Under-treatment of Pain

I have a friend who has a variety of acute medical problems including severe diabetes, hepatitis C and liver cancer. He is now in the final stage of life.

The Washington Post has a disturbing piece that ought to broaden recent discussion of the conflict between the drug war and legitimate medical treatments. The DEA is taking legal medicines away from elderly people who need them:

Heightened efforts by the Drug Enforcement Administration to crack down on narcotics abuse are producing a troubling side effect by denying some hospice and elderly patients needed pain medication, according to two Senate Democrats and a coalition of pharmacists and geriatric experts.
…
Terence McCormally, a doctor who cares for patients in nursing homes in Northern Virginia, said the tug of war reflects "the tension between the war on drugs and the war on pain."

"For the doctor and the nurse, it's a nuisance," he said, "but for the patient it is needless suffering."

Our efforts to control the lives of people who take drugs for fun have led us to destroy the lives of people who take drugs for serious medical conditions. The harsh reality here is that the best medicines often become popular with people they weren't intended for. That's going to happen no matter what you do. But if every effective pain reliever is overly restricted, then the medicine's primary purpose of relieving pain can never be achieved.

The drug war has gone blind even to the most basic functions that drugs are supposed to serve in our society. As efforts to prevent diversion and recreational use continue their inevitable failure, we face a very real threat that desperate drug war bureaucrats will legislate many of our best medicines out of existence.

The government's war against pain doctors hit a new low last spring, when federal prosecutor Tanya Treadway, busy prosecuting Kansans Steve and Linda Schneider, subpoenaed pain control advocate Siobhan Reynolds for information on the Pain Relief Network's (PRN) public advocacy in support of the Schneiders. Despite ACLU efforts to quash the subpoena as an attempt to shut down free speech, judge US District Judge Julie Robinson allowed it. Friday, according an update from Jacob Sullum on Reason, Robinson imposed a $200/day civil contempt fine on both Reynolds and PRN, to begin in 10 days if she does not comply with the subpoena. An appeal is planned -- stay tuned. Earlier in the week, Boston-based civil liberties attorney Harvey Silverglate criticized Treadway in a column in Forbes magazine. We reprint a few paragraphs, also via Sullum:

When Reynolds wrote op-eds in local newspapers and granted interviews to other media outlets, Assistant U.S. Attorney Tanya Treadway attempted to impose a gag order on her public advocacy. The district judge correctly denied this extraordinary request. Undeterred, Treadway filed on March 27 a subpoena demanding a broad range of documents and records, obviously hoping to deter the peripatetic pain relief advocate, or even target her for a criminal trial of her own. Just what was Reynolds' suspected criminal activity? "Obstruction of justice" is the subpoena's listed offense being investigated, but some of the requested records could, in no possible way, prove such a crime. The prosecutor has demanded copies of an ominous-sounding "movie," which, in reality, is a PRN-produced documentary showing the plight of pain physicians. Also requested were records relating to a billboard Reynolds paid to have erected over a busy Wichita highway. It read: "Dr. Schneider never killed anyone." Suddenly, a rather ordinary exercise in free speech and political activism became evidence of an obstruction of justice.

We haven't reported lately on the issue of under-treatment of pain, so this weekend day seemed like a good time to link to a couple of the sites whose people labor in trenches of the pain struggle every day. First, the war on pain doctors continues, with the latest major battle being that of Wichita-area Dr. Stephen Schneider and his wife Linda Schneider. The Schneiders were charged with the deaths of 56 patients by over-prescribing pain medications, but the judge has now limited the case to just four. My guess is that most of these patients passed due to the medical issues that led them to seek treatment, just as one would expect to happen in any medical practice that takes on seriously ill patients; and that a few might have needed the drugs for pain but misused them (as one would also expect to happen sometimes). I haven't examined the case closely enough for that to be more than a guess, but it's an educated guess, as that is usually what is going on in these pain doctor trials. Visit the Pain Relief Network news update page for info. How have things come to this? Big topic, but Dr. Alex DeLuca has a post last week on his "War on Doctors / Pain Crisis" blog, "The Distortion of Medicine and Confusion of Standards," that goes into some of it. A key part of the problem is that while modern pain management textbooks recommend "titration to effect" -- e.g. "gradually increasing the opioid dose until the pain is relieved or until untreatable side effects prevent further dosage increase" -- most doctors just don't do that. And so patients in ongoing, serious pain go without adequate treatment. This makes the typical standard of pain care below medical standards. But it also means that doctors who wrongly believe they shouldn't be relieving a patient's pain are available to testify in trials for the prosecution -- hence the Schneider trial and many others. Even when the defense brings in experts to testify as to what the expert view really is, it creates confusion that can lead to false convictions. This is in fact what happened in the famous William Hurwitz case. DeLuca goes into this in more detail in an interview filmed by the Competitive Enterprise Institute, linked to in his post, so check it out. Another physician victim of the pain wars, Dr. William Mangino, recently submitted a Reply Brief in the appeal of his case. He is imprisoned in Pennsylvania, and he wrote the brief himself. It paints a pretty terrible picture of the what the government is doing in these cases. Dr. Mangino sent us a copy, via one of his friends, and we've posted it here.

In July and September I wrote here about the plight of Bill Mangino, a Pennsylvania physician who was decent enough to treat patients with the pain medications (opiates) that they needed, and was punished for these good deeds with a prosecution and now imprisonment -- all over a crime that never happened and for which no evidence exists happened. Yesterday I heard from Dr. James Stacks, a Mangino supporter and board member of the Pain Relief Network, with the news that Dr. Mangino had asked we post correspondence he sent to a judge prior to a hearing today that he hopes will get him a new trial and freedom in the meantime. The briefs were put together by Mangino himself, written by hand, but has been scanned for our edification online as well. Interested parties can read some commentary on it by Alex DeLuca here, or go straight to the briefs online here or here. A cutting quote that Dr. Mangino used as his signature line in the documents:

Statutes must mean what they say... and say what they mean.

