June 22, 2000
The Food and Drug Administration (FDA) today announced its final ruleestablishing current good manufacturing practices (cGMPs) for dietarysupplements.In the Dietary Supplement Health and Education Act of 1994 (DSHEA),Congressgave the Secretary of Health and Human Services and, by delegation, FDAauthority to issue regulations establishing cGMPs for dietarysupplements. The GMPs will require that dietary supplements are produced in a qualitymanner,are not adulterated with contaminants or impurities, and are accuratelylabeledto reflect the ingredients in the product. The cGMPs apply to alldomestic andforeign companies that manufacture, package, or hold dietary supplementsintended for sale in U.S. commerce, including those involved with theactivitiesof testing, quality control, packaging, labeling, and distributing.In a companion document, FDA is also announcing today an interim finalrule(IFR) that outlines a petition process for manufacturers to request anexemptionto the cGMP requirement for 100 percent identity testing of specificdietaryingredients. If the manufacturer can provide sufficient documentationthat thesupplier maintains appropriate in-process manufacturing controls and hasconsistently produced the dietary ingredient over a period of time, themanufacturer may be exempted from the testing requirement. FDA issolicitingcomment from the public on the IFR. There will be a 90-day commentperiod.Written comments may be submitted to the Dockets Management Branch(HFA-305),Food and Drug Administration, 5630 Fishers Lane, Room 1061, Rockville,MD 20852or on line at:http://www.fda.gov/dockets/ecommentsAdditional information regarding the cGMPs is available through theCFSANwebsite athttp://www.cfsan.fda.gov/~dms/supplmnt.html.NOTE:* TO GET PAST ISSUES OF FDA-DSFL, go to Electronic InformationNetworks:http://www.cfsan.fda.gov/~dms/infonet.html.********************************FDA Web Page Addresses:* Dietary Supplements http://www.cfsan.fda.gov/~dms/supplmnt.html* Food Labeling and Nutrition http://www.cfsan.fda.gov/label.html* Infant Formula http://www.cfsan.fda.gov/~dms/inf-toc.html* Qualified Health Claims http://www.cfsan.fda.gov/~dms/lab-qhc.html* Center for Food Safety and Applied Nutrition http://www.cfsan.fda.gov/list.htmlOther Federal Government Links:* Federal Trade Commission http://www.ftc.gov/* Office of Dietary Supplements, NIH http://dietary-supplements.info.nih.gov/* US Department of Agriculture - Food Safety and Inspection Service http://www.fsis.usda.gov/ - Food and Nutrition Service http://www.fns.usda.gov/fns/Non-Federal Government Links:* National Academy of Sciences http://www.iom.edu/CMS/3788.aspx
Wednesday
Sunday
Psychedelic Medicine (Book review)
---http://www.greenwood.com/catalog/C9023.aspxPsychedelic Medicine (two volumes)List Price: $200.00To order, visit http://www.greenwood.com/, call 1-800-225-5800Description:Psychedelic substances present in nature have been used by humans acrosshundreds of years to produce mind-altering changes in thought, mood, andperception--changes we do not experience otherwise except rarely indreams, religious exaltation, or psychosis. U.S. scientists werestudying the practical and therapeutic uses for hallucinogens, includingLSD and mescaline, in the 1950s and 1960s supplied by largemanufacturers including Sandoz.But the government took steps to ban all human consumption ofhallucinogens, and thus the research. By the 1970s, all human testingwas stopped. Medical concerns were not the issue, the ban was motivatedby social concerns, not the least of which were created by legendaryresearcher Timothy Leary, a psychologist who advocated free use ofhallucinogens by all who desired.Nationwide, however, a cadre of scholars and researchers has persistedin pushing the federal government to again allow human testing. And themoratorium has been lifted. The FDA has begun approving hallucinogenicresearch using human subjects. In these groundbreaking volumes, topresearchers explain the testing and research underway to use - under theguidance of a trained provider - psychedelic substances for betterphysical and mental health.Experts including physicians and psychiatrists at some of the mostrespected medical schools in the nation, show how psychedelics mayalleviate symptoms or spur cures for disorders from AIDS to arthritis topost traumatic stress disorder. Spiritual uses are also addressed andthe perceived benefits described. Medical and legal issues fortherapeutic uses are also presented. The psychedelic drugs explained inthese pages for potential health use include: LSD, Ayahuasca,Psyilocybin, Peyote, MDMA, Marijauana.---------Volume I: Psychedelic Medicine: Social, Clinical and Legal PerspectivesThomas B. RobertsEditor's Overview of Psychedelic Medicines Volume 1.Michael WinkelmanSection I: The Social and Clinical ContextChapter 1: Therapeutic Bases of Psychedelic Medicines: PsychointegrativeEffects. Michael WinkelmanChapter 2: The Healing Vine: Ayahuasca as Medicine in the 21st Century.Dennis McKennaChapter 3: Contemporary Psychedelic Therapy: An Overview. Torsten PassieChapter 4: Therapeutic Guidelines: Dangers and Contra-Indications inTherapeutic Applications of Hallucinogens. Ede FrecskaSection II: Medical ApplicationsChapter 5: Response of Cluster Headaches to Psilocybin and LSD. AndrewSewell & John H. HalpernChapter 6: Psilocybin Treatment of Obsessive- Compulsive Disorder. F. A.Moreno & P. L. DelgadoChapter 7: Therapeutic Uses of MDMA. George Greer & Requa TolbertChapter 8: MDMA-Assisted Psychotherapy for the Treatment ofPosttraumatic Stress Disorder. Michael MithoeferChapter 9: Psychedelic Drugs for the Treatment of Depression. MichaelMontagneChapter 10: Marijuana and AIDS. Donald AbramsChapter 11: The Use of Psilocybin in Patients with Advanced Cancer andExistential Anxiety. C. GrobSection III: Legal Aspects of the Medical UseChapter 12: Psychedelic Medicine and the Law. Richard BoireChapter 13: The Legal Bases for Religious Peyote Use. Kevin FeeneyChapter 14: The Supreme Court's Psychedelic Case. Alberto Groisman &Marlene de RiosChapter 15: Conclusions. Michael Winkelman & Thomas B. Roberts-------Volume II: Psychedelic Medicine: Addictions Medicine and TranspersonalHealingPreface- Lancet EditorialChapter 1: Introduction ? The Adventure Continues. Thomas B. RobertsSection I: Treating Substance AbuseChapter 2: Hallucinogens in the Treatment of Alcoholism and OtherAddictions. J. H. HalpernChapter 3: Addiction, Despair, and the Soul: Psychedelic Psychotherapy.R. Yensen & D. DryerChapter 4: The Therapeutic Use of Peyote in the Native American Church.Joseph CalabreseChapter 5: Ibogaine and Substance Abuse Rehabilitation. Kenneth R.Alper & Howard LotsofChapter 6: Ketamine Psychedelic Psychotherapy. Evgeny Krupitsky & EliKolpChapter 7: Ayahuasca Treatment of Cocaine-Paste Addiction. JacquesMabitSection II: Guidelines for Psychotherapeutic ApplicationsChapter 8: The Ten Lessons of Psychedelic Psychotherapy? Rediscovered.Neal M. GoldsmithChapter 9: Therapeutic Guidelines from Shamanic Traditions. MichaelWinkelmanChapter 10: Common Processes in Psychospiritual Change. Sean HouseChapter 11: Preliminary Remarks on Interpreting Resistance toPsychedelic Insights. Dan MerkurSection III: Transpersonal Dimension of Healing with PsychedelicMedicinesChapter 12: Psychedelics in Psychological Health and Growth. RogerWalsh & Charles GrobChapter 13: Psilocybin Can Occasion Mystical-type Experiences HavingSubstantial and Sustained Personal Meaning and Spiritual Significance.R. Griffiths, W. Richards, U. McCann & R. Jesse.Chapter 14: Remarkable Healing During Psychedelic Psychotherapy.Stanislav GrofChapter 15: Transpersonal Healing with Hallucinogens. Roger Marsden &David LukoffChapter 16: Conclusions and Future Recommendations: The Wider Contexts.Thomas B. RobertsAuthor biographiesIndex---------Endorsement From Harriet de Wit, PhDProfessor, Department of PsychiatryThe University of Chicago:These books are a comprehensive and scholarly review of the currentstatus of the therapeutic potential of hallucinogens. The contributorsrepresent an outstanding group of scientists, scholars and clinicians,most of whom have had direct experience using and administering thesedrugs in either therapeutic or religious contexts. The result is animpressive collection. The authors provide scholarly historical reviewsof the use of these drugs, as well as detailed instructions and advicefor the clinician on how to administer these drugs safely andeffectively in a therapeutic context. The authors provide a balancedview and acknowledge the many risks and pitfalls of improper use ofthese drugs. Likely to be of interest to scientists, clergy, mentalhealth professionals, and anyone interested in the mind. It provides anup to date review of the status of hallucinogens in modern medicine, aswell as a historical review of their status in the past. It is highlyrecommended.Endorsement From Professor Jonathan D. Moreno,University of Pennsylvania Center for Bioethics:Until they were caught up in the cultural revolution of the 1960s,hallucinogens were being seriously examined by top researchers for theirpotential to alleviate many human ills. The contributors to thesevolumes make a persuasive case that science should now do more to pursuethese questions.Endorsement From Stephen Ross, M.D.Assistant Clinical Professor, Psychiatry, NYU School of MedicineDirector, Division of Alcoholism and Drug Abuse, Bellevue HospitalAssociate Director, Addiction Psychiatry Fellowship, NYU School ofMedicine:Roberts and Winkelman have assembled one of the most impressive andcomprehensive collections of writings in the field of psychedelicmedicine. The chapters, written by first-rate academic scholars, arerigorous and clear. The topics range from neuroscience to the legal,spiritual, medicinal, and ethical implications of using this novel classof agents. This work is an invaluable resource for educators,clinicians, and policy makers who are interested in rejuvenating thefield of psychedelic research.Endorsement From Nicholas V. Cozzi, Ph.D.Department of PharmacologyUniversity of Wisconsin School of Medicine and Public Health:These volumes present fresh ideas for using psychedelic drugs astherapeutic agents to treat some of the most intractable ofpsychological ailments. As the authors make clear, the ability of thesesubstances to facilitate direct experiential access to our deepestthoughts, feelings, and spirituality makes them uniquely suited for thispurpose. Undoubtedly, their amazing healing potential has yet to befully realized. Thanks to these forward-thinking educators, researchers,and clinicians, we now have new paths to explore in the cure for olddiseases.
NYT: Pain doc as pusher?
NYT: Pain doc as pusher?
http://www.nytimes.com/2007/06/17/magazine/17pain-t.html
June 17, 2007
Cover Story: When Is a Pain Doctor a Drug Pusher?
By TINA ROSENBERG Correction Appended
Ronald McIver is a prisoner in a medium-security federal compound in Butner, N.C. He is 63 years old, of medium height and overweight, with a white Santa Claus beard, white hair and a calm, direct and intelligent manner. He is serving 30 years for drug trafficking, and so will likely live there the rest of his life. McIver (pronounced mi-KEE-ver) has not been convicted of drug trafficking in the classic sense. He is a doctor who for years treated patients suffering from chronic pain. At the Pain Therapy Center, his small storefront office not far from Main Street in Greenwood, S.C., he cracked backs, gave trigger-point injections and put patients through physical therapy. He administered ultrasound and gravity-inversion therapy and devised exercise regimens. And he wrote prescriptions for high doses of opioid drugs like OxyContin.
McIver was a particularly aggressive pain doctor. Pain can be measured only by how patients say they feel: on a scale from 0 to 10, a report of 0 signifies the absence of pain; 10 is unbearable pain. Many pain doctors will try to reduce a patient\'s pain to the level of 5. McIver tried for a 2. He prescribed more, and sooner, than most doctors.\u003cbr /\>\u003cbr /\>Some of his patients sold their pills. Some abused them. One man, Larry Shealy, died with high doses of opioids that McIver had prescribed him in his bloodstream. In April 2005, McIver was convicted in federal court of one count of conspiracy to distribute controlled substances and eight counts of distribution. (He was also acquitted of six counts of distribution.) The jury also found that Shealy was killed by the drugs McIver prescribed. McIver is serving concurrent sentences of 20 years for distribution and 30 years for dispensing drugs that resulted in Shealy\'s death. His appeals to the U.S. Court of Appeals for the Fourth Circuit and the Supreme Court were rejected.\u003cbr /\>\u003cbr /\>McIver\'s case is not simply the story of a narcotics conviction. It has enormous relevance to the lives of the one in five adult Americans who, according to a 2005 survey by Stanford University Medical Center, ABC News and USA Today, reported they suffered from chronic pain - pain lasting for several months or longer. According to a 2003 study in The Journal of the American Medical Association, pain costs American workers more than $61 billion a year in lost productive time - and that doesn\'t include medical bills.\u003cbr /\>\u003cbr /\>Contrary to the old saw, pain kills. A body in pain produces high levels of hormones that cause stress to the heart and lungs. Pain can cause blood pressure to spike, leading to heart attacks and strokes. Pain can also consume so much of the body\'s energy that the immune system degrades. Severe chronic pain sometimes leads to suicide. There are, of course, many ways to treat pain: some pain sufferers respond well to surgery, physical therapy, ultrasound, acupuncture, trigger-point injections, meditation or over-the-counter painkillers like Advil (ibuprofen) or Tylenol (acetaminophen). But for many people in severe chronic pain, an opioid (an opiumlike compound) like OxyContin, Dilaudid, Vicodin, Percocet, oxycodone, methadone or morphine is the only thing that allows them to get out of bed. Yet most doctors prescribe opioids conservatively, and many patients and their families are just as cautious as their doctors. Men, especially, will simply tough it out, reasoning that pain is better than addiction.\u003cbr /\>",1]
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McIver was a particularly aggressive pain doctor. Pain can be measured only by how patients say they feel: on a scale from 0 to 10, a report of 0 signifies the absence of pain; 10 is unbearable pain. Many pain doctors will try to reduce a patient's pain to the level of 5. McIver tried for a 2. He prescribed more, and sooner, than most doctors.Some of his patients sold their pills. Some abused them. One man, Larry Shealy, died with high doses of opioids that McIver had prescribed him in his bloodstream. In April 2005, McIver was convicted in federal court of one count of conspiracy to distribute controlled substances and eight counts of distribution. (He was also acquitted of six counts of distribution.) The jury also found that Shealy was killed by the drugs McIver prescribed. McIver is serving concurrent sentences of 20 years for distribution and 30 years for dispensing drugs that resulted in Shealy's death. His appeals to the U.S. Court of Appeals for the Fourth Circuit and the Supreme Court were rejected.McIver's case is not simply the story of a narcotics conviction. It has enormous relevance to the lives of the one in five adult Americans who, according to a 2005 survey by Stanford University Medical Center, ABC News and USA Today, reported they suffered from chronic pain - pain lasting for several months or longer. According to a 2003 study in The Journal of the American Medical Association, pain costs American workers more than $61 billion a year in lost productive time - and that doesn't include medical bills.Contrary to the old saw, pain kills. A body in pain produces high levels of hormones that cause stress to the heart and lungs. Pain can cause blood pressure to spike, leading to heart attacks and strokes. Pain can also consume so much of the body's energy that the immune system degrades. Severe chronic pain sometimes leads to suicide. There are, of course, many ways to treat pain: some pain sufferers respond well to surgery, physical therapy, ultrasound, acupuncture, trigger-point injections, meditation or over-the-counter painkillers like Advil (ibuprofen) or Tylenol (acetaminophen). But for many people in severe chronic pain, an opioid (an opiumlike compound) like OxyContin, Dilaudid, Vicodin, Percocet, oxycodone, methadone or morphine is the only thing that allows them to get out of bed. Yet most doctors prescribe opioids conservatively, and many patients and their families are just as cautious as their doctors. Men, especially, will simply tough it out, reasoning that pain is better than addiction.
Video\u003cbr /\>More Video »\u003cbr /\>It\'s a false choice. Virtually everyone who takes opioids will become physically dependent on them, which means that withdrawal symptoms like nausea and sweats can occur if usage ends abruptly. But tapering off gradually allows most people to avoid those symptoms, and physical dependence is not the same thing as addiction. Addiction - which is defined by cravings, loss of control and a psychological compulsion to take a drug even when it is harmful - occurs in patients with a predisposition (biological or otherwise) to become addicted. At the very least, these include just below 10 percent of Americans, the number estimated by the United States Department of Health and Human Services to have active substance-abuse problems. Even a predisposition to addiction, however, doesn\'t mean a patient will become addicted to opioids. Vast numbers do not. Pain patients without prior abuse problems most likely run little risk. "Someone who has never abused alcohol or other drugs would be extremely unlikely to become addicted to opioid pain medicines, particularly if he or she is older," says Russell K. Portenoy, chairman of pain medicine and palliative care at Beth Israel Medical Center in New York and a leading authority on the treatment of pain.\u003cbr /\>\u003cbr /\>The other popular misconception is that a high dose of opioids is always a dangerous dose. Even many doctors assume it; but they are nonetheless incorrect. It is true that high doses can cause respiratory failure in people who are not already taking the drugs. But that same high dose will not cause respiratory failure in someone whose drug levels have been increased gradually over time, a process called titration. For individuals who are properly titrated and monitored, there is no ceiling on opioid dosage. In this sense, high-dose prescription opioids can be safer than taking high doses of aspirin, Tylenol or Advil, which cause organ damage in high doses, regardless of how those doses are administered. (Every year, an estimated 5,000 to 6,000 Americans die from gastrointestinal bleeding associated with drugs like ibuprofen or aspirin, according to a paper published in The American Journal of Gastroenterology.)\u003cbr /\>",1]
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VideoMore Video »It's a false choice. Virtually everyone who takes opioids will become physically dependent on them, which means that withdrawal symptoms like nausea and sweats can occur if usage ends abruptly. But tapering off gradually allows most people to avoid those symptoms, and physical dependence is not the same thing as addiction. Addiction - which is defined by cravings, loss of control and a psychological compulsion to take a drug even when it is harmful - occurs in patients with a predisposition (biological or otherwise) to become addicted. At the very least, these include just below 10 percent of Americans, the number estimated by the United States Department of Health and Human Services to have active substance-abuse problems. Even a predisposition to addiction, however, doesn't mean a patient will become addicted to opioids. Vast numbers do not. Pain patients without prior abuse problems most likely run little risk. "Someone who has never abused alcohol or other drugs would be extremely unlikely to become addicted to opioid pain medicines, particularly if he or she is older," says Russell K. Portenoy, chairman of pain medicine and palliative care at Beth Israel Medical Center in New York and a leading authority on the treatment of pain.The other popular misconception is that a high dose of opioids is always a dangerous dose. Even many doctors assume it; but they are nonetheless incorrect. It is true that high doses can cause respiratory failure in people who are not already taking the drugs. But that same high dose will not cause respiratory failure in someone whose drug levels have been increased gradually over time, a process called titration. For individuals who are properly titrated and monitored, there is no ceiling on opioid dosage. In this sense, high-dose prescription opioids can be safer than taking high doses of aspirin, Tylenol or Advil, which cause organ damage in high doses, regardless of how those doses are administered. (Every year, an estimated 5,000 to 6,000 Americans die from gastrointestinal bleeding associated with drugs like ibuprofen or aspirin, according to a paper published in The American Journal of Gastroenterology.)
