From Balanced Pain Care to Drug Trafficking: The Case of Dr. William Hurwitz and the DEA

The featured article in this issue of the Forensic Pain Medicine Section is titled The Challenge of Prescription Drug Misuse: A Review and Commentary. It is authored by Dr. William Hurwitz, a Virginia physician who was recently found guilty in a federal court of 50 counts including racketeering and drug trafficking. At the time of this writing, he has yet to be sentenced. Controversy peaked when a letter was sent to the court from past presidents of the American Pain Society (APS) repudiating the testimony of the prosecution's expert witness, who was also a former APS president as well as former assistant to Senator Orin Hatch [1,2]. Some believe that Dr. Hurwitz received a just outcome from the legal system while others are convinced that he was a well-intended clinician who served his patients with dedication and compassion. Irrespective of the standard of his care, this case has raised serious questions about whether Dr. Hurwitz was inappropriately prosecuted in the criminal justice system when his offenses were within the scope of professional medical practice and therefore should have been dealt with through civil and administrative processes. The outcome of the Hurwitz case has the potential for collateral effects on the average practitioner who may now have heightened fear of opioid prescribing. Such fear has been fueled by current events involving the Drug Enforcement Agency (DEA) who recently disowned a series of frequently asked questions (FAQ) on appropriate use of opioids for treating pain [1,3–5]. The FAQ was released with much fanfare in August 2004, including a ceremonious press conference hosted by the DEA that resulted in widespread national media coverage. It was subsequently published on the DEA website and represented the position of balance as a result of substantial collaboration between the DEA and the pain care community. Shortly after the FAQ was admitted into evidence in the Federal trial of Dr. Hurwitz, the DEA abruptly withdrew the FAQ, stating that it was inaccurate and had never been officially sanctioned. At that time, the DEA stated it would offer more information at a later date. In November 2004, an interim policy statement was entered into the federal register in which the DEA offered brief explanations of the inaccuracies within the FAQ. This statement has been uniformly opposed by major pain societies including the American Academy of Pain Medicine (AAPM) (Figure 1: Letter to the DEA from AAPM). The same week that this interim statement was published, the judge in the federal trial of Dr. Hurwitz removed the previously accepted DEA FAQ out of evidence. The temporal proximity of these events has led many to speculate that the change in the DEA position was a direct result of its role in the Hurwitz trial. AAPM letter to the DEA. Legal and regulatory issues have impacted and will continue to impact the care of pain, mostly as a result of society attempting to simultaneously eliminate prescription drug abuse as well as the undertreatment of pain. How physicians and the public interpret these most recent events will almost certainly influence the climate of pain care in America. Whether the outcome of the Hurwitz trial, and possible appeal actions, will clarify the line between professional misconduct and criminal activity that is outside the scope of medical practice is uncertain. Moving the DEA, and its leadership within the office of the U.S. Attorney General, back toward policies that balance society's need for prevention of prescription drug abuse and effective pain control is likely to become a high priority of most pain advocacy groups. The backdrop of this policy crisis is a well-documented escalation of prescription drug abuse in the U.S. The 2004 President's National Drug Control Strategy implies that the prescription drug problem may be mitigated by targeting the prescribers of these abused drugs. While prescription drug abuse is a very serious public health problem, restraining legitimate prescribing of opioid medications is unlikely to benefit the war on drugs but carries the likely risk of limiting necessary treatments for suffering. As prescribers of potentially abusible drugs, physicians who treat pain with opioids have been increasingly viewed as having substantial risk management obligations. These obligations are no different from those associated with general medical prescribing; that benefits outweigh risks and risks are managed. Exactly how physicians will adopt risk vigilance around opioid therapy is rapidly evolving. The following article speaks to the controversy of appropriate and inappropriate use of prescription opioids. Moreover, it states the views of a controversial physician who now faces a possible life sentence following one of the most notorious trials in the short history of Pain Medicine.