See also:
Chronic Pain in Veterans - DeLuca; 2007
and,
Bounds of Medical Practice, and the Standard of Care - DeLuca; 2007
and,
Untreated Chronic Pain is a Medical Emergency - DeLuca; 2008

A More Practical Perspective on Opioids
Most arguments against the use of opioids for a significant short-term or longterm pain problem are usually based on irrational fears, or so-called “opiophobia.” However, this ignores a more practical perspective.

The only direct biologic pain-relief system in the human body is the endogenous opioid receptor system, consisting of endorphins and their tissuebased action sites, or receptors. Any potent attack on pain must trigger or enhance this system. All other systems in the human body that may relieve pain must do it indirectly. Hence, pain treatment agents that exert their biologic effects by suppressing inflammation, blocking synapses or anion channels, or activating hormones for growth or healing must all act indirectly.

Only opioids go to the heart of the matter, which is the endogenous opioid receptor system. When pain is severe, whether acute or chronic, indirect treatment agents such as antiinflammatory or neuro-synaptic blocking agents may not only fail to adequately control pain, they may produce significant complications.

Astonishingly, there is still widespread belief that pain is merely a psychological phenomenon with no inherent physical complications of its own, and aggressive medical treatment is, therefore, unwarranted. For example, some drug detoxification centers promote the self-serving concept that withdrawal from opioids can cure pain.

While some rare forms of pain may be purely psychic manifestations, the notion that opioids should be withheld from a patient with severe pain in favor of various psychological, behavioral, or physical therapies is folly and dangerous. The scientific literature and extensive clinical experience abundantly demonstrate that the failure to adequately treat severe acute or chronic pain may produce a plethora of serious complications, including death from pain-related cardiovascular collapse [Brookhoff 2000; Tennant 2004].

Opioid Treatment of Post-Surgical, Accident, and Other Acute Conditions
Acute pain, be it from an injury, infection, or post-surgical procedure, is clearly known to over-activate the pituitary-adrenal axis and interfere with healing [Greisen et al. 1998, 1999]. Opioids have clearly been shown to shorten recovery and promote healing in acute conditions, to say nothing about the humanitarian relief of suffering [Brookhoff 2000; Yakota et al. 2000]. There remains a belief by some, however, that a patient recovering from surgery, accident, or myocardial infarction is better served by writhing in a hospital bed rather than having their pain relieved.

There are excellent controlled studies demonstrating the positive effects of pain control following surgery, including dental and obstetrical procedures. Opioids stabilize cortisol, catecholamines, and blood pressure among other restorative homeostatic mechanisms [Greisen et al. 1998, 1999; Yakota et al. 2000]. Post-operative patients who have excellent pain control are routinely observed to begin eating, ambulating, and socializing within hours after surgery. See Table.

Since most patients who present to the healthcare system due to accident or in need of surgical intervention are not opioid tolerant, the only significant risk of opioid administration is respiratory suppression. This complication can be easily avoided if the initial opioid dosage is low and raised as necessary. Severe pain appears to have the affect of “absorbing opioids” and preventing respiratory depression. In the event, however, that respiratory depression does occur, naloxone, an opioid antagonist, will immediately reverse this complication.

Opioid Treatment of Headache and Other Pain-Flare Conditions
Chronic medical conditions that periodically flare and require emergency pain treatment with opioids plague emergency rooms and primary care physicians. While headaches are the predominant condition, there are other diseases that produce periodic, debilitating pain flares including sickle cell disease, pancreatitis, porphyria, and some gastrointestinal diseases, including ulcerative colitis and regional enteritis.

Simple, short-term opioid therapy consistently, rapidly, and effectively relieves pain flares from these conditions, particularly when given by injection, suppository, sublingual, or buccal administration. See Table. Although many opioids for pain flare conditions are routinely stocked and used in hospitals and emergency rooms, there is great reluctance to prescribe opioids for at-home, pain flare treatment by the patient and family.

Broader prescribing and patient-teaching of safe, at-home techniques for opioid administration are the most effective ways to treat pain flares and avoid a bed/house-bound state, and to prevent emergency room and physician visits. The irrational fear of opioids for at-home use is simply un- founded. It is this restriction that leads many patients to overuse triptans and antiinflammatory agents to toxic levels and serious complications. Another misplaced fear is that patients who self-administer opioids for flare conditions will drive poorly. In reality, an untreated patient with a pain flare from headache, pancreatitis, or sickle cell disease is clearly a driving hazard since uncontrolled pain may adversely affect attention span, muscle coordination, and vision.

Still, opiophobia relating to pain-flare treatment is prevalent. For example, some hospitals and other medical institutions have removed meperidine (Demerol®) from their formularies due to fear that a seizure may occur in some patients if meperidine metabolites accumulate to toxic levels. This fear is valid only with chronic administration and not the occasional use normally required for pain-flare conditions. Injectable meperidine remains the superior “stop-the-pain now” opioid for many patients. Another concern is that pain-flare treatment with opioids will be overdone and cause a fall or auto accident. This can happen, but these risks can essentially be eliminated if the patient is accompanied by an advocate who can observe the patient after opioid administration.

