The Deception: Tylenol, Opioids and the DEA; Alex DeLuca; Addiction, Pain and Public Health website; Date. Source

We are in the midst of a fascinating media firestorm, an ejaculation of drug war Trash Journalism brought about by a veritable perfect storm of events including:

1. The rediscovery by the FDA that acetaminophen (Tylenol) and NSAID (aspirin, ibuprophen, naprosyn, Vioxx, etc) toxicity are serious public health problems;
2. A focus on “Vicodin” and “Percoset” as representatives of the class of low-potency opioid formulations which include Tylenol, and widespread calls for banning these medications;
3. A very recently released medical guideline document from the American Geriatrics Society (AGS) entitled: Pharmacological Management of Persistent Pain in Older Persons – 2009 Guideline Recommendations, which (finally!) states the true medical standard of care for pain management: “All patients with moderate-severe pain, pain-related functional impairment or diminished quality of life due to pain should be considered for opioid therapy.”; and finally,
4. New DEA revelations that “Most obtain the drugs by stealing them, hooking up to false Internet pharmacies or from friends and relatives.” Wow, and for the past decade they’ve been identifying and targeting bad doctors and bad pain patients as the primary source of diverted drugs fueling a “prescription drug abuse” crisis (for which scant scientific evidence exists);

Footnotes

[agsindex]: http://www.americangeriatrics.org/education/pharm_management.shtml “AGS Clinical Practice Guideline: Pharmacological Management of Persistent Pain in Older Persons – American Geriatrics Society, 2009″

Petition for Writ of Certiorari to the Pennsylvania Supreme Court (PDF); by William Mangino II, petitioner v. Commonwealth of Pennsylvania; 2010.

Permalink: http://doctordeluca.com/wordpress/archive/manginopetition2sc/

See also:
Omnibus Motion for Directed Verdict or Alternative Jury Instructions – Mangino; 2007

NOTE:
Dr. William Mangino is serving 8 1/2 to 20 years in prison having been convicted of 9 felony charges including 5 violations of the state drug act, three violations of Medicaid fraud, and one charge of conspiracy to violate the drug act. He wrote and filed this Petition and forwarded it to me to be disseminated. The document can be reproduced, but not altered.

His case has been well covered here and on Drug War Chronicle. Mangino Verdict I: Is Treating Pain a Crime?; Mangino Verdict II – Conviction; Mangino Sentencing: a Crime-less Conviction (by Christine Heberle); and Another Pain Doctor on the Ropes (by David Borden, Drug War Chronicle.)

Dr. Mangino writes that he is “currently preparing a review article which outlines – in depth – every single type of “irrelevant” medical standard used in about 50-60 various prosecutions over the past 40-50 years – and how and why these standards are misapplied, with case citations.”

What follows is a brief excerpt – the opening paragraphs – of Mangino’s Petition for Writ of Certiorari. ..alex… Alex DeLuca, M.D.

Excerpt from beginning and end of the Mangino Petition:

QUESTIONS PRESENTED
1- Should “criminal standards” in illegal prescribing be “undercover penetration” and “direct patient testimony”?

2- Was petitioner improperly convicted under the Pennsylvania statute for illegally dispensing controlled substances?

3- Were petitioner’s medical records improperly excluded as evidence?

4-Did the Trial Court abuse its discretion by not ruling in favor of defense motion for a directed verdict of not guilty?

5- Did the Trial Court commit plain error by not instructing jurors on all of the elements of the crime?

6- Should the Trial Court have instructed jurors that “good faith” was an element of the crime to be disproved?

7- Did Doctor Mangino deserve a “good-faith” instruction to jurors since he was not charged with violating “good-faith”?

8- Did the Trial Court abuse its discretion or commit plain error by not instructing jurors that opioid prescribing guidelines have no force in the law.

9 – Was “the statute” vague as applied to petitioner’s prescribing and treatment principles?
…
The treatment of chronic pain is an issue of national importance. If petitioner’s conviction is allowed to stand then any single opioid prescription can be called into question based upon misconceptions which should not be allowed to permeate the atmosphere of The American Courtroom.

These misconceptions are further fostered when prosecutors employ irrelevant medical standards which jurors assume ascribe criminal liability. Even courts also confuse civil medical with criminal standards.

Pain specialists, by training and experience, are compelled to alleviate the suffering which always accompanies chronic pain. They become easier targets for politically motivated or overzealous prosecutions.

As the specialist’s knowledge of the biochemical and genetic intricasies underlying the genesis of the pain-state increases, he is more willing to prescribe the medications most likely to alleviate this suffering. The jury pool is unlikely to look upon this level of prescribing favorably.

PRN Takes on the State of Washington; Press Release; Pain Relief Network; 2010-07-09. Arguments in Federal Court Seattle, and Press Conference: 2010-07-12 at 1:00pm

Permalink: http://doctordeluca.com/wordpress/archive/prn-takes-on-wa

See also:
PRN Sues State of Washington – D. Blankinship; AP; 2008-06-25
PRN Tort Claim vs. WA State – L. Cooper, Esq; 2008-07-08

Responding to what doctors and patients are calling a dangerous crackdown on people with chronic pain, Pain Relief Network is seeking the protection of the courts, hoping to have the deadly disease of chronic pain declared a disability under the Americans With Disabilities Act.

Siobhan Reynolds, President of the Pain Relief Network and defender of people in pain sees Washington State as the patient’s last real opportunity to stop the War On Drugs from completely destroying a free and voluntary doctor/patient relationship, “Between Obamacare, The War On Drugs and the media’s rapacious focus on celebrity addiction, people in pain who merely want to live their lives and take care of their families are instead being herded like cattle into “safety programs’ which are anything but safe.”

She goes on to say, “despite Washington State’s contentions that they are merely looking out for the welfare of citizens in pain, the data does not demonstrate that a public health crisis in overdose and addiction even exists. What the data does say is that some 25 to 33 percent of the American people suffer from the deadly disease of chronic non-cancer pain.”

Laura Cooper Esq. General Counsel for PRN and the lawyer who will be arguing on behalf of the doctor/patient relationship in Washington State from her wheel chair said, “Physician assisted suicide is now legal in Washington State but pain treatment is no longer supported in the law. So it’s ok for doctors to prescribe Controlled Substances to kill us but not to allow us to live. The courts have said they will step in if such a state of affairs comes to characterize pain treatment in the US and I am afraid that we are here.”

A recent article in Time Magazine¹ explains the groundlessness of the state’s claims that a ‘wave of deaths by opioids’ necessitated this crackdown. According to one of the top medical experts in the world, the science around cause of death by opioids in people who were otherwise critically ill is far from exact. Dr. Steven Karch called the acceptance of the state’s word on the cause of death when pain medicines are present, “a giant miscarriage of justice.” He goes on to explain, “You can die from a drug and you can die with a drug, When you have four orders of magnitude separating either end of the curve, many of these deaths may not have to do with drugs at all.”