Still, doctors who put patients on long-term high-dose opioids must be very careful. They must monitor the patients often to ensure that the drugs are being used correctly and that side effects like constipation and mental cloudiness are not too severe. Doctors should also not automatically assume that if small doses aren\'t working, that high doses will - opioids don\'t help everyone. And research indicates that in some cases, high doses of opioids can lose their effectiveness and that some patients are better off if they take drug "holidays" or alternate between different medicines. Pain doctors also concede that more studies are needed to determine the safety of long-term opioid use.\u003cbr /\>\u003cbr /\>But with careful treatment, many patients whose opioid levels are increased gradually can function well on high doses for years. "Dose alone says nothing about proper medical practice," Portenoy says. "Very few patients require doses that exceed even 200 milligrams of OxyContin on a daily basis. Having said this, pain specialists are very familiar with a subpopulation of patients who require higher doses to gain effect. I myself have several patients who take more than 1,000 milligrams of OxyContin or its equivalent every day. One is a high-functioning executive who is pain-free most of the time, and the others have a level of pain control that allows a reasonable quality of life."\u003cbr /\>\u003cbr /\>All modern pain-management textbooks advocate "titration to effect" - in other words, in cases where opioids are helping, gradually increasing the dosage until either the pain is acceptably controlled or the side effects begin to outweigh the pain-relief benefits. But the vast majority of doctors don\'t practice what the textbooks counsel. In part, this is because of the stigma associated with high-dose opioids, the fear that patients will become addicted and the fact that careful monitoring is very time-consuming. And most doctors have received virtually no training in medical school about managing pain: many hold the same misconceptions about addiction and dosage as the general public.\u003cbr /\>",1]
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Still, doctors who put patients on long-term high-dose opioids must be very careful. They must monitor the patients often to ensure that the drugs are being used correctly and that side effects like constipation and mental cloudiness are not too severe. Doctors should also not automatically assume that if small doses aren't working, that high doses will - opioids don't help everyone. And research indicates that in some cases, high doses of opioids can lose their effectiveness and that some patients are better off if they take drug "holidays" or alternate between different medicines. Pain doctors also concede that more studies are needed to determine the safety of long-term opioid use.But with careful treatment, many patients whose opioid levels are increased gradually can function well on high doses for years. "Dose alone says nothing about proper medical practice," Portenoy says. "Very few patients require doses that exceed even 200 milligrams of OxyContin on a daily basis. Having said this, pain specialists are very familiar with a subpopulation of patients who require higher doses to gain effect. I myself have several patients who take more than 1,000 milligrams of OxyContin or its equivalent every day. One is a high-functioning executive who is pain-free most of the time, and the others have a level of pain control that allows a reasonable quality of life."All modern pain-management textbooks advocate "titration to effect" - in other words, in cases where opioids are helping, gradually increasing the dosage until either the pain is acceptably controlled or the side effects begin to outweigh the pain-relief benefits. But the vast majority of doctors don't practice what the textbooks counsel. In part, this is because of the stigma associated with high-dose opioids, the fear that patients will become addicted and the fact that careful monitoring is very time-consuming. And most doctors have received virtually no training in medical school about managing pain: many hold the same misconceptions about addiction and dosage as the general public.
And even pain specialists can be conservative. Sean E. Greenwood died in August at age 50 of a cerebral hemorrhage that his wife, Siobhan Reynolds, attributes to untreated pain. Greenwood was seeing various pain specialists. What makes his undertreatment especially remarkable is that he and his wife founded the Pain Relief Network, an advocacy group that has been the most vocal opponent of prosecutions of doctors and financed part of the legal defense of many pain doctors. "Here I am - I know everyone, and even I couldn\'t get him care that didn\'t first regard him as a potential criminal," Reynolds said.\u003cbr /\>\u003cbr /\>According to the pharmaceutical research company IMS Health, prescriptions for opioids have risen over the past few years. They are used now more than ever before. Yet study after study has concluded that pain is still radically undertreated. The Stanford University Medical Center survey found that only 50 percent of chronic-pain sufferers who had spoken to a doctor about their pain got sufficient relief. According to the American Pain Society, an advocacy group, fewer than half of cancer patients in pain get adequate pain relief.\u003cbr /\>\u003cbr /\>Several states are now preparing new opioid-dosing guidelines that may inadvertently worsen undertreatment. This year, the state of Washington advised nonspecialist doctors that daily opioid doses should not exceed the equivalent of 120 milligrams of oral morphine daily - for oxycodone or OxyContin, that\'s just 80 milligrams per day - without the patient\'s also consulting a pain specialist. Along with the guidelines, officials published a statewide directory of such specialists. It contains 12 names. "There are just not enough pain specialists," says Scott M. Fishman, chief of pain medicine at the University of California at Davis and a past president of the American Academy of Pain Medicine. And the guidelines may keep nonspecialists from prescribing higher doses. "Many doctors will assume that if the state of Washington suggests this level of care, then it is unacceptable to proceed otherwise," Fishman says.\u003cbr /\>",1]
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And even pain specialists can be conservative. Sean E. Greenwood died in August at age 50 of a cerebral hemorrhage that his wife, Siobhan Reynolds, attributes to untreated pain. Greenwood was seeing various pain specialists. What makes his undertreatment especially remarkable is that he and his wife founded the Pain Relief Network, an advocacy group that has been the most vocal opponent of prosecutions of doctors and financed part of the legal defense of many pain doctors. "Here I am - I know everyone, and even I couldn't get him care that didn't first regard him as a potential criminal," Reynolds said.According to the pharmaceutical research company IMS Health, prescriptions for opioids have risen over the past few years. They are used now more than ever before. Yet study after study has concluded that pain is still radically undertreated. The Stanford University Medical Center survey found that only 50 percent of chronic-pain sufferers who had spoken to a doctor about their pain got sufficient relief. According to the American Pain Society, an advocacy group, fewer than half of cancer patients in pain get adequate pain relief.Several states are now preparing new opioid-dosing guidelines that may inadvertently worsen undertreatment. This year, the state of Washington advised nonspecialist doctors that daily opioid doses should not exceed the equivalent of 120 milligrams of oral morphine daily - for oxycodone or OxyContin, that's just 80 milligrams per day - without the patient's also consulting a pain specialist. Along with the guidelines, officials published a statewide directory of such specialists. It contains 12 names. "There are just not enough pain specialists," says Scott M. Fishman, chief of pain medicine at the University of California at Davis and a past president of the American Academy of Pain Medicine. And the guidelines may keep nonspecialists from prescribing higher doses. "Many doctors will assume that if the state of Washington suggests this level of care, then it is unacceptable to proceed otherwise," Fishman says.
In addition to medical considerations real or imagined, there is another deterrent to opioid use: fear. According to the D.E.A., 71 doctors were arrested last year for crimes related to "diversion" - the leakage of prescription medicine into illegal drug markets. The D.E.A. also opened 735 investigations of doctors, and an investigation alone can be enough to put a doctor out of business, as doctors can lose their licenses and practices and have their homes, offices and cars seized even if no federal criminal charges are ever filed. Both figures - arrests and investigations - have risen steadily over the last few years.\u003cbr /\>\u003cbr /\>Opioid drugs have been used to treat pain for decades, mostly for acute postsurgical pain or the pain of cancer patients. But in January 1996, Purdue Pharma helped increase the use of these drugs by introducing OxyContin - oxycodone with a time-release mechanism. Oncologists and pain doctors were the principal prescribers of opioids. But Purdue introduced the drug with an aggressive marketing campaign promoting OxyContin to general practitioners and the idea of opioid pain relief to doctors and consumers. The product\'s time-release mechanism, Purdue claimed, allowed steadier pain relief and deterred abuse.\u003cbr /\>\u003cbr /\>Many pain sufferers found that OxyContin gave them better relief than they ever had before. But Purdue misrepresented the drug\'s potential for abuse. Last month, the company and three of its executives pleaded guilty to federal charges that they misled doctors and patients. The company agreed to pay $600 million in fines; and the executives, a total of $34.5 million. The pill\'s time-release mechanism turned out to be easily circumvented by crushing the pill and snorting or injecting the resulting powder. By the late 1990s, OxyContin abuse was devastating small towns throughout Appalachia and rural New England. Pharmaceuticals, mainly opioids, are still widely abused - now more so than any illegal drug except marijuana. In 2005, according to the government\'s National Survey on Drug Use and Health, 6.4 million Americans, many of them teenagers, had abused pharmaceuticals recently. Most got the drug from friends or family - often, in the case of teenagers, from their parents\' medicine cabinets.\u003cbr /\>",1]
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In addition to medical considerations real or imagined, there is another deterrent to opioid use: fear. According to the D.E.A., 71 doctors were arrested last year for crimes related to "diversion" - the leakage of prescription medicine into illegal drug markets. The D.E.A. also opened 735 investigations of doctors, and an investigation alone can be enough to put a doctor out of business, as doctors can lose their licenses and practices and have their homes, offices and cars seized even if no federal criminal charges are ever filed. Both figures - arrests and investigations - have risen steadily over the last few years.Opioid drugs have been used to treat pain for decades, mostly for acute postsurgical pain or the pain of cancer patients. But in January 1996, Purdue Pharma helped increase the use of these drugs by introducing OxyContin - oxycodone with a time-release mechanism. Oncologists and pain doctors were the principal prescribers of opioids. But Purdue introduced the drug with an aggressive marketing campaign promoting OxyContin to general practitioners and the idea of opioid pain relief to doctors and consumers. The product's time-release mechanism, Purdue claimed, allowed steadier pain relief and deterred abuse.Many pain sufferers found that OxyContin gave them better relief than they ever had before. But Purdue misrepresented the drug's potential for abuse. Last month, the company and three of its executives pleaded guilty to federal charges that they misled doctors and patients. The company agreed to pay $600 million in fines; and the executives, a total of $34.5 million. The pill's time-release mechanism turned out to be easily circumvented by crushing the pill and snorting or injecting the resulting powder. By the late 1990s, OxyContin abuse was devastating small towns throughout Appalachia and rural New England. Pharmaceuticals, mainly opioids, are still widely abused - now more so than any illegal drug except marijuana. In 2005, according to the government's National Survey on Drug Use and Health, 6.4 million Americans, many of them teenagers, had abused pharmaceuticals recently. Most got the drug from friends or family - often, in the case of teenagers, from their parents' medicine cabinets.
At the time the OxyContin epidemic emerged, the D.E.A. had far more experience seizing illegal drugs like cocaine and heroin. According to Mark Caverly, the head of the liaison and policy section for the D.E.A.\'s Office of Diversion Control, the OxyContin epidemic, however, required the agency to step up its antidiversion efforts. In 2001 the D.E.A. established the OxyContin Action Plan. The D.E.A. dispatched investigators to the most troubled states and trained local law-enforcement officials.\u003cbr /\>\u003cbr /\>The basis of the physician-patient relationship is trust. Trust is especially valued by pain patients, who often have long experience of being treated like criminals or hysterics. But when prescribing opioids, a physician\'s trust is easily abused. Pain doctors dispense drugs with a high street value that are attractive to addicts. All pain doctors encounter scammers; some doctors estimate that as many as 20 percent of their patients are selling their medicine or are addicted to opioids or other drugs. Experts are virtually unanimous in agreeing that even addicts who are suffering pain can be successfully treated with opioids. Indeed, opioids can be lifesaving for addicts - witness the methadone maintenance therapy given to heroin addicts. But treating addicts requires extra care.\u003cbr /\>\u003cbr /\>Identifying the scammers is especially tricky because there is no objective test for pain - it doesn\'t show up on an X-ray. In one British study, half the respondents who complained of lower-back pain had normal M.R.I.\'s. Conversely, a third of those with no pain showed disk degeneration on their M.R.I.\'s. The study suggested there could be a profound disconnection between what an M.R.I. sees and what a patient feels.\u003cbr /\>\u003cbr /\>There are red flags that indicate possible abuse or diversion: patients who drive long distances to see the doctor, or ask for specific drugs by name, or claim to need more and more of them. But people with real pain also occasionally do these things. The doctor\'s dilemma is how to stop the diverters without condemning other patients to suffer unnecessarily, since a drug diverter and a legitimate patient can look very much alike. The dishonest prescriber and the honest one can also look alike. Society has a parallel dilemma: how to stop drug-dealing doctors without discouraging real ones and worsening America\'s undertreatment of pain.\u003cbr /\>",1]
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At the time the OxyContin epidemic emerged, the D.E.A. had far more experience seizing illegal drugs like cocaine and heroin. According to Mark Caverly, the head of the liaison and policy section for the D.E.A.'s Office of Diversion Control, the OxyContin epidemic, however, required the agency to step up its antidiversion efforts. In 2001 the D.E.A. established the OxyContin Action Plan. The D.E.A. dispatched investigators to the most troubled states and trained local law-enforcement officials.The basis of the physician-patient relationship is trust. Trust is especially valued by pain patients, who often have long experience of being treated like criminals or hysterics. But when prescribing opioids, a physician's trust is easily abused. Pain doctors dispense drugs with a high street value that are attractive to addicts. All pain doctors encounter scammers; some doctors estimate that as many as 20 percent of their patients are selling their medicine or are addicted to opioids or other drugs. Experts are virtually unanimous in agreeing that even addicts who are suffering pain can be successfully treated with opioids. Indeed, opioids can be lifesaving for addicts - witness the methadone maintenance therapy given to heroin addicts. But treating addicts requires extra care.Identifying the scammers is especially tricky because there is no objective test for pain - it doesn't show up on an X-ray. In one British study, half the respondents who complained of lower-back pain had normal M.R.I.'s. Conversely, a third of those with no pain showed disk degeneration on their M.R.I.'s. The study suggested there could be a profound disconnection between what an M.R.I. sees and what a patient feels.There are red flags that indicate possible abuse or diversion: patients who drive long distances to see the doctor, or ask for specific drugs by name, or claim to need more and more of them. But people with real pain also occasionally do these things. The doctor's dilemma is how to stop the diverters without condemning other patients to suffer unnecessarily, since a drug diverter and a legitimate patient can look very much alike. The dishonest prescriber and the honest one can also look alike. Society has a parallel dilemma: how to stop drug-dealing doctors without discouraging real ones and worsening America's undertreatment of pain.
In July 2002, an insurance agent was sifting through records in Columbia, S.C., and paused at the file of one Larry Shealy. Shealy was getting OxyContin from a doctor named Ronald McIver - a lot of it. "The amounts were incredible; it jumped out in my face," the agent, who spoke on condition of anonymity, told me. "He was either selling them or taking so much he couldn\'t live." The agent did two things. He recommended to Shealy\'s employers that they exclude OxyContin coverage from their health insurance plan - which they did. And he called the D.E.A. Two days later, a D.E.A. agent showed up in the insurance agent\'s office with an administrative subpoena to collect Shealy\'s file.\u003cbr /\>\u003cbr /\>McIver wanted to be a doctor all his life, two of his daughters told me. But he taught and traveled for years before he finally enrolled at Michigan State University to become a D.O., or doctor of osteopathy, a more holistic alternative to a traditional medical education. (Osteopaths can do everything that traditional M.D.\'s can do, including prescribe opioids.) He began practicing pain medicine in the late 1980s. He had a practice in Florence, S.C., which ended when he declared bankruptcy in 2000. He moved to Greenwood to start over, establishing his new office in a storefront next to a chiropractor.\u003cbr /\>\u003cbr /\>McIver was, by the account of his patients, an unusual doctor in the age of the 10-minute managed-care visit. He usually saw about 6 to 12 patients each day. One patient I spoke with - who never got high-dose opioids - said that his first visit with McIver lasted four hours, and in subsequent visits he spent an hour or more doing various therapies. Many patients said their visits lasted an hour. Patients taking opioids had to sign a pain contract and bring their pills in at each visit to be counted.\u003cbr /\>\u003cbr /\>Many doctors take little interest in the administrative side of their practices, but McIver\'s neglect was epic. To save money, he employed mostly family. His wife, Carolyn, whose only medical training was from her husband, served as his assistant, giving shots and administering therapies. "His doctor\'s office did not resemble my family\'s doctor\'s office," said Sgt. Bobby Grogan, who was the investigator on the case for the Greenwood County Sheriff. While McIver\'s treatment rooms were normal, his and his wife\'s offices - off limits to patients - were a mess, according to pictures presented at McIver\'s trial by Adam Roberson, the D.E.A.\'s principal investigator. Used syringes, for example, overflowed their storage box. "His patient records were manila envelopes stuffed with receipts," Grogan told me.\u003cbr /\>",1]
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In July 2002, an insurance agent was sifting through records in Columbia, S.C., and paused at the file of one Larry Shealy. Shealy was getting OxyContin from a doctor named Ronald McIver - a lot of it. "The amounts were incredible; it jumped out in my face," the agent, who spoke on condition of anonymity, told me. "He was either selling them or taking so much he couldn't live." The agent did two things. He recommended to Shealy's employers that they exclude OxyContin coverage from their health insurance plan - which they did. And he called the D.E.A. Two days later, a D.E.A. agent showed up in the insurance agent's office with an administrative subpoena to collect Shealy's file.McIver wanted to be a doctor all his life, two of his daughters told me. But he taught and traveled for years before he finally enrolled at Michigan State University to become a D.O., or doctor of osteopathy, a more holistic alternative to a traditional medical education. (Osteopaths can do everything that traditional M.D.'s can do, including prescribe opioids.) He began practicing pain medicine in the late 1980s. He had a practice in Florence, S.C., which ended when he declared bankruptcy in 2000. He moved to Greenwood to start over, establishing his new office in a storefront next to a chiropractor.McIver was, by the account of his patients, an unusual doctor in the age of the 10-minute managed-care visit. He usually saw about 6 to 12 patients each day. One patient I spoke with - who never got high-dose opioids - said that his first visit with McIver lasted four hours, and in subsequent visits he spent an hour or more doing various therapies. Many patients said their visits lasted an hour. Patients taking opioids had to sign a pain contract and bring their pills in at each visit to be counted.Many doctors take little interest in the administrative side of their practices, but McIver's neglect was epic. To save money, he employed mostly family. His wife, Carolyn, whose only medical training was from her husband, served as his assistant, giving shots and administering therapies. "His doctor's office did not resemble my family's doctor's office," said Sgt. Bobby Grogan, who was the investigator on the case for the Greenwood County Sheriff. While McIver's treatment rooms were normal, his and his wife's offices - off limits to patients - were a mess, according to pictures presented at McIver's trial by Adam Roberson, the D.E.A.'s principal investigator. Used syringes, for example, overflowed their storage box. "His patient records were manila envelopes stuffed with receipts," Grogan told me.