Opioid Treatment in Chronic Pain Conditions
Untreated, severe chronic pain has multiple, major complications, which debilitate patients and shorten their life spans [Tennant 2000]. For example, if chronic pain is severe, it will produce a negative biologic state characterized by high pulse rate, hypertension, abnormal adrenal hormone levels, insomnia, anorexia, immobility, and other effects. Regardless of clinical risks, this condition must usually be treated with high doses of opioids.

Clinical risks after initiation of opioid treatment include the nuisance problems of constipation, edema, nausea, dizziness, and itching. (See lower Table.) Other than constipation these side effects usually disappear after a few days of opioid treatment. Weight gain commonly occurs with chronic opioid administration. Once opioid tolerance and an effective pain-control dosage is achieved following upward titration from a starting dose, the major risk is suppression of testosterone and possibly dehydroepiandrosterone (DHEA) [Daniell 2001]. This complication may occur in males and females, and no other hormone suppression has been documented. There is no conclusive evidence that chronic opioid administration in a tolerant patient causes mental, neurologic, or immune deterioration. However, since chronic opioid administration does have documented testosterone suppression, constipation, and weight gain, it is recommended only after nonopioid therapies have failed to adequately control the chronic pain condition.

Chronic opioid administration benefits are profound (see Table). In the patient whose pain is severe, constant, and alters blood pressure, pulse rate, and pituitary-adrenal hormones due to its stressor properties, opioid administration is the only treatment that can consistently and predictably control pain. Chronic opioid therapy is documented to normalize blood pressure, pulse rate, and pituitary- adrenal secretions [Tennant and Hermann 2002]. Even milder forms of chronic pain may benefit from low-dose opioid treatment as demonstrated by a number of clinical studies.

Opioid treatment leads to enhanced biologic functions, including eating, sleeping, socializing, and sexual relations. Physical functions, including the ability to walk, drive, and work usually improve. Patients and clinicians commonly refer to the benefits of chronic opioid administration as improving “quality of life.” Much of the improved quality is in the stability brought to a chronic pain patient who, without opioids, is in-and-out of the hospital or sickbed and unable to participate in normal family, vocational, and other desired pursuits.

An emerging revelation involving chronic opioid administration is neurogenesis. There exists the outdated belief that nerves cannot regrow or regenerate and that pain that results from damaged nerve tissue is fixed and permanent. Numerous animal and laboratory studies reveal that nerve tissue can at least partially regenerate. Clinically, chronic pain patients who have taken opioids for extended periods are now being observed to permanently reduce their pain levels presumably due to neurogenesis. Opioids appear to function as a type of “splint,” allowing homeostasis and healing to take place. Conversely, uncontrolled pain suppresses immune function and does not permit such rehabilitative nerve growth.

There is no ceiling or maximal level of opioid dose in chronic pan. The appropriate dosage is determined by starting low and titrating upward until a dose is reached that reduces pain 70% to 90%, but does not impair or sedate the patient. Multiple opioids may be required for this purpose. Overdoses, deaths, and accidents that occur in chronic-pain patients whose dose is initially determined in this fashion are due to patients failing to take their opioids as prescribed. Patients may also take other drugs or substances unknown to the prescribing physician and produce a drug interaction, with potential cardiac arrest and death. Simply stated, opioids as formulated, marketed, and properly prescribed in the United States are quite safe and have minimal clinical risk – when they are taken as prescribed.

The Harmful Consequences of Misinformation
Prescribing physicians and the general public are constantly barraged with negative and misleading information about opioids. The worst misinformation is that patients who take opioids chronically become “addicted.” It is remarkable, and instructional, to observe that patients who daily take insulin, antihypertensives, antidepressants, or sedatives are never referred to as “addicts.”

Just as with chronic pain patients, these patients need daily medication. Chronic pain patients who take opioids become physiologically dependent and experience withdrawal symptoms when their daily opioids are abruptly stopped. This is also true for patients who daily take most antihypertensives, antidepressants, and sedatives, among other drug classes. When a chronic pain patient is able to totally eliminate pain as a result of effective treatment, they can easily withdraw and remain off opioids.

Another bit of misinformation thrust upon us is that a patient taking chronic opioids cannot drive, work, or volunteer. In a tolerant patient, this is simply false. The American Society of Addiction Medicine and every other professional physician group basically defines an “addict” as someone who compulsively takes a drug, such as an opioid, for a nonmedical purpose, like euphoria or pleasure. However, is not pain a most legitimate medical purpose? Yet another harmful media effect has been perhaps unintended, but the onslaught of attention given to celebrities and other persons who sell, abuse, overdose, or die from opioids gives the public a false impression that no opioid drug should ever be prescribed by physicians. In reality a mere glance at the high-profile media cases reveals these people did not take opioids legitimately or as prescribed. The number of celebrities and street users combined who misuse and die from opioid overdose is miniscule, compared with the many millions of ordinary persons with painful conditions who daily take their opioids as prescribed and greatly benefit from them.