Footnotes

DOJ Eyes Kan. Complaint Against Federal Prosecutor; Roxana Hegeman; AP, Witchita Eagle; 2009-07-10. Source

Permalink: http://doctordeluca.com/wordpress/archive/doj-eyes-complaint/

See also:
ACLU Backs Reynold’s Motion to Quash – DeLuca; 2009-05-09
Drug Control? No, Citizen Control – Reynolds, 2009-04-20

WICHITA, Kan. – A political activist targeted in a federal obstruction investigation in Kansas said she has filed a complaint with the Justice Department alleging prosecutorial misconduct in a grand jury investigation of her role in the case of a doctor whose clinic has been linked by prosecutors to 59 overdose deaths.

Siobhan Reynolds, president of the Santa Fe, N.M.-based Pain Relief Network, said Friday that her complaint against Assistant U.S. Attorney Tanya Treadway was referred to the Justice Department’s Office of Professional Responsibility. The office examines possible ethics violations by Justice Department employees.

The Justice Department in Washington, D.C., and the U.S. attorney’s office in Kansas declined Friday to confirm whether the complaint was filed.

“Our attorneys are dedicated to performing their duties in accordance with the highest professional standards,” said Jim Cross, spokesman for the U.S. attorney’s office. “I think we welcome any questions, direction or assistance from the Office of Professional Responsibility.”

Reynolds’ group has supported Dr. Stephen Schneider and his wife, Linda, who were indicted in December 2007 on 34 counts accusing them of unlawfully prescribing painkillers and overbilling for services at their clinic in the Wichita suburb of Haysville.

The Pain Relief Network, which opposes what it sees as federal efforts to crack down on chronic pain treatment, has helped the Schneiders line up attorneys and expert witnesses, and has put up billboards supporting them.

The Justice Department has issued a grand jury subpoena for Reynolds and her group seeking all correspondence and other documents related to the Schneider case, including Reynolds’ interactions with attorneys, patients, Schneider family members, doctors and others.

Reynolds has refused to comply with the subpoena. She said Friday that she has not yet been found in contempt of court.

“Ms. Treadway’s conduct in the case has been nothing short of shocking and ruthless; she has in fact displayed the kind of ‘win at all costs’ mentality that you have publicly stated your department will no longer tolerate,” Reynolds wrote in her June 18 letter to U.S. Attorney General Eric Holder.

The American Civil Liberties Union has taken up the Reynolds defense in the grand jury proceedings, claiming in initial court papers that subpoenas sought by a “frustrated prosecutor seeking to silence a dissenting advocate” have a chilling effect on First Amendment rights.

The ACLU has also contended Treadway – who also is prosecuting the Schneiders – had misused the grand jury process to circumvent the standard criminal discovery process in the related pending case against the doctor and his wife.

U.S. District Judge Julie Robinson rejected earlier this week the ACLU’s motion asking the judge to reconsider an earlier ruling declining to quash the subpoenas, Reynolds said Friday.

Pain Relief Network to Obama Administration: STAND DOWN in War on Patients and Doctors; Siobhan Reynolds, Pain Relief Network; 2009-05-18. Source

Permalink: http://doctordeluca.com/wordpress/archive/prn-to-obama

See also:
Dr. Johnston v USA, Petition for Writ of Certiorari to Supreme Court (PDF)
Laura D. Cooper and Kevin P. Byers, filed: 2009-05-01

Full text of Pain Relief Network press release

WASHINGTON, DC (May 18, 2009) – The Pain Relief Network (PRN) is calling on the Obama Administration to require the U.S. Department of Justice to join the organization’s recent filing of a Petition for a Writ of Certiorari before the United States Supreme Court on behalf of Dr. Sharon Johnston.

“Regardless of how you try to explain to people it’s a ‘war on drugs’ or a ‘war on a product,’ people see a war as a war on them,” [newly confirmed confirmed "drug czar" head of ONDCP, Gil Kerlikowske] said. “We’re not at war with people in this country.”

“This is a great opportunity for the Obama Administration to put its money where its mouth is concerning what is perhaps the most damaging aspect of the failed War On Drugs,” said Siobhan Reynolds, President of PRN and nationally renowned pain relief advocate.

“The Department of Justice has been prosecuting physicians at a frightening clip. The DEA has charged some 400 doctors with violating Federal drug dealing laws within the context of their medical practices since 2003. While the DEA was clearly proud of the figure when it released it to the Orlando Sentinel, the Obama Administration should stop the carnage at once.”

Full text of Pain Relief Network press release

[END]

ACLU Raises First Amendment Argument Over Subpoena – Roxana Hegeman, Associated Press; 2009-05-11. [AP Editor notes: "UPDATES with comment by Reynolds; ADDS Tuesday hearing on separate motion by Schneider defense team."] Source

Permalink: http://doctordeluca.com/wordpress/archive/aclu-reynolds-schneider/

See also:
Reynolds Grand Jury Investigation – Motion to Quash Subpoena
American Civil Liberties Union, 2009-05-07

Drug Control? No, Citizen Control – Siobhan Reynolds, 2009-04-20

WICHITA, Kan. (AP) — The American Civil Liberties Union has taken up the defense of a political activist in a federal obstruction investigation, claiming subpoenas sought by a “frustrated prosecutor seeking to silence a dissenting advocate” have a chilling effect on First Amendment rights.

Siobhan Reynolds, president of the Santa Fe, N.M.-based Pain Relief Network, is being investigated by a federal grand jury in Topeka for her role in the case of a Kansas doctor whose clinic has been cited by the government as linked to 59 overdose deaths.

The Justice Department issued a grand jury subpoena for Reynolds and her group seeking all correspondence and other documents related to the case against Dr. Stephen Schneider and his wife, Linda, including Reynolds’ interactions with attorneys, patients, Schneider family members, doctors and others.

A hearing is scheduled Tuesday in Topeka on the ACLU’s motion to throw out or narrow the scope of the March 10 subpoenas issued to Reynolds and the Pain Relief Network. The judge also will hear at the same time a separate motion by the Schneiders’ defense team to quash the subpoenas issued to Reynolds and her group.

The ACLU argued that Reynolds’ activities are a far cry from the offenses of witness tampering, jury tampering and conspiracy, which the government claims to be investigating.

In its motion, the ACLU argued the subpoenas unjustifiably invade Reynolds’ and PRN’s freedom of speech and association. It noted the trial judge overseeing the Schneider case denied a prosecution request last year to gag Reynolds and others from talking to the media.

Their filing, posted on the ACLU’s Web site, further contends the subpoenas are overbroad.

The ACLU also claimed that Assistant U.S. Attorney Tanya Treadway – who also is prosecuting the Schneiders – had misused the grand jury process to circumvent the standard criminal discovery process in the related pending case against the doctor and his wife.

The U.S. attorney’s office declined comment on the ACLU motion, and since grand jury proceedings are secret, its filings in the case are under seal. Jim Cross, spokesman for the U.S. attorney’s office, said Monday the government will make its response to the court.

“If I were to hand it over then I would in effect become a confidential informant against my will in cases where I have been helpful to the defense or to the accused, and so I wouldn’t be welcomed ever again anywhere – not by the attorneys, not by the experts,” she said Monday. “So the very heart and soul of my work would be destroyed.”

Reynolds told The Associated Press last month she would go to jail rather than turn over the subpoenaed documents.

