The Pain Relief Network

Dec 25, 2009
By: Karen McCowan
The Register-Guard
An Oregon native is honored for her work to help others in pain

Most people would not use the word “gift” to describe a diagnosis of not one but two chronic, debilitating diseases.

Laura Cooper is not most people.

The Eugene lawyer has embraced as opportunities her multiple sclerosis and a condition that causes painful spinal tumors. With her living expenses now covered by disability payments and an annuity from her days as a private finance attorney, she is free to practice an area of law she is passionate about: advocating for the rights of patients in pain.

Cooper cares so deeply about the issue that, last year alone, she donated more than 1,200 hours in legal services to the cause, earning her a top pro bono award from the Oregon State Bar.

Often working literally from her sickbed, she has helped prepare a class action lawsuit now before the U.S. Ninth Circuit Court of Appeals. Filed on behalf of Spokane physician Dr. Merle Janes and 27 Eastern Washington pain patients, the case challenges that state’s “Opiod Dosing Guidelines.” The suit alleges that Washington’s efforts to enforce the guidelines have prevented Janes from providing — and patients from receiving — adequate pain treatment.

The premise of the suit: Patients needing medical pain management with opioid drugs must be accommodated under the Americans with Disabilities Act. Opiods are a class of opium-based and synthetic drugs prescribed by a physician for medical purposes.

“It’s been a godsend,” Cooper said of her forced early retirement from paid legal practice. “My disability allows me to do the kind of work everybody would do if they could. I can work on things that matter in my heart.”

As pro bono (unpaid) counsel to the national Pain Relief Network, she has worked mostly over the Internet, consulting with other attorneys nationwide to research, draft and file motions in the case. Not only is she working to correct what she considers a grave injustice, but in a cutting-edge area of the law. By tackling the issue of pain patients’ rights, “I’m able to deal with a lot of meaty issues,” she said.

The Oregon State Bar’s New Lawyers Division recently gave her its Pro Bono Challenge Award for her work on Janes vs. Washington. The award spotlights “the highest level of pro bono service,” with Cooper honored in the sole practitioner category.

Oregon State Bar President Gerry Gaydos, also a Eugene lawyer, put Coop­er’s 1,200 hours in context.

“Last year, we had 56,000 pro bono hours reported by 1,800 Oregon lawyers,” he said — an average of about 32 hours per reporting attorney.

“You look at Laura’s service compared to that, and it is remarkable,” he said. “She’s encouraged a lot of people with pain to believe in the future, both by her personal modeling and by her legal work.”

Oregon native returns home

Cooper, 53, grew up in Reedsport. She earned an undergraduate general science degree from the University of Oregon before being diagnosed with multiple sclerosis at age 23. She experienced a rapid onset of the disease, which attacks the central nervous system.

“Within a year I was involuntarily placed in a nursing home,” she said.

Determined not to stay there, she decided a law degree would be her best ticket to regaining financial and other control over her life. She graduated from the University of Washington Law School in 1986, clerked in New Orleans for the Fifth Circuit U.S. Court of Appeals, then went to work at a San Francisco firm. While there, she served as outside counsel to the Federal Savings and Loan Insurance Corp. during the scandals rocking that industry. That work led to a Washington, D.C., job as counsel to the chairman of the Interstate Commerce Commission.

Then, in 1992, she was diagnosed with intradural extramedullary spinal cysts, a rare, progressive condition that causes weakness, pain and numbness.

“Technically, it’s a terminal condition,” she quipped during a recent interview. “But I’ve been ‘terminal’ for years. Shhhh!”

No longer able to handle the pressure, stress and long hours of her profession, she decided to return to Oregon and create a living space where she could still use her legal skills on behalf of pain patients and doctors who fear prosecution for adequately treating them. Cooper remodeled a ranch house off Oakway Road, removing walls and adding skylights and space to create a light-filled, wheelchair-friendly room where she can move easily between her hospital-style bed and a nearby desk.

“I can literally do all this work from my sickbed, which is kind of cool,” she said. “It’s a testament to the fact that people don’t have to stop doing what they do when they become disabled. You just have to find a different way to do it.”

Oregon a leader in pain treatment

Cooper said she’s also happy to be back in her home state because it is a leader in considering the distinctive needs of pain patients in its drug law enforcement practices. Oregon is the only state in the nation with a Pain Management Commission to represent the concerns of pain patients to the governor and the Legislature, to require seven hours of pain management training for all medical professionals, and to support research and policy analysis in the field. Oregon also is the only state with a full-time pain management coordinator appointed by and advising the governor.

Even so, there are still “whole areas of Oregon where it’s impossible for patients to get adequate pain care,” said Eugene nurse Jennifer Wagner, who holds the pain management coordinator position. “And one of the top three reasons is physician concerns about regulatory scrutiny for opiod prescriptions.”