So why the constant onslaught of negative misinformation? There appear to be two basic reasons. The first is economic – parties with an economic reason to reduce or deny clinical opioid treatment constantly feed and goad the media. They include health insurance plans, because opioid treatment may be expensive and prolong survival. Opioids also reduce the need for costly care from some healthcare institutions and practitioners, such as hospitals, surgeons, and mental health specialists. Lastly, there is the ugly reality that heroin dealers want pain patients to buy illegal opioids from them, rather than receive legitimately prescribed opioid medications from the local pharmacy.

A second reason for the constant negative onslaught on opioids is religious and emotional bias. Apparently, there are some persons in society, including some physicians, who have a belief that pain and suffering are “good.” There are others who believe that persons who take opioids are weak-willed and should not be allowed these drugs in order to live or function. For example, the author recalls a recent severe pain patient with only a few months to live who remorsefully related that her son refused to see her because he would rather have her die in pain than have her take opioids to function and prolong her life. These beliefs are irrational because every human nervous system and blood system are already filled with the opioid, endorphin. The simple fact is that persons who propagandize against opioids might be shocked to know they constantly have opioids floating in their blood and cannot live without them.

Prescribing Opioids the “Right” Way
The argument that opioids should not be used for long-term pain management is nonsensical, if they are prescribed under these two circumstances:

1. There is a legitimately diagnosed pain condition;
2. Nonopioid pharmaceuticals have failed to control the pain.

Unfortunately, physicians today are being deluged by a suspicious population of patients who do not exhibit obvious causes of pain. They claim to hurt “all over” or have a diffuse back, head, or limb pain that does not appear to have any causative event or physical evidence of neuropathy. These patients also present with no medical records or 3rd-party person to validate evidence of legitimate pain. Sadly, these persons have become such a plague on some physicians and medical institutions that they have given both opioids and patients who legitimately need opioids a poor reputation. The correct response to confirmed drug-seekers is recommending detoxification and psychiatric or addiction referral – no physician should prescribe opioids for these people.

Conversely, there are millions of Americans who have authentic structural tissue damage and legitimate pain. Medical practitioners should not prejudge patients who complain of pain, but do a careful history-taking and physical exam, review x-rays and medical records, and do validation interviews with family members to separate the bona fide, opioid-deserving patients from those who need psychiatric or addiction referral.

Once a legitimate, structural cause of pain has been identified, a prescribing practitioner should attempt the various nonopioid agents that are available. Recent research has produced several new analgesic drugs to go with some older agents, and these should be attempted before opioids are prescribed. See Table.

If the agents listed in this table are not effective in controlling pain, it is appropriate to add or substitute a Schedule III or IV opioid. These include opioids that may contain acetaminophen, such as propoxyphene, hydrocodone, codeine, and dihydrocodeine. The addition of acetaminophen potentiates the opioid’s pain-relieving capability and reduces its abuse potential, since it is difficult to inject, ignite, or nasally inhale acetaminophen. Mixed agonist-antagonist preparations – including nalbuphine, butorphanol, buprenorphine, and pentazocine – are sometimes excellent pain relievers and have relatively low abuse potential.

There are some patients with severe chronic pain who will require the use of long-term Schedule II opioids, such as methadone, morphine, oxycodone, oxymorphone, or hydromorphone. These agents should only be prescribed by practitioners who have a well-structured pain-treatment program as part of their regular practice or as their sole practice. Why? The initial evaluation of these patients may require 1 to 3 hours and extensive record-keeping. Patients needing ongoing Schedule II opioids also require regular clinic visits for monitoring of complications and compliance.

A Commonsense Conclusion
Only opioids can effectively treat significant pain resulting from surgery, injury, and certain disease processes. The idea that there are meaningful alternatives in many clinical situations is nonsensical, since opioids are the only class of drugs that can directly enhance the body’s natural endorphin system. Opioids have many detractors, reflecting a variety of economic and emotional biases. Common sense, however, dictates that all physicians, along with their clinical allies and the general public, need to reject the opioid naysayers and their campaign to under-treat pain. Currently, misuse of opioids by persons failing to take the medications as prescribed is resulting in some high profile media cases that are giving opioids an unwarranted negative image. The clinical benefits of opioid treatment, however, dwarf the clinical risks.

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References
Brookhoff D. Chronic pain: A new disease? Hosp Prac. 2000;7:1-13.

Daniell HW. The association of endogenous hormone levels and exogenously administered opiates in males. Amer J Pain Man. 2001;11:5-10.

Greisen J, Grofte T, Hansen PV, et al. Acute, non-traumatic pain increases the hepatic amino-to-urea-N conversion in normal man. J Hepatol. 1998;4:647-655.

Greisen J, Hakland M, Grofte T, et al. Acute pain induces an instant increase in natural killer cell cytotoxicity in humans and this response is abolished by local anesthesia. Br J Anaesth. 1999;83:235-240.

Tennant F, Hermann L. Normalization of serum cortisol concentrations with opioid treatment of severe chronic pain. Pain Med. 2002;3:132-134.

Tennant F. Complications of uncontrolled, persistent pain. Prac Pain Man. 2004;Jan/Feb:11-17.

Yakota T, Uekara K, Nomoto Y. Intrathecal morphine suppresses NK cell activity following abdominal surgery. 2000;47:303-308.