“Given the sweeping nature of the subpoenas here, their chilling effect on First Amendment rights, and the circumstances under which they were obtained – a frustrated prosecutor seeking to silence a dissenting advocate – this Court should quash the subpoenas as an unjustified infringement on Ms. Reynolds’ and PRN’s First Amendment rights,” the ACLU wrote in its pleading.

ACLU lawyers cited the subpoenas’ demand for records of payments to a billboard company as an example of how the government’s subpoenas are targeting protected speech rather than criminal activity. PRN paid to erect a billboard in January in Wichita proclaiming in large letters: “Dr. Schneider never killed anybody.” (Also subpoenaed: PRN’s signature video documentary, The Chilling Effect – Pain Patients in the War on Drugs. ..alex…)

Reynolds’ group has supported the Schneiders, who were indicted in December 2007 on 34 counts accusing them of unlawfully prescribing painkillers and overbilling for services at their clinic in the Wichita suburb of Haysville.

“At a more fundamental level, once again, there is a serious danger to First Amendment rights where prosecutors are permitted to infer criminal obstruction of justice from mere First Amendment advocacy in a criminal case,” ACLU lawyers wrote.

Treadway’s contention that Reynolds’ continued advocacy is proof that her speech has not been chilled, and therefore no First Amendment infringement has occurred, is incorrect, the ACLU motion contends.

Reynolds has testified before Congress in her role as president of the Pain Relief Network. The group seeks to overturn the Controlled Substances Act as it pertains to physicians treating chronic pain patients, arguing it improperly interferes in the doctor-patient relationship. The organization has been involved in about 15 cases nationwide in which physicians are charged with violating the act.

The federal indictment charged the Schneiders with 21 overdose deaths and linked their Haysville clinic to 59 deaths overall. A federal judge’s decision limiting their trial to four deaths is under appeal. The Schneiders maintain their innocence.

ACLU Asks Court To Block Government’s Unconstitutional Attempt To Silence Pain Relief Advocate; ACLU Press Release; 2009-05-07. Published here: 2009-05-10. Revised: 2009-05-12 – added “Background” links.

Permalink: http://doctordeluca.com/wordpress/archive/aclu-v-silencing-prn/

See also:
ACLU Backs Reynolds’ Motion to Quash – DeLuca, 2009-05-09

Reynolds’ Amended Motion to Quash Subpoenas – ACLU, 2009-05-07

FOR IMMEDIATE RELEASE – May 7, 2009
CONTACT: Dan Berger, ACLU, (831) 471-9000 x26 or (917) 602-2445/cell
HEARING: scheduled for Tuesday, May 12, at 3:30, in federal district court in Topeka.

TOPEKA, KS – The American Civil Liberties Union today filed a motion to quash a pair of subpoenas that were issued to nationally renowned pain relief advocate Siobhan Reynolds in an effort to chill her constitutionally protected speech supporting physicians’ ability to provide appropriate pain management treatment without risk of criminal prosecution. The subpoenas are part of an ongoing grand jury investigation related to the federal prosecution of Dr. Stephen Schneider and his wife Linda, who operated a medical practice specializing in pain relief, and whose prosecution Reynolds has publicly condemned.

“The government may not use the subpoena power to chill the First Amendment rights of those with opposing views,” said ACLU attorney Scott Michelman, who, with the ACLU of Kansas & Western Missouri, represents Reynolds. “It is vital to the proper functioning of our democracy that advocates, like Ms. Reynolds, be free to speak out without fear of government retaliation.”

Reynolds is President of the Pain Relief Network (PRN), a national advocacy organization that opposes the criminal prosecution of physicians based on medical judgment. On March 10, 2009, subpoenas were issued to both Reynolds and PRN ordering that Reynolds turn over all personal and organizational communications on any subject with any former employees or patients of the Schneider Medical Clinic or with any of dozens of named individuals, including members of the Schneider family and members of the Schneiders’ legal and medical defense team, as well as a record of all Reynolds’ phone calls for the past seventeen months.

Emblematic of the subpoenas’ First Amendment intrusion is the request for correspondence with a company that Reynolds enlisted to erect a billboard in support of the Schneiders – a clear example of constitutionally protected speech, according to the ACLU. The subpoena also seeks a copy of an advocacy video Reynolds made concerning pain relief and the government’s related prosecution of physicians. (Here is the video in question: “The Chilling Effect – Pain Patients in the War on Drugs” – by Siobhan Reynolds, On-Beyond Films. ..alex…)

The subpoenas (PDF) are part of a grand jury investigation initiated by Assistant U.S. Attorney Tanya Treadway, who is prosecuting the Schneiders and who had previously sought, and was denied, a gag order to prevent Reynolds from speaking about the Schneiders’ case. With the gag order denied, Treadway convened a grand jury and issued the subpoenas in an attempt to silence Reynolds by invading her privacy and by raising the specter of criminal prosecution, according to the ACLU.

“The chilling effect of the subpoenas on the advocacy of Ms. Reynolds, PRN, and other potential speakers is undeniable and impermissible under the First Amendment,” said Michelman.

The subpoenas are striking in their breadth, as they would force Reynolds and PRN to disclose all of their communications with a long list of individuals, whether or not the communications are in any way related to the Schneider case.

“I will not be intimidated and I will not be silenced,” said Reynolds, who founded PRN with her husband, since deceased, who suffered from an extremely painful congenital connective tissue disorder – a condition that their son inherited. “As I testified before Congress, an obsession with prescription drug abuse has resulted in the gross under-treatment of pain in this country. We have turned honest physicians and desperate patients into criminals, and policymakers and the public need to hear about it…”

The ACLU also contends that the subpoenas are an impermissible intrusion into the Schneiders’ defense team – an attempt to gain confidential information not otherwise available to the prosecution. The Schneiders have filed their own motion to quash on the basis that this material must be requested through the ordinary legal discovery process, if at all. Both motions will be heard together. (See: Schneider Pre-trial Motions in Judges Hands – DeLuca, 2008-06-25; includes links to relevant legal briefs. ..alex…)

“The First Amendment bars both direct restrictions on protected speech as well as attempts to silence speakers via indirect burdens which can be potentially just as effective,” said William Raney, Board President of the ACLU of Kansas & Western Missouri. “The ACLU will investigate and oppose outright bans on speech as well as efforts to ‘chill’ speakers by making them so uncomfortable, via threat of criminal prosecution or otherwise, that they cease communication without a straightforward gag.”

A hearing in the matter is scheduled for Tuesday, May 12, at 3:30, in federal district court in Topeka.

---

Background on Schneider Case:
PRN vs Kansas & DOJ – the Complete Lawsuit (ZIP)

PRN in Kansas News Archive / Discussion

[END]

ACLU Backs Reynolds’ Motion to Quash Grand Jury Subpoena for Obstruction of Justice in U.S.A. v Dr. Schneider; Alex DeLuca; Addiction, Pain and Public Health website; 2009-05-09.

