Pitching Relief

As Shugol continued to talk of the active life she can now have because of the opioids and her care by Heit, the doctor went through the detailed paperwork he keeps on all patients. He found a photocopy of his last prescription for her and, to his chagrin, he had indeed overprescribed by 100 pills.

"What you're seeing here is that we're all human and make mistakes," Heit said, somewhat sheepishly. "But Wendy returned them, as she should, and I can see from my records exactly what happened. These are powerful and valuable drugs, and so we should take great care."

Without intending to, Heit had demonstrated an issue at the heart of the doctor-DEA debate: What constitutes a medical error in prescribing, and what constitutes criminal behavior? Many doctors who have been prosecuted argue that they were aggressively treating pain as the literature now recommends, and that sometimes they made mistakes by trusting a patient who said he or she was in great pain and needed opioid painkillers. In response, the DEA says doctors who are prosecuted show a pattern of misprescribing that has more to do with a desire for money, easy-to-please return patients or even sexual favors than with the proper treatment of pain.

Shugol had followed Kathryn Brock of Reston -- another woman in a wheelchair with an easy smile and a strong desire to remain active -- into Heit's office. Brock sufferers from rheumatoid arthritis in virtually every joint in her body, and she, too, is subject to constant pain. She says that her regimen of six OxyContin and eight Dilaudid pills a day has kept her marriage going, and gives her the ability to continue painting, which she does regularly.

Like Shugol and most other chronic pain sufferers, she says the opioids don't make her feel euphoric or "high" at all. (Researchers believe that the pain essentially soaks up the drugs' active ingredients for most legitimate users.) Another Heit patient the same afternoon was an administrator in a healthcare business, a man in his mid-forties who developed a condition 10 years ago that caused him to pass frequent kidney stones. The pain was so excruciating he would collapse on the floor. He was going to a nearby emergency room regularly.

The man, who requested anonymity because of the continuing stigma associated with opioid use, began pain treatment with Heit three years ago. He hasn't been to the emergency room since.

Coming to Terms

Heit began learning about pain in earnest at 41, two decades ago, after a speeding car smashed into his in McLean. He didn't immediately feel his injuries, but in the following weeks he began to have increasingly intense spasms of pain around his neck and head. A lifelong athlete, he tried to ignore the pain but it grew, and his neck began to rotate uncontrollably with a condition later diagnosed as axial spastic torticollis.

Heit says it took a long time for him to come to terms with his changed life, after going through the classic steps of denial, bargaining, anger, depression and late acceptance. His anger phase featured an obsession with people who park their cars illegally in handicap spots. He would glue a sticker that read "Stupidity is NOT a physical handicap" on their windshields and ultimately got into 18 fistfights with motorists who weren't happy with what he'd done. (He says he left the field undefeated.) His depression emerged after it became clear that he couldn't practice medicine as he had known it.

But at the end of a conference about the brain that he attended, an epiphany: He could still be useful, he had something to contribute, and he would rededicate his professional energies to pain management and addiction. Over several years he retrained in this underappreciated specialty, and in 1992 opened his practice.

While caring for 250 to 300 patients in his practice, he also teaches at Georgetown University School of Medicine, speaks regularly at pain and addiction conferences, writes and co-writes dozens of journal articles and does consulting work for some major manufacturers of prescription opioids. One of his ambitions is to persuade medical schools to give more attention to training students in pain management and what he always calls "the disease of addiction."

While Heit isn't shy about prescribing high-dose opioids when he thinks they're necessary, he's also a great believer in the maxim that satisfying activity is one of the greatest analgesics. This is an approach he often shares with his patients and says his own history and condition -- he can walk only short distances before needing his wheelchair -- appears to give him credibility.

"A patient will tell me of a problem they're having, a feeling, and I'll be able to quickly know exactly what they mean," he said. "I've been there, and they know it."

Heit's personal story also appears to give him some added credibility with federal authorities. He worked closely with DEA liaison and policy chief Patricia Good on the ill-fated Frequently Asked Questions, and the two remain friends. Good says she was impressed by Heit's dedication to patients, his determination to run a tight ship in terms of narcotics he prescribes, and his willingness to engage with -- and even take on -- the DEA. She found Heit to be open to the DEA's conclusion that some pain doctors were careless or worse with their narcotic prescriptions, and he was eager to put together professional guidelines that could help the DEA while protecting doctors and their patients.

The FAQ document was widely applauded as a successful collaboration, and was welcomed by the Journal of the American Medical Association. But soon after, lawyers at the DEA concluded that there were errors in the statement, and so it was withdrawn. Good says the agency plans to present its own policy guidance soon, but many pain doctors are skeptical that anything positive will come of it. (Heit is not one of those. Despite his broadside against the DEA, he hopes that the agency will resume its discussion and even collaboration with pain and addiction doctors.)

Good, who retired last year, says she supports her former agency's narcotics-control mission, but remains disappointed that the FAQs were deemed flawed. And so, when the agency was planning her retirement party, she asked that a number of pain doctors be invited to recognize their collaboration. Howard Heit was the only one who made it.

The Gift of a Baby

A fourth patient seeing Heit earlier this month was a young woman who had fallen down a flight of stairs at a nightclub and ruptured two disks in her neck. Another jock accustomed to playing with pain, she tried to gut her way through it. Doctors recommended surgery, but she resisted.

Her boyfriend recommended Heit, and she began treatment. She improved markedly, married the boyfriend and, while still on OxyContin, got pregnant. She knew she could never get through the pregnancy without the medication, but she was concerned that the child could be in withdrawal at birth.

When the baby was born in 2004, Heit was at the hospital to examine the newborn for signs of opioid trouble, and was relieved to find none. Heit is the kind of person who likes to connect quickly and deeply to others, and so it wasn't entirely unexpected that he would be in the hospital. But there was another reason for his presence.

The new mother, whom Heit had received permission from Virginia medical authorities to treat, was Jamie Heit -- his son David's wife. And the healthy child, born to a woman who wasn't sure she could ever carry a baby after her fall, was his first granddaughter, Lilly.