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Big Prescription Drug Lies; Alex DeLuca; War on Doctors/Pain Crisis blog of the Pain Relief Network; 2008-04-27.
 

See also:
Self-Refuting Drug Warriors - Sullum; Reason; 2008-04-18
The Challenge of Prescription Drug Misuse - Hurwitz; Pain Medicine; 2005

Jacob Sullum makes an important point in a recent item on the Reason Hit and Run blog entitled, “Self-Refuting Drug Warriors.”

“A new analysis of data from the National Survey on Drug Use and Health once again confirms a point I emphasize in my book Saying Yes: The vast majority of illegal drug users do not fit the stereotype of addiction and degradation promoted by the government and the news media.”

Pain Relief Network members, readers of this blog, and other serious students of the war on doctors and the pain crisis will not be surprised by these 2008 government findings. Dr. William Hurwitz did a far more sophisticated analysis of a wider array of government databases, using only his brain and the internet and no tax dollars, which was published in 2005 (while he was in federal detention for drug trafficking) in the journal Pain Medicine entitled, “The Challenge of Prescription Drug Misuse.” An example of this excellent work:

“Most individuals who engage in illicit use of pain relievers do so infrequently… As noted in Table 7, slightly fewer than one quarter of those reporting use in the prior year used on only 1 or 2 days. The majority (52.4%) had used these medications on 10 days or fewer in the prior year [supporting] the proposition that mere exposure does not inevitably lead to abuse and dependence. It also suggests the informal and opportunistic… pattern of most youthful drug use (Table 7).”

TABLE 7 - FREQUENCY OF PAIN RELIEVER USE AMONG 18-25 YEARS OLDS PERCENT USING FOR THE SPECIFIED NUMBER OF DAYS OR FEWER IN PRIOR YEAR (2002)

Days	1	2	3	5	10	15	30	60	90
Percent	12.9	24.1	32.3	42.4	52.4	60.7	71.3	85.2	86.7
These data were generated by online analysis available at http://www.oas.samhsa.gov/samhda.htm (accessed in June 2004).

Sullum, referring to an analysis of 2004-2006 survey data by the government Substance Abuse and Mental Health Services Administration (SAMHSA), notes that the calculated rates of “dependence” or addiction (tolerance plus continued use despite adverse consequences) within two years of using various substances are very low. For example, SAMHSA estimates that 3.1% of people who ‘nonmedically use’ prescription painkillers show evidence of addiction, 96.9% do not. For comparison, the two-year addiction rate estimate for alcohol is 3.2%, and for cannabis 5.8%

Huh? So, according to the U.S. government’s best scientific guess, cannabis is more addictive than either alcohol or opioid analgesics like morphine and OxyContin? How much did this un-parse-able nonsense cost us? [Some 18 BILLION dollars a year funnel through the drug czar (ONDCP) to fund the drug war including the academics in NIDA and SAMHSA]

So why, with the drug war money flowing like water for decades, is the scientific research so incredibly crude? As I try to explain in an interview done earlier this year with CEI (see raw footage: Part 6: Reign of Terror - Let the Pain In), if the Government really cared so much about the children, wouldn’t they have found a way to study them? All this money for the drug war including funds for substance abuse research (NIDA and SAMHSA), and all we get is survey data? Not one lousy prospective, longitudinal study that would tell us exactly what happened to the 25% of adolescent “prescription drug abusers” who only used a few times, or the majority who used 10 times or less? Please.

In fact the U.S. Govt doesn’t give a rats ass about either drug abuse or drug addiction. Don’t take my word for it, read the yearly White House Drug Strategy. They are obsessed by drug USE, and that is all they measure - raw use. This simply is not sufficient data upon which to make rational public policy. GIGO - Garbage In, Garbage Out.

I highly recommend Scherlen and Robinson, “Lies, Damned Lies, and Drug War Statistics,” published in 2007, if you are at all confused by the yawning chasm between the endless prescription drug abuse propaganda and the data the Govt actually bothers to collect. Jacob Sullum’s Saying Yes is likewise a demystifying experience. (Why not click on the iGive icon below and buy yourself a copy of “Saying Yes” and benefit the Pain Relief Network at the same time!!)

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See also:
Prosecutors Seek to Shut Up Doctor, Critics - Drug War Chronicle; 2008-04-11
Doctor, Wife Held Incommunicado from Family - Hegeman, AP; 2008-01-10

Stephen Schneider said if the Kansas Board of Healing Arts had conducted its investigation into his Haysville medical clinic swiftly, he might not be facing federal criminal charges.

“I think there have to be some changes made, so things don’t get out of hand like they did with me,” Schneider said Friday morning, following his return home after four months in jail.

Schneider said that if the board had handled its investigation properly, he might have been exonerated through a medical review, alleviating the need for criminal prosecution.

“I thought that’s the way it was starting out, anyway,” he said.

Citing advice from his lawyer, Schneider declined to discuss specifics of the 34-count federal indictment against him and his wife, Linda, related to their prescribing of painkillers.

But Schneider said he’s confident he could have passed a medical review.

“It took too long,” he said.

The board said the Schneider investigation included multiple patients and complex issues not easily resolved.