When I interviewed him in prison recently, McIver told me that his records were complete but scattered. He said that he and his wife, distracted by a series of family tragedies, had employed a series of temporary receptionists who had botched the filing. He and his wife were trying to piece them together. "The records were probably half in the office and half at home for me to work on at night," he said. "I kept a box in the back of the car I worked on while Carolyn drove."\u003cbr /\>\u003cbr /\>Leslie Smith first came to see McIver in the fall of 2001. Smith was in his mid-40s and lived in Chapin, a small town near Columbia, a 60-mile drive from Greenwood. He filled out a medical-history form and told McIver that his wrists hurt so badly that he was getting only three or four hours\' sleep a night. He also said that a previous doctor helped him by prescribing OxyContin, and he mentioned the name of a doctor he said referred him. McIver examined Smith\'s wrists. Smith walked out with an opioid prescription and an appointment to come back the next week.\u003cbr /\>\u003cbr /\>Smith\'s wrists did not hurt him, as he testified at McIver\'s trial. He was addicted to OxyContin and Dilaudid, which he injected. He complained of wrist pain because it was plausible: he had injured one wrist previously, requiring an operation that left scars, and he had arthritis in the other. Until June 2002, Smith kept getting prescriptions.\u003cbr /\>\u003cbr /\>Smith saw McIver every few weeks. He testified that he had track marks on his arm at the time but always wore long sleeves to cover them. He said McIver never saw them. McIver put him on an electric nerve stimulator every visit for 15 or 30 minutes on each hand and did osteopathic manipulations. He prescribed exercises. Smith bought a nerve-stimulator machine to use at home and told McIver it was helping. At McIver\'s request he filled out a pain chart and reported that his pain rated a 5 or 6 upon awakening, reached 7 during the day and occasionally hit 9. "I answered all the questions exactly like I thought he\'d want to hear them answered," Smith testified. At one point McIver found a syringe in Smith\'s pocket. Smith told McIver that he was going fishing later that day and that he used the syringe as part of his fishing equipment. That apparently satisfied McIver, who testified that his grandfather kept syringes in his tackle box to pump air into his bait.\u003cbr /\>",1]
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When I interviewed him in prison recently, McIver told me that his records were complete but scattered. He said that he and his wife, distracted by a series of family tragedies, had employed a series of temporary receptionists who had botched the filing. He and his wife were trying to piece them together. "The records were probably half in the office and half at home for me to work on at night," he said. "I kept a box in the back of the car I worked on while Carolyn drove."Leslie Smith first came to see McIver in the fall of 2001. Smith was in his mid-40s and lived in Chapin, a small town near Columbia, a 60-mile drive from Greenwood. He filled out a medical-history form and told McIver that his wrists hurt so badly that he was getting only three or four hours' sleep a night. He also said that a previous doctor helped him by prescribing OxyContin, and he mentioned the name of a doctor he said referred him. McIver examined Smith's wrists. Smith walked out with an opioid prescription and an appointment to come back the next week.Smith's wrists did not hurt him, as he testified at McIver's trial. He was addicted to OxyContin and Dilaudid, which he injected. He complained of wrist pain because it was plausible: he had injured one wrist previously, requiring an operation that left scars, and he had arthritis in the other. Until June 2002, Smith kept getting prescriptions.Smith saw McIver every few weeks. He testified that he had track marks on his arm at the time but always wore long sleeves to cover them. He said McIver never saw them. McIver put him on an electric nerve stimulator every visit for 15 or 30 minutes on each hand and did osteopathic manipulations. He prescribed exercises. Smith bought a nerve-stimulator machine to use at home and told McIver it was helping. At McIver's request he filled out a pain chart and reported that his pain rated a 5 or 6 upon awakening, reached 7 during the day and occasionally hit 9. "I answered all the questions exactly like I thought he'd want to hear them answered," Smith testified. At one point McIver found a syringe in Smith's pocket. Smith told McIver that he was going fishing later that day and that he used the syringe as part of his fishing equipment. That apparently satisfied McIver, who testified that his grandfather kept syringes in his tackle box to pump air into his bait.
Smith filled some of his prescriptions at the Hawthorne Pharmacy in West Columbia. There, Addison Livingston, the pharmacist, got suspicious. He noticed that Smith sometimes came in with other patients of McIver\'s, despite the fact that McIver worked nearly two hours\' drive away. The patients obviously knew each other and would pick up large opioid prescriptions, paying cash and asking for brand-name drugs. Livingston called McIver, who confirmed he had written the prescriptions. At one point, McIver told Livingston that he, too, was suspicious, and that he had sent a letter about Smith to the state\'s Bureau of Drug Control.\u003cbr /\>\u003cbr /\>In February 2002, McIver wrote to Larry McElrath, a B.D.C. inspector, who read the letter at the trial. "Dear Larry," it read, "There are several people out of the Columbia/Chapin area who have aroused my curiosity about their use and possible misuse of medications. Some are referred by [another doctor] and seem legitimate. . . . They all pay cash despite some of them having insurance with prescription cards. . . . When they are in the office, they sometimes make a show of not knowing each other. . . . The situation is made complicated by the fact that each has some real pathology with objective findings that would justify the use of opiates if their pains are as bad as they say. I have given them the benefit of the doubt, but I\'m becoming less inclined to do so. I would appreciate it if you could make some discrete inquiries and let me know whether my concerns are justified. . . . I certainly don\'t want to refuse help to someone who needs it. On the other hand, I want even less to be implicated in diversion or other improprieties." He listed their names and Social Security numbers.\u003cbr /\>\u003cbr /\>McElrath did nothing with the letter. "It\'s incumbent upon the physician to have a trust with his patients," McElrath testified at the trial. "Here there was nothing that I could assume or conclude that any crimes had been committed."\u003cbr /\>\u003cbr /\>Smith was the most damning of the several patients who testified against McIver. (Smith and the other patients mentioned here did not agree to be interviewed for this article, as they are suing McIver for alleged overprescription of addictive drugs. Such suits often prosper after successful criminal convictions, as civil suits are easier to win.) Smith had a confederate in Seth Boyer, who lived in Chapin and followed a similar pattern in his dealings with McIver: he exaggerated pains in his foot, never provided records from a previous doctor and had needle tracks that he later testified McIver never saw. At one point, Boyer told McIver that he had spilled a bottle of liquid OxyFast, another opioid. (In reality, Boyer had injected it.) McIver wrote him a prescription for a replacement - apparently a violation of his standard pain-medication contract, which had a "no early refills" stipulation.\u003cbr /\>",1]
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Smith filled some of his prescriptions at the Hawthorne Pharmacy in West Columbia. There, Addison Livingston, the pharmacist, got suspicious. He noticed that Smith sometimes came in with other patients of McIver's, despite the fact that McIver worked nearly two hours' drive away. The patients obviously knew each other and would pick up large opioid prescriptions, paying cash and asking for brand-name drugs. Livingston called McIver, who confirmed he had written the prescriptions. At one point, McIver told Livingston that he, too, was suspicious, and that he had sent a letter about Smith to the state's Bureau of Drug Control.In February 2002, McIver wrote to Larry McElrath, a B.D.C. inspector, who read the letter at the trial. "Dear Larry," it read, "There are several people out of the Columbia/Chapin area who have aroused my curiosity about their use and possible misuse of medications. Some are referred by [another doctor] and seem legitimate. . . . They all pay cash despite some of them having insurance with prescription cards. . . . When they are in the office, they sometimes make a show of not knowing each other. . . . The situation is made complicated by the fact that each has some real pathology with objective findings that would justify the use of opiates if their pains are as bad as they say. I have given them the benefit of the doubt, but I'm becoming less inclined to do so. I would appreciate it if you could make some discrete inquiries and let me know whether my concerns are justified. . . . I certainly don't want to refuse help to someone who needs it. On the other hand, I want even less to be implicated in diversion or other improprieties." He listed their names and Social Security numbers.McElrath did nothing with the letter. "It's incumbent upon the physician to have a trust with his patients," McElrath testified at the trial. "Here there was nothing that I could assume or conclude that any crimes had been committed."Smith was the most damning of the several patients who testified against McIver. (Smith and the other patients mentioned here did not agree to be interviewed for this article, as they are suing McIver for alleged overprescription of addictive drugs. Such suits often prosper after successful criminal convictions, as civil suits are easier to win.) Smith had a confederate in Seth Boyer, who lived in Chapin and followed a similar pattern in his dealings with McIver: he exaggerated pains in his foot, never provided records from a previous doctor and had needle tracks that he later testified McIver never saw. At one point, Boyer told McIver that he had spilled a bottle of liquid OxyFast, another opioid. (In reality, Boyer had injected it.) McIver wrote him a prescription for a replacement - apparently a violation of his standard pain-medication contract, which had a "no early refills" stipulation.
But McIver ended up discharging Boyer in June 2002, when Boyer altered a prescription so he could fill it three days early. He wrote McIver three pleading letters of protest, to no avail. "I was looking for an excuse to discharge them, and with Seth I found it," McIver told me. "I needed more than suspicion. With Les, he never actually did anything that allowed me to say, \'O.K., here\'s that concrete piece of evidence.\' "\u003cbr /\>\u003cbr /\>McIver may have felt he needed more proof, but medically he probably had enough. Pain specialists told me that doctors can stop prescribing a drug whenever the risks outweigh the benefits, which includes the risk of abuse.\u003cbr /\>\u003cbr /\>Another drug-dealing patient of McIver\'s was Kyle Barnes. She testified that she suffered from fibromyalgia, a chronic-pain syndrome, but exaggerated her pain to get higher levels of OxyContin and Roxicodone. She was addicted to those drugs before she began seeing McIver in July 2001. She also brought no medical records and drove three hours to each appointment. She got prescriptions on her second visit, during which McIver also did osteopathic manipulations and massage.\u003cbr /\>\u003cbr /\>Barnes was in real pain. McIver did several different therapies at each visit. He set up an appointment for her at a sleep clinic, sent her for X-rays and put a cast on her wrist. He knew she had trouble paying for her medicines, and he contacted Purdue Pharma to see if she qualified for reduced-price drugs. She kept claiming the drugs were not helping enough and was soon taking 16 times the dose of OxyContin she took when she first saw him. One tip-off in her case should have been that she paid thousands of dollars a month in cash for her prescriptions, even though she was on Medicaid. She told McIver that her father and boyfriend were helping her buy them, which she later testified was partly true. But most of her income came from selling some of the drugs he prescribed, she testified. In December 2003, McIver told her that he would stop treating her unless she took a drug screen. She did nothing. Three weeks later he told her again. She never returned.\u003cbr /\>",1]
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But McIver ended up discharging Boyer in June 2002, when Boyer altered a prescription so he could fill it three days early. He wrote McIver three pleading letters of protest, to no avail. "I was looking for an excuse to discharge them, and with Seth I found it," McIver told me. "I needed more than suspicion. With Les, he never actually did anything that allowed me to say, 'O.K., here's that concrete piece of evidence.' "McIver may have felt he needed more proof, but medically he probably had enough. Pain specialists told me that doctors can stop prescribing a drug whenever the risks outweigh the benefits, which includes the risk of abuse.Another drug-dealing patient of McIver's was Kyle Barnes. She testified that she suffered from fibromyalgia, a chronic-pain syndrome, but exaggerated her pain to get higher levels of OxyContin and Roxicodone. She was addicted to those drugs before she began seeing McIver in July 2001. She also brought no medical records and drove three hours to each appointment. She got prescriptions on her second visit, during which McIver also did osteopathic manipulations and massage.Barnes was in real pain. McIver did several different therapies at each visit. He set up an appointment for her at a sleep clinic, sent her for X-rays and put a cast on her wrist. He knew she had trouble paying for her medicines, and he contacted Purdue Pharma to see if she qualified for reduced-price drugs. She kept claiming the drugs were not helping enough and was soon taking 16 times the dose of OxyContin she took when she first saw him. One tip-off in her case should have been that she paid thousands of dollars a month in cash for her prescriptions, even though she was on Medicaid. She told McIver that her father and boyfriend were helping her buy them, which she later testified was partly true. But most of her income came from selling some of the drugs he prescribed, she testified. In December 2003, McIver told her that he would stop treating her unless she took a drug screen. She did nothing. Three weeks later he told her again. She never returned.
Another patient whose story was particularly troubling was Barbee Brown. Brown was not a drug seeker but a genuine pain patient seeking relief from Reflex Sympathetic Dystrophy. McIver gave her very high doses of OxyContin right away, before she produced any records from other doctors. This was especially disturbing, because she had been addicted to crack cocaine for three months in the year before she came to him.\u003cbr /\>\u003cbr /\>Brown saw McIver at least twice a week for six weeks. He did a thorough physical exam and took a complete history. He used many different kinds of therapies. But he also started her - someone who had never taken opioids - on 40-milligram pills of OxyContin and allowed her to control her own dosing schedule. "As long as you are not having side effects, do not be afraid to take the doses you need to get out of pain," he wrote to her. It was the same advice he gave many patients. "The number of milligrams does not matter. What matters is the number on the 0-to-10 scale."\u003cbr /\>\u003cbr /\>The medicine helped. Brown testified that she ranked her pain at 9 or 10 when she first got to McIver. After seeing him, it dropped to a 4. Her pain diary, which appears to be sincere, had various passages giving thanks that she met McIver. Brown did not become addicted. But allowing an opioid-naïve recovering crack addict to start on high-dose pills and control her own dosage, and telling her that her dosage didn\'t matter, seems reckless.\u003cbr /\>\u003cbr /\>McIver\'s 30-year sentence was the result of the death of Larry Shealy, a 56-year-old man who suffered intense back and knee pain, in addition to many other health problems. He first came to see McIver in February 2002, with full referrals and records. He was on OxyContin before seeing McIver but complained that his pain was still terrible, so McIver doubled his dose. This allowed Shealy to go back to work in an auto body shop.\u003cbr /\>\u003cbr /\>Shealy was not a careful patient. A month after he started with McIver, he took 15 OxyContin tablets in one day instead of the 6 he was prescribed. He was not harmed, but McIver testified that he asked Shealy to bring his family in so he could explain the dosing to them. At one point, McIver tried to taper down the OxyContin and replace it with methadone, but Shealy complained that the methadone made him drowsy. Shealy\'s son, David, an auto mechanic, testified that the OxyContin pain relief also came at a price. He said he felt his father was overmedicated - often sleepy. Once, his father backed his truck into a tree.\u003cbr /\>",1]
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Another patient whose story was particularly troubling was Barbee Brown. Brown was not a drug seeker but a genuine pain patient seeking relief from Reflex Sympathetic Dystrophy. McIver gave her very high doses of OxyContin right away, before she produced any records from other doctors. This was especially disturbing, because she had been addicted to crack cocaine for three months in the year before she came to him.Brown saw McIver at least twice a week for six weeks. He did a thorough physical exam and took a complete history. He used many different kinds of therapies. But he also started her - someone who had never taken opioids - on 40-milligram pills of OxyContin and allowed her to control her own dosing schedule. "As long as you are not having side effects, do not be afraid to take the doses you need to get out of pain," he wrote to her. It was the same advice he gave many patients. "The number of milligrams does not matter. What matters is the number on the 0-to-10 scale."The medicine helped. Brown testified that she ranked her pain at 9 or 10 when she first got to McIver. After seeing him, it dropped to a 4. Her pain diary, which appears to be sincere, had various passages giving thanks that she met McIver. Brown did not become addicted. But allowing an opioid-naïve recovering crack addict to start on high-dose pills and control her own dosage, and telling her that her dosage didn't matter, seems reckless.McIver's 30-year sentence was the result of the death of Larry Shealy, a 56-year-old man who suffered intense back and knee pain, in addition to many other health problems. He first came to see McIver in February 2002, with full referrals and records. He was on OxyContin before seeing McIver but complained that his pain was still terrible, so McIver doubled his dose. This allowed Shealy to go back to work in an auto body shop.Shealy was not a careful patient. A month after he started with McIver, he took 15 OxyContin tablets in one day instead of the 6 he was prescribed. He was not harmed, but McIver testified that he asked Shealy to bring his family in so he could explain the dosing to them. At one point, McIver tried to taper down the OxyContin and replace it with methadone, but Shealy complained that the methadone made him drowsy. Shealy's son, David, an auto mechanic, testified that the OxyContin pain relief also came at a price. He said he felt his father was overmedicated - often sleepy. Once, his father backed his truck into a tree.
