to address common concerns of clinicians and to demonstrate the cooperation of the DEA..."

Frankly, this article give me the willies.
<shudder>  A better title might be "DEA DEAREST."
See also:
"Clinical Guidelines, Public Policy, and the Regulation of Opioids" from the same issue of Pain Medicine.

National Drug Threat Assessment 2002; from the National Drug Intelligence Center; DOJ; December 2002. -- "The illegal abuse of pharmaceuticals... is the lowest threat among the major drug categories."

Wait a minute! Drug Czar Walters said, about the Fed Drug Strategy:
"Only marijuana posed a greater drug abuse threat to the nation [than 'doctor shopping']."

Anyone else feeling jerked around?

Trends in Medical Use and Abuse of Sustained-Release Opioid Analgesics: A Revisit; by S. Novak et al.; Pain Medicine; 5(1); pg 59; 03/2004 -- "[T]he rates of drug abuse, and resultant morbidity secondary to the use of opioid analgesics, remain low in spite of the increase in medical use of these substances."

 A good study methodology stands up to replication. Don't expect any diminution of the continued hysteria from academics and fed drug warriors, though. Evidence has nothing to do with the war on doctors. <sigh>

See also:
"Trends in the medical use and abuse of opioid analgesics," "Outcome Obfuscation" and "Denominator Abuse"

Trends in the medical use and abuse of opioid analgesics - by David Joranson, JAMA, 2000. "The trend of increasing medical use of opioid analgesics to treat pain does not appear to contribute to increases in the health consequences of opioid analgesic abuse."

This is a very important paper, and for this reason it is very gratifying that there is a follow-up study using a similar methodology confirming Joranson's approach and results.
"Trends in Medical Use and Abuse of Sustained-Release Opioid Analgesics: A Revisit;" by  Novak ; Pain Medicine; 2004.

The Effects of Transdermal Fentanyl on Driving, Cognitive Performance, and Balance in Patients with Chronic Nonmalignant Pain Conditions; by Menafee et al.; Pain Medicine; 5(1); pg 42; 2004. -- "[D]riving performance[, reaction time, and cognition] did not change... with transdermal fentanyl. This result is similar to other studies that found few differences in driving performance measures between patients taking opioid medication and healthy controls..."

Prescription Pain Medications: FAQ for Clinicians and Law Enforcement (PDF) by DEA and the Pain & Policy Studies Group; 8/4/04  

Here it is!
Yet another "Let a hundred flowers bloom (so we can chop their heads off!)" effort,  brought to you at taxpayer expense, by those warm fuzzy people at the DEA who, after all, just want to help us docs do our difficult job of identifying and shunning evil drug abusers and suspicious pain patients so that the policeman's life is easier. 
Published Aug 4th, announced to get fanfare at a press conference on Aug 11th, and now disavowed two months later. Hmmm.  ..alex...
See also: "DEA Withdraws Pain Med FAQ" and "
Physicians Who Provide Compassionate and Ethical Care Risk Prosecution" and "The Myth of Available Pain Care"

** Oct 16, 2004:  New version - now standard 8 X 11 format and black & white. Much easier to read and print!**

Ron Paul in Opposition to HR 3015: the National All Schedules Prescription Electronic Reporting Act (NASPER)
by Ron Paul, US House of Representatives, 10/5/2004. -- "By creating a ... database of prescriptions ... the fed... would take another step forward in the war on pain patients and their doctors. This war has already resulted in the harassment and prosecution of many doctors, and... have scared other doctors so that they are unwilling to prescribe [controlled substances]."

Workplace Drug Testing: A Case Study In The Misapplication Of Technology by Mark Rothstein; Harvard J. Law & Tech.; 1991. -- "[D]iscusses six problems in relying on drug testing... [including] the failure to understand the drug abuse problem, the failure to consider the technology's limitations, [and] the adoption of workplace testing for reasons unrelated to the efficacy..."

** Oct 2, 2004: Major reformatting & added PDF version **
See also:
"Impact of Workplace Drug Testing" by DeLuca, 2002.

The Tragedy of Needless Pain by Ronald Melzack; Scientific American; 262(2); 1990. -- "Society's failure to distinguish between the emotionally impaired addict and the psychologically healthy pain sufferer has affected every segment of the population. Perhaps the most distressing example is unnecessary pain in children."

