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Under-treatment of Pain

Hurwitz Prosecutor Caught Up in US Attorneys Controversy

good riddance, let us hope
We have not previously commented here about the US Attorneys firing controversy (or scandal, depending on how one looks at it) -- mostly because drug policy has not come up in it -- partly because we assume that both the people who got canned and the people replacing them are all all likely to be serious SOBs from our point of view. For example, it was one of the firees, San Diego's Carol Lam, who prosecuted medical marijuana provider Steve McWilliams, an act that ended in McWilliams' suicide. Readers who have followed the pain issue will doubtless be interested to know that the guy who prosecuted pain physician Dr. Hurwitz, Paul McNulty, and who was responsible for the infamous withdrawal by the DEA during that prosecution of the pain FAQ it had worked together on with doctors and other experts, is in serious hot water. McNulty was the US Attorney for eastern Virginia at the time, but was subsequently promoted to the #2 spot at DOJ. According to his official bio he played a key role in abolishing parole in Virginia in 1994. McNulty's name has come up on and off within the firings matter since early on, but until this evening it seemed like he might survive it and quite possibly become the next Attorney General. But things have shifted again in this fast-changing story. According to the Politico, in a story filed at 9:06 EST:
Republican sources also disclosed that it is now a virtual certainty that Deputy Attorney General Paul J. McNulty, whose incomplete and inaccurate congressional testimony about the prosecutors helped precipitate the crisis, will also resign shortly. Officials were debating whether Gonzales and McNulty should depart at the same time or whether McNulty should go a day or two after Gonzales.
Let's hope the reporting about McNulty at least is on target. Whatever the cause for his career's abrupt ending, it will be a good thing. McNulty's actions in the Hurwitz case caused incalculable damage to the cause of pain management with opioids for patients who need it -- effectively he caused large numbers of pain patients to be tortured through denial of medication or under-use of it. Having met Dr. Hurwitz a number of times, and counting a number of his former patients friends, I could be biased about that -- though his conviction has since been overturned due to the trial flaws that prosecutors and the judge created. But I think McNulty's instigation of the withdrawal of the FAQ demonstrates objectively that he is willing to attack the rule of law itself if it suits his purposes. No tears shed for this guy's career, none deserved -- good riddance to at least one really, really cruel, unethical and dishonest prosecutor.

Is the Bush Administration Getting Nervous About Afghan Opium Licensing Schemes?

When the European drug policy and defense think-tank the Senlis Council in late 2005 unveiled its proposal to deal with illicit Afghan opium by licensing growers and diverting production to the global legal medicinal market for opioid pain medications, just about nobody thought the idea had a chance of going anywhere. Since then, as opium production there has continued to increase—Afghanistan now accounts for 90% of the global illicit opium supply—and Taliban insurgents have gathered strength, the licensing scheme has picked up support from politicians in Canada, England, and Italy, but still remains a long-shot. This week, as I will report in the Chronicle on Friday, the licensing notion gained new support, as the British Medical Association is suggesting that Afghan opium be used to produce medicinal diamorphine (heroin) for use in the National Health Service. The licensing idea also made it to the op-ed pages of the Washington Post last week, when columnist Anne Applebaum wrote a piece, "Ending an Opium War; Poppies and Afghan Recovery Can Both Bloom, arguing that the US should do in Afghanistan now what it did so successfully in Turkey under President Nixon. Then, faced with an influx of Turkish heroin (the stuff of the infamous French Connection), the US worked with the Turkish government and farmers to regulate poppy production. Now, Turkey is the main supplier of medicinal narcotics to the US. The current US administration, however, is adamantly opposed to any such effort in Afghanistan. Instead, drug war extremists in Washington are pushing the Afghans to make stronger efforts to eradicate the poppy crop and are even trying to push herbicidal eradication down the throat of the Karzai government. That idea has little support in Afghanistan or even among our NATO allies. Both groups fear a sustained attack on the country's economic mainstay will lead to political upheaval and end up benefiting the Taliban, a not unreasonable worry. But it seems like the Bush administration is starting to worry that the licensing scheme is gaining too much ground. Or, at least, it has bestirred itself to attack the notion. In a letter from James O'Gara, the drug czars deputy for supply reduction in today's Washington Post, the administration tried to fight back:
The Wrong Plan for Afghanistan's Opium Anne Applebaum's proposal to foster legal Afghan opium ["Ending an Opium War; Poppies and Afghan Recovery Can Both Bloom," op-ed, Jan. 16] is based on a misdiagnosis of the problem. First, there is no licit demand for Afghanistan's enormous supply of opium, currently more than 90 percent of the world's illicit market and almost double the world's entire licit production requirement. The United Nations reports a current global oversupply of opium-based products from existing licit producers. Pouring vastly more legal opium into the world system would cause prices to plummet, making the illicit trade that much more attractive to farmers. Second, Afghanistan produces opium because some regions remain under attack and lack security, to say nothing of the controls that are a prerequisite for any legal trade in narcotics. In the absence of such institutional controls, the distinction between legal and illicit opium is meaningless. Afghanistan needs peace, a flourishing economy and the rule of law. Each of these conditions is undone by narcotics production. Nowhere in the world do narco-warlords willingly relinquish their stranglehold on poor opium farmers, and nowhere in the world do such farmers become rich. The opium trade must be broken, not fostered, before it undoes the rest of Afghanistan.
O'Gara first claims there is no global need for more opioid pain relievers, citing the International Narcotics Control Board. That claim is debatable. In its proposal, the Senlis Council begged to differ, citing serious undersupplies, especially in the underdeveloped world. Second, O'Gara suggests that opium is being grown in Afghanistan only because of a lack of security and an effective national state. But the US government's insistence on attacking the poppy crop is precisely what contributes greatly to continued insecurity and political conflict within the country. Does he really think an all-out assault on the poppies is going to bring peace and tranquility? Whether the idea of licensing Afghan opium production is a good idea is open for debate. It is certainly as reasonable a response to the problem as heavy-handed repression efforts, and is much less likely to incite peasant resistance and support for the Taliban. But what is really interesting about all this is the fact that the drug czar's office feels a need to attack supporters of the idea. That suggests the idea is getting enough traction to pose a threat to the drug war as usual. We'll be staying tuned to this debate.