Permalink: http://doctordeluca.com/wordpress/archive/aclu-backs-reynolds/

See also:
Fed Prosecutor Tries to Silence Drug Policy Activist, Again – Sullum; 2009-04-17
Big Hearing in 10th Circuit on Painkiller Issue – Balko; 2009-05-06
Grand Jury Subpoenas Pain Relief Activist – Drug War Chronicle; 2009-04-17
Abuse of Grand Jury Subpoena – Halderman; 2009-04-20

Siobhan Reynolds’ Amended Motion to Quash Subpoenas
Bonney, Michelman, and Rorty; ACLU attorneys for Reynolds and PRN
I am grateful to Jacob Sullum, Radley Balko, Drug War Chronicle, and Keith Halderman for their coverage of AUSA Tanya Treadway’s outrageous actions against Siobhan Reynolds, president of the Pain Relief Network (see the “See also:” links, above), and am especially grateful to the ACLU for stepping up and getting involved with this case.

This is so important because Treadway’s subpoena named every lawyer in Kansas, in fact almost every lawyer anywhere, that Ms. Reynolds knows, and she found herself effectively unable to retain legal counsel (hence her previously filed, pro se, Motion to Quash Subpoena) (PDF).

The ACLU’s Amended Motion to Quash Subpoenas (PDF) is not terribly long and is very readable. It establishes Siobhan Reynolds’ record of aggressive activism and emphasizes the First Amendment interests at stake. It reviews AUSA Tanya Treadway’s March 2008 effort to have Ms. Reynolds and her Pain Relief Network (PRN) gagged by the court, which motion was denied, leading to Treadway’s attempt to get from a Grand Jury what she could not get from the Judge Belot.

“These subpoenas constitute an abuse of the grand jury process… Because [Treadway's obstruction of justice] investigation lacks any good faith basis, Ms. Reynolds does not claim a Fifth Amendment privilege with respect to any of the materials sought by the subpoena.(1) Ms. Reynolds maintains that she has committed no crime and that there is nothing in the requested materials that could inculpate her in the obstruction of justice, witness tampering or jury tampering. For all of these reasons, this Court should quash the March 10 subpoenas issued to Siobhan Reynolds and PRN.” (pages 2 and 4)

The brief criticizes the “broad and invasive scope” of Treadway’s subpoena (PDF) of Reynolds, and characterizes it as “a misuse of the grand jury process because it is aimed at invading the defense camp of the Schneiders,” otherwise known as a “fishing expedition.” It also reviews legal precedent regarding the “chilling effect” such prosecutorial misconduct has on Constitutionally protected speech.

ACLU also raises the specific issue of “the appearance of [prosecutorial] impropriety, if not the fact of it,” citing copious prior legal decisions (including USA. v Shaygan):

“It is additionally curious that AUSA Treadway is representing the government in both the Schneider case and the matter of the Reynolds/PRN subpoenas; if these subpoenas were indeed a bona fide use of the grand jury for an independent and legitimate investigation, it would seem the safest course, to avoid at least the appearance of impropriety if not the fact of it, to assign a different prosecutor to the grand jury matter.” (page 17)

The ACLU brief Argues (starting on page 4):

1. “The Subpoenas Unjustifiably Invade Ms. Reynolds’ and PRN’s Freedoms of Speech and Association;”
2. “The Subpoenas are Overbroad;”
3. “The Subpoenas Are a Misuse of the Grand Jury Process To Circumvent Standard Criminal Discovery;”

and finally Concludes:

“On its face, AUSA Treadway’s fishing expedition appears to have the impermissible purpose of obtaining information about the Schneider’s defense. Therefore the subpoenas should be quashed as an abuse of the grand jury process.” (page 18)

---

Siobhan Reynolds’ Amended Motion to Quash Subpoenas
Bonney, Michelman, and Rorty; ACLU attorneys for Reynolds and PRN

[END]

Dr. Sharon Johnston v. U.S.A. – Petition for Writ of Certiorari to U.S. Court of Appeals for the Eleventh Circuit; Laura D. Cooper, Counsel of Record and Kevin P. Byers, Co-counsel; filed in the Supreme Court of the United States; 2009-05-01.

Permalink: http://doctordeluca.com/wordpress/archive/johnstonvsusacertiorari/

Full text of the brief presented for Supreme Court review
The Introduction begins:

Dr. Sharon Johnston comes to this Court having been convicted of a crime that does not exist, by a court without jurisdiction to enter a conviction, and affirmed by a court that did not confirm that it had jurisdiction to do so and – worse yet – blatantly attempted to “bury” its decision through depublication.

The fact that the Circuit Court spilled so much ink explaining the “facts” but dishonestly “ducked” the fundamental question of jurisdiction (which challenged the fundamental “standard” by which those very “facts” could be measured) — and then depublished the decision — should itself sound alarm bells to the supervisory review court.

This entire proceeding has been indelibly painted with the bright and unmistakable color of unconstitutional outcome-driven caprice.

[END]

It’s About the Pain, Schmuck – regarding the Testimony of Terry Lynn Knight, patient of Dr. Ali Shaygan; Alex DeLuca; Addiction, Pain and Public Health website; 2009-05-02. [Revised same day: changed subject, overly aggressive paragraphs deleted, other minor edits.]

Permalink: http://doctordeluca.com/wordpress/archive/pain-schmuck

See also:
Govt. Acknowledges Misconduct in US v Shaygan – DeLuca, 2009-03-29

I just this evening received and read this testimony regarding a patient of Dr. Ali Shaygan, recently persecuted in your name, on your nickle, for no good reason. By all honest accounts, Dr. Shaygan was exceptional only in his compassion and dedication to the art of medicine and to his patients.

This letter, duly filed in U.S.A. v Ali Shaygan, is the testimony of one of Dr. Shaygan’s patients. It concludes:

I beg you, Judge Gold, to not only impose sanctions on the Federal Prosecutors and DEA agents, but to impose criminal charges for their wrongdoing. [To] deliberately and maliciously – and without regard for the LAW THEY ARE CHARGED TO UPHOLD – fabricate stories to make a case – this is the worst kind of injustice.

I urge you all to read this account, written by a fellow citizen, a person just like you. Read about how Federal police agents, paid by you, intimidate sick people.

While you worry yourself sick about your personal family finances, ponder a moment on the bloody gall of your Dept. of “Justice” in their relentless pursuit of innocent physicians ministering to patients guilty only of being ill. A police state living large at your expense.

How phat are you feeling, my fellow Americans? Phat enough to indulge in doctor-bashing to the literal point of wiping out docs willing to treat chronic pain? Perhaps you (we) are simply too stupid, too hateful and selfish, to survive.

While my colleagues in the mainstream anti-drug-war movement focus fixedly on cannabis, as if marijuana users were the only or even primary victims of global prohibition, opioid therapy for non-cancer chronic pain has been virtually eliminated in this country (and also in the Third World). As in “Not for YOU or YOUR kid or YOUR grandma.”

Oh what a lovely drug war. Medical marijuana – rah rah rah.

You or someone you love will be in a car crash, or will get cancer, or will suffer some chronic, painful and debilitating illness. Not IF, friends; WHEN. Duh.

And WHEN you or yours get injured, or get cancer, or some ongoing, painful chronic medical condition, your primary care physician may VERY LIKELY NOT treat you with the potent analgesic medications most appropriate for your condition, because she is very rightly afraid of ending up like Dr. Shaygan.

