By Marc Kaufman
Washington Post Staff Writer
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.
The strongest and most effective pain relievers are opioids, derived from the opium poppy or synthetic versions of its active compounds. In the popular imagination, and traditionally in law enforcement, opioids have been associated with addiction, moral weakness and crime. That the same compounds are a godsend to millions of suffering but otherwise unexceptional and law-abiding people is far less widely understood.
The nation's qualms about narcotic pain relief seemed to lessen in the 1990s, when many researchers concluded that the drugs were less likely to cause addiction in pain sufferers than earlier believed. While many patients will become physically dependent on opioids -- just as other patients become dependent on insulin, calcium channel blockers or anti-depression medicine -- the overwhelming majority can and will be weaned off if their pain subsides. The advent of OxyContin, a time-released, partly synthetic opioid that provides unique pain relief, added to the sense that a new day had arrived in the nation's thinking about opium-based pain relief.
But that was before OxyContin abuse and overdoses became a widespread problem in places like Appalachia and rural New England, and before local leaders and politicians began calling for stronger action to keep these prescription products from turning into a street drug of choice. It has proved very difficult to stop the criminal diversion of prescription narcotics from the nation's drug supply chain, but relatively easy to identify doctors who write large numbers of Percocet or Vicodin or OxyContin prescriptions that -- through carelessness, bad luck or, as prosecutors charge, criminal intent -- sometimes fall into the wrong hands.
Using sometimes novel legal theories, prosecutors have charged many pain doctors with prescribing opioids "outside the normal practice of medicine," and dozens are now in, or facing, jail. One of the most prominent is William Hurwitz, a nationally known pain doctor also based in Fairfax. After a trial last year, Hurwitz was convicted of 50 counts of drug trafficking, and was found responsible for the overdose death of a patient and serious injuries of two other patients. He was sentenced to 25 years in federal prison.
At the time of his sentencing, DEA Administrator Karen Tandy held up a plastic bag with 1,600 pills and said they were prescribed by Hurwitz to one patient on one day. "Dr. Hurwitz was no different from a cocaine or heroin dealer peddling poison on the street corner," she said. "Indeed he was worse, because unlike the street dealer, he had and abused the trust and authority to treat people in pain. He hid behind his white lab coat and Stanford medical degree to try to conceal the fact that he had become a common drug trafficker."
(Regarding the prescription for 1,600 pills, Hurwitz said it was a clerical error that was corrected by a pharmacist before it was filled.)
That case is now on appeal and has become -- along with several other prosecutions -- a cause celebre for advocates including those in the Pain Relief Network, who are helping Hurwitz and a number of other arrested and convicted doctors to fight the charges against them. While acknowledging that Hurwitz could have been more careful in some of his prescribing, his supporters cast him as a dedicated and courageous professional who has been railroaded by the government.
The new era in pain relief anticipated and promoted by pain doctors and drug manufacturers seems increasingly far off.Lives Transformed
Wendy Shugol is a nationally recognized special-education teacher at Falls Church High School, a French horn player in the Fairfax City Band, a horseback rider and avid woodcarver. She also has cerebral palsy and a host of other serious conditions, and doubts she could even get out of bed were it not for the massive doses of opioids she takes daily. She says her referral to Howard Heit in 1998 marked a fundamental transformation in her life. "I'm a different person now," she says. "My life was miserable, and I was basically miserable to be around."
Shugol, 54, wheeled herself into Heit's Arlington Boulevard office two weeks ago for a monthly appointment, smiling broadly and filled with an energy seldom seen in people who don't carry her many physical burdens. The first order of business was, as always, to hand Heit her vials of drugs, so he could see exactly how many pills she had used since the last visit. Heit took out a pill counter and went to work, first on the OxyContin, and then the Dilaudid. He was puzzled to find more than 100 extra pills.
"Have you been taking everything you need?" he asked.
"Yep, but I think you made a mistake last time," she replied. Rather than writing a prescription for 230 pills, Heit had written one for 330 pills, and that's what the pharmacist filled.
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.