Shealy died in his sleep early on the morning of May 29, 2003. He had OxyContin pills in his stomach, and his bloodstream contained alprazolam - Xanax - as well. The pathologist at McIver\'s trial testified that the levels of drugs were consistent with the prescriptions McIver had been writing - the high levels that so alarmed the insurance agent. Shealy was taking five 80-milligram tablets of OxyContin every 12 hours, plus up to six 30-milligram tablets of Roxicodone every 4 hours for breakthrough pain, plus as much as 2 milligrams of alprazolam every 8 hours. The prosecution\'s toxicologist, Demi Garvin, concluded that the OxyContin and Roxicodone caused Shealy\'s death by respiratory depression. The pathologist testified that she looked up this dosage and found it to be a fatal level.\u003cbr /\>\u003cbr /\>But there is reason for doubt. According to Shealy\'s prescriptions, he had been taking the same dosage for at least two months, and possibly much longer. Pain specialists say that respiratory depression is extremely unlikely when dosage is consistent. In her testimony, Garvin agreed that what would be a toxic level in an opioid-naïve patient would be safe for someone titrated up properly. But she said she could not conclude he had been properly titrated, in part because she had not seen his medical records. Garvin declined to talk about the Shealy case with me because she is a witness for the Shealy family in their planned civil suit against McIver. But in a deposition for that lawsuit, she appeared to back away from blaming the OxyContin. She described her view as: "Hey, there\'s a red flag here. This can certainly be your cause of death, but you need to go further in exploring whether or not it is."\u003cbr /\>\u003cbr /\>There was something else that might have caused Shealy\'s death: he suffered from advanced congestive heart failure. The pathologist testified that he had 90 percent blockage in one coronary artery and 50 percent in another, and a greatly enlarged heart and other organs. He had a scar on the back wall of his heart that indicated he at one time suffered a heart attack. Opioids do not worsen heart disease and would likely have helped, because pain causes stress to the heart.\u003cbr /\>",1]
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Shealy died in his sleep early on the morning of May 29, 2003. He had OxyContin pills in his stomach, and his bloodstream contained alprazolam - Xanax - as well. The pathologist at McIver's trial testified that the levels of drugs were consistent with the prescriptions McIver had been writing - the high levels that so alarmed the insurance agent. Shealy was taking five 80-milligram tablets of OxyContin every 12 hours, plus up to six 30-milligram tablets of Roxicodone every 4 hours for breakthrough pain, plus as much as 2 milligrams of alprazolam every 8 hours. The prosecution's toxicologist, Demi Garvin, concluded that the OxyContin and Roxicodone caused Shealy's death by respiratory depression. The pathologist testified that she looked up this dosage and found it to be a fatal level.But there is reason for doubt. According to Shealy's prescriptions, he had been taking the same dosage for at least two months, and possibly much longer. Pain specialists say that respiratory depression is extremely unlikely when dosage is consistent. In her testimony, Garvin agreed that what would be a toxic level in an opioid-naïve patient would be safe for someone titrated up properly. But she said she could not conclude he had been properly titrated, in part because she had not seen his medical records. Garvin declined to talk about the Shealy case with me because she is a witness for the Shealy family in their planned civil suit against McIver. But in a deposition for that lawsuit, she appeared to back away from blaming the OxyContin. She described her view as: "Hey, there's a red flag here. This can certainly be your cause of death, but you need to go further in exploring whether or not it is."There was something else that might have caused Shealy's death: he suffered from advanced congestive heart failure. The pathologist testified that he had 90 percent blockage in one coronary artery and 50 percent in another, and a greatly enlarged heart and other organs. He had a scar on the back wall of his heart that indicated he at one time suffered a heart attack. Opioids do not worsen heart disease and would likely have helped, because pain causes stress to the heart.
The testimonies of the patients Smith, Boyer and Barnes were the parts of the trial that most directly addressed the question of whether McIver intentionally wrote prescriptions for a nonmedical purpose. This is the relevant legal test for the statute under which he was prosecuted. Several Supreme Court and district court cases have made it clear that under the Controlled Substances Act, a doctor is guilty of a crime if he intentionally acts as a drug pusher.\u003cbr /\>\u003cbr /\>The judge in the McIver case, Henry F. Floyd, told the jurors that bad prescribing is the standard for malpractice, a civil matter. "That is not what we are talking about," he said. "We\'re not talking about this physician acting better or worse than other physicians." If McIver was a bad doctor - but still a doctor, with intent to treat patients - he was innocent. "If you find that a defendant acted in good faith in dispensing the drugs charged in this indictment, then you must find that defendant not guilty," Floyd said. But Floyd also told the jury to take bad doctoring into account in deciding McIver\'s intent.\u003cbr /\>\u003cbr /\>This instruction - that bad doctoring does not prove intent but could be considered when weighing his intent - is subtle and potentially extremely confusing. It apparently confused the jurors. I spoke to two jurors, who told me their own views and characterized the jury discussion. The overwhelming factor, they said, was that McIver prescribed too much - the very red flag that alerted the insurance agent and set the case in motion.\u003cbr /\>\u003cbr /\>The jurors I spoke with said that by far the most important testimony came from Steven Storick, a pain-management doctor in Columbia and the government\'s expert witness. Reviewing the records of patient after patient, Storick consistently testified that there were too many drugs. "This amount of medication is just extremely high in a situation like this," he said of one patient. This is "excessive," he said of another. "That\'s just an extremely high dose of drug," he said of a third. Storick, who declined to be interviewed for this article, testified that if he had a patient who exhibited no objective evidence of pain, he would not prescribe opioids. He would not have titrated patients as rapidly as McIver did or given them discretion. He disagreed with McIver\'s position that a doctor should try to bring a patient\'s chronic pain down to a level of 2. He would stop titrating when a patient reached 5 out of 10.\u003cbr /\>\u003cbr /\>The jurors took Storick\'s caution to heart, in part, they told me, because it resonated with their own experience with opioids and fears of addiction. I asked Jo Handy, a tall, elegant woman who is now 39 and a real estate agent outside Greenville, why McIver was convicted. "It was the excessive prescriptions," she said in a\u003cbr /\>\u003cbr /\>\u003cbr /\>\u003c/div\>",0]
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The testimonies of the patients Smith, Boyer and Barnes were the parts of the trial that most directly addressed the question of whether McIver intentionally wrote prescriptions for a nonmedical purpose. This is the relevant legal test for the statute under which he was prosecuted. Several Supreme Court and district court cases have made it clear that under the Controlled Substances Act, a doctor is guilty of a crime if he intentionally acts as a drug pusher.The judge in the McIver case, Henry F. Floyd, told the jurors that bad prescribing is the standard for malpractice, a civil matter. "That is not what we are talking about," he said. "We're not talking about this physician acting better or worse than other physicians." If McIver was a bad doctor - but still a doctor, with intent to treat patients - he was innocent. "If you find that a defendant acted in good faith in dispensing the drugs charged in this indictment, then you must find that defendant not guilty," Floyd said. But Floyd also told the jury to take bad doctoring into account in deciding McIver's intent.This instruction - that bad doctoring does not prove intent but could be considered when weighing his intent - is subtle and potentially extremely confusing. It apparently confused the jurors. I spoke to two jurors, who told me their own views and characterized the jury discussion. The overwhelming factor, they said, was that McIver prescribed too much - the very red flag that alerted the insurance agent and set the case in motion.The jurors I spoke with said that by far the most important testimony came from Steven Storick, a pain-management doctor in Columbia and the government's expert witness. Reviewing the records of patient after patient, Storick consistently testified that there were too many drugs. "This amount of medication is just extremely high in a situation like this," he said of one patient. This is "excessive," he said of another. "That's just an extremely high dose of drug," he said of a third. Storick, who declined to be interviewed for this article, testified that if he had a patient who exhibited no objective evidence of pain, he would not prescribe opioids. He would not have titrated patients as rapidly as McIver did or given them discretion. He disagreed with McIver's position that a doctor should try to bring a patient's chronic pain down to a level of 2. He would stop titrating when a patient reached 5 out of 10.The jurors took Storick's caution to heart, in part, they told me, because it resonated with their own experience with opioids and fears of addiction. I asked Jo Handy, a tall, elegant woman who is now 39 and a real estate agent outside Greenville, why McIver was convicted. "It was the excessive prescriptions," she said in a
http://www.nytimes.com/2007/06/17/magazine/17pain-t.html
June 17, 2007
Cover Story: When Is a Pain Doctor a Drug Pusher?
By TINA ROSENBERG Correction Appended
Ronald McIver is a prisoner in a medium-security federal compound in Butner, N.C. He is 63 years old, of medium height and overweight, with a white Santa Claus beard, white hair and a calm, direct and intelligent manner. He is serving 30 years for drug trafficking, and so will likely live there the rest of his life. McIver (pronounced mi-KEE-ver) has not been convicted of drug trafficking in the classic sense. He is a doctor who for years treated patients suffering from chronic pain. At the Pain Therapy Center, his small storefront office not far from Main Street in Greenwood, S.C., he cracked backs, gave trigger-point injections and put patients through physical therapy. He administered ultrasound and gravity-inversion therapy and devised exercise regimens. And he wrote prescriptions for high doses of opioid drugs like OxyContin.
McIver was a particularly aggressive pain doctor. Pain can be measured only by how patients say they feel: on a scale from 0 to 10, a report of 0 signifies the absence of pain; 10 is unbearable pain. Many pain doctors will try to reduce a patient\'s pain to the level of 5. McIver tried for a 2. He prescribed more, and sooner, than most doctors.\u003cbr /\>\u003cbr /\>Some of his patients sold their pills. Some abused them. One man, Larry Shealy, died with high doses of opioids that McIver had prescribed him in his bloodstream. In April 2005, McIver was convicted in federal court of one count of conspiracy to distribute controlled substances and eight counts of distribution. (He was also acquitted of six counts of distribution.) The jury also found that Shealy was killed by the drugs McIver prescribed. McIver is serving concurrent sentences of 20 years for distribution and 30 years for dispensing drugs that resulted in Shealy\'s death. His appeals to the U.S. Court of Appeals for the Fourth Circuit and the Supreme Court were rejected.\u003cbr /\>\u003cbr /\>McIver\'s case is not simply the story of a narcotics conviction. It has enormous relevance to the lives of the one in five adult Americans who, according to a 2005 survey by Stanford University Medical Center, ABC News and USA Today, reported they suffered from chronic pain - pain lasting for several months or longer. According to a 2003 study in The Journal of the American Medical Association, pain costs American workers more than $61 billion a year in lost productive time - and that doesn\'t include medical bills.\u003cbr /\>\u003cbr /\>Contrary to the old saw, pain kills. A body in pain produces high levels of hormones that cause stress to the heart and lungs. Pain can cause blood pressure to spike, leading to heart attacks and strokes. Pain can also consume so much of the body\'s energy that the immune system degrades. Severe chronic pain sometimes leads to suicide. There are, of course, many ways to treat pain: some pain sufferers respond well to surgery, physical therapy, ultrasound, acupuncture, trigger-point injections, meditation or over-the-counter painkillers like Advil (ibuprofen) or Tylenol (acetaminophen). But for many people in severe chronic pain, an opioid (an opiumlike compound) like OxyContin, Dilaudid, Vicodin, Percocet, oxycodone, methadone or morphine is the only thing that allows them to get out of bed. Yet most doctors prescribe opioids conservatively, and many patients and their families are just as cautious as their doctors. Men, especially, will simply tough it out, reasoning that pain is better than addiction.\u003cbr /\>",1]
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McIver was a particularly aggressive pain doctor. Pain can be measured only by how patients say they feel: on a scale from 0 to 10, a report of 0 signifies the absence of pain; 10 is unbearable pain. Many pain doctors will try to reduce a patient's pain to the level of 5. McIver tried for a 2. He prescribed more, and sooner, than most doctors.Some of his patients sold their pills. Some abused them. One man, Larry Shealy, died with high doses of opioids that McIver had prescribed him in his bloodstream. In April 2005, McIver was convicted in federal court of one count of conspiracy to distribute controlled substances and eight counts of distribution. (He was also acquitted of six counts of distribution.) The jury also found that Shealy was killed by the drugs McIver prescribed. McIver is serving concurrent sentences of 20 years for distribution and 30 years for dispensing drugs that resulted in Shealy's death. His appeals to the U.S. Court of Appeals for the Fourth Circuit and the Supreme Court were rejected.McIver's case is not simply the story of a narcotics conviction. It has enormous relevance to the lives of the one in five adult Americans who, according to a 2005 survey by Stanford University Medical Center, ABC News and USA Today, reported they suffered from chronic pain - pain lasting for several months or longer. According to a 2003 study in The Journal of the American Medical Association, pain costs American workers more than $61 billion a year in lost productive time - and that doesn't include medical bills.Contrary to the old saw, pain kills. A body in pain produces high levels of hormones that cause stress to the heart and lungs. Pain can cause blood pressure to spike, leading to heart attacks and strokes. Pain can also consume so much of the body's energy that the immune system degrades. Severe chronic pain sometimes leads to suicide. There are, of course, many ways to treat pain: some pain sufferers respond well to surgery, physical therapy, ultrasound, acupuncture, trigger-point injections, meditation or over-the-counter painkillers like Advil (ibuprofen) or Tylenol (acetaminophen). But for many people in severe chronic pain, an opioid (an opiumlike compound) like OxyContin, Dilaudid, Vicodin, Percocet, oxycodone, methadone or morphine is the only thing that allows them to get out of bed. Yet most doctors prescribe opioids conservatively, and many patients and their families are just as cautious as their doctors. Men, especially, will simply tough it out, reasoning that pain is better than addiction.
Video\u003cbr /\>More Video »\u003cbr /\>It\'s a false choice. Virtually everyone who takes opioids will become physically dependent on them, which means that withdrawal symptoms like nausea and sweats can occur if usage ends abruptly. But tapering off gradually allows most people to avoid those symptoms, and physical dependence is not the same thing as addiction. Addiction - which is defined by cravings, loss of control and a psychological compulsion to take a drug even when it is harmful - occurs in patients with a predisposition (biological or otherwise) to become addicted. At the very least, these include just below 10 percent of Americans, the number estimated by the United States Department of Health and Human Services to have active substance-abuse problems. Even a predisposition to addiction, however, doesn\'t mean a patient will become addicted to opioids. Vast numbers do not. Pain patients without prior abuse problems most likely run little risk. "Someone who has never abused alcohol or other drugs would be extremely unlikely to become addicted to opioid pain medicines, particularly if he or she is older," says Russell K. Portenoy, chairman of pain medicine and palliative care at Beth Israel Medical Center in New York and a leading authority on the treatment of pain.\u003cbr /\>\u003cbr /\>The other popular misconception is that a high dose of opioids is always a dangerous dose. Even many doctors assume it; but they are nonetheless incorrect. It is true that high doses can cause respiratory failure in people who are not already taking the drugs. But that same high dose will not cause respiratory failure in someone whose drug levels have been increased gradually over time, a process called titration. For individuals who are properly titrated and monitored, there is no ceiling on opioid dosage. In this sense, high-dose prescription opioids can be safer than taking high doses of aspirin, Tylenol or Advil, which cause organ damage in high doses, regardless of how those doses are administered. (Every year, an estimated 5,000 to 6,000 Americans die from gastrointestinal bleeding associated with drugs like ibuprofen or aspirin, according to a paper published in The American Journal of Gastroenterology.)\u003cbr /\>",1]
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VideoMore Video »It's a false choice. Virtually everyone who takes opioids will become physically dependent on them, which means that withdrawal symptoms like nausea and sweats can occur if usage ends abruptly. But tapering off gradually allows most people to avoid those symptoms, and physical dependence is not the same thing as addiction. Addiction - which is defined by cravings, loss of control and a psychological compulsion to take a drug even when it is harmful - occurs in patients with a predisposition (biological or otherwise) to become addicted. At the very least, these include just below 10 percent of Americans, the number estimated by the United States Department of Health and Human Services to have active substance-abuse problems. Even a predisposition to addiction, however, doesn't mean a patient will become addicted to opioids. Vast numbers do not. Pain patients without prior abuse problems most likely run little risk. "Someone who has never abused alcohol or other drugs would be extremely unlikely to become addicted to opioid pain medicines, particularly if he or she is older," says Russell K. Portenoy, chairman of pain medicine and palliative care at Beth Israel Medical Center in New York and a leading authority on the treatment of pain.The other popular misconception is that a high dose of opioids is always a dangerous dose. Even many doctors assume it; but they are nonetheless incorrect. It is true that high doses can cause respiratory failure in people who are not already taking the drugs. But that same high dose will not cause respiratory failure in someone whose drug levels have been increased gradually over time, a process called titration. For individuals who are properly titrated and monitored, there is no ceiling on opioid dosage. In this sense, high-dose prescription opioids can be safer than taking high doses of aspirin, Tylenol or Advil, which cause organ damage in high doses, regardless of how those doses are administered. (Every year, an estimated 5,000 to 6,000 Americans die from gastrointestinal bleeding associated with drugs like ibuprofen or aspirin, according to a paper published in The American Journal of Gastroenterology.)
Still, doctors who put patients on long-term high-dose opioids must be very careful. They must monitor the patients often to ensure that the drugs are being used correctly and that side effects like constipation and mental cloudiness are not too severe. Doctors should also not automatically assume that if small doses aren\'t working, that high doses will - opioids don\'t help everyone. And research indicates that in some cases, high doses of opioids can lose their effectiveness and that some patients are better off if they take drug "holidays" or alternate between different medicines. Pain doctors also concede that more studies are needed to determine the safety of long-term opioid use.\u003cbr /\>\u003cbr /\>But with careful treatment, many patients whose opioid levels are increased gradually can function well on high doses for years. "Dose alone says nothing about proper medical practice," Portenoy says. "Very few patients require doses that exceed even 200 milligrams of OxyContin on a daily basis. Having said this, pain specialists are very familiar with a subpopulation of patients who require higher doses to gain effect. I myself have several patients who take more than 1,000 milligrams of OxyContin or its equivalent every day. One is a high-functioning executive who is pain-free most of the time, and the others have a level of pain control that allows a reasonable quality of life."\u003cbr /\>\u003cbr /\>All modern pain-management textbooks advocate "titration to effect" - in other words, in cases where opioids are helping, gradually increasing the dosage until either the pain is acceptably controlled or the side effects begin to outweigh the pain-relief benefits. But the vast majority of doctors don\'t practice what the textbooks counsel. In part, this is because of the stigma associated with high-dose opioids, the fear that patients will become addicted and the fact that careful monitoring is very time-consuming. And most doctors have received virtually no training in medical school about managing pain: many hold the same misconceptions about addiction and dosage as the general public.\u003cbr /\>",1]
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Still, doctors who put patients on long-term high-dose opioids must be very careful. They must monitor the patients often to ensure that the drugs are being used correctly and that side effects like constipation and mental cloudiness are not too severe. Doctors should also not automatically assume that if small doses aren't working, that high doses will - opioids don't help everyone. And research indicates that in some cases, high doses of opioids can lose their effectiveness and that some patients are better off if they take drug "holidays" or alternate between different medicines. Pain doctors also concede that more studies are needed to determine the safety of long-term opioid use.But with careful treatment, many patients whose opioid levels are increased gradually can function well on high doses for years. "Dose alone says nothing about proper medical practice," Portenoy says. "Very few patients require doses that exceed even 200 milligrams of OxyContin on a daily basis. Having said this, pain specialists are very familiar with a subpopulation of patients who require higher doses to gain effect. I myself have several patients who take more than 1,000 milligrams of OxyContin or its equivalent every day. One is a high-functioning executive who is pain-free most of the time, and the others have a level of pain control that allows a reasonable quality of life."All modern pain-management textbooks advocate "titration to effect" - in other words, in cases where opioids are helping, gradually increasing the dosage until either the pain is acceptably controlled or the side effects begin to outweigh the pain-relief benefits. But the vast majority of doctors don't practice what the textbooks counsel. In part, this is because of the stigma associated with high-dose opioids, the fear that patients will become addicted and the fact that careful monitoring is very time-consuming. And most doctors have received virtually no training in medical school about managing pain: many hold the same misconceptions about addiction and dosage as the general public.