But the board’s delay in suspending Schneider’s medical license drew criticism from lawmakers. Its director and general counsel resigned earlier this month, because of Schneider’s and other cases.

The board, which licenses doctors in Kansas, didn’t suspend Schneider’s medical privileges until a month after federal charges were filed.

The U.S. Attorney’s Office and the Board of Healing Arts have differing views on how decisions were made in each agency’s case against Schneider.

The board has said federal prosecutors asked it to halt its investigation until after the criminal case was charged. The U.S. Attorney’s office said it did not ask the board to alter its investigation.

“That’s the impasse we have,” said Kelli Stevens, a lawyer for the board.

Stevens said she could not discuss specifics of the board’s investigation of Schneider.

“But you have to remember that what we do and the criminal case are two different investigations,” Stevens said.

A status conference on further board action on Schneider’s case is set for next month. His trial in the criminal case is scheduled for February 2009.

Schneider also said he felt uncomfortable talking about nearly a dozen civil lawsuits against him. Some of the suits are pending. Five settled cases have become a contention in the criminal proceedings.

Prosecutor Tanya Treadway has subpoenaed the confidential settlements in those cases.

Lawyers for the Schneider Medical Clinic and its insurance carrier have entered the criminal case, arguing that revealing the settlement details would infringe on the doctor’s privacy.

Settlements in two of the cases have paid more than $230,000 from the Kansas Health Care Stabilization Fund. The fund augments private medical malpractice insurance and usually represents only a fraction of the total settlements.

The Eagle obtained amounts the fund paid for Schneider under the Kansas Open Records Act.

The fund paid $75,000 for Schneider to patient Lacie Flickinger.

Flickinger said Schneider failed to properly supervise her and monitor prescriptions he gave her for morphine, fentanyl and other drugs derived from opium. She said she became addicted to the drugs and suffered kidney damage.

The fund also paid $156,250 toward a settlement between Schneider and the family of Patricia Gaskill, who died in June 2005.

Her family alleged that two days after she was admitted to a Wichita emergency room for a drug overdose, she was able to go back to the Schneider clinic and receive prescriptions for powerful narcotics from a physician’s assistant. She died two days later of drug intoxication.

Schneider has practiced family medicine as an osteopath since 1988.

“I’m a family practitioner that helps people in chronic pain,” he said.

Prosecutors had feared that Schneider would abscond to Mexico, where he and his wife have a house.

“That ain’t happening,” Schneider said.

“That’s not even a consideration,” he added. “I want to see this through. I want to show our innocence.”

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Brief Comment from me:
Note the Judge did not grant Prosecutor Tanya Treadway’s disturbing request that a “no-contact” condition (gag order) extend to “members of the Pain Relief Network advocacy group, including its leader, Siobhan Reynolds.” So I guess I’m still allowed to publish this, here in America. [see: More Limits Sought for Schneider Bond]
..alex…

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WICHITA, Kan. (AP) — When Dr. Stephen Schneider finally returns home Friday, the indicted Kansas doctor will step into a house seemingly frozen in time. The family’s Christmas tree is still up; all the presents underneath it remain unopened.

His two daughters - 15-year-old Gina and 16-year-old Zoey - said they planned to keep it that way until their mother, Linda Schneider, is freed from jail as well.

Four months after the Schneiders were arrested on charges of running a “pill mill” linked to 56 deaths, Magistrate Judge Donald Bostwick on Thursday ordered that the doctor be released on bond and other conditions pending his February 2009 trial. A decision on Schneider’s wife’s release will not be made until after the results of her psychological evaluation are in.

“It really won’t be a celebration until mom gets home,” Gina Schneider said.

More than a dozen former patients and family members showed up at the doctor’s bond hearing Thursday in hopes he would be immediately released. But the one-day delay will give court officials time to set up the GPS monitoring that will track Schneider’s movements while he awaits trial.

Gina Schneider said outside the courtroom that the family planned to “make a lot of food - real food” to mark her father’s return. Spaghetti was his favorite meal, Zoey Schneider said.

The girls, who had been staying with their grandparents while their parents were incarcerated, said they will get to sleep in their own beds now that their father is home.

“This is going to take a big load from Linda’s mind,” her sister, Pat Hatcher, told reporters outside the courtroom.

Bostwick slightly modified the release conditions for Stephen Schneider. But he refused to grant a government request to require a security bond rather than the unsecured $325,000 bond. The doctor agreed to forfeit more than $2 million in assets if he does not show up for court dates.

“There have been some serious charges in this matter - and the government has tried to keep you in,” Bostwick told Schneider as he admonished him on the conditions of his release.

The doctor must also notify the court of any action to reinstate his medical license, and he must agree not to apply for another Drug Enforcement Administration registration number that would allow him to prescribe controlled substances.

Other release conditions include electronic monitoring. Schneider would be restricted to home detention except for employment, religious services, attorney visits and other specified activities.

The judge prohibited Schneider from contacting any of the families of the 56 patients cited in the indictment or the families of the three additional patients whose deaths were linked to the clinic after his arrest. He refused to grant the government’s request to keep Schneider, his family and others from contact with all other former patients. [See: More Limits Sought for Schneider's Bond]

The couple was arrested Dec. 19 on a 34-count federal indictment alleging conspiracy, unlawful distribution of a controlled substance resulting in death, health care fraud, illegal money transactions and money laundering.