Free Richard Paey!

Call Florida Governor Jeb Bush and urge him to pardon Richard Paey.

The number is 850-488-7146.

Paey just lost his appeal, which means he'll have to complete his 25-year sentence unless the Governor intervenes.

I just spoke with a nice lady at the Governor's office and informed her that Richard Paey is a paraplegic whose substantial need for pain medication resulted in a misguided conviction for drug dealing. I asked her to inform the Governor that I support the Florida Court of Appeals recommendation that he pardon Mr. Paey.

It only takes a minute and together we might be able to help make life a little more bearable for this most unfortunate man.

For a quick refresher on the case before you call, check out Maia Salavitz at The Huffington Post and Radley Balko's article in National Review Online.

Now put down your laptop and make the call. We'll still be here when you're done.

Thanks!

Reflections from a Dr. Hurwitz patient

I am sure many of you recognize the name of Dr. Wm. Hurwitz. Dr. Hurwitz was a nationally known very prominent pain management physician. He was known for his very aggressive pain treatment and had patients from almost every state in the country. These were the patients that nobody else would take, they were too complicated, needed doses that were too high for other doctors. I was one of these patients and Dr. H saved my life. He is the most caring and compassionate dr I have ever known. In his younger years he served with Doctors Without Borders in Brazil. He was known never to turn away people who couldn't pay.

What's up with these "pain contracts"?

Spurred by the federal government's crackdown on prescription drug abuse, doctors around the country are resorting to "pain contracts" with patients in an attempt to protect themselves from charges they are Dr. Feelgoods. Such contracts typically require the patient to agree that "lost, stolen, or misplaced" drugs are not to be replaced and that the patient agree to be drug tested. Patients who refuse to sign such an agreement or who test positive for non-prescribed drugs--i.e. marijuana--are likely to be cut off.

Making Sense of the DEA's New Proposed Policy Statement on Pain Prescribing

There are definitely mixed feelings in the pain medicine community when it comes to the DEA's new proposed policy statement on prescribing pain medications. While everyone is pleased that the agency has loosened up its prescribing rules—allowing doctors to write three one-month pain med prescriptions at a time—there is some dispute over whether the DEA's latest policy statement represents anything other than the agency doing business as usual.

Heroin Lifers, DEA Pain Guidance, California Lowest Priority Initiatives

Those are the feature stories I think I will be doing this week. It doesn't always happen that way, though. Some readers may recall that I was going to do the Louisiana heroin lifer story last week, but I didn't manage to get ahold of any of the people critical to the story. I'm back on it again this week. Similarly, something may break during the week. This typically happens on Thursday, the day we're supposed to be wrapping up the Chronicle.