And Dr. Shaygan WON one of the most stunning victories in War on Doctors history.

And it IS our fault. This is our Government, they do our bidding, my fellow greedy, sad, short-sighted Americans. I fear our willingness to see our fellow citizens suffer and die will be our destiny.

Apparently Americans hate ill people way more than we love liberty. You love hating “addicts” and locking “them” up more than you love your own damn sick parents and children.

Maybe we all deserve the pain. If we are too stupid or hateful to understand that aspirin kills way more people than opioids, and that there are a whole lot worse things for you and your damn Federal cops to worry about than if maybe your neighbor is getting too much pain relief (sheesh!) – if you are that effin stupid and selfish then maybe you deserve the chronic pain which YOUR government has already imposed on you and your children as the defacto law of the land.

[END]

Drug Control? No, Citizen Control; Guest Editorial: Siobhan Reynolds, Pain Relief Network; 2009-04-20. Source (2009 Campaign for Liberty)

Permalink: http://doctordeluca.com/wordpress/archive/citizen-control/

See also:
Who is Obstructing Justice in Kansas? – DeLuca, 2009-04-14

We keep hearing about how the War on Drugs has failed. But the truth is, the War on Drugs has been tremendously successful, that is if you wanted your country to be a police state, your Congress completely unresponsive to the needs of the people, and your doctors letting you and your loved ones live and die in unnecessary pain.

The marijuana activists have made a lot of progress toward marijuana legalization and overall, that is a positive development. What isn’t positive is that they have done so, at least in part, by covering up the crackdown on medical pain management that has been going on full tilt since 2001. Veterans, cancer patients, people who have been unfortunate in any number of ways (and I am talking here about millions of Americans), have been unable to get pain medications that are supposed to be legal, but which, in reality, are only “semi-legal” – drugs whose legality can be withdrawn by law enforcement whenever the DEA decides that this or that doctor isn’t controlling his patients sufficiently.

This has meant that while no one was looking, our most vulnerable citizens, those in crushing chronic pain, have been denied pain care and allowed to die abandoned by us all.

The Controlled Substances Act makes it a crime to buy or sell controlled substances except as authorized by the Attorney General of the United States. When the act was passed in the early 1970′s doctors were told that possession of a medical license and the issuance of a DEA certificate would automatically exempt them from prosecution – in other words, if a doctor was acting as a doctor, he or she would be safe. Shortly thereafter the Department of Justice included some language in the Code of Federal Regulations that changed the terms of the deal. A doctor had to write such prescriptions not only in “the course of professional practice” but with a “legitimate medical purpose.” Now the coast was clear for the USDOJ to criminalize any physician whose practice of pain medicine didn’t meet with a single prosecutor’s notions of how medicine ought to be practiced.

When then Attorney General John Ashcroft went into the state of Oregon and attempted to defeat the state’s assisted suicide law by declaring the practice of assisted suicide “illegitimate,” the ruse was exposed. It was US government attorneys themselves who in court documents acknowledged that they had been prosecuting pain treating physicians on what amounted to medical disagreements. District Judge Jones scolded the government and later the United States Supreme Court forcefully clarified that the act only criminalized physician conduct that was drug dealing as “conventionally understood.” But the Feds were undeterred. In direct defiance of the Supreme Court, the Department of Justice continued its crackdown on medical pain management, prosecuting some 400 physicians since 2003.

Many of these doctors are serving decades-long prison sentences, having been found guilty of writing “illegitimate prescriptions” by lay juries. How does a jury come to conclude that a prescription was illegitimate? Patients looking for reductions in their sentences testify that they exaggerated their pain to the doctor, and, too, the government brings in one of several hired gun “expert witnesses” to testify that the doctor “should have known” the patients were abusing the medications, based on the presence of certain “red flags” that the “expert” says should have been a clear warning to the doctor that the patient should have been cut off his medications. Sound to you like witch trials? That is exactly what they are.

Recently, the FDA got into the act and withdrew some 13 pain medicines from the market. Those few patients who had been getting by were now told by pharmacists that they would not be able to fill their prescriptions. Shockingly, academic medicine, funded by government grants, has nothing to say in the face of these outrages. Moreover, the mainstream press such as the New York Times and the Associated Press continue to trumpet the government’s press strategy – portraying actions taken against sick people as responsive to an utterly undemonstrated “health crisis” of prescription drug overdoses. Time and again, stories about what’s actually happening to the patients are buried by editors.

The political consequences of this latest crackdown are almost as grim. The Federal government has managed to completely subvert the regulation of medicine in the states, as concerns the management of pain, turning medical boards into kangaroo courts where doctors who mistakenly thought their job was to heal the sick and relieve suffering, get their medical licenses summarily taken away on the DEA’s say so.

Patients are afraid to speak out, lest they lose the medicine that keeps them working. Physicians are counseled by white collar attorneys to put their heads down and take a plea deal. And all of us are being registered with pharmacy computers so that those who take any controlled substances – or in the latest insanity, even cold medicines – are being monitored by the government. And the abuses proliferate.

The War on Terror was not the first overblown fear campaign that was used to destroy our liberties. The War on Drugs and the nearly one hundred year old Federal campaign against us all, called “drug prohibition,” pioneered the tactics that many people now view as transparently authoritarian. Once you come to understand that “drug control” was never intended to control drugs, but rather to create a pretext for the Federal control of citizens, you come to see that the “War’s” goals have been met… and then some.

PRN’s Siobhan Reynolds Investigated for Possible Obstruction of Justice – Prosecutor Treadway Gets a Pass; Alexander DeLuca; Addiction, Pain and Public Health website; 2009-04-14. Revised: 2009-04-15: broken link to “Motion to Quash” fixed, and orig date corrected (apologies).

Permalink: http://doctordeluca.com/wordpress/archive/grand-jury-investigates-prn/

See also these PDF’s:
Siobhan Reynolds Subpoena to Grand Jury – AUSA T. Treadway; 2009-03-27
Reynolds’ Motion to Quash Subpoena – S. Reynolds, 2009-04-09

I guess you can tell when it is springtime in Kansas… AUSA Tanya Treadway goes off the rails.

Just about this time last year the U.S. Attorney prosecuting Dr. Stephen Schneider and his wife attempted to have Siobhan Reynolds, president of the Pain Relief Network, gagged by the Court. Judge Belot found that the government had not shown a compelling interest in restraining speech. (See: Judge Refuses to Gag Dr. Schneider’s Defense – Hegeman, AP, 2008)

Now Treadway wants to drag Ms. Reynolds before a Grand Jury for, get this, obstruction of justice! If we were not talking about the mockery of the American justice system Bush administration Attorneys General and their minions routinely make in War on Doctors cases like Schneider and Shaygan, this would be really funny. Siobhan Reynolds is obstructing justice? Utter nonsense.

It is Tanya Treadway for the prosecution who, if not obstructing justice in this case, is surely doing everything she can to delay it. She greatly annoyed Judge Belot in January when the Government appealed his ruling limiting the number of deaths the government could charge Schneider with – an appeal the Government will surely lose – but which delayed the case allowing the Treadway to keep Linda Schneider imprisoned for as long as possible. (Read more about AUSA Treadway’s antics in US v. Schneider in this Jan. ’09 article from TalkLeft: Even a Bush Appointee Can Only Take So Much!)