The federal indictment alleges the Schneiders directly caused four deaths and contributed to the deaths of 11 other patients. In all, the indictment links the clinic to the accidental overdose deaths of 56 patients.

The Schneiders have pleaded not guilty to all the charges.

“We are really encouraged at this point. We know we have a strong fight ahead of us. It is a small sense of relief, but he knows he has a long way to go,” his attorney, Lawrence Williamson, told reporters outside the courthouse.

The original criminal complaint against the Schneiders - filed under seal on Nov. 29, 2007 - was unsealed on Wednesday along with the previously sealed motion by the government that asked for its dismissal in favor of prosecuting the indictment returned by the grand jury.

That now-public document - which focused only on allegations relating to the conspiracy to distribute controlled substances and health care fraud allegations - provided a glimpse into the government’s case against the Schneiders.

Rebecca Martin, a special agent of the Federal Bureau of Investigation, alleged in an affidavit attached to it that the Schneiders received more than $4.24 million from more than 90 health care benefit programs.

She noted as an example that the Walgreens Pharmacy located near the clinic had to keep a weekly inventory of $10,000 worth of narcotics - two to three times the normal inventory of other Wichita pharmacies - because of the customer load from prescriptions issued by the clinic.

The government contended that from October 2002 through December 2006, the Schneider Medical Clinic billed health care programs for more than 10,400 patients, more than half of whom were pain-management patients.

Still to be worked out among the parties is who will be the custodian of patient records to handle any future subpoenas and patient requests for their medical records.

“This investigation has not ceased - it continues,” Assistant U.S. Attorney Alan Metzger told the court.

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See also:
Judge Orders Schneider Released - DeLuca on Release Order, 04/23/08
Prosecutors Try to Silence Pain Activist - Szalavitz; 04/08/08

Just a brief comment from me:
This is starting to get silly. Every time ANY motion comes before a judge regarding ANY aspect of the Dr. Schneider affair, Prosecutor Tanya Treadway raises her hand to say, “Oh, oh, Judge! Could you please also stop political activist Siobhan Reynolds from expressing herself?” (sheesh!)
..alex…

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WICHITA. Stephen Schneider won’t win his freedom without an argument.

Federal prosecutor Tanya Treadway has asked a judge to modify the conditions for the former doctor’s bond, set for a hearing at 2 p.m. today in Wichita.

Schneider, 54, is charged with his wife in a 34-count indictment accusing them of writing illegal prescriptions for painkillers to the patients at their Haysville clinic.

U.S. Magistrate Judge Don Bostwick ruled Monday that Schneider should be released under 15 conditions, including that he not practice medicine or be involved in his clinic.

The judge allowed the prosecution and defense to file objections until Wednesday.

Treadway asked for “minor modifications,” including ordering Schneider to put up a secured bond of $325,000.

Bostwick had ordered that Schneider didn’t have to put down a deposit, but would forfeit half of his property that the government had not seized if he didn’t comply with all of the conditions.

“The Court, the United States Attorney’s Office and the U.S. Marshal would have little ability to enforce or collect an unsecured bond,” Treadway said.

Prosecutors fear Schneider might flee, because he and his wife own property in Mexico, and he faces a potential life prison sentence if convicted.

Bostwick ordered Schneider to surrender his passport. Treadway also wants the judge to order the former doctor placed on the State Department’s “watch list” at the border.

“The government does not believe that a passport is needed to enter Mexico, although one is required to re-enter the Unites States from Mexico,” Treadway wrote.

Bostwick also ordered that Schneider not contact any of his former patients cited by the government as purported victims in the charges against him.

Treadway said that includes all of the estimated 10,000 patients who went to the Schneider Medical Clinic, because any of them could be the victims in health care fraud charges against the Schneiders.

The government wants the “no-contact” condition extended to Schneider’s family, friends, former employees and members of the Pain Relief Network advocacy group, including its leader, Siobhan Reynolds.

Schneider’s lawyer, Lawrence Williamson, said he plans to argue against some of the new conditions at today’s hearing.

Bostwick has postponed ruling on releasing Schneider’s wife, Linda, from jail pending a court-ordered psychological evaluation.

[END]

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My comments Regarding:
U.S. District Court - District of Kansas
U.S.A. v. Stephen and Linda Schneider
Memorandum and Order (PDF) - Judge D.W. Bostwick, 2008-04-21
(releasing Stephen Schneider, on Wednesday April 23, 2008, at 4:30 PM)

Judge Bostwick has ordered Dr. Stephen Schneider released pending trial. The Memorandum and Order (PDF) is an interesting read, if you are a terminal war on docs nerd junkie.

I think the judge is taking the Govt’s line and thinking to a silly extent, on some of the issues raised in this complicated case. For example, if the govt taps your phone calls in jail, and places signs all over the place saying your calls might be monitored, then they can do ANYTHING they want with the info they collect, because you “consented” by using the phone?