And even pain specialists can be conservative. Sean E. Greenwood died in August at age 50 of a cerebral hemorrhage that his wife, Siobhan Reynolds, attributes to untreated pain. Greenwood was seeing various pain specialists. What makes his undertreatment especially remarkable is that he and his wife founded the Pain Relief Network, an advocacy group that has been the most vocal opponent of prosecutions of doctors and financed part of the legal defense of many pain doctors. "Here I am - I know everyone, and even I couldn\'t get him care that didn\'t first regard him as a potential criminal," Reynolds said.\u003cbr /\>\u003cbr /\>According to the pharmaceutical research company IMS Health, prescriptions for opioids have risen over the past few years. They are used now more than ever before. Yet study after study has concluded that pain is still radically undertreated. The Stanford University Medical Center survey found that only 50 percent of chronic-pain sufferers who had spoken to a doctor about their pain got sufficient relief. According to the American Pain Society, an advocacy group, fewer than half of cancer patients in pain get adequate pain relief.\u003cbr /\>\u003cbr /\>Several states are now preparing new opioid-dosing guidelines that may inadvertently worsen undertreatment. This year, the state of Washington advised nonspecialist doctors that daily opioid doses should not exceed the equivalent of 120 milligrams of oral morphine daily - for oxycodone or OxyContin, that\'s just 80 milligrams per day - without the patient\'s also consulting a pain specialist. Along with the guidelines, officials published a statewide directory of such specialists. It contains 12 names. "There are just not enough pain specialists," says Scott M. Fishman, chief of pain medicine at the University of California at Davis and a past president of the American Academy of Pain Medicine. And the guidelines may keep nonspecialists from prescribing higher doses. "Many doctors will assume that if the state of Washington suggests this level of care, then it is unacceptable to proceed otherwise," Fishman says.\u003cbr /\>",1]
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And even pain specialists can be conservative. Sean E. Greenwood died in August at age 50 of a cerebral hemorrhage that his wife, Siobhan Reynolds, attributes to untreated pain. Greenwood was seeing various pain specialists. What makes his undertreatment especially remarkable is that he and his wife founded the Pain Relief Network, an advocacy group that has been the most vocal opponent of prosecutions of doctors and financed part of the legal defense of many pain doctors. "Here I am - I know everyone, and even I couldn't get him care that didn't first regard him as a potential criminal," Reynolds said.According to the pharmaceutical research company IMS Health, prescriptions for opioids have risen over the past few years. They are used now more than ever before. Yet study after study has concluded that pain is still radically undertreated. The Stanford University Medical Center survey found that only 50 percent of chronic-pain sufferers who had spoken to a doctor about their pain got sufficient relief. According to the American Pain Society, an advocacy group, fewer than half of cancer patients in pain get adequate pain relief.Several states are now preparing new opioid-dosing guidelines that may inadvertently worsen undertreatment. This year, the state of Washington advised nonspecialist doctors that daily opioid doses should not exceed the equivalent of 120 milligrams of oral morphine daily - for oxycodone or OxyContin, that's just 80 milligrams per day - without the patient's also consulting a pain specialist. Along with the guidelines, officials published a statewide directory of such specialists. It contains 12 names. "There are just not enough pain specialists," says Scott M. Fishman, chief of pain medicine at the University of California at Davis and a past president of the American Academy of Pain Medicine. And the guidelines may keep nonspecialists from prescribing higher doses. "Many doctors will assume that if the state of Washington suggests this level of care, then it is unacceptable to proceed otherwise," Fishman says.
In addition to medical considerations real or imagined, there is another deterrent to opioid use: fear. According to the D.E.A., 71 doctors were arrested last year for crimes related to "diversion" - the leakage of prescription medicine into illegal drug markets. The D.E.A. also opened 735 investigations of doctors, and an investigation alone can be enough to put a doctor out of business, as doctors can lose their licenses and practices and have their homes, offices and cars seized even if no federal criminal charges are ever filed. Both figures - arrests and investigations - have risen steadily over the last few years.\u003cbr /\>\u003cbr /\>Opioid drugs have been used to treat pain for decades, mostly for acute postsurgical pain or the pain of cancer patients. But in January 1996, Purdue Pharma helped increase the use of these drugs by introducing OxyContin - oxycodone with a time-release mechanism. Oncologists and pain doctors were the principal prescribers of opioids. But Purdue introduced the drug with an aggressive marketing campaign promoting OxyContin to general practitioners and the idea of opioid pain relief to doctors and consumers. The product\'s time-release mechanism, Purdue claimed, allowed steadier pain relief and deterred abuse.\u003cbr /\>\u003cbr /\>Many pain sufferers found that OxyContin gave them better relief than they ever had before. But Purdue misrepresented the drug\'s potential for abuse. Last month, the company and three of its executives pleaded guilty to federal charges that they misled doctors and patients. The company agreed to pay $600 million in fines; and the executives, a total of $34.5 million. The pill\'s time-release mechanism turned out to be easily circumvented by crushing the pill and snorting or injecting the resulting powder. By the late 1990s, OxyContin abuse was devastating small towns throughout Appalachia and rural New England. Pharmaceuticals, mainly opioids, are still widely abused - now more so than any illegal drug except marijuana. In 2005, according to the government\'s National Survey on Drug Use and Health, 6.4 million Americans, many of them teenagers, had abused pharmaceuticals recently. Most got the drug from friends or family - often, in the case of teenagers, from their parents\' medicine cabinets.\u003cbr /\>",1]
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In addition to medical considerations real or imagined, there is another deterrent to opioid use: fear. According to the D.E.A., 71 doctors were arrested last year for crimes related to "diversion" - the leakage of prescription medicine into illegal drug markets. The D.E.A. also opened 735 investigations of doctors, and an investigation alone can be enough to put a doctor out of business, as doctors can lose their licenses and practices and have their homes, offices and cars seized even if no federal criminal charges are ever filed. Both figures - arrests and investigations - have risen steadily over the last few years.Opioid drugs have been used to treat pain for decades, mostly for acute postsurgical pain or the pain of cancer patients. But in January 1996, Purdue Pharma helped increase the use of these drugs by introducing OxyContin - oxycodone with a time-release mechanism. Oncologists and pain doctors were the principal prescribers of opioids. But Purdue introduced the drug with an aggressive marketing campaign promoting OxyContin to general practitioners and the idea of opioid pain relief to doctors and consumers. The product's time-release mechanism, Purdue claimed, allowed steadier pain relief and deterred abuse.Many pain sufferers found that OxyContin gave them better relief than they ever had before. But Purdue misrepresented the drug's potential for abuse. Last month, the company and three of its executives pleaded guilty to federal charges that they misled doctors and patients. The company agreed to pay $600 million in fines; and the executives, a total of $34.5 million. The pill's time-release mechanism turned out to be easily circumvented by crushing the pill and snorting or injecting the resulting powder. By the late 1990s, OxyContin abuse was devastating small towns throughout Appalachia and rural New England. Pharmaceuticals, mainly opioids, are still widely abused - now more so than any illegal drug except marijuana. In 2005, according to the government's National Survey on Drug Use and Health, 6.4 million Americans, many of them teenagers, had abused pharmaceuticals recently. Most got the drug from friends or family - often, in the case of teenagers, from their parents' medicine cabinets.
At the time the OxyContin epidemic emerged, the D.E.A. had far more experience seizing illegal drugs like cocaine and heroin. According to Mark Caverly, the head of the liaison and policy section for the D.E.A.\'s Office of Diversion Control, the OxyContin epidemic, however, required the agency to step up its antidiversion efforts. In 2001 the D.E.A. established the OxyContin Action Plan. The D.E.A. dispatched investigators to the most troubled states and trained local law-enforcement officials.\u003cbr /\>\u003cbr /\>The basis of the physician-patient relationship is trust. Trust is especially valued by pain patients, who often have long experience of being treated like criminals or hysterics. But when prescribing opioids, a physician\'s trust is easily abused. Pain doctors dispense drugs with a high street value that are attractive to addicts. All pain doctors encounter scammers; some doctors estimate that as many as 20 percent of their patients are selling their medicine or are addicted to opioids or other drugs. Experts are virtually unanimous in agreeing that even addicts who are suffering pain can be successfully treated with opioids. Indeed, opioids can be lifesaving for addicts - witness the methadone maintenance therapy given to heroin addicts. But treating addicts requires extra care.\u003cbr /\>\u003cbr /\>Identifying the scammers is especially tricky because there is no objective test for pain - it doesn\'t show up on an X-ray. In one British study, half the respondents who complained of lower-back pain had normal M.R.I.\'s. Conversely, a third of those with no pain showed disk degeneration on their M.R.I.\'s. The study suggested there could be a profound disconnection between what an M.R.I. sees and what a patient feels.\u003cbr /\>\u003cbr /\>There are red flags that indicate possible abuse or diversion: patients who drive long distances to see the doctor, or ask for specific drugs by name, or claim to need more and more of them. But people with real pain also occasionally do these things. The doctor\'s dilemma is how to stop the diverters without condemning other patients to suffer unnecessarily, since a drug diverter and a legitimate patient can look very much alike. The dishonest prescriber and the honest one can also look alike. Society has a parallel dilemma: how to stop drug-dealing doctors without discouraging real ones and worsening America\'s undertreatment of pain.\u003cbr /\>",1]
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At the time the OxyContin epidemic emerged, the D.E.A. had far more experience seizing illegal drugs like cocaine and heroin. According to Mark Caverly, the head of the liaison and policy section for the D.E.A.'s Office of Diversion Control, the OxyContin epidemic, however, required the agency to step up its antidiversion efforts. In 2001 the D.E.A. established the OxyContin Action Plan. The D.E.A. dispatched investigators to the most troubled states and trained local law-enforcement officials.The basis of the physician-patient relationship is trust. Trust is especially valued by pain patients, who often have long experience of being treated like criminals or hysterics. But when prescribing opioids, a physician's trust is easily abused. Pain doctors dispense drugs with a high street value that are attractive to addicts. All pain doctors encounter scammers; some doctors estimate that as many as 20 percent of their patients are selling their medicine or are addicted to opioids or other drugs. Experts are virtually unanimous in agreeing that even addicts who are suffering pain can be successfully treated with opioids. Indeed, opioids can be lifesaving for addicts - witness the methadone maintenance therapy given to heroin addicts. But treating addicts requires extra care.Identifying the scammers is especially tricky because there is no objective test for pain - it doesn't show up on an X-ray. In one British study, half the respondents who complained of lower-back pain had normal M.R.I.'s. Conversely, a third of those with no pain showed disk degeneration on their M.R.I.'s. The study suggested there could be a profound disconnection between what an M.R.I. sees and what a patient feels.There are red flags that indicate possible abuse or diversion: patients who drive long distances to see the doctor, or ask for specific drugs by name, or claim to need more and more of them. But people with real pain also occasionally do these things. The doctor's dilemma is how to stop the diverters without condemning other patients to suffer unnecessarily, since a drug diverter and a legitimate patient can look very much alike. The dishonest prescriber and the honest one can also look alike. Society has a parallel dilemma: how to stop drug-dealing doctors without discouraging real ones and worsening America's undertreatment of pain.
In July 2002, an insurance agent was sifting through records in Columbia, S.C., and paused at the file of one Larry Shealy. Shealy was getting OxyContin from a doctor named Ronald McIver - a lot of it. "The amounts were incredible; it jumped out in my face," the agent, who spoke on condition of anonymity, told me. "He was either selling them or taking so much he couldn\'t live." The agent did two things. He recommended to Shealy\'s employers that they exclude OxyContin coverage from their health insurance plan - which they did. And he called the D.E.A. Two days later, a D.E.A. agent showed up in the insurance agent\'s office with an administrative subpoena to collect Shealy\'s file.\u003cbr /\>\u003cbr /\>McIver wanted to be a doctor all his life, two of his daughters told me. But he taught and traveled for years before he finally enrolled at Michigan State University to become a D.O., or doctor of osteopathy, a more holistic alternative to a traditional medical education. (Osteopaths can do everything that traditional M.D.\'s can do, including prescribe opioids.) He began practicing pain medicine in the late 1980s. He had a practice in Florence, S.C., which ended when he declared bankruptcy in 2000. He moved to Greenwood to start over, establishing his new office in a storefront next to a chiropractor.\u003cbr /\>\u003cbr /\>McIver was, by the account of his patients, an unusual doctor in the age of the 10-minute managed-care visit. He usually saw about 6 to 12 patients each day. One patient I spoke with - who never got high-dose opioids - said that his first visit with McIver lasted four hours, and in subsequent visits he spent an hour or more doing various therapies. Many patients said their visits lasted an hour. Patients taking opioids had to sign a pain contract and bring their pills in at each visit to be counted.\u003cbr /\>\u003cbr /\>Many doctors take little interest in the administrative side of their practices, but McIver\'s neglect was epic. To save money, he employed mostly family. His wife, Carolyn, whose only medical training was from her husband, served as his assistant, giving shots and administering therapies. "His doctor\'s office did not resemble my family\'s doctor\'s office," said Sgt. Bobby Grogan, who was the investigator on the case for the Greenwood County Sheriff. While McIver\'s treatment rooms were normal, his and his wife\'s offices - off limits to patients - were a mess, according to pictures presented at McIver\'s trial by Adam Roberson, the D.E.A.\'s principal investigator. Used syringes, for example, overflowed their storage box. "His patient records were manila envelopes stuffed with receipts," Grogan told me.\u003cbr /\>",1]
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In July 2002, an insurance agent was sifting through records in Columbia, S.C., and paused at the file of one Larry Shealy. Shealy was getting OxyContin from a doctor named Ronald McIver - a lot of it. "The amounts were incredible; it jumped out in my face," the agent, who spoke on condition of anonymity, told me. "He was either selling them or taking so much he couldn't live." The agent did two things. He recommended to Shealy's employers that they exclude OxyContin coverage from their health insurance plan - which they did. And he called the D.E.A. Two days later, a D.E.A. agent showed up in the insurance agent's office with an administrative subpoena to collect Shealy's file.McIver wanted to be a doctor all his life, two of his daughters told me. But he taught and traveled for years before he finally enrolled at Michigan State University to become a D.O., or doctor of osteopathy, a more holistic alternative to a traditional medical education. (Osteopaths can do everything that traditional M.D.'s can do, including prescribe opioids.) He began practicing pain medicine in the late 1980s. He had a practice in Florence, S.C., which ended when he declared bankruptcy in 2000. He moved to Greenwood to start over, establishing his new office in a storefront next to a chiropractor.McIver was, by the account of his patients, an unusual doctor in the age of the 10-minute managed-care visit. He usually saw about 6 to 12 patients each day. One patient I spoke with - who never got high-dose opioids - said that his first visit with McIver lasted four hours, and in subsequent visits he spent an hour or more doing various therapies. Many patients said their visits lasted an hour. Patients taking opioids had to sign a pain contract and bring their pills in at each visit to be counted.Many doctors take little interest in the administrative side of their practices, but McIver's neglect was epic. To save money, he employed mostly family. His wife, Carolyn, whose only medical training was from her husband, served as his assistant, giving shots and administering therapies. "His doctor's office did not resemble my family's doctor's office," said Sgt. Bobby Grogan, who was the investigator on the case for the Greenwood County Sheriff. While McIver's treatment rooms were normal, his and his wife's offices - off limits to patients - were a mess, according to pictures presented at McIver's trial by Adam Roberson, the D.E.A.'s principal investigator. Used syringes, for example, overflowed their storage box. "His patient records were manila envelopes stuffed with receipts," Grogan told me.