A true classic. 

No Friends of Bill Wilson by Radley Balko, New Republic, 5/17/2004. -- "The same mindset that finds a symbolic victory over alcoholism more important than a deathbed drink for a sick man can see fit to justify a 25-year prison term for an oxycodone-using MS sufferer and handcuffing an elderly post-polio marijuana user to her bed at the point of a gun."

Well written article finds toxic similarities in the mindsets behind both the 'abstinence-uber-alles' mentality and drug war thinking. Recommended. 
See also:
"Back Door to Prohibition: The New War on Social Drinking" by Radley Balko.

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Chronic Pain: Part 1. A New Disease?  Part 2. The Case for Opiates  by Daniel Brookoff; Hospital Practice; 2000.  --  "If a patient's physical pain has prevented him or her from living life fully, using a medication that allows a return to normal activities cannot be called drug abuse." --

Compare and contrast to the article by Ballantyne  (directly below). Brookoff is accurate, thorough, and lacks the creepy, vapid feeling of Ballantyne's work. This is a far better Review, IMO.     ..alex...

Opioid Therapy for Chronic Pain by Ballantyne & Mao; NEJM; 11/13/2003. I disagree with many of the conclusions and implications that arise from this review, for example, the concept of a "ceiling" dose limit. But this is an important article even though I find it perpetuates traditional, wrongheaded, WOD thinking.     ..alex...

Lost Productive Time & Cost Due to Common Pain Conditions in the US by Walter Stewart, et. al., JAMA, 11/12/2003. "Conclusion: Pain is inordinately common and disabling... Most pain-related lost productive time occurs... as reduced performance."

Race, Ethnicity, & Pain Treatment - by Vence Bonham; J. Law, Med. & Ethics, 2001. "Racial and ethnic minorities are at higher risk for the ineffective treatment of pain. While others have investigated racial and ethnic disparities in access to health services generally, Bonham presents the first comprehensive review of the literature on racial and ethnic disparities in the treatment of pain."

Pain Management and Provider Liability: No More Excuses - by Barry Furrow; J. Law, Med. & Ethics, 2001. "Pain is undertreated in the American health-care system at all levels: physician offices, hospitals, longterm facilities. The result is needless suffering for patients, complications that cause further injury or death, and the added costs in treatment overall. ... Excuses for shortcomings are simply not acceptable any longer."

Interpretation of "Aberrant" Drug-Related Behaviors [PDF] - by Frank B. Fisher, M.D., J.Amer.Physicians & Surg. 2004. -- Excellent examination, by a guy who has really been  there, of the crucial "Doctors Dilemma"- the impossibility of distinguishing the “deserving” chronic pain patient from the presumably undeserving drug addict.   ..alex...

Mixed Message on Prescription Drug Abuse. by Brian Vastag; JAMA, 2001.-- "The most egregious underprescribing occurred with idiopathic back pain, the most common kind. While the expert panel recommended that virtually all patients with such pain-and who do not respond to other treatments-be given an opioid analgesic, only 20% of physicians said they would actually write that prescription. "

Pain Patients and Docs Now Causalities of War on Drugs - Yearbook of Experts, Authorities and Spokespersons, June 30, 2004. -- "'The war on drugs has turned into a war on doctors and the legal drugs they prescribe and on the suffering patients who need the drugs to attempt anything approaching a normal life," said Kathryn Serkes, of the AAPS... Assistant U.S. Attorney Gene Rossi declared to a reporter that 'our office will try our best to root out [certain doctors] like the Taliban. Stay tuned.'"

Pain Without Treatment,  Wrong Without Remedy  by William Hurwitz, M.D., 1992. -- "This [paper] argues that pain patients are protected as persons with disabilities entitled to appropriate medical treatment and that the regulatory scheme, through its disparate impact on their access to such treatment, violates the law."

Dr. DeLuca's Addiction, Pain, and Public Health Website

Alexander DeLuca, M.D., FASAM

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Originally posted: 2004-10-15

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