Wagner declined to comment on the specifics of the Janes case, but said national pain management groups have expressed concern about Washington state’s guidelines. And she affirmed what Cooper describes as a bottom line in the case.

“People in pain have a right to timely, appropriate and effective pain care,” she said, noting that the American Pain Foundation recently reported that chronic pain afflicts an estimated 72.6 million U.S. residents.

Cooper attributes much of Oregon’s pain treatment progressiveness to passage of its Death with Dignity Act in 1994.

“That forced some soul-searching, when people realized that some are going to commit suicide because they can’t get adequate pain relief,” she said.

And the state went all the way to the U.S. Supreme Court to successfully fight a 2001 policy announced by then-U.S. Attorney General John Ashcroft warning physicians they would be violating federal law if they prescribed narcotics for terminally ill patients seeking to end their lives.

Cooper said she cites as precedent in Janes vs. Washington a section from Supreme Court Justice Anthony Kennedy’s majority opinion in that federal case.

“In layman’s language, he said, ‘Your authority is limited to prosecuting drug-dealing as conventionally understood. You are not to be prosecuting based on medical practice,’ ” Cooper said.

Personal history prompts legal work

Cooper said her own personal history with pain treatment prompted her fierce interest in government treatment of pain doctors and patients.

The galvanizing event for her was the prosecution, conviction and imprisonment of Dr. William Hurwitz, a Virginia pain specialist whom Cooper credits with saving her life. Hurwitz was convicted of drug trafficking after some of his patients were caught selling pain medication he’d prescribed to them.

He was sentenced in 2007 to nearly five years in prison, even though the judge said most of Hurwitz’s “high-dosage opiod” prescriptions for pain patients were legitimate and supported by “an increasing body of respectable medical literature and expertise.”

Cooper credits Hurwitz with diagnosing scarring in her trachea caused by repeated insertion of breathing tubes during flare-ups of her MS. Laser treatments of the scar tissue eased her pain and breathing difficulties, she said.

“And he came up with an MS treatment that stopped me from being hospitalized all the time,” she said.

In Cooper’s eyes, doctors such as Hurwitz and Janes “are being persecuted for ‘over-prescribing’ pain medication even if it’s standard-of-care treatment. And people in chronic pain who need those medications can’t get them because of doctors’ fears of regulatory authority.”

Pain patients pay an excruciating price for what Cooper considers fear- and ignorance-driven government policies restricting the use of opiods for legitimate medical purposes.

Too many government officials “view addiction as not a public health issue, but a legal and criminal issue,” she said. “Doctors are pressured to be a cog in the war on drugs, even though science demonstrates that when people have actual pain, they can take these drugs around the clock and can’t get high.”

Aggressive prosecution of pain management specialists may prevent some people from feigning intractable pain to obtain drugs for illicit purposes, she acknowledged. But she contends the approach has increased public health problems — and costs — by driving hundreds of thousands of actual pain patients to rely on less-effective alternatives with lethal side effects.

“The Drug Enforcement Administration only sees deaths from (controlled substances),” she said. “But no one is comparing those deaths with Food and Drug Administration data showing that more people died from side effects of over-the-counter pain relievers.”

Pain patients are dying of gastrointestinal bleeding from ibuprofen and end-stage liver disease from acetaminophen, she said.

One aim of Janes vs. Washington, she said, is to “bring together two arms of federal government at war with each other.”

As a lawyer, Cooper said she is thrilled to be tackling the issue in civil court as a civil rights matter, saying a favorable Ninth Circuit decision would be a gift to hundreds of thousands of patients in pain.

“Instead of constantly defending individual (doctors) in criminal court, this lets us get at the policies,” she said. “That’s the heart of the issue.”

“My disability allows me to do the kind of work everybody would do if they could. I can work on things that matter in my heart.”

Laura Cooper

http://www.registerguard.com/csp/cms/sites/web/news/cityregion/24262709-41/pain-cooper-oregon-patients-washington.csp?utm_source=Email+Contact+List&utm_campaign=7791c2c306-priceofspeech_PRN_20099_2_2009&utm_medium=email

Reason Hit & Run
By: Jacob Sullum
Dec 9, 2009

This week the Institute for Justice and the Reason Foundation (which publishes Reason magazine and Reason Online) filed a friend-of-the-court brief on behalf of Siobhan Reynolds, the pain treatment activist who is fighting a federal prosecutor’s vindictive obstruction-of-justice investigation. As I explained in a September column, Reynolds, president of the Pain Relief Network (PRN), ran afoul of Assistant U.S. Attorney Tanya Treadway by publicly defending Haysville, Kansas, physician Stephen Schneider, whom Treadway is prosecuting on drug charges related to his painkiller prescriptions. After unsuccessfully seeking a gag order to prevent Reynolds from talking about the case, Treadway tried a different tack. She obtained grand jury subpoenas that demanded a wide range of material detailing PRN’s efforts on behalf of Schneider and other doctors Reynolds believes have been wrongly accused of running “pill mills.” Reynolds refused to comply with the subpoenas on First Amendment grounds and consequently is paying $400 a day in contempt fines. With help from the ACLU, she is asking the U.S. Court of Appeals for the 10th Circuit  to overturn the contempt finding and quash the subpoenas.