When I interviewed him in prison recently, McIver told me that his records were complete but scattered. He said that he and his wife, distracted by a series of family tragedies, had employed a series of temporary receptionists who had botched the filing. He and his wife were trying to piece them together. "The records were probably half in the office and half at home for me to work on at night," he said. "I kept a box in the back of the car I worked on while Carolyn drove."\u003cbr /\>\u003cbr /\>Leslie Smith first came to see McIver in the fall of 2001. Smith was in his mid-40s and lived in Chapin, a small town near Columbia, a 60-mile drive from Greenwood. He filled out a medical-history form and told McIver that his wrists hurt so badly that he was getting only three or four hours\' sleep a night. He also said that a previous doctor helped him by prescribing OxyContin, and he mentioned the name of a doctor he said referred him. McIver examined Smith\'s wrists. Smith walked out with an opioid prescription and an appointment to come back the next week.\u003cbr /\>\u003cbr /\>Smith\'s wrists did not hurt him, as he testified at McIver\'s trial. He was addicted to OxyContin and Dilaudid, which he injected. He complained of wrist pain because it was plausible: he had injured one wrist previously, requiring an operation that left scars, and he had arthritis in the other. Until June 2002, Smith kept getting prescriptions.\u003cbr /\>\u003cbr /\>Smith saw McIver every few weeks. He testified that he had track marks on his arm at the time but always wore long sleeves to cover them. He said McIver never saw them. McIver put him on an electric nerve stimulator every visit for 15 or 30 minutes on each hand and did osteopathic manipulations. He prescribed exercises. Smith bought a nerve-stimulator machine to use at home and told McIver it was helping. At McIver\'s request he filled out a pain chart and reported that his pain rated a 5 or 6 upon awakening, reached 7 during the day and occasionally hit 9. "I answered all the questions exactly like I thought he\'d want to hear them answered," Smith testified. At one point McIver found a syringe in Smith\'s pocket. Smith told McIver that he was going fishing later that day and that he used the syringe as part of his fishing equipment. That apparently satisfied McIver, who testified that his grandfather kept syringes in his tackle box to pump air into his bait.\u003cbr /\>",1]
);
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When I interviewed him in prison recently, McIver told me that his records were complete but scattered. He said that he and his wife, distracted by a series of family tragedies, had employed a series of temporary receptionists who had botched the filing. He and his wife were trying to piece them together. "The records were probably half in the office and half at home for me to work on at night," he said. "I kept a box in the back of the car I worked on while Carolyn drove."Leslie Smith first came to see McIver in the fall of 2001. Smith was in his mid-40s and lived in Chapin, a small town near Columbia, a 60-mile drive from Greenwood. He filled out a medical-history form and told McIver that his wrists hurt so badly that he was getting only three or four hours' sleep a night. He also said that a previous doctor helped him by prescribing OxyContin, and he mentioned the name of a doctor he said referred him. McIver examined Smith's wrists. Smith walked out with an opioid prescription and an appointment to come back the next week.Smith's wrists did not hurt him, as he testified at McIver's trial. He was addicted to OxyContin and Dilaudid, which he injected. He complained of wrist pain because it was plausible: he had injured one wrist previously, requiring an operation that left scars, and he had arthritis in the other. Until June 2002, Smith kept getting prescriptions.Smith saw McIver every few weeks. He testified that he had track marks on his arm at the time but always wore long sleeves to cover them. He said McIver never saw them. McIver put him on an electric nerve stimulator every visit for 15 or 30 minutes on each hand and did osteopathic manipulations. He prescribed exercises. Smith bought a nerve-stimulator machine to use at home and told McIver it was helping. At McIver's request he filled out a pain chart and reported that his pain rated a 5 or 6 upon awakening, reached 7 during the day and occasionally hit 9. "I answered all the questions exactly like I thought he'd want to hear them answered," Smith testified. At one point McIver found a syringe in Smith's pocket. Smith told McIver that he was going fishing later that day and that he used the syringe as part of his fishing equipment. That apparently satisfied McIver, who testified that his grandfather kept syringes in his tackle box to pump air into his bait.
Smith filled some of his prescriptions at the Hawthorne Pharmacy in West Columbia. There, Addison Livingston, the pharmacist, got suspicious. He noticed that Smith sometimes came in with other patients of McIver\'s, despite the fact that McIver worked nearly two hours\' drive away. The patients obviously knew each other and would pick up large opioid prescriptions, paying cash and asking for brand-name drugs. Livingston called McIver, who confirmed he had written the prescriptions. At one point, McIver told Livingston that he, too, was suspicious, and that he had sent a letter about Smith to the state\'s Bureau of Drug Control.\u003cbr /\>\u003cbr /\>In February 2002, McIver wrote to Larry McElrath, a B.D.C. inspector, who read the letter at the trial. "Dear Larry," it read, "There are several people out of the Columbia/Chapin area who have aroused my curiosity about their use and possible misuse of medications. Some are referred by [another doctor] and seem legitimate. . . . They all pay cash despite some of them having insurance with prescription cards. . . . When they are in the office, they sometimes make a show of not knowing each other. . . . The situation is made complicated by the fact that each has some real pathology with objective findings that would justify the use of opiates if their pains are as bad as they say. I have given them the benefit of the doubt, but I\'m becoming less inclined to do so. I would appreciate it if you could make some discrete inquiries and let me know whether my concerns are justified. . . . I certainly don\'t want to refuse help to someone who needs it. On the other hand, I want even less to be implicated in diversion or other improprieties." He listed their names and Social Security numbers.\u003cbr /\>\u003cbr /\>McElrath did nothing with the letter. "It\'s incumbent upon the physician to have a trust with his patients," McElrath testified at the trial. "Here there was nothing that I could assume or conclude that any crimes had been committed."\u003cbr /\>\u003cbr /\>Smith was the most damning of the several patients who testified against McIver. (Smith and the other patients mentioned here did not agree to be interviewed for this article, as they are suing McIver for alleged overprescription of addictive drugs. Such suits often prosper after successful criminal convictions, as civil suits are easier to win.) Smith had a confederate in Seth Boyer, who lived in Chapin and followed a similar pattern in his dealings with McIver: he exaggerated pains in his foot, never provided records from a previous doctor and had needle tracks that he later testified McIver never saw. At one point, Boyer told McIver that he had spilled a bottle of liquid OxyFast, another opioid. (In reality, Boyer had injected it.) McIver wrote him a prescription for a replacement - apparently a violation of his standard pain-medication contract, which had a "no early refills" stipulation.\u003cbr /\>",1]
);
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Smith filled some of his prescriptions at the Hawthorne Pharmacy in West Columbia. There, Addison Livingston, the pharmacist, got suspicious. He noticed that Smith sometimes came in with other patients of McIver's, despite the fact that McIver worked nearly two hours' drive away. The patients obviously knew each other and would pick up large opioid prescriptions, paying cash and asking for brand-name drugs. Livingston called McIver, who confirmed he had written the prescriptions. At one point, McIver told Livingston that he, too, was suspicious, and that he had sent a letter about Smith to the state's Bureau of Drug Control.In February 2002, McIver wrote to Larry McElrath, a B.D.C. inspector, who read the letter at the trial. "Dear Larry," it read, "There are several people out of the Columbia/Chapin area who have aroused my curiosity about their use and possible misuse of medications. Some are referred by [another doctor] and seem legitimate. . . . They all pay cash despite some of them having insurance with prescription cards. . . . When they are in the office, they sometimes make a show of not knowing each other. . . . The situation is made complicated by the fact that each has some real pathology with objective findings that would justify the use of opiates if their pains are as bad as they say. I have given them the benefit of the doubt, but I'm becoming less inclined to do so. I would appreciate it if you could make some discrete inquiries and let me know whether my concerns are justified. . . . I certainly don't want to refuse help to someone who needs it. On the other hand, I want even less to be implicated in diversion or other improprieties." He listed their names and Social Security numbers.McElrath did nothing with the letter. "It's incumbent upon the physician to have a trust with his patients," McElrath testified at the trial. "Here there was nothing that I could assume or conclude that any crimes had been committed."Smith was the most damning of the several patients who testified against McIver. (Smith and the other patients mentioned here did not agree to be interviewed for this article, as they are suing McIver for alleged overprescription of addictive drugs. Such suits often prosper after successful criminal convictions, as civil suits are easier to win.) Smith had a confederate in Seth Boyer, who lived in Chapin and followed a similar pattern in his dealings with McIver: he exaggerated pains in his foot, never provided records from a previous doctor and had needle tracks that he later testified McIver never saw. At one point, Boyer told McIver that he had spilled a bottle of liquid OxyFast, another opioid. (In reality, Boyer had injected it.) McIver wrote him a prescription for a replacement - apparently a violation of his standard pain-medication contract, which had a "no early refills" stipulation.
But McIver ended up discharging Boyer in June 2002, when Boyer altered a prescription so he could fill it three days early. He wrote McIver three pleading letters of protest, to no avail. "I was looking for an excuse to discharge them, and with Seth I found it," McIver told me. "I needed more than suspicion. With Les, he never actually did anything that allowed me to say, \'O.K., here\'s that concrete piece of evidence.\' "\u003cbr /\>\u003cbr /\>McIver may have felt he needed more proof, but medically he probably had enough. Pain specialists told me that doctors can stop prescribing a drug whenever the risks outweigh the benefits, which includes the risk of abuse.\u003cbr /\>\u003cbr /\>Another drug-dealing patient of McIver\'s was Kyle Barnes. She testified that she suffered from fibromyalgia, a chronic-pain syndrome, but exaggerated her pain to get higher levels of OxyContin and Roxicodone. She was addicted to those drugs before she began seeing McIver in July 2001. She also brought no medical records and drove three hours to each appointment. She got prescriptions on her second visit, during which McIver also did osteopathic manipulations and massage.\u003cbr /\>\u003cbr /\>Barnes was in real pain. McIver did several different therapies at each visit. He set up an appointment for her at a sleep clinic, sent her for X-rays and put a cast on her wrist. He knew she had trouble paying for her medicines, and he contacted Purdue Pharma to see if she qualified for reduced-price drugs. She kept claiming the drugs were not helping enough and was soon taking 16 times the dose of OxyContin she took when she first saw him. One tip-off in her case should have been that she paid thousands of dollars a month in cash for her prescriptions, even though she was on Medicaid. She told McIver that her father and boyfriend were helping her buy them, which she later testified was partly true. But most of her income came from selling some of the drugs he prescribed, she testified. In December 2003, McIver told her that he would stop treating her unless she took a drug screen. She did nothing. Three weeks later he told her again. She never returned.\u003cbr /\>",1]
);
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But McIver ended up discharging Boyer in June 2002, when Boyer altered a prescription so he could fill it three days early. He wrote McIver three pleading letters of protest, to no avail. "I was looking for an excuse to discharge them, and with Seth I found it," McIver told me. "I needed more than suspicion. With Les, he never actually did anything that allowed me to say, 'O.K., here's that concrete piece of evidence.' "McIver may have felt he needed more proof, but medically he probably had enough. Pain specialists told me that doctors can stop prescribing a drug whenever the risks outweigh the benefits, which includes the risk of abuse.Another drug-dealing patient of McIver's was Kyle Barnes. She testified that she suffered from fibromyalgia, a chronic-pain syndrome, but exaggerated her pain to get higher levels of OxyContin and Roxicodone. She was addicted to those drugs before she began seeing McIver in July 2001. She also brought no medical records and drove three hours to each appointment. She got prescriptions on her second visit, during which McIver also did osteopathic manipulations and massage.Barnes was in real pain. McIver did several different therapies at each visit. He set up an appointment for her at a sleep clinic, sent her for X-rays and put a cast on her wrist. He knew she had trouble paying for her medicines, and he contacted Purdue Pharma to see if she qualified for reduced-price drugs. She kept claiming the drugs were not helping enough and was soon taking 16 times the dose of OxyContin she took when she first saw him. One tip-off in her case should have been that she paid thousands of dollars a month in cash for her prescriptions, even though she was on Medicaid. She told McIver that her father and boyfriend were helping her buy them, which she later testified was partly true. But most of her income came from selling some of the drugs he prescribed, she testified. In December 2003, McIver told her that he would stop treating her unless she took a drug screen. She did nothing. Three weeks later he told her again. She never returned.
Another patient whose story was particularly troubling was Barbee Brown. Brown was not a drug seeker but a genuine pain patient seeking relief from Reflex Sympathetic Dystrophy. McIver gave her very high doses of OxyContin right away, before she produced any records from other doctors. This was especially disturbing, because she had been addicted to crack cocaine for three months in the year before she came to him.\u003cbr /\>\u003cbr /\>Brown saw McIver at least twice a week for six weeks. He did a thorough physical exam and took a complete history. He used many different kinds of therapies. But he also started her - someone who had never taken opioids - on 40-milligram pills of OxyContin and allowed her to control her own dosing schedule. "As long as you are not having side effects, do not be afraid to take the doses you need to get out of pain," he wrote to her. It was the same advice he gave many patients. "The number of milligrams does not matter. What matters is the number on the 0-to-10 scale."\u003cbr /\>\u003cbr /\>The medicine helped. Brown testified that she ranked her pain at 9 or 10 when she first got to McIver. After seeing him, it dropped to a 4. Her pain diary, which appears to be sincere, had various passages giving thanks that she met McIver. Brown did not become addicted. But allowing an opioid-naïve recovering crack addict to start on high-dose pills and control her own dosage, and telling her that her dosage didn\'t matter, seems reckless.\u003cbr /\>\u003cbr /\>McIver\'s 30-year sentence was the result of the death of Larry Shealy, a 56-year-old man who suffered intense back and knee pain, in addition to many other health problems. He first came to see McIver in February 2002, with full referrals and records. He was on OxyContin before seeing McIver but complained that his pain was still terrible, so McIver doubled his dose. This allowed Shealy to go back to work in an auto body shop.\u003cbr /\>\u003cbr /\>Shealy was not a careful patient. A month after he started with McIver, he took 15 OxyContin tablets in one day instead of the 6 he was prescribed. He was not harmed, but McIver testified that he asked Shealy to bring his family in so he could explain the dosing to them. At one point, McIver tried to taper down the OxyContin and replace it with methadone, but Shealy complained that the methadone made him drowsy. Shealy\'s son, David, an auto mechanic, testified that the OxyContin pain relief also came at a price. He said he felt his father was overmedicated - often sleepy. Once, his father backed his truck into a tree.\u003cbr /\>",1]
);
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Another patient whose story was particularly troubling was Barbee Brown. Brown was not a drug seeker but a genuine pain patient seeking relief from Reflex Sympathetic Dystrophy. McIver gave her very high doses of OxyContin right away, before she produced any records from other doctors. This was especially disturbing, because she had been addicted to crack cocaine for three months in the year before she came to him.Brown saw McIver at least twice a week for six weeks. He did a thorough physical exam and took a complete history. He used many different kinds of therapies. But he also started her - someone who had never taken opioids - on 40-milligram pills of OxyContin and allowed her to control her own dosing schedule. "As long as you are not having side effects, do not be afraid to take the doses you need to get out of pain," he wrote to her. It was the same advice he gave many patients. "The number of milligrams does not matter. What matters is the number on the 0-to-10 scale."The medicine helped. Brown testified that she ranked her pain at 9 or 10 when she first got to McIver. After seeing him, it dropped to a 4. Her pain diary, which appears to be sincere, had various passages giving thanks that she met McIver. Brown did not become addicted. But allowing an opioid-naïve recovering crack addict to start on high-dose pills and control her own dosage, and telling her that her dosage didn't matter, seems reckless.McIver's 30-year sentence was the result of the death of Larry Shealy, a 56-year-old man who suffered intense back and knee pain, in addition to many other health problems. He first came to see McIver in February 2002, with full referrals and records. He was on OxyContin before seeing McIver but complained that his pain was still terrible, so McIver doubled his dose. This allowed Shealy to go back to work in an auto body shop.Shealy was not a careful patient. A month after he started with McIver, he took 15 OxyContin tablets in one day instead of the 6 he was prescribed. He was not harmed, but McIver testified that he asked Shealy to bring his family in so he could explain the dosing to them. At one point, McIver tried to taper down the OxyContin and replace it with methadone, but Shealy complained that the methadone made him drowsy. Shealy's son, David, an auto mechanic, testified that the OxyContin pain relief also came at a price. He said he felt his father was overmedicated - often sleepy. Once, his father backed his truck into a tree.
Shealy died in his sleep early on the morning of May 29, 2003. He had OxyContin pills in his stomach, and his bloodstream contained alprazolam - Xanax - as well. The pathologist at McIver\'s trial testified that the levels of drugs were consistent with the prescriptions McIver had been writing - the high levels that so alarmed the insurance agent. Shealy was taking five 80-milligram tablets of OxyContin every 12 hours, plus up to six 30-milligram tablets of Roxicodone every 4 hours for breakthrough pain, plus as much as 2 milligrams of alprazolam every 8 hours. The prosecution\'s toxicologist, Demi Garvin, concluded that the OxyContin and Roxicodone caused Shealy\'s death by respiratory depression. The pathologist testified that she looked up this dosage and found it to be a fatal level.\u003cbr /\>\u003cbr /\>But there is reason for doubt. According to Shealy\'s prescriptions, he had been taking the same dosage for at least two months, and possibly much longer. Pain specialists say that respiratory depression is extremely unlikely when dosage is consistent. In her testimony, Garvin agreed that what would be a toxic level in an opioid-naïve patient would be safe for someone titrated up properly. But she said she could not conclude he had been properly titrated, in part because she had not seen his medical records. Garvin declined to talk about the Shealy case with me because she is a witness for the Shealy family in their planned civil suit against McIver. But in a deposition for that lawsuit, she appeared to back away from blaming the OxyContin. She described her view as: "Hey, there\'s a red flag here. This can certainly be your cause of death, but you need to go further in exploring whether or not it is."\u003cbr /\>\u003cbr /\>There was something else that might have caused Shealy\'s death: he suffered from advanced congestive heart failure. The pathologist testified that he had 90 percent blockage in one coronary artery and 50 percent in another, and a greatly enlarged heart and other organs. He had a scar on the back wall of his heart that indicated he at one time suffered a heart attack. Opioids do not worsen heart disease and would likely have helped, because pain causes stress to the heart.\u003cbr /\>",1]
);
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Shealy died in his sleep early on the morning of May 29, 2003. He had OxyContin pills in his stomach, and his bloodstream contained alprazolam - Xanax - as well. The pathologist at McIver's trial testified that the levels of drugs were consistent with the prescriptions McIver had been writing - the high levels that so alarmed the insurance agent. Shealy was taking five 80-milligram tablets of OxyContin every 12 hours, plus up to six 30-milligram tablets of Roxicodone every 4 hours for breakthrough pain, plus as much as 2 milligrams of alprazolam every 8 hours. The prosecution's toxicologist, Demi Garvin, concluded that the OxyContin and Roxicodone caused Shealy's death by respiratory depression. The pathologist testified that she looked up this dosage and found it to be a fatal level.But there is reason for doubt. According to Shealy's prescriptions, he had been taking the same dosage for at least two months, and possibly much longer. Pain specialists say that respiratory depression is extremely unlikely when dosage is consistent. In her testimony, Garvin agreed that what would be a toxic level in an opioid-naïve patient would be safe for someone titrated up properly. But she said she could not conclude he had been properly titrated, in part because she had not seen his medical records. Garvin declined to talk about the Shealy case with me because she is a witness for the Shealy family in their planned civil suit against McIver. But in a deposition for that lawsuit, she appeared to back away from blaming the OxyContin. She described her view as: "Hey, there's a red flag here. This can certainly be your cause of death, but you need to go further in exploring whether or not it is."There was something else that might have caused Shealy's death: he suffered from advanced congestive heart failure. The pathologist testified that he had 90 percent blockage in one coronary artery and 50 percent in another, and a greatly enlarged heart and other organs. He had a scar on the back wall of his heart that indicated he at one time suffered a heart attack. Opioids do not worsen heart disease and would likely have helped, because pain causes stress to the heart.