Treadway has good reason to want to delay the case, to make it as expensive and grueling for Dr. Schneider and his wife Linda and his patients and his supporters as possible. Her case is weak, the defense is strong, and I think she is going to lose.

I also think Obama should just accept the resignation of every last Bush appointed AG and AUSA. Talk about a bunch of bad apples… sheesh! I wonder if Eric Holder approves of the War on Doctors Prosecutors’ Cheat Sheet – the basic game-plan his AG’s follow in prosecuting pain docs?

..alex…

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Full text of Advocate Subject to Grand Jury
Associated Press, Topeka Capital-Journal, 2009-04-14:

WICHITA – A federal grand jury is investigating the head of the Pain Relief Network for her role in the case of a Kansas doctor whose clinic prosecutors have linked to 59 overdose deaths.

Siobhan Reynolds, president of the Santa Fe, N.M.-based group, is a subject in the grand jury investigation of possible obstruction of justice in the case of Dr. Stephen Schneider and his wife, Linda, according to court documents. A subject is a person of interest the prosecution may be considering charging.

Reynolds’ group has supported the Schneiders, who were indicted in December 2007 on 34 counts alleging they unlawfully prescribed painkillers and overbilled for services at their Haysville clinic. The Schneiders maintain that they are innocent.

Reynolds confirmed that she is the subject of an investigation and said a grand jury in Topeka has ordered her to provide documents related to the Schneiders’ case by Wednesday.

Reynolds has filed a motion asking a federal judge to throw out the grand jury’s subpoena and told The Associated Press that she would go to jail rather than turn over the documents.

“I am going to fight it as far as I need to,” she said. “If I were to give in here, lawful advocacy against the United States in court will effectively be brought to an end. So … a lot is at stake here.”

The U.S. attorney’s office declined to comment.

However, in court documents filed last year in the Schneiders’ case, prosecutors portrayed Reynolds as having a “sycophantic or parasitic relationship” with the couple. Prosecutors alleged she was using the case to further her group’s political agenda and her personal interests.

The group supports physicians charged with violations of the Controlled Substances Act, Reynolds said, and has become involved in about 15 such cases nationwide. The group filed a short-lived lawsuit against the Justice Department after the Schneiders’ indictment, but withdrew it a month later.

The Topeka grand jury’s subpoena, of which the AP obtained a copy, ordered Reynolds to provide all correspondence with attorneys, patients, Schneider family members, doctors and others related to the criminal case and malpractice lawsuits against the Schneiders.

In her motion, Reynolds argued that turning over such documents would destroy her work as a political activist and that it violates her First Amendment rights of speech and association.

“This is a direct attempt to intimidate me and silence me,” Reynolds said.

The subpoena also demanded bank and credit card statements showing payments to and from clinic employees, patients, potential witnesses and others.

Former Schneider patient Marti Beatty said a government investigator recently interviewed him about his conversations with the group, which he called “innocent and unexciting.”

“He was trying to get me to say we as a group or she really, in particular had ulterior motives,” Beatty said of the investigator.

[END]

Govt. Acknowledges Misconduct in Case of Dr. Ali Shaygan; Alex DeLuca; Addiction, Pain and Public Health website; 2009-03-29. Source

Permalink: http://doctordeluca.com/wordpress/archive/GovtMisconductInShaygan/

See also:
Govt’s Response to Motion for Sanctions (PDF) – filed: 2009-03-25

Dr. Shaygan Acquitted of Drug Trafficking – 2009-09-15

Tom Withers, for the Federal Criminal Defense Blog, reviews the outcome of the Shaygan Govt Misconduct hearings (see also: “Flagrant Violations”) in which Dr. Shaygan’s government prosecutors concede:

1. that the Narcotics Section Chief failed to seek appropriate authorization to investigate the defense for allegations of witness tampering,
2. that the case agent in the investigation of Shaygan was also the case agent in the collateral witness tampering investigation,
3. that the government violated its discovery obligations by not disclosing to the defense that two witnesses were cooperating informants and in failing to disclose their secret recordings of the defense investigator and attorney at the time the witnesses testified, and,
4. the government failed to produce all of the interview reports to the Court for inspection when ordered to do so.

Heads rolled. Withers continues:

“As a result of [their] misconduct, the government has offered to pay attorneys’ fees and costs associated with Shaygan’s motion to dismiss and for sanctions. The US Attorneys’ Office for the Southern District of Florida has made a referral to the DOJ’s Office of Professional Responsibility for an independent investigation and associated disciplinary proceedings. AUSA Gilbert voluntarily resigned as the Chief of the Narcotics Section and the lead prosecutor, AUSA Cronin, voluntarily requested a transfer out of the Criminal Division.”

I am not sure how serious a DOJ Office of Professional Responsibility investigation is, or what sort of report we can ultimately expect, or what the time frame would be for such a report.

Perhaps a knowledgeable reader with will enlighten us with a brief Comment? Thanks in advance!

“Flagrant Violations” in Dr. Shaygan Govt. Misconduct Case; Alex DeLuca; Addiction, Pain and Public Health website; 2009-03-19. (Fixed errant link to the Southern District of Florida blog – I apologize, my bad; 2009-03-26.)

Permalink: http://doctordeluca.com/wordpress/archive/flagrant-violations/

The stunning acquittal of Dr. Ali Shaygan is causing even weathered legal bloggers to scratch their heads and say, “Wow.” ¹ Dr. Shaygan faced 141 charges that carried a mandatory minimum sentence of 20 years had he been convicted.

Now the shoe is on the other foot. During the trial, Shaygan’s lead attorney David O. Markus (of the Southern District of Florida Blog) discovered that government prosecutors authorized two witnesses to surreptitiously record conversations with the defense team, had them attempt to bribe counselor Markus, and never disclosed that these two witnesses just happened to be paid, confidential informants for the DEA.

In a March 18th Miami Herald article with a slightly misleading title, US Prosecutors Accused of Misconduct in Case, AP Legal Affairs writer Curt Anderson writes:

“U.S. District Judge Alan S. Gold, who held two days of hearings this week on the matter, said there were “flagrant violations” of basic rules by prosecutors and indicated he would likely order the U.S. government to pay the defense lawyers thousands of dollars in fees and costs… Judge Gold is expected to issue an order in several weeks.”

I’m not a lawyer, but isn’t this grounds for disbarment? Outside the bounds of legitimate legal practice, maybe? And it’s not as if the Government is going out of its way to express sincere remorse – the AP reports U.S. Attorney R. Alexander Acosta termed the misconduct “regrettable.”

I say we make it “regrettable” enough that drug warrior prosecutors nationwide, and defense counsel and judges who face them, get an important message.

War on Docs prosecutions routinely make a travesty of the Constitution and the Bill of Rights and any sense of common decency, fairness, and good judgment. The enforcement and legal communities have a long way to go in reining in their own.