Because most of the record in the case (including Reynolds’ appeal brief) is sealed*, ostensibly to protect the secrecy of grand jury proceedings, it is hard to tell exactly how Treadway thinks Reynolds obstructed justice. But her theory seems to be that Reynolds did so by criticizing the government’s case against Schneider and thereby influencing the jury pool—i.e., by exercising her constitutional right to freedom of speech. The “evidence” sought by Treadway includes correspondence related to a billboard defending Schneider and a PRN video about the conflict between drug control and pain control. The I.J./Reason brief argues that forcing PRN to divulge information about its membership, finances, communications, and internal operations “chills speech and burdens the right to engage in anonymous speech and association.” It reinforces that point by citing I.J.’s research on the chilling effect of public disclosure requirements. It also argues that a fishing expedition like Treadway’s violates the First Amendment right to freedom of association by requiring disclosure of an activist group’s political strategies.

*Update: Before I wrote this post, I checked with Geoffrey Michael, the lead attorney on the I.J./Reason brief, to make sure it was OK to make the file available here. He thought that was fine, since the brief did not contain any secret grand jury information. But he has since informed me that the 10th Circuit’s clerk says the brief should not be published, which is why it is no longer here. This instruction illustrates the ridiculously broad notion of grand jury secrecy at play in this case, since the amicus brief is based entirely on publicly available information. Scott Michelman, the ACLU attorney who is representing Reynolds, told me he was not allowed to share his U.S. District Court brief opposing the subpoenas, although he was free to reiterate the arguments it contained.

http://reason.com/blog/2009/12/09/tanya-treadways-unconstitution

The New York Times
Nov 5, 2009
By John Tierney

Chronic pain affects more than 70 million Americans, which makes it more widespread than heart disease, cancer and diabetes combined. It costs the economy more than $100 billion per year. So why don’t more doctors and researchers take it seriously?

That is the challenge raised by a new report from the Mayday Fund, a nonprofit group that studies pain treatment. The report, which been endorsed by an array of medical groups, advocates a revolution in the training of doctors, the financing of research and the education of law-enforcement officials.

“The fact is that people aren’t getting competent and cost-effective treatment for chronic pain,” said Dr. Russell Portenoy, one of the co-chairmen of the panel that prepared the report.

Dr. Portenoy, the chairman of the department of pain medicine and palliative care at Beth Israel Medical Center, was one of the pain experts who supported William Hurwitz, the Virginia doctor who was imprisoned for prescribing opioid painkillers to patients who resold them. (Dr. Hurwitz’s sentence was reduced after a retrial in which Dr. Portenoy and other experts testified on his behalf.)

At a news conference Wednesday, Dr. Portenoy and the other co-chairman of the Mayday panel, Dr. Lonnie Zeltzer of the University of California, Los Angeles, said patients’ needs had to be better balanced against the concerns of law-enforcement officials, whose prosecutions of Dr. Hurtwitz and other doctors have made physicians reluctant to prescribe opioids. Dr. Zeltzer said doctors were especially reluctant to prescribe such painkillers to young people, and she cited the example of a teenager who had been incapacitated for six months until finding a doctor willing to prescribe opioids.

“Don’t assume that your doctor knows what to do to treat your pain,” Dr. Zeltzer advised patients. Read more…
She and the other members of the panel urged better pain-management training in medical schools and more money for pain research, which, according to the report, receives 1 percent of the budget of the National Institutes of Health.

The panel also urged the federal Department of Health and Human Services to reform the way doctors are reimbursed for treating pain. Dr. Portenoy said that the current system had “misaligned incentives” encouraging doctors to preform procedures like injections and surgery and that doctors who performed those procedures could make 10 times as much per hour as doctors who treated pain in other ways.

Distorted incentives and inadequate treatment are hurting patients at the same time they are driving up health costs, according to the report:

Instead of receiving effective relief, patients with persistent pain often find themselves in an endless cycle, seeing multiple health care providers, including many specialists in areas other than pain, who are not prepared to respond effectively. They often endure repeated tests and inadequate or unproven treatments. This may include unnecessary surgeries, injections or procedures that have no long-term impact on comfort and function. Patients with chronic pain have more hospital admissions, longer hospital stays and unnecessary trips to the emergency department. Such inefficient and even wasteful treatment for pain is contributing to the rapid rise in health care costs in the United States.