The testimonies of the patients Smith, Boyer and Barnes were the parts of the trial that most directly addressed the question of whether McIver intentionally wrote prescriptions for a nonmedical purpose. This is the relevant legal test for the statute under which he was prosecuted. Several Supreme Court and district court cases have made it clear that under the Controlled Substances Act, a doctor is guilty of a crime if he intentionally acts as a drug pusher.\u003cbr /\>\u003cbr /\>The judge in the McIver case, Henry F. Floyd, told the jurors that bad prescribing is the standard for malpractice, a civil matter. "That is not what we are talking about," he said. "We\'re not talking about this physician acting better or worse than other physicians." If McIver was a bad doctor - but still a doctor, with intent to treat patients - he was innocent. "If you find that a defendant acted in good faith in dispensing the drugs charged in this indictment, then you must find that defendant not guilty," Floyd said. But Floyd also told the jury to take bad doctoring into account in deciding McIver\'s intent.\u003cbr /\>\u003cbr /\>This instruction - that bad doctoring does not prove intent but could be considered when weighing his intent - is subtle and potentially extremely confusing. It apparently confused the jurors. I spoke to two jurors, who told me their own views and characterized the jury discussion. The overwhelming factor, they said, was that McIver prescribed too much - the very red flag that alerted the insurance agent and set the case in motion.\u003cbr /\>\u003cbr /\>The jurors I spoke with said that by far the most important testimony came from Steven Storick, a pain-management doctor in Columbia and the government\'s expert witness. Reviewing the records of patient after patient, Storick consistently testified that there were too many drugs. "This amount of medication is just extremely high in a situation like this," he said of one patient. This is "excessive," he said of another. "That\'s just an extremely high dose of drug," he said of a third. Storick, who declined to be interviewed for this article, testified that if he had a patient who exhibited no objective evidence of pain, he would not prescribe opioids. He would not have titrated patients as rapidly as McIver did or given them discretion. He disagreed with McIver\'s position that a doctor should try to bring a patient\'s chronic pain down to a level of 2. He would stop titrating when a patient reached 5 out of 10.\u003cbr /\>\u003cbr /\>The jurors took Storick\'s caution to heart, in part, they told me, because it resonated with their own experience with opioids and fears of addiction. I asked Jo Handy, a tall, elegant woman who is now 39 and a real estate agent outside Greenville, why McIver was convicted. "It was the excessive prescriptions," she said in a\u003cbr /\>\u003cbr /\>\u003cbr /\>\u003c/div\>",0]
);
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The testimonies of the patients Smith, Boyer and Barnes were the parts of the trial that most directly addressed the question of whether McIver intentionally wrote prescriptions for a nonmedical purpose. This is the relevant legal test for the statute under which he was prosecuted. Several Supreme Court and district court cases have made it clear that under the Controlled Substances Act, a doctor is guilty of a crime if he intentionally acts as a drug pusher.The judge in the McIver case, Henry F. Floyd, told the jurors that bad prescribing is the standard for malpractice, a civil matter. "That is not what we are talking about," he said. "We're not talking about this physician acting better or worse than other physicians." If McIver was a bad doctor - but still a doctor, with intent to treat patients - he was innocent. "If you find that a defendant acted in good faith in dispensing the drugs charged in this indictment, then you must find that defendant not guilty," Floyd said. But Floyd also told the jury to take bad doctoring into account in deciding McIver's intent.This instruction - that bad doctoring does not prove intent but could be considered when weighing his intent - is subtle and potentially extremely confusing. It apparently confused the jurors. I spoke to two jurors, who told me their own views and characterized the jury discussion. The overwhelming factor, they said, was that McIver prescribed too much - the very red flag that alerted the insurance agent and set the case in motion.The jurors I spoke with said that by far the most important testimony came from Steven Storick, a pain-management doctor in Columbia and the government's expert witness. Reviewing the records of patient after patient, Storick consistently testified that there were too many drugs. "This amount of medication is just extremely high in a situation like this," he said of one patient. This is "excessive," he said of another. "That's just an extremely high dose of drug," he said of a third. Storick, who declined to be interviewed for this article, testified that if he had a patient who exhibited no objective evidence of pain, he would not prescribe opioids. He would not have titrated patients as rapidly as McIver did or given them discretion. He disagreed with McIver's position that a doctor should try to bring a patient's chronic pain down to a level of 2. He would stop titrating when a patient reached 5 out of 10.The jurors took Storick's caution to heart, in part, they told me, because it resonated with their own experience with opioids and fears of addiction. I asked Jo Handy, a tall, elegant woman who is now 39 and a real estate agent outside Greenville, why McIver was convicted. "It was the excessive prescriptions," she said in a
Grey Literature Report (Vol. 9, No. 3, May 2007)
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The Grey Literature Team
The New York Academy of Medicine
NGA Center for Best Practices
Integrating schools into healthy community design - 2007
Office of Applied Studies, Substance Abuse and Mental Health Service Administration, Dept. of Health & Human Services
Depression and the initiation of alcohol and other drug use among youths aged 12 to 17 - 2007
Heroin, changes in how it is used : 1995-2005 - 2007
Hispanic female admissions in substance abuse treatment : 2005 - 2007
Patterns and trends in inhalant use by adolescent males and females : 2002-2005 - 2007
Patterns and trends in nonmedical prescription pain reliever use : 2002 to 2005 - 2007
Primary alcohol admissions aged 21 or older : alcohol only vs alcohol plus a secondary drug : 2005 - 2007
Religious involvement and substance use among adults - 2007
Sexually transmitted diseases and substance use - 2007
Use of marijuana and blunts among adolescents : 2005 - 2007
Youth activities, substance use, and family income - 2007
Older Women's League
best optical illusions of 2007
http://illusioncontest.neuralcorrelate.com/index.php?module=pagemaster&PAGE_user_op=view_page&PAGE_id=114
Wednesday
New Research Shows Supervised Drug Injection Sites Work
http://www.drugpolicy.org/news/053107vancouver.cfm
New Research Shows Supervised Drug Injection Sites Work
Thursday, May 31, 2007
New research indicates that Vancouver's safe injection site, Insite,
is getting more people into treatment without increasing drug use.
Tony Newman, communications director for the Drug Policy Alliance,
offers his thoughts.
What should be done about the millions of people in the United States
and around the world who inject heroin and other drugs? For 30-plus
years, the U.S. has pushed a war on drugs that is more accurately a
war on drug users. This war on drugs has not delivered on its promise
to keep drugs off our streets or prevent people from using, but it has
filled our prisons beyond capacity and led to far too many cases of
HIV/AIDS related to sharing contaminated needles.
Vancouver, Canada, adopted a different approach to deal with their
city’s problems associated with injection drug use. In 2003, the city
established a clean injection site where users can take their drugs in
a sterile environment, and under the supervision of clinical staff.
The rationale is that as much as we don’t want people shooting up
drugs, some—-often society’s most marginalized—-inevitably will.
There are three likely settings for injection drug use: 1) public
places like parks and street corners; 2) "shooting galleries" that are
often dirty, violent, controlled by drug dealers, and conducive to the
sharing of dirty needles; and 3) safe, clean facilities under the
supervision of nurses and public health officials. Aside from making
sure people are using clean needles and are not overdosing, health
professionals can use the opportunity to provide treatment options
designed to curb and eventually eliminate the use of drugs.
So what are the results of Vancouver’s strategy? A study released on
Friday in the esteemed British journal Addiction found that not only
is the Vancouver injection site accomplishing the goals of reducing
public drug use, cutting down on the spread of HIV/AIDS and overdose
deaths, but is also a bridge helping people get into treatment. The
study found that the city’s supervised injection site increased the
rate of addicts entering detox by 30 percent. The study confirmed that
all of these concrete benefits are happening without increasing drug
use. Similar findings were reported in studies of safer injection
rooms in Germany, Switzerland and Australia. Despite these encouraging
results, the supervised injection backers worry that the recently
elected Conservative leadership in Canada will terminate the
successful program by year’s end.
While some may hope and pray for a "drug free society," the reality is
that there will always be some who will find their way to drugs. We
need to do everything we can to make treatment available to heroin
users and everyone trying to quit drugs. But we should also study what
Vancouver and other countries are exploring. We need to find ways to
reduce the death, disease, crime and suffering of people who are
unwilling or unable to stop.
New Research Shows Supervised Drug Injection Sites Work
DPA Awards Rapid Response Grants for Work on Civil Liberties and Medical Marijuana Access
California Legislators Show Support for Treatment-vs-Incarceration
New Research Shows Supervised Drug Injection Sites Work
Tony Newman, communications director for the Drug Policy Alliance, offers his thoughts on Vancouver's safe injection site, Insite.
What should be done about the millions of people in the United States and around the world who inject heroin and other drugs? For 30-plus years, the U.S. has pushed a war on drugs that is more accurately a war on drug users. This war on drugs has not delivered on its promise to keep drugs off our streets or prevent people from using, but it has filled our prisons beyond capacity and led to far too many cases of HIV/AIDS related to sharing contaminated needles.
Vancouver, Canada, adopted a different approach to deal with their city's problems associated with injection drug use. In 2003, the city established a clean injection site where users can take their drugs in a sterile environment, and under the supervision of clinical staff. The rationale is that as much as we don't want people shooting up drugs, some--often society's most marginalized--inevitably will.
There are three likely settings for injection drug use: 1) public places like parks and street corners; 2) "shooting galleries" that are often dirty, violent, controlled by drug dealers, and conducive to the sharing of dirty needles; and 3) safe, clean facilities under the supervision of nurses and public health officials. Aside from making sure people are using clean needles and are not overdosing, health professionals can use the opportunity to provide treatment options designed to curb and eventually eliminate the use of drugs.
So what are the results of Vancouver's strategy? A study released on Friday in the esteemed British journal Addiction found that not only is the Vancouver injection site accomplishing the goals of reducing public drug use, cutting down on the spread of HIV/AIDS and overdose deaths, but is also a bridge helping people get into treatment. The study found that the city's supervised injection site increased the rate of addicts entering detox by 30 percent. The study confirmed that all of these concrete benefits are happening without increasing drug use. Similar findings were reported in studies of safer injection rooms in Germany, Switzerland and Australia. Despite these encouraging results, the supervised injection backers worry that the recently elected Conservative leadership in Canada will terminate the successful program by year's end.
While some may hope and pray for a "drug free society," the reality is that there will always be some who will find their way to drugs. We need to do everything we can to make treatment available to heroin users and everyone trying to quit drugs. But we should also study what Vancouver and other countries are exploring. We need to find ways to reduce the death, disease, crime and suffering of people who are unwilling or unable to stop.
New Research Shows Supervised Drug Injection Sites Work
Thursday, May 31, 2007
New research indicates that Vancouver's safe injection site, Insite,
is getting more people into treatment without increasing drug use.
Tony Newman, communications director for the Drug Policy Alliance,
offers his thoughts.
What should be done about the millions of people in the United States
and around the world who inject heroin and other drugs? For 30-plus
years, the U.S. has pushed a war on drugs that is more accurately a
war on drug users. This war on drugs has not delivered on its promise
to keep drugs off our streets or prevent people from using, but it has
filled our prisons beyond capacity and led to far too many cases of
HIV/AIDS related to sharing contaminated needles.
Vancouver, Canada, adopted a different approach to deal with their
city’s problems associated with injection drug use. In 2003, the city
established a clean injection site where users can take their drugs in
a sterile environment, and under the supervision of clinical staff.
The rationale is that as much as we don’t want people shooting up
drugs, some—-often society’s most marginalized—-inevitably will.
There are three likely settings for injection drug use: 1) public
places like parks and street corners; 2) "shooting galleries" that are
often dirty, violent, controlled by drug dealers, and conducive to the
sharing of dirty needles; and 3) safe, clean facilities under the
supervision of nurses and public health officials. Aside from making
sure people are using clean needles and are not overdosing, health
professionals can use the opportunity to provide treatment options
designed to curb and eventually eliminate the use of drugs.
So what are the results of Vancouver’s strategy? A study released on
Friday in the esteemed British journal Addiction found that not only
is the Vancouver injection site accomplishing the goals of reducing
public drug use, cutting down on the spread of HIV/AIDS and overdose
deaths, but is also a bridge helping people get into treatment. The
study found that the city’s supervised injection site increased the
rate of addicts entering detox by 30 percent. The study confirmed that
all of these concrete benefits are happening without increasing drug
use. Similar findings were reported in studies of safer injection
rooms in Germany, Switzerland and Australia. Despite these encouraging
results, the supervised injection backers worry that the recently
elected Conservative leadership in Canada will terminate the
successful program by year’s end.
While some may hope and pray for a "drug free society," the reality is
that there will always be some who will find their way to drugs. We
need to do everything we can to make treatment available to heroin
users and everyone trying to quit drugs. But we should also study what
Vancouver and other countries are exploring. We need to find ways to
reduce the death, disease, crime and suffering of people who are
unwilling or unable to stop.
New Research Shows Supervised Drug Injection Sites Work
DPA Awards Rapid Response Grants for Work on Civil Liberties and Medical Marijuana Access
California Legislators Show Support for Treatment-vs-Incarceration
New Research Shows Supervised Drug Injection Sites Work
Tony Newman, communications director for the Drug Policy Alliance, offers his thoughts on Vancouver's safe injection site, Insite.
What should be done about the millions of people in the United States and around the world who inject heroin and other drugs? For 30-plus years, the U.S. has pushed a war on drugs that is more accurately a war on drug users. This war on drugs has not delivered on its promise to keep drugs off our streets or prevent people from using, but it has filled our prisons beyond capacity and led to far too many cases of HIV/AIDS related to sharing contaminated needles.
Vancouver, Canada, adopted a different approach to deal with their city's problems associated with injection drug use. In 2003, the city established a clean injection site where users can take their drugs in a sterile environment, and under the supervision of clinical staff. The rationale is that as much as we don't want people shooting up drugs, some--often society's most marginalized--inevitably will.
There are three likely settings for injection drug use: 1) public places like parks and street corners; 2) "shooting galleries" that are often dirty, violent, controlled by drug dealers, and conducive to the sharing of dirty needles; and 3) safe, clean facilities under the supervision of nurses and public health officials. Aside from making sure people are using clean needles and are not overdosing, health professionals can use the opportunity to provide treatment options designed to curb and eventually eliminate the use of drugs.
So what are the results of Vancouver's strategy? A study released on Friday in the esteemed British journal Addiction found that not only is the Vancouver injection site accomplishing the goals of reducing public drug use, cutting down on the spread of HIV/AIDS and overdose deaths, but is also a bridge helping people get into treatment. The study found that the city's supervised injection site increased the rate of addicts entering detox by 30 percent. The study confirmed that all of these concrete benefits are happening without increasing drug use. Similar findings were reported in studies of safer injection rooms in Germany, Switzerland and Australia. Despite these encouraging results, the supervised injection backers worry that the recently elected Conservative leadership in Canada will terminate the successful program by year's end.
While some may hope and pray for a "drug free society," the reality is that there will always be some who will find their way to drugs. We need to do everything we can to make treatment available to heroin users and everyone trying to quit drugs. But we should also study what Vancouver and other countries are exploring. We need to find ways to reduce the death, disease, crime and suffering of people who are unwilling or unable to stop.
altruism and the brain
altruism and the brain
Proc Natl Acad Sci U S A. 2006 Oct 17;103(42):15623-8. Epub 2006 Oct 9.
Human fronto-mesolimbic networks guide decisions about charitable
donation.
Moll J, Krueger F, Zahn R, Pardini M, de Oliveira-Souza R, Grafman J.
Cognitive Neuroscience Section, National Institute of Neurological
Disorders and
Stroke, National Institutes of Health, Bethesda, MD 20892-1440, USA.
Humans often sacrifice material benefits to endorse or to oppose
societal
causes based on moral beliefs. Charitable donation behavior, which has
been the target of recent experimental economics studies, is an
outstanding contemporary manifestation of this ability. Yet the neural
bases of this unique aspect of human altruism, which extends beyond
interpersonal interactions, remain obscure. In this article, we use
functional magnetic resonance imaging while participants anonymously
donated to or opposed real charitable organizations related to major
societal causes. We show that the mesolimbic reward system is engaged by
donations in the same way as when monetary rewards are obtained.
Furthermore, medial orbitofrontal-subgenual and lateral orbitofrontal
areas, which also play key roles in more primitive mechanisms of social
attachment and aversion, specifically mediate decisions to donate or to
oppose societal causes. Remarkably, more anterior sectors of the
prefrontal cortex are distinctively recruited when altruistic choices
prevail over selfish material interests.
PMID: 17030808 [PubMed - indexed for MEDLINE]
http://www.washingtonpost.com/wp-dyn/content/article/2007/05/27/AR2007052701056_pf.html
>
> If It Feels Good to Be Good, It Might Be Only Natural
>
> By Shankar Vedantam
> Washington Post Staff Writer
> Monday, May 28, 2007; A01
>
>
> The e-mail came from the next room.
>
> "You gotta see this!" Jorge Moll had written. Moll and Jordan Grafman,
neuroscientists at the National Institutes of Health, had been scanning
the brains of volunteers as they were asked to think about a scenario
involving either donating a sum of money to charity or keeping it for
themselves.
>
> As Grafman read the e-mail, Moll came bursting in. The scientists
stared at each other. Grafman was thinking, "Whoa -- wait a minute!"
>
> The results were showing that when the volunteers placed the interests
of others before their own, the generosity activated a primitive part of
the brain that usually lights up in response to food or sex. Altruism,
the experiment suggested, was not a superior moral faculty that
suppresses basic selfish urges but rather was basic to the brain,
hard-wired and pleasurable.
>
> Their 2006 finding that unselfishness can feel good lends scientific
support to the admonitions of spiritual leaders such as Saint Francis of
Assisi, who said, "For it is in giving that we receive." But it is also
a dramatic example of the way neuroscience has begun to elbow its way
into discussions about morality and has opened up a new window on what
it means to be good.
>
> Grafman and others are using brain imaging and psychological
experiments to study whether the brain has a built-in moral compass. The
results -- many of them published just in recent months -- are showing,
unexpectedly, that many aspects of morality appear to be hard-wired in
the brain, most likely the result of evolutionary processes that began
in other species.
>
> No one can say whether giraffes and lions experience moral qualms in
the same way people do because no one has been inside a giraffe's head,
but it is known that animals can sacrifice their own interests: One
experiment found that if each time a rat is given food, its neighbor
receives an electric shock, the first rat will eventually forgo eating.
>
> What the new research is showing is that morality has biological roots
-- such as the reward center in the brain that lit up in Grafman's
experiment -- that have been around for a very long time.