The Paey Pardon, as Scott blogged about here and here, was a nice piece of news, of the kind that doesn't come around too often. The last such pleasant surprise I had came in late 2000, when Kemba Smith and Dorothy Gaines were pardoned by then-President Clinton. I immediately left a message for my friend Rob Stewart, who had played a major role in bringing the Gaines case to prominence by writing it in the old Drug Policy Letter (Drug Policy Foundation, predecessor to Drug Policy Alliance), which led to coverage of her case by Frontline. Rob told me later he had two messages on his voicemail -- one from me and one from Dorothy Gaines. These moments are rewards for all the rest of it. Unfortunately, not many political leaders seem to be of the moral caliber of Gov. Crist, and there are many more victims of the drug laws who remain unpardoned. Two of them, whom I happen to know, were sentenced to prison a week ago. One of them was Bryan Epis, the first person prosecuted by the feds for medical marijuana. He received the same 10-year sentence. The other was William Mangino, a pain physician in Pennsylvania, sentenced to 8 1/2 - 20 years. Bryan was allowed to remain free pending appeal. See our upcoming Chronicle newsbrief for some detail. Bryan actually told me a few days before the court date that he anticipated getting another 10 years, but being allowed to stay free pending appeal, and he was right. He says he has a good chance on appeal, and it sounds like it -- the prosecution really acted unethically in his case, and the judge, who is by no means biased toward defendants, commented that there are issues the appellate court may want to look at. Dr. Mangino predicted a harsh sentence, and that he would not be allowed to stay free pending appeal. Unfortunately, he was right too. Christine Heberle's blog post on the War on Doctors/Pain Crisis blog lays out the glaring absence of any crime. Accountability for injustices committed under the guise of law may be too much to hope for. But at least we should have justice now. I simply don't feel that letting people like Richard Paey and Bryan Epis and Bill Mangino live their lives unmolested by the government is asking for too much.

As we celebrate Richard Paey's freedom today, it is important to remember that his tragic fate was no accident. Many people worked very hard at tax-payers' expense to put this innocent and miserable man behind bars. They deserve recognition today as well.

Certainly, these events vividly depict the insanity of a war on drugs that targets seriously ill people for trying to treat their own pain:

State prosecutors concede there's no evidence Paey ever sold or gave his medication away. Nevertheless, under draconian drug-war statutes, these prosecutors could pursue distribution charges against him based solely on the amount of medication he possessed (the unauthorized possession of as few as 60 tablets of some pain medications can qualify a person as a "drug trafficker"). [National Review]

Yet, as Radley Balko revealed at National Review, the persecution of Richard Paey involved so much more than the reckless enforcement of short-sighted laws. This was a prolonged and deliberate campaign on the part of malicious prosecutors and vengeful prison officials.

*Prosecutors blamed Paey's harsh sentence on Paey himself, claiming that he should have accepted a plea bargain. As Balko explains, they essentially retaliated against him for asserting his factual innocence and insisting on his right to a jury trial.

*Prison officials transferred Paey further away from his family after he gave a New York Times interview that was critical of the State of Florida.

*Prison medical staff threatened to withhold Paey's medication, also in apparent retaliation for his interview with the New York Times. Since he could die without it, this was the functional equivalent of a death threat and caused him great distress.

Now that Florida's Governor and Cabinet have concluded that Paey did nothing wrong, it is time to examine the way he was treated throughout this great travesty. If there are sociopaths working in Florida's criminal justice system, that's something Governor Crist would want to know about. If we can afford to imprison people for decades in order to protect ourselves from drugs, surely we can also afford to evaluate public servants who wield extraordinary power in order to ensure that they aren't deeply disturbed.

Mentally healthy people do not persecute the seriously ill, even if the drug war says it's ok.

The plight of Richard Paey has been shocking even by the drug war's rock bottom standards. Sentenced to 25 years in a Florida prison for possession of the pain medication he used to treat his own crippling back pain, Paey spent the last 3½ years behind bars.

Today, he is free:

Gov. Charlie Crist and the Florida Cabinet voted unanimously to grant Paey a full pardon Thursday morning for his 2004 conviction on drug trafficking and possession charges.

"We aim to right a wrong and exercise compassion and to do it with grace," the governor said. "Congratulations … and I state he should be released today."

With that, Paey's wife Linda, their three children, a family friend and attorney John Flannery II hugged and cried at the podium, the entire cabinet meeting room erupting into applause at 9:40 a.m. [St. Petersburg Times]

Justice in the war on drugs is a rare spectacle, and it is just delightful to witness. We've reported endlessly on this case, as have so many others, and it is wonderful to find that these efforts have not been in vain.

Pain Relief Network's Siobhan Reynolds and son are slated to appear on The Morning Show with Mike and Juliet --- tomorrow morning, I think, Tuesday -- a Fox network talk program that airs at 9:00am in the New York area and on various Fox stations around the country. Dr. William Mangino is out on bail and able to work on his own appeal as was hoped. Richard Paey's clemency petition has been granted expedited consideration by Gov. Crist and the Florida Board of Clemency. Visit Alex DeLuca/PRN's War on Doctors / Pain Crisis blog for info. (See our pain archive here. Subscribe to our pain feed via RSS here.