Sunday, April 23, 2006
Howard Heit knows pain.
He lives it, he studies it, he works to reduce it. His own pain used to get so bad that he wore patches of hair off the back of his head by rubbing it hard against walls in a desperate effort to get some relief.
"What I was feeling was like a cramp in my leg, but multiply that by 100 times and make it continuous," he now says. He no longer hurts like that, but he still wears a brace with a head attachment he can push against for acupressure when a pain spasm hits.
Heit is a doctor. Today he's a pain and addiction specialist in Fairfax, but once he was an up-and-coming gastroenterologist, a football player, a jock. That was before his auto accident, the one that changed his life and taught him about pain problems the very hard way -- as a patient who often didn't get the help he so badly needed.
The doctor still spends a lot of time in his wheelchair, but that hasn't stopped him from becoming a prominent practitioner and lecturer over the past decade. More recently, his profession and personal history have propelled him to the center of a contentious national dispute that he virtually personifies.
On one side, the Drug Enforcement Administration and Justice Department -- alarmed by the seemingly widespread diversion of opium-based prescription drugs such as OxyContin and Dilaudid to addicts and abusers -- have investigated, arrested and prosecuted as "drug dealers" scores of pain doctors who allegedly misused their authority to write prescriptions for narcotic painkillers. On the other side, many pain doctors and patients have protested the DEA's approach as overly aggressive and punitive, saying that it's unfairly penalizing pain patients.
Heit, 61, doesn't use prescription opioids for his own pain now, but he does prescribe them in high doses to many of his patients, and he's seen the drugs (in conjunction with proper monitoring) provide remarkable relief -- the kind he still wishes he had had available back when he really needed it. As the showdown between pain doctors and prosecutors stiffened several years ago, he felt obliged to get more actively involved in defense of opioid treatment despite the potential risk to his practice.
So he joined a team of 18 pain and addiction specialists, hospice and cancer-care workers and DEA officials to write and review guidelines for the proper prescribing of narcotics. He was delighted when, after more than two years of work, their Frequently Asked Questions presentation was posted on the DEA Web site in the summer of 2004. But several weeks later the FAQs disappeared from the site and was soon essentially repudiated by the agency, leading 30 state attorneys general to write to the agency in protest. The chill in the world of pain management has grown worse ever since.
"It now is apparent to me that the spirit of cooperation that existed between the DEA and the pain community to achieve the goal of balance has broken down," Heit wrote in a much-discussed commentary in the journal Pain Medicine last month. "The DEA seems to have ignored the input and needs of the healthcare professionals and pain patients who actually prescribe, dispense, and use [prescription opioids]."
Tough words from a man who shares some of the DEA's concern over drug diversion, but who clearly cares most passionately about making sure that pain sufferers get the relief they need.
"Our government is letting the misbehavior of a relatively small number of people too often trump the needs of many, many good people with complex medical problems and lots of pain," he said recently, seating behind his office desk where a chart of pain levels is prominently displayed. (1-2 is mild pain, 5-6 is distressing pain, 9-10 is excruciating pain.) "Many doctors won't prescribe for pain now. And believe me, that's not where we as a society want to be."
A New Era Reversed
Pain is the most common symptom that brings patients to a doctor's office, but it remains one of the least understood. There's no CAT scan, no blood test to objectively measure the level of a person's pain, and years of research have determined that different people experience pain very differently. So pain patients are an inherently challenging group for doctors, their ailments difficult to assess and their suffering often difficult to treat.