And please spare us another round of self-righteous, flak-catching, and grossly hypocritical documents like the National Association of Attorneys General (NAAG) letters to DEA, “Comment[s] on Dispensing of Controlled Substances for the Treatment of Pain” ² in 2005, signed by the likes of AG Lockyer, the vindictive persecutor of Dr. Frank Fisher.

Spare us the beautiful, vapid, prose. Actually rein in your own, instead.

Footnotes

Dr. Shaygan Acquitted of Drug Trafficking; Alex DeLuca; Addiction, Pain and Public Health website; 2009-03-15.

Permalink: http://doctordeluca.com/wordpress/archive/shaygan-acquitted/
See also:
Dr. Shaygan’s Motion to Dismiss for Govt. Misconduct (PDF), 2009-03-01

In a March 13 South Florida Sun-Sentinel article entitled S. Florida Doctor Acquitted of Illegal Prescription Charges Vanessa Blum writes:

[A]fter just four hours of deliberations, the jury found Shaygan not guilty of 141 counts of unlawful prescribing, setting off a cheer from his friends and relatives. If convicted, he could have been sentenced to more than 20 years in prison…

Throughout the trial, Shaygan’s lawyers called him a caring and trusting doctor who did his best to treat patients.

But wait, there’s more! This from the AP, March 13, Florida Doctor Acquitted on Illegal Prescription Drug Charges:

The judge who presided over the trial is holding a hearing Monday on prosecutor misconduct claims [centering] on prosecutors’ decision to have witnesses tape-record conversations with [defense attorney] Markus and his private investigator. If a violation is found, the judge could sanction prosecutors.

Wow. To win acquittal on federal drug trafficking charges is very difficult and very rare, as I have discussed before. A resounding win is almost unheard of.

Congratulations to Dr. Shaygan and the defense team for a significant win. I would love to know more about the arguments made at trial, and especially any details about the expert witness testimony involved.

Bravo to defense attorney Markus for going after the prosecutors for the usual dirty tricks – what lawyers sarcastically refer to as “the drug war exception to the Bill of Rights.” Maybe not this time.

I will be very interested in the outcome of the prosecutorial misconduct case being brought by defense Counselor Markus. Jay Weaver wrote an article focusing on that aspect of the Shaygan trial, Prosecutors Accused of Misconduct, in the Miami Herald, March 3, 2009.

[END]

Update on Behalf of William Mangino, M.D.; Alex DeLuca; Addiction, Pain and Public Health website; 2009-02-05.

Permalink: http://doctordeluca.com/wordpress/archive/mangino-update-feb09/
See also:
Mangino Sentencing: a Crimeless Conviction – C. Heberle, 2007
and,
Another Pain Doc on the Ropes – D. Borden, Drug War Chronicle, 2007

Note:
I received the text below in an email from Dr. William Mangino. I, and others, have written about this terrible travesty of justice. I know Dr. Mangino, and I have reviewed the charges against him and pertinent medical records and there is nothing in that record to suggest that he was anything other than an expert and honest physician, acting in good faith and well within the bounds of professional practice. (See: Mangino Verdict: Is Treating Pain a Crime?)

To his email to me, Dr. Mangino attached several PDF files – handwritten documents which together comprise what I am calling the Mangino Appellant Brief. I have made these five PDF documents available as:

Preliminary // Brief-0 // Brief-1 // Brief-2 // ReplyBrief

---

Dr. Mangino’s, February 2009, email to supporters:

“William Mangino M.D. has been unjustly prosecuted and convicted in Pennsylvania. His case is unusual. He is currently incarcerated at SCI-Cresson. These briefs were completed without access to a typewriter. His address is on the brief. You may email to this address and messages will be forwarded to him.

“He is the only anesthesiologist (pain specialist; others in the past have been general practitioners) to be prosecuted in this Commonwealth. The brunt of the evidence presented to jurors was based upon what the prosecutors characterize as faulty documentation. The Commonwealth never claimed that patients were over medicated or that dosages of opioids were too high. No patient testified that they had not been examined or that the doctor had knowingly prescribed opioids to patients who were not in pain. There was no evidence of undercover penetration of the activities of Dr. Mangino to indicate anything illegal. No one sold their prescriptions.

“The Commonwealth claims that the doctor made statements to agents that some patients did not need the medication and that the doctor conspired with other physicians in a get-rich-quick scheme. Jurors were incapable of sorting out complex medical testimony. Dr. Mangino insists that he did not do these things; that all patients were examined on each visit; that there was no conspiracy; that all patients had a proven need for pain medications; and that he never gave any statement that patients didnt need medications.

“For the legal community the issues are complex and some involve first impression arguments, which involve U.S.C.A. 5 and 14. Essentially, in Pennsylvania and nationwide, if this conviction is allowed to stand on the grounds presented by prosecution, then any single opioid prescription can be deemed illegal.

“While Dr. Mangino is proceeding pro se he would appreciate any technical assistance from the legal community. He cannot afford representation.

“In addition, Dr. Mangino would appreciate any amicus curie briefings from the medical and pain groups who in the past have paid much attention to the issue of deprivation of pain treatment to patients who have no other option but to receive opioids based on the refractoriness of their pain. Such was the case in this instant prosecution.“

Abstinence vs. Harm Reduction – a False Dichotomy; by Alexander DeLuca, M.D., FASAM, originally published: August 2000. Represented with minor reformatting: 2009-01-15.

See also:
12 Steps Back – Maia Szalavitz, Brills Content, 2001
—
The Controlled Drinking Debates – Brook Hersey, 2001
—
Abstinence vs. Harm Reduction Follies, Summer 2000

Note:
I am re-presenting this ‘oldie but goodie’ essay (originally written as a NYTimes op-ed article but, alas, not published there) because it bears on issues currently being raised around Obama’s appointments of surgeon general and ‘drug czar.’ See John Tierney’s Drug Czar Controversy for background on the current furor.

---

On July 10th, 2000, I was fired as Chief of the Smithers Addiction Treatment and Research Center. My offense? No longer supporting the ‘program philosophy of total abstinence,’ according to an unidentified St. Luke’s/Roosevelt Hospital spokesperson as quoted in the New York Times.

Since then, I have been surprised to find myself cast as a speaker for the harm reduction movement. I have received hate mail, solicitations to write books, and multiple requests for interviews to discuss whether abstinence or moderation is the best treatment for alcoholism. This is about as rational as asking whether coronary bypass surgery or medication is the best treatment for heart disease.

To pose harm reduction against abstinence is to make the good the enemy of the best. Drinking problems exist on a continuum, from the very minor to the very fatal. Effective medical response varies from suggestions to cut down or limit alcohol intake to inpatient stays in therapeutic communities lasting months to years. Any textbook of addiction medicine will tell you this.

So why all the fuss? Why when we consider the addictions do we find ourselves discussing philosophy instead of research? Historically, addiction treatment developed not as a medical discipline, but as an outgrowth of the self-help movement epitomized by Alcoholics Anonymous. These are our roots; and the fact that many people who work in the field achieved their own recoveries through AA has complicated our progress towards evidence-based treatment.