>
> The more researchers learn, the more it appears that the foundation of
morality is empathy. Being able to recognize -- even experience
vicariously -- what another creature is going through was an important
leap in the evolution of social behavior. And it is only a short step
from this awareness to many human notions of right and wrong, says Jean
Decety, a neuroscientist at the University of Chicago.
>
> The research enterprise has been viewed with interest by philosophers
and theologians, but already some worry that it raises troubling
questions. Reducing morality and immorality to brain chemistry -- rather
than free will -- might diminish the importance of personal
responsibility. Even more important, some wonder whether the very idea
of morality is somehow degraded if it turns out to be just another
evolutionary tool that nature uses to help species survive and
propagate.
>
> Moral decisions can often feel like abstract intellectual challenges,
but a number of experiments such as the one by Grafman have shown that
emotions are central to moral thinking. In another experiment published
in March, University of Southern California neuroscientist Antonio R.
Damasio and his colleagues showed that patients with damage to an area
of the brain known as the ventromedial prefrontal cortex lack the
ability to feel their way to moral answers.
>
> When confronted with moral dilemmas, the brain-damaged patients coldly
came up with "end-justifies-the-means" answers. Damasio said the point
was not that they reached immoral conclusions, but that when confronted
by a difficult issue -- such as whether to shoot down a passenger plane
hijacked by terrorists before it hits a major city -- these patients
appear to reach decisions without the anguish that afflicts those with
normally functioning brains.
>
> Such experiments have two important implications. One is that morality
is not merely about the decisions people reach but also about the
process by which they get there. Another implication, said Adrian Raine,
a clinical neuroscientist at the University of Southern California, is
that society may have to rethink how it judges immoral people.
>
> Psychopaths often feel no empathy or remorse. Without that awareness,
people relying exclusively on reasoning seem to find it harder to sort
their way through moral thickets. Does that mean they should be held to
different standards of accountability?
>
> "Eventually, you are bound to get into areas that for thousands of
years we have preferred to keep mystical," said Grafman, the chief
cognitive neuroscientist at the National Institute of Neurological
Disorders and Stroke. "Some of the questions that are important are not
just of intellectual interest, but challenging and frightening to the
ways we ground our lives. We need to step very carefully."
>
> Joshua D. Greene, a Harvard neuroscientist and philosopher, said
multiple experiments suggest that morality arises from basic brain
activities. Morality, he said, is not a brain function elevated above
our baser impulses. Greene said it is not "handed down" by philosophers
and clergy, but "handed up," an outgrowth of the brain's basic
propensities.
>
> Moral decision-making often involves competing brain networks vying
for supremacy, he said. Simple moral decisions -- is killing a child
right or wrong? -- are simple because they activate a straightforward
brain response. Difficult moral decisions, by contrast, activate
multiple brain regions that conflict with one another, he said.
>
> In one 2004 brain-imaging experiment, Greene asked volunteers to
imagine that they were hiding in a cellar of a village as enemy soldiers
came looking to kill all the inhabitants. If a baby was crying in the
cellar, Greene asked, was it right to smother the child to keep the
soldiers from discovering the cellar and killing everyone?
>
> The reason people are slow to answer such an awful question, the study
indicated, is that emotion-linked circuits automatically signaling that
killing a baby is wrong clash with areas of the brain that involve
cooler aspects of cognition. One brain region activated when people
process such difficult choices is the inferior parietal lobe, which has
been shown to be active in more impersonal decision-making. This part of
the brain, in essence, was "arguing" with brain networks that reacted
with visceral horror.
>
> Such studies point to a pattern, Greene said, showing "competing
forces that may have come online at different points in our evolutionary
history. A basic emotional response is probably much older than the
ability to evaluate costs and benefits."
>
> While one implication of such findings is that people with certain
kinds of brain damage may do bad things they cannot be held responsible
for, the new research could also expand the boundaries of moral
responsibility. Neuroscience research, Greene said, is finally
explaining a problem that has long troubled philosophers and moral
teachers: Why is it that people who are willing to help someone in front
of them will ignore abstract pleas for help from those who are distant,
such as a request for a charitable contribution that could save the life
of a child overseas?
>
> "We evolved in a world where people in trouble right in front of you
existed, so our emotions were tuned to them, whereas we didn't face the
other kind of situation," Greene said. "It is comforting to think your
moral intuitions are reliable and you can trust them. But if my analysis
is right, your intuitions are not trustworthy. Once you realize why you
have the intuitions you have, it puts a burden on you" to think about
morality differently.
>
> Marc Hauser, another Harvard researcher, has used cleverly designed
psychological experiments to study morality. He said his research has
found that people all over the world process moral questions in the same
way, suggesting that moral thinking is intrinsic to the human brain,
rather than a product of culture. It may be useful to think about
morality much like language, in that its basic features are hard-wired,
Hauser said. Different cultures and religions build on that framework in
much the way children in different cultures learn different languages
using the same neural machinery.
>
> Hauser said that if his theory is right, there should be aspects of
morality that are automatic and unconscious -- just like language.
People would reach moral conclusions in the same way they construct a
sentence without having been trained in linguistics. Hauser said the
idea could shed light on contradictions in common moral stances.
>
> U.S. law, for example, distinguishes between a physician who removes a
feeding tube from a terminally ill patient and a physician who
administers a drug to kill the patient.
>
> Hauser said the only difference is that the second scenario is more
emotionally charged -- and therefore feels like a different moral
problem, when it really is not: "In the end, the doctor's intent is to
reduce suffering, and that is as true in active as in passive
euthanasia, and either way the patient is dead."
Proc Natl Acad Sci U S A. 2006 Oct 17;103(42):15623-8. Epub 2006 Oct 9.
Human fronto-mesolimbic networks guide decisions about charitable
donation.
Moll J, Krueger F, Zahn R, Pardini M, de Oliveira-Souza R, Grafman J.
Cognitive Neuroscience Section, National Institute of Neurological
Disorders and
Stroke, National Institutes of Health, Bethesda, MD 20892-1440, USA.
Humans often sacrifice material benefits to endorse or to oppose
societal
causes based on moral beliefs. Charitable donation behavior, which has
been the target of recent experimental economics studies, is an
outstanding contemporary manifestation of this ability. Yet the neural
bases of this unique aspect of human altruism, which extends beyond
interpersonal interactions, remain obscure. In this article, we use
functional magnetic resonance imaging while participants anonymously
donated to or opposed real charitable organizations related to major
societal causes. We show that the mesolimbic reward system is engaged by
donations in the same way as when monetary rewards are obtained.
Furthermore, medial orbitofrontal-subgenual and lateral orbitofrontal
areas, which also play key roles in more primitive mechanisms of social
attachment and aversion, specifically mediate decisions to donate or to
oppose societal causes. Remarkably, more anterior sectors of the
prefrontal cortex are distinctively recruited when altruistic choices
prevail over selfish material interests.
PMID: 17030808 [PubMed - indexed for MEDLINE]
http://www.washingtonpost.com/wp-dyn/content/article/2007/05/27/AR2007052701056_pf.html
>
> If It Feels Good to Be Good, It Might Be Only Natural
>
> By Shankar Vedantam
> Washington Post Staff Writer
> Monday, May 28, 2007; A01
>
>
> The e-mail came from the next room.
>
> "You gotta see this!" Jorge Moll had written. Moll and Jordan Grafman,
neuroscientists at the National Institutes of Health, had been scanning
the brains of volunteers as they were asked to think about a scenario
involving either donating a sum of money to charity or keeping it for
themselves.
>
> As Grafman read the e-mail, Moll came bursting in. The scientists
stared at each other. Grafman was thinking, "Whoa -- wait a minute!"
>
> The results were showing that when the volunteers placed the interests
of others before their own, the generosity activated a primitive part of
the brain that usually lights up in response to food or sex. Altruism,
the experiment suggested, was not a superior moral faculty that
suppresses basic selfish urges but rather was basic to the brain,
hard-wired and pleasurable.
>
> Their 2006 finding that unselfishness can feel good lends scientific
support to the admonitions of spiritual leaders such as Saint Francis of
Assisi, who said, "For it is in giving that we receive." But it is also
a dramatic example of the way neuroscience has begun to elbow its way
into discussions about morality and has opened up a new window on what
it means to be good.
>
> Grafman and others are using brain imaging and psychological
experiments to study whether the brain has a built-in moral compass. The
results -- many of them published just in recent months -- are showing,
unexpectedly, that many aspects of morality appear to be hard-wired in
the brain, most likely the result of evolutionary processes that began
in other species.
>
> No one can say whether giraffes and lions experience moral qualms in
the same way people do because no one has been inside a giraffe's head,
but it is known that animals can sacrifice their own interests: One
experiment found that if each time a rat is given food, its neighbor
receives an electric shock, the first rat will eventually forgo eating.
>
> What the new research is showing is that morality has biological roots
-- such as the reward center in the brain that lit up in Grafman's
experiment -- that have been around for a very long time.
>
> The more researchers learn, the more it appears that the foundation of
morality is empathy. Being able to recognize -- even experience
vicariously -- what another creature is going through was an important
leap in the evolution of social behavior. And it is only a short step
from this awareness to many human notions of right and wrong, says Jean
Decety, a neuroscientist at the University of Chicago.
>
> The research enterprise has been viewed with interest by philosophers
and theologians, but already some worry that it raises troubling
questions. Reducing morality and immorality to brain chemistry -- rather
than free will -- might diminish the importance of personal
responsibility. Even more important, some wonder whether the very idea
of morality is somehow degraded if it turns out to be just another
evolutionary tool that nature uses to help species survive and
propagate.
>
> Moral decisions can often feel like abstract intellectual challenges,
but a number of experiments such as the one by Grafman have shown that
emotions are central to moral thinking. In another experiment published
in March, University of Southern California neuroscientist Antonio R.
Damasio and his colleagues showed that patients with damage to an area
of the brain known as the ventromedial prefrontal cortex lack the
ability to feel their way to moral answers.
>
> When confronted with moral dilemmas, the brain-damaged patients coldly
came up with "end-justifies-the-means" answers. Damasio said the point
was not that they reached immoral conclusions, but that when confronted
by a difficult issue -- such as whether to shoot down a passenger plane
hijacked by terrorists before it hits a major city -- these patients
appear to reach decisions without the anguish that afflicts those with
normally functioning brains.
>
> Such experiments have two important implications. One is that morality
is not merely about the decisions people reach but also about the
process by which they get there. Another implication, said Adrian Raine,
a clinical neuroscientist at the University of Southern California, is
that society may have to rethink how it judges immoral people.
>
> Psychopaths often feel no empathy or remorse. Without that awareness,
people relying exclusively on reasoning seem to find it harder to sort
their way through moral thickets. Does that mean they should be held to
different standards of accountability?
>
> "Eventually, you are bound to get into areas that for thousands of
years we have preferred to keep mystical," said Grafman, the chief
cognitive neuroscientist at the National Institute of Neurological
Disorders and Stroke. "Some of the questions that are important are not
just of intellectual interest, but challenging and frightening to the
ways we ground our lives. We need to step very carefully."
>
> Joshua D. Greene, a Harvard neuroscientist and philosopher, said
multiple experiments suggest that morality arises from basic brain
activities. Morality, he said, is not a brain function elevated above
our baser impulses. Greene said it is not "handed down" by philosophers
and clergy, but "handed up," an outgrowth of the brain's basic
propensities.
>
> Moral decision-making often involves competing brain networks vying
for supremacy, he said. Simple moral decisions -- is killing a child
right or wrong? -- are simple because they activate a straightforward
brain response. Difficult moral decisions, by contrast, activate
multiple brain regions that conflict with one another, he said.
>
> In one 2004 brain-imaging experiment, Greene asked volunteers to
imagine that they were hiding in a cellar of a village as enemy soldiers
came looking to kill all the inhabitants. If a baby was crying in the
cellar, Greene asked, was it right to smother the child to keep the
soldiers from discovering the cellar and killing everyone?
>
> The reason people are slow to answer such an awful question, the study
indicated, is that emotion-linked circuits automatically signaling that
killing a baby is wrong clash with areas of the brain that involve
cooler aspects of cognition. One brain region activated when people
process such difficult choices is the inferior parietal lobe, which has
been shown to be active in more impersonal decision-making. This part of
the brain, in essence, was "arguing" with brain networks that reacted
with visceral horror.
>
> Such studies point to a pattern, Greene said, showing "competing
forces that may have come online at different points in our evolutionary
history. A basic emotional response is probably much older than the
ability to evaluate costs and benefits."
>
> While one implication of such findings is that people with certain
kinds of brain damage may do bad things they cannot be held responsible
for, the new research could also expand the boundaries of moral
responsibility. Neuroscience research, Greene said, is finally
explaining a problem that has long troubled philosophers and moral
teachers: Why is it that people who are willing to help someone in front
of them will ignore abstract pleas for help from those who are distant,
such as a request for a charitable contribution that could save the life
of a child overseas?
>
> "We evolved in a world where people in trouble right in front of you
existed, so our emotions were tuned to them, whereas we didn't face the
other kind of situation," Greene said. "It is comforting to think your
moral intuitions are reliable and you can trust them. But if my analysis
is right, your intuitions are not trustworthy. Once you realize why you
have the intuitions you have, it puts a burden on you" to think about
morality differently.
>
> Marc Hauser, another Harvard researcher, has used cleverly designed
psychological experiments to study morality. He said his research has
found that people all over the world process moral questions in the same
way, suggesting that moral thinking is intrinsic to the human brain,
rather than a product of culture. It may be useful to think about
morality much like language, in that its basic features are hard-wired,
Hauser said. Different cultures and religions build on that framework in
much the way children in different cultures learn different languages
using the same neural machinery.
>
> Hauser said that if his theory is right, there should be aspects of
morality that are automatic and unconscious -- just like language.
People would reach moral conclusions in the same way they construct a
sentence without having been trained in linguistics. Hauser said the
idea could shed light on contradictions in common moral stances.
>
> U.S. law, for example, distinguishes between a physician who removes a
feeding tube from a terminally ill patient and a physician who
administers a drug to kill the patient.
>
> Hauser said the only difference is that the second scenario is more
emotionally charged -- and therefore feels like a different moral
problem, when it really is not: "In the end, the doctor's intent is to
reduce suffering, and that is as true in active as in passive
euthanasia, and either way the patient is dead."
more on drug testing
more on drug testing
---------
http://news.yahoo.com/s/usatoday/20070508/cm_usatoday/noquickfix
No quick fix
By Marsha Rosenbaum
USA Today
May 8, 2007
Though touted by the Bush administration as the "silver bullet" that
will force teenagers to "just say no," random drug testing is of
questionable effectiveness. It is also costly, counterproductive and
violates basic American values. That's why the million-member California
State PTA, the American Academy of Pediatrics, the National Education
Association, the National Council on Alcoholism and Drug Dependence, and
the majority of the nation's school districts oppose school-based drug
testing.
According to the Academy of Pediatrics, "There is little evidence of the
effectiveness of school-based drug testing in the scientific
literature." In fact, the only federally funded, peer-reviewed study,
which compared 94,000 students in 900 U.S. schools, found no difference
in illegal drug use between schools with and without a testing program.
Before subjecting secondary school students to a policy as invasive as
random drug testing, evidence of its efficacy should be more conclusive
than anecdotes offered by a few enthusiastic proponents and a drug
testing industry that stands to reap billions.
Drug testing is costly. With federal grants, individual schools, many of
them strapped for funds, spend between $10,000 and $40,000 per year for
testing. This money could be used more productively for sports, arts,
drama, music and other extracurricular activities that keep teens
engaged between3 and 6 p.m., when they are bored and unsupervised. The
funds could also be used to hire credentialed counselors who couldfocus
full-time on substance abuse and related mental health issues.
Drug testing, regardless of how it's packaged, is an invasive diagnostic
procedure. Like other health issues, alcohol and other drug use should
first and foremost be the domain of parents and physicians. If parents
want to drug-test their own children, they can easily buy
over-the-counter kits at their local pharmacies or see their family
doctors, leaving schools out of it.
There is no quick fix for the complex issue of substance abuse. Quality
drug education and after-school programs that help students thrive will
best result in the kind of responsible decision-making that endures
beyond the teen years and into adulthood.
Dr. Marsha Rosenbaum, a medical sociologist, directs the San Francisco
office of the Drug Policy Alliance. She is co-author of Making Sense of
Student Drug Testing: Why Educators are Saying No
---------
http://news.yahoo.com/s/usatoday/20070508/cm_usatoday/noquickfix
No quick fix
By Marsha Rosenbaum
USA Today
May 8, 2007
Though touted by the Bush administration as the "silver bullet" that
will force teenagers to "just say no," random drug testing is of
questionable effectiveness. It is also costly, counterproductive and
violates basic American values. That's why the million-member California
State PTA, the American Academy of Pediatrics, the National Education
Association, the National Council on Alcoholism and Drug Dependence, and
the majority of the nation's school districts oppose school-based drug
testing.
According to the Academy of Pediatrics, "There is little evidence of the
effectiveness of school-based drug testing in the scientific
literature." In fact, the only federally funded, peer-reviewed study,
which compared 94,000 students in 900 U.S. schools, found no difference
in illegal drug use between schools with and without a testing program.
Before subjecting secondary school students to a policy as invasive as
random drug testing, evidence of its efficacy should be more conclusive
than anecdotes offered by a few enthusiastic proponents and a drug
testing industry that stands to reap billions.
Drug testing is costly. With federal grants, individual schools, many of
them strapped for funds, spend between $10,000 and $40,000 per year for
testing. This money could be used more productively for sports, arts,
drama, music and other extracurricular activities that keep teens
engaged between3 and 6 p.m., when they are bored and unsupervised. The
funds could also be used to hire credentialed counselors who couldfocus
full-time on substance abuse and related mental health issues.
Drug testing, regardless of how it's packaged, is an invasive diagnostic
procedure. Like other health issues, alcohol and other drug use should
first and foremost be the domain of parents and physicians. If parents
want to drug-test their own children, they can easily buy
over-the-counter kits at their local pharmacies or see their family
doctors, leaving schools out of it.
There is no quick fix for the complex issue of substance abuse. Quality
drug education and after-school programs that help students thrive will
best result in the kind of responsible decision-making that endures
beyond the teen years and into adulthood.
Dr. Marsha Rosenbaum, a medical sociologist, directs the San Francisco
office of the Drug Policy Alliance. She is co-author of Making Sense of
Student Drug Testing: Why Educators are Saying No
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