Whoa! - I knew the govt was listening, but I do not give my consent for them to do unethical or illegal things with the information, just by using the phone. But as I read this, the judge is just blowing by such uncomfortable issues.

This isn’t slacking. Rather, I think what the judge is doing in places is working REALLY HARD digging up precedent and weaving it all together so that it just sort of seems more reasonable than I think it is.

I am confused as to why exactly Schneider’s DEA license got offered up… sounds like a mistake was made somewhere, because in this document Judge makes it sound like Schneider himself keeps shouting, “hey - take my DEA license by all means if you have to to let me go”. Something confusing happened here.

BUT, reading through the document, there is absolutely no reason Dr. Schneider should give up his DEA license. This is all about “public safety” as the Judge clearly reviews, and the Release Memo and Order have provisions that ensure that Dr. Schneider will not be endangering the public by manipulating any doc who takes over the now closed clinic on lease, if that should happen, etc and so on. Also, I believe his medical license in Kansas is suspended. Therefore, any surrender of his DEA license was unnecessary, gains Schneider nothing, and does exactly nothing to protect the people of Kansas.

The problem is, down the line after Dr. Schneider is completely exonerated, he is going to find it VERY, VERY difficult to get that license back. Nobody ever said DEA was nice guys. If they hate you or fear you, they will hurt you, any way they can. It’s in their genetic code. Read the history.

So, NEVER “give” Them anything - it will not make Them like you, or treat you any better than they otherwise have in mind for you.

Yum! Pain patients and doc sauce!!

Anyway, Friends, if you are curious, go ahead and click the link above (here it is). This legal brief is more accessible than many, in my experience. And it’s about a case you are familiar with - so, hell, give it a shot. It’s sort of fun to see how much of the legal thinking and rationale is common sense understandable…

This Judge actually seems to be making some effort to clearly explain the issues raised by the various motions from prosecutors and defense, and the precedent on which he relied to resolve them. It is the latter sections, in parts, that strike me as sleight-of-hand or govt bias as I suggest above.

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For background on the legal issues involved in the larger Schneider case, see The Complete Lawsuit (PDF).

For an archive of national press articles about Schneider and PRN’s efforts on behalf of his abandoned patients, see: Newsflash - PRN in Kansas, an updated news archive.

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As always, we ask that you help PRN fight to protect the rights of patients and the doctors who treat them. Thank you for clicking the link below.



www.painreliefnetwork.org
info@painreliefnetwork.org

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See also:
Chronic Pain in America - Roadblocks to Relief
American Pain Society, 1999
and,
War on Drugs, War on Doctors, and the Pain Crisis in America
Alex DeLuca, 2004
and,
Chronic Pain in Veterans - a Brief Review
Alex DeLuca, 2007

On the off chance that people remain unconvinced that there is indeed a terrible pain crisis, I will offer some thoughts which might help shed light on this situation.

The World Health Organization has said that undertreated pain is the number one health problem in America. Further, I quote from Rovine and Ferrerio, of the APS, about the “Roadblocks to Relief” study:

FEBRUARY 17, 1999, Glenview, IL - More than four out of every 10 people with moderate to severe chronic pain have yet to find adequate relief, saying their pain is out of control, according to a new survey released today by the American Pain Society, the American Academy of Pain Medicine and Janssen Pharmaceutica.

The survey of 805 individuals also revealed a population of sufferers who often don’t receive the type of care experts consider necessary - despite the fact that nearly half have switched physicians at least once and more than 50 percent have been in pain for more than five years.

“Many Americans with chronic pain are suffering too much for too long and need more aggressive treatment,” says Russell Portenoy, MD, president of the American Pain Society and chairman of the Department of Pain Medicine and Palliative Care at the Beth Israel Medical Center in New York City. “This survey suggests that there are millions of people living with severe uncontrolled pain. This is a great tragedy. Although not everyone can be helped, it is very likely that most of these patients could benefit if provided with state-of-the-art therapies and improved access to pain specialists when needed.” …

A majority of all survey respondents reported some difficulty doing such basic activities as sleeping, doing chores at home and walking. These problems are accentuated among those whose pain is very severe (8, 9 or 10 on the pain scale) - of whom nearly one in five had been forced to visit an emergency room at least once in the past year due to their pain…

Among those with very severe pain, almost a third (29 percent) had switched physicians three or more times. The most common reasons for the decision to search for a new doctor were “too much pain” (42%), the perception that their last physician did not know a lot about pain treatment (31%), the belief that their doctor didn’t take their pain seriously enough (29%) and the physician’s unwillingness to treat their pain aggressively (27%).

Pain Treatments: Too Little Too Late

Despite the fact that “opioid” drugs, such as morphine and the fentanyl skin patch, were rated the most effective treatments by those respondents who had used them, these medications were seldom used. …

This was from a 1999 study, back before the Government Crackdown on Pain Care. Unfortunately, patients die of conditions related to the sedentary lifestyle imposed on them by the undertreated pain and so would not be said to have died of the pain, yet had they been treated for the pain, they would not have succumbed to high blood pressure, cardiac arrest, cancer, adult-onset diabetes, etc. You would have to use your imagination to figure out how else a body might deteriorate if it didn’t function, and was continually stressed, unable to rest or move or even eat properly, but as you have a medical degree perhaps you will do that on your own time.

