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Alexander DeLuca, M.D.
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The Collapse of Medical Ethics and Standards for Pain Management

Frank Fisher, M.D.; Drug Cops and Docs, Cato Institute Conference; 2005-09-09; Posted: 2005-09-11
Related resources:
See also:
Ethical Analysis of Barriers to Effective Pain Management -
Rich, Cambridge Quarterly Healthcare Ethics, 2000
[Cops and Docs from Cato:
Introduction and Conference Schedule and streaming audio of entire conference]

[This Article in PDF print format]

The undertreatment of chronic pain is an ongoing public health disaster. The means to reverse this disaster is a class of medications known as opioid analgesics. The pain crisis exists for just one reason. Physicians don't prescribe enough of these medications. I'm going to explain why we don't.

The war on drugs has become a war on legal drugs. This exposes physicians to the risk of unwarranted prosecution. In response to this threat, the academic pain establishment has developed a set of standards for the purpose of protecting themselves from prosecution.

These standards are inimical to appropriate pain care because physician protection is accomplished at the expense of the well being of patients. This occurs through the restriction of necessary treatment. As a result, these standards violate the physician's ethical imperative to put the interests of his patients first. The consequence of this collapse of medical ethics is that the war on drugs is now a war on sick people.

The Rational Standard
Before I go into the details of the harmful standards, in order to maintain some perspective, I'd like to review the rational standard of care for pain management. This standard is based on medical principles, science, and compassion. Ethically it is correct in the sense that it serves the interests of the patient.

This standard can be boiled down to one essential element. The rational standard of care for pain management requires of the pain-treating physician that he control the patient's pain. If this standard prevailed there wouldn't be a pain crisis and we wouldn't be here today.

The Drug Control Standard
The worst problem with the standard that academic physicians invented in order to protect themselves from prosecution is that this standard has nothing to do with pain control. It also has nothing to do with science. This standard is all about drug control. The harm that it does to patients is enormous.

The centerpiece of the drug control standard is a set of patient behaviors that have been classified as "aberrant". Let me show you a piece of it through the eyes of a patient.

Imagine for a moment that you are a patient afflicted with chronic pain. Now suppose that during your last doctor's visit, your physician didn't prescribe enough medication to control your pain until your next visit. So you ran out. You'd just call his office for a refill right? That's what you'd do if you ran out of blood pressure medicine, isn't it?

If your physician is treating you for chronic pain you would be well-advised not to call him. Here's why. If you decide you can't handle the pain, and you call him anyway, he will identify your behavior as an unsanctioned dosage escalation. In his eyes you will have committed one of these aberrant, drug-related behaviors. As a patient, you don't want this to happen under any circumstances because it can mean the end of your medical care.

Your physician has been trained by his colleagues in academic pain medicine to suspect that you have slipped into drug addiction. No more pills for you, ever. Now you have an idea what it's like to be on the receiving end of the drug control standard.

This standard is harmful because it causes physicians to behave as if it were better that 1,000 pain sufferers should go untreated than just one drug addict abuse a prescribed pharmaceutical.

In a nutshell, that's what the drug control standard does to patients. Now, I'm going to shift gears and talk about how academic pain medicine forces physicians to go along with this insanity. I'm going to tell you, about the witch trial, of Dr. William Hurwitz.

Dr. Hurwitz is a physician, from Virginia, who treated chronic pain, appropriately. Last fall, the federal government put him on trial for criminal drug distribution. I sat in a courtroom in Alexandria Virginia and observed as Dr. Michael Ashburn, a former president of the American Pain Society, testified against Dr. Hurwitz. Dr. Ashburn spoke about the ways in which he felt that Dr. Hurwitz violated the drug control standard as he cared for his patients.

I have known Dr. Hurwitz for most of the last 10 years. He is one of the most ethical men I have ever met and he is innocent. Dr. Ashburn's testimony was instrumental in sending this caring physician to federal prison where he is now serving a 25-year sentence.

If pain management were a legitimate discipline the professional societies to which Dr. Ashburn belongs would issue sanctions against him. Instead, academic pain medicine lays the pain crisis at the feet of primary care physicians like me and Dr. Hurwitz.

During educational seminars they exhort us to get out there on the front lines and treat pain aggressively. They assure us that if we do so we will not be at risk. Most of us remain profoundly skeptical of these reassurances.

A military analogy serves to describe the relationship between academic pain medicine and primary care. In the war on pain academic physicians are the generals. Primary care physicians are the foot soldiers. Here's what happens.

First, the generals, give us order to charge. When we get halfway across the battlefield we look back and find the generals shooting at us, from behind our own lines. This behavior, on the part of the academic pain establishment is the immediate cause of the pain crisis.

The under treatment of chronic pain demands changes that will establish an environment in which physicians can treat their patients in a humane and ethical manner, in accordance with standards that arise from science.

I'll leave it to Ms. Reynolds and Mrs. Paey to expand on how the drug control standard impacts the physician-patient relationship. Mr. Stutsman will explain further how the misuse of medical standards menaces physicians in the courtroom.

[This Article in PDF print format]


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

Alexander DeLuca, M.D., MPH

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Originally posted: 2005-09-11

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