Rapid developments in our understanding of the brain, new and promising psychological approaches, and significant pharmacological advances have led to a clash of cultures. On the one hand we have a tradition of ‘tough love,’ ‘hitting bottom,‘ ‘confronting denial,’ and avoidance of psychotropic medications. On the other, a more modern and medical approach works directly with ambivalence and motivation, and is often accompanied by pharmacotherapy for the craving, anxiety, depression, and insomnia so common in early recovery.

When talking about addiction, harm reduction carries connotations of permissiveness and of effective but marginalized approaches such as needle exchange and methadone maintenance. Yet in every other field of medicine, harm reduction is the default approach.

If a person is overweight and has elevated blood sugar and is at risk of developing adult onset diabetes, a physician might recommend a strict diet and exercise program. But if the patient cannot or will not comply with the recommendations, the physician doesn’t send him away to return when he is ready to accept the diagnosis and be compliant. Rather, the physician might start drug therapy while continuing to work with the patient on his resistance to, or problems with, the diet and exercise regimen. This is harm reduction. We accept the refusal or inability of the patient to do the best thing, and try our hardest to do the next best thing.

The practice of medicine IS the practice of harm reduction. It is a fundamental principle of medical care that the patient has the right to disagree, to be non-compliant, to choose a path or a goal other than the one we might desire for them. The physician’s job is to do everything possible to help such a patient do the best he can, to minimize harm since, at least temporarily, it cannot be eliminated. Only in addiction medicine is it insisted that patients and staff hew to a ‘philosophy’ of ‘total abstinence’ rather than support appropriately individualized goals.

To refuse to work with a patient because he or she will not accept our goals for them, to not inform patients of legitimate treatment alternatives when such exist, to refuse to try legitimate alternative treatments when a particular approach has repeatedly failed because to do so would violate some ‘philosophy’ of treatment, all such behavior constitutes sub-standard medical care. This is true whether it takes place on an alcohol rehabilitation unit or an asthma ward.

[END]

Morphine: Someday, a Cure for Pain; Alex DeLuca; War on Doctors/Pain Crisis; 2009-01-15. Source

Permalink: http://doctordeluca.com/wordpress/archive/morphine-cure-4-pain/

You might also enjoy:
Stickshifts & Safety Belts / Love You Madly – Cake music video
and,
War on Docs/Pain Crisis youTube channel

I have fallen in love with this sound, and these lyrics, and this video and the feelings it evokes in me. Sad that Mr. Sandman apparently died on a stage in Rome of a heart attack at the age of 47. Damn – he gets put on the short list of people I oddly feel close to, but never got the chance to meet.

(and yes, that IS a two string slide bass)

Morphine: Cure for Pain

 
Anyway, it’s a great song. ..alex…
(Hat Tip to Tami – thanks!)
 

The Distortion of Medicine, the Standard of Care, and Medical Community Norms; Alex DeLuca; War on Doctors/Pain Crisis; 2008-12-30. Revised: 2009-01-27 (footnote #4 inserted); 2009-02-19 (footnote #1 inserted).

Permalink: http://doctordeluca.com/wordpress/archive/distorted-confused-med-standards/
See also:
raw video footage from (CEI) interview of Dr. DeLuca, March 2008:
The Distortion of Pain Medicine – part 1 of 6
and,
Medical Ethics and Red Flags – part 2 of 6
and,
Why I Don’t Practice Medicine, Anymore – part 5 of 6

In fields of medicine involving controlled substances, especially addiction medicine and pain medicine, the doctor-patient relationship has become distorted. This distortion is complex and can be gross or subtle. Examples include a blanket refusal to prescribe controlled substances even when clearly indicated, or selecting less effective and more toxic non-controlled medications when a trial of opioid analgesics would be in the best interests of a particular patient.

One manifestation of this distortion is the ‘chilling effect’ – the ‘chilling effect’ is the withdrawal, for fear of litigation or loss of livelihood, by physicians, from the appropriate treatment of pain.¹ The chilling effect on appropriate pain management leads inexorably to the national problems of the undertreatment of pain² and the shortage of physicians knowledgeable and experienced in opioid therapy for chronic pain, and willing to provide this legitimate professional service. At the very least, some degree of suspicion and mistrust will surely arise in any medical relationship involving controlled substances.³

In most medical fields we could say: “How most reputable physicians practice approaches the (textbook) standard of care.” For common medical conditions (not involving controlled substances) the quality of care most physicians provide is fairly close to the medical standard of care which is what the textbooks say one should do, and which is generally in line with core medical ethical obligations such as holding the interests of the individual patient before you above all other interests, patient confidentiality, etc. For example, the care a person would receive for an acute asthma attack is pretty much the same no matter what ER he walked into, and that care would be pretty much by-the-book.

This is NOT true in the fields of addiction and pain medicine. For example, modern pain management textbooks universally recommend ‘titration to effect’ (simplistically: gradually increasing the opioid dose until the pain is relieved or until untreatable side effects prevent further dosage increase) as the procedure by which one properly treats chronic pain with opioid medications.⁴ Yet the overwhelmingly physicians in America do not practice titration to effect, or anything even vaguely resembling it, for fear of becoming ‘high dose prescriber’ targets.

In pain medicine we have the deeply disturbing situation that what most doctors do (medical community norm) is at odds with, and clearly below, the medical standard of care. Literally, in the treatment of chronic pain, an ethical physician attempting to practice in good faith, according to the clinical literature, is an outlier deviating from how most reputable physicians would practice.

For a stark example, Brown and colleagues reported, at a National Institute on Drug Abuse symposium in April 2001, on a survey they developed that measured the prescribing practices for benzodiazepines and for opioid analgesics by groups of physicians in response to variations of a single presented case. The physicians’ prescribing decisions were then compared with recommendations from a panel of pain management experts. They found that while the expert panel recommended that virtually all patients with [common idiopathic back pain] who do not respond to other treatments be given an opioid analgesic, only 20% of physicians said they would actually write that prescription.⁵

Where some medical board investigators and prosecutors err, in cases involving opioid prescribing, is in confusing or conflating the concepts: “medical standard of care,” on the one hand, and “community norms of medical practice,” on the other. Physicians willing to testify that they couldn’t conceive of writing this or that prescription, or that the defendant’s prescriptions were ‘absurd’ or ‘outrageous’ or ‘outside the bounds of legitimate medical practice’ are often not in fact testifying to the medical standard of care, but rather to what they conceive of as the medical community norm – what they think most reputable physicians in the community would do.

The “Reasonable Physician” Standard. While drug war prosecutors invariably attempt to confuse juries and journalists, and usually succeed, regarding this crucial difference between the ‘medical standard of care’ and ‘community norms of medical behavior,’ that difference is in fact very clearly drawn, as a matter of both medical ethics and precedence in criminal law. As Ben Rich explains in “Medical Custom and Medical Ethics: Rethinking the Standard of Care” (citation/abstract – full text PDF):

“When credible evidence has been presented that not just a particular physician, or an isolated, retrograde group of them, but a majority of the profession has failed to adopt practices that would materially reduce patient suffering, courts may properly conclude, in the tradition of great justices like Holmes and Hand, that a reasonable physician would not practice in this way and those who do should be called to account for the adverse consequences such practice has on the well-being of patients.”⁶ (emphasis mine)

Footnotes