Suicides are concealed by the patients who do it because they want to enable their families to get whatever small benefit they might have coming to them for death of the non-suicidal variety like car accidents. If the patient doesn’t commit suicide or becomes a drunk, patient’s families watch as their loved ones deteriorate unnecessarily.

Worst of all, since there was a flowering of pain care that has since been crushed by the Government Crackdown, patients had a taste of how they might have lived had they been able to continue with their medical care. They had found their lives restored, their dignity returned, their bodily functions under their control; able to work, to love, to have conversations, friends, interests. Stuff I bet you take for granted.

To those who deny the pain crisis - I wish you would rethink your position.

– Siobhan Reynolds, president - Pain Relief Network

[END]

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As always, we ask that you help PRN fight to protect the rights of patients and the doctors who treat them. Thank you for clicking the link below.



www.painreliefnetwork.org
info@painreliefnetwork.org

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Shop online using iGive, and Support the Pain Relief Network!

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See also:
It’s the Pain Crisis… - Siobhan Reynolds, LTE: Topeka Capital-Journal; 2008-04-04
Feds Seek Gag Orders in “Pill Mill” Case - Associated Press; 2008-04-05

Every time I think this action by Siobhan Reynolds on behalf of the abandoned pain patients of Dr. Stephen Schneider can’t get any worse, on the human-suffering scale, the Fed. lashes out again, digging themselves in deeper, making themselves look dopey; not to mention the State, as Congressional Clowns pander and Medical Board members dither… The band played on.

But it is also true that it rarely gets any better than this, either. Siobhan Reynolds has made sure that we will hear both sides this time. That for once this is going to be about the pain crisis, not just -gasp!- addiction. This is real “Emperor Has No Clothes” stuff. This time it is all being reported.

Chaos! in the war on drugs. I’m loving it.

..alex…

Doctor Seeks to Quash Subpoenas on Malpractice Settlements
Roxana Hegeman; Associated Press; 2008-04-18
WICHITA, Kan. — Federal prosecutors have essentially “deputized attorneys” in their efforts to use confidential malpractice settlements to prosecute a Kansas physician accused of illegally prescribing medication, defense attorneys said in documents filed Friday.

Attorneys for Dr. Stephen Schneider and his wife, Linda, filed a motion to quash the subpoenas seeking information about the settlements, arguing the government was circumventing the criminal discovery process through civil litigation.

The defense also contended the government abused its subpoena powers to cover up what they called malpractice attorney Larry Wall’s “blatant disregard” for confidentiality clauses.

In an e-mail, Wall told civil defense attorneys that if they did not want Assistant U.S. Attorney Tanya Treadway to have the settlement agreements they should send objections to her.

Wall did not immediately return a message left Friday at his office for comment.

The Schneiders’ criminal defense attorneys told the court that Wall sends copies of correspondence between himself and the attorneys representing the doctor in civil cases to the government.

The Schneiders were indicted in December on 34 federal counts. The indictment accuses the Haysville couple of directly causing four deaths and contributing to at least 11 others. The couple has pleaded not guilty.

The doctor’s criminal defense attorneys alleged in court papers that Wall did not plan to challenge the subpoena even though he negotiated the confidentiality clause.

“Obviously Wall’s loyalty to his clients’ confidential information is secondary to his desire to please the government,” according to the motion.

In an e-mail sent earlier this month, Wall told the doctor’s civil defense attorney he did not intend to file a motion to quash the subpoenas because he believed it was unwarranted.

“My clients do not want me to impede or to unduly delay the investigations of Dr. Schneider and Linda Schneider,” he wrote. “The agreement also states the confidentiality provision is subject to disclosure required by law and a lawful subpoena is the type of disclosure I anticipate was envisioned by myself and my clients at the time we signed the agreement.”

At least five malpractice cases were settled, according to the documents.

Siobhan Reynolds, president of the Pain Relief Network, told The Associated Press in January that she urged the doctor to not settle any more civil lawsuits because other doctors in similar malpractice cases had successfully fought them.

The AP, citing interviews and documents it obtained, reported in February that malpractice attorneys had worked closely with prosecutors to help indict the Kansas doctor and his wife.

While the malpractice attorneys contended their help wasn’t improper, the Schneiders’ supporters argued the close involvement by malpractice attorneys in civil lawsuits against the doctor tainted the federal prosecution. Reynolds contended the malpractice attorneys and their clients stand to financially gain from a criminal indictment that justifies their lawsuits.

The AP analyzed court documents filed in numerous civil lawsuits against the doctor over the past several years and found that the bulk of the death cases in the indictment were first filed as malpractice lawsuits by Wall and another malpractice attorney, Andrew Hutton.

Their findings, as set out in exhibits filed in those civil cases, are used throughout the criminal indictment - sometimes verbatim.

[END]

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As always, we ask that you help PRN fight to protect the rights of patients and the doctors who treat them. Thank you for clicking the link below.



www.painreliefnetwork.org
info@painreliefnetwork.org

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Shop online using iGive, and Support the Pain Relief Network!

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