You can read the rest of the Mayday report and its recommendations here. Do you have any recommendations on what should be done, and any guess as to the likelihood of reforms in the treatment of chronic pain?

http://tierneylab.blogs.nytimes.com/2009/11/05/treating-the-pain-epidemic/#more-7005

Nov 4, 2009
Author Unknown
medicalnewstoday.com

Science now offers us ever more advanced ways to understand and control pain. But with those new treatments come new questions about the use (and misuse) of state-of-the-art technology and how far pain management can and should go. Is pain a symptom or a disease? How much pain should be relieved? Can reducing pain be inappropriate or detrimental? Can technologies capable of scanning the brain tell us whether a patient is really experiencing pain? And what questions arise in confronting (and treating) pain in animals and other non-human beings?

On November 13, the Center for Neurotechnology Studies at the Potomac Institute for Policy Studies will present the lecture “From a Neuroscience of Pain to a Neuroethics of Care” by Prof. James Giordano, internationally known for his work on the neuroscience and neuroethics of pain. The program will address the neuroscientific progress achieved during the Congressionally-designated Decade of Pain Control and Research, and discuss the ethical implications of this knowledge for medicine, and society at large. Researchers are now looking ahead to a Decade of the Mind, and this lecture raises questions about whether what we know about pain will both guide and be guided by what we seek to learn about the mind, and the nature of self and others.

What: CCNELSI Lecture: “From a Neuroscience of Pain to a Neuroethics of Care”

Who: James Giordano, Ph.D.

Where: Potomac Institute for Policy Studies, 901 North Stuart Street, Suite 200, Arlington, VA, 22203

When: November 13, 2009, 3:30 – 6:00 pm

More info: http://www.ccnelsi.com

http://www.medicalnewstoday.com/articles/169847.php

Oct 29, 2009
By Carrie Johnson
Washington Post Staff Writer

Heightened efforts by the Drug Enforcement Administration to crack down on narcotics abuse are producing a troubling side effect by denying some hospice and elderly patients needed pain medication, according to two Senate Democrats and a coalition of pharmacists and geriatric experts.

Tougher enforcement of the Controlled Substances Act, which tightly restricts the distribution of pain medicines such as morphine and Percocet, is causing pharmacies to balk and is leading to delays in pain relief for those patients and seniors in long-term-care facilities, wrote Sens. Herb Kohl (D-Wis.) and Sheldon Whitehouse (D-R.I.).
The lawmakers wrote to Attorney General Eric H. Holder Jr. this month, urging that the Obama administration issue new directives to the DEA and support a possible legislative fix for the problem, which has bothered nursing home administrators and geriatric experts for years.

The DEA has sought to prevent drug theft and abuse by staff members in nursing homes, requiring signatures from doctors and an extra layer of approvals when certain pain drugs are ordered for sick patients.
The law, however, “fails to recognize how prescribing practitioners and the nurses who work for long-term care facilities and hospice programs actually order prescription medications,” Kohl and Whitehouse write. They conclude that delays can lead to “adverse health outcomes and unnecessary rehospitalizations, not to mention needless suffering.”

Most nursing homes do not have pharmacies or doctors on site, adding to delays for patients who fall ill late at night or in transition from a hospital.

Justice Department and DEA officials had no immediate comment. The DEA sent out guidance last summer in response to some of the pleas, but it did not resolve the central issue of whether a nurse could serve as an agent of a doctor and administer pain medication with a verbal directive rather than a written prescription from a doctor.
The problem took on new urgency this year after the drug agents heightened their enforcement of the rules at pharmacies in Ohio, Michigan, Wisconsin and Virginia. The pharmacies face tens of thousands of dollars in fines if they deviate from strict controls that require doctors to sign paper prescriptions and fax them to a pharmacy before a nurse can administer them in the nursing home setting.

“The system is broken. It isn’t working, and patients are suffering,” said Claudia Schlosberg, director of policy and advocacy for the American Society of Consultant Pharmacists. “While we need to ensure there are proper controls on the medications, the overall law enforcement concern has to be compatible with meeting patients’ needs, and right now it’s not.”

Doctors in nursing homes say the restrictions do not take into account that many more patients, with higher levels of illness and pain, are moving into long-term-care sites and out of hospitals.
William Smucker, medical director of the Altenheim Nursing Home in Ohio, said that the “delay is not what I would want for myself or my family, and it’s not the way I practice in other settings.”
Terence McCormally, a doctor who cares for patients in nursing homes in Northern Virginia, said the tug of war reflects “the tension between the war on drugs and the war on pain.”
“For the doctor and the nurse, it’s a nuisance,” he said, “but for the patient it is needless suffering.”

http://www.washingtonpost.com/wp-dyn/content/article/2009/10/28/AR2009102803146.html?utm_source=The+Freeman&utm_campaign=26e0b19fdd-In_brief_10-20-2009&utm_medium=email