Sunday, June 17, 2007

That Damn Calvinism Again: The "Case" Against Dr. McIver

The NYTimes Magazine has an excellent article, "When is a Pain Doctor a Drug Pusher?" on Ronald McIver, the Pain Doctor who was sentenced to 30 years in prison for writing prescriptions of high doses of opiods like Oxycontin. What emerges in Tina Rosenberg's piece is the sense that McIver was prosecuted for offending the 'common wisdom' of jurors for what constitutes credible pain prescribing practices. The D.E.A. is also a player, trying to crack down on the epidemic of Oxycontin abuse in rural places of the U.S. And, finally, the fact that McIver was a D.O., who spent a lot of time with patients, only employed family in his office, and had sort of messy record keeping strategies, all count against him.

The prosecution did not really demonstrate that McIver had intent to break the law and become a drug pusher. In fact, what Rosenberg paints is a portrait of a man who was zealous and passionate in his drive to ease the pain of chronic pain sufferers. He was willing to prescribe high doses of opiniods and "titrate" them to high levels if it brought their pain levels down to a "2" rather than a "10."

What I like about this essay is that is illustrates there is a difference between "addiction" and "dependence" and that our underlying Calvinism is what leads to so many restrictions and unease among physicians to properly medicate chronic pain sufferers. I have always been interested in the treatment--or undertreatment of chronic pain sufferers--long before I became one after back surgery in 2000. Physicians have not been properly trained in pain management and so they get squeamish about prescribing enough pain medication to free a sufferer from pain. Likewise, patients panic that if they take some kind of opiniod they will become a drug addict, which they believe is worse than suffering from chronic pain.

The dilemma of preventing diversion without discouraging pain care is part of a larger problem: pain is discussed amid a swirl of ignorance and myth. Howard Heit, a pain and addiction specialist in Fairfax, Va., told me: “If we take the fact that 10 percent of the population has the disease of addiction, and if we say that pain is the most common presentation to a doctor’s office, please tell me why the interface of pain and addiction is not part of the core curriculum of health care training in the United States?” Will Rowe, the executive director of the American Pain Foundation, notes that “pain education is still barely on the radar in most medical schools.”

The public also needs education. Misconception reigns: that addiction is inevitable, that pain is harmless, that suffering has redemptive power, that pain medicine is for sissies, that sufferers are just faking. Many law-enforcement officers are as in the dark as the general public. Very few cities and only one state police force have officers who specialize in prescription-drug cases. Charles Cichon, executive director of the National Association of Drug Diversion Investigators (Naddi), says that Naddi offers just about the only training on prescription drugs and reaches only a small percentage of those who end up investigating diversion. I asked if, absent Naddi training, officers would understand such basics as the whether there is a ceiling dose for opioids. “Probably not,” he said.

There is another factor that might encourage overzealous prosecution: Local police can use these cases to finance further investigations. A doctor’s possessions can be seized as drug profits, and as much as 80 percent can go back to the local police.

I couldn't help but compare McIver's plight to WJ Bryan Henrie, the D.O. who performed abortions pre-Roe that I spent some time studying. Here is a physician who flouts convention and spends 4 hours with patients, rather than 10 minute check ups. He decides to give high doses of pain medication if he can bring the pain levels down to 2, knowing full well that such a practice is open to intense scrutiny. And, what really interests me about this case is that his trial--and conviction--will deter even more physicians from entering into the field of Pain Management, even if the need is great.

We have an entire system built on a prejudice: pain medication is bad for you. We also have a strong, underlying belief that pain is what makes us stronger or better as humans (a nod to Nietzsche). Of course, that is just empirically false, since chronic pain wears on our health dramatically and reduces our quality of life.

I am sorry to hear of McIver's conviction and I hope that Rosenberg's piece leads to a re-examination of this prosecution, our Calvinistic attitudes toward pain medication, and we begin to take seriously the need to alleviate pain.

In the past few years, it has become increasingly clear to me that what I cannot abide in 'ethical debates' about medications is an underlying Calvinism and glorification of withstanding pain (hence, why I have not been so keen on the 'natural' childbirth route). Perhaps my rejection of this worldview comes from the fact that I don't possess the concomitant religious view that pain is valuable and necessary to developing moral character. Pain is pain.