DOCTOR DEFENDS HIS PAIN-CONTROL CREED

DEA Has Lifted His Power to Prescribe

GROVER - The atmosphere was grim in Dr. Joseph Talley's waiting room last
week. Patients sat on scruffy cushioned stacking chairs, the kind common to
buffet diners, eager to see Talley for assurance or a referral.

None were getting what they really wanted -- a prescription renewal for
narcotic pain relievers or other powerful drugs they had come to rely on
Talley to write. Talley was pretty low himself.

The federal Drug Enforcement Administration, in an order suspending his
privilege to prescribe narcotics, had called him an "imminent danger to the
public health and safety." It accused him of prescribing to known drug
addicts and contributing to the deaths of 23 people. Agents told him his
small clinic was the largest single source of the painkiller OxyContin in
the nation.

"I'm scared to death," Talley said. At 64, he may be through as a doctor.
The DEA's order Jan. 28 basically shut him down. Since all but a fraction
of his practice in this tiny mill village consisted of prescribing
narcotics, he has been left to assure and refer.

Even scared, Talley remained defiant. He admitted to prescribing
exuberantly, but he denied that his patients were addicts or dealers, or
that he had anything to do with people abusing legal drugs and dying. Pain
relief, he contended, has been his only mission. And he has a great number
of supporters. Many of them traveled to Grover from as far away as Oklahoma
City to be treated by the one person they said was willing to give them as
many drugs as they needed to live free of insufferable, unending pain.

The Talley case is the latest in the nation to raise questions about the
proper use of narcotics in managing pain. The prevailing wisdom has shifted
radically in recent years as the medical establishment has moved from
extreme caution in prescribing narcotics to a more liberal approach.

The turnabout began in the late 1980s, after research showed that people
healed faster if they got relief from pain. What's more, research showed
that powerful opiates such as morphine, or their synthetic cousins, the
opioids such as oxycodone, did not turn pain sufferers into sniveling
addicts, even after protracted use and at high dosages.

Medical boards, including North Carolina's in 1996, came out with
statements encouraging doctors to treat pain, when appropriate, with "even
large amounts" of narcotics without fear of reprisal.

Yet confusion abounds. What, exactly, constitutes an "appropriate" use of
narcotics is often as subjective as pain itself.

In the hands of a country doctor who acknowledges he has no formal training
in pain management, and with patients who, in many cases, lack the
resources to head to big-city clinics for new-fangled therapy,
"appropriate" takes on a different meaning.

"We are not pain specialists," Talley said in an interview last week in his
office. "We can't do shots in the back, or implant morphine pumps. If a man
comes in with no money, and I'm convinced he has disc disease, I would
spare him the expense of going and getting an MRI."

So he'd offer what he could. In most cases, that was a regimen of narcotic
pain relief. And often, according to Talley and the DEA's order, it was at
frequent, high dosages.

Accused of Self-prescribing

Talley's enthusiasm for pill therapy, in fact, goes back decades and
includes his own use. He eagerly joined the fen-phen phenomenon in the
1990s, when the combination of fenfluramine and phentermine were heralded
as the answer to a dieter's prayers -- quick and easy weight loss without
diet or exercise. Talley took the pills himself in an effort to trim down
from 280 pounds.

Then fears emerged that the drug combination caused heart problems, even
death, and many of his patients told him they were going to stop taking
what was left of their prescriptions and throw the pills away.

"I told them that if they were just going to throw them in the trash can,
they could give them to me," he said. He took the pills himself, to
maintain the 60-pound weight loss the pills had spurred. "I stayed thin for
two years after everyone else," he said.

But such recycling isn't allowed, and the N.C. Medical Board has accused
him of self-prescribing in a long list of charges it issued against Talley
last October.

Even before fen-phen, though, Talley was keen on pill therapy for his
patients. In the 1980s and early '90s, he was a heavy prescriber of
antidepressants and anti-anxiety drugs such as Xanax, Valium and Ativan.
The drugs, known as benzodiezapines, are considered addictive under the
Controlled Substances Act.

That's when he first came under the state medical board's scrutiny. In
1991, the board summoned him to Raleigh to explain what, exactly, he was doing.

"I saw some good men being hounded out of practice, and I wrote letters to
the board asking them what the guidelines were," Talley said. "The next
thing I know, pow, I'm down there. It was a lively meeting. But in the end,
I walked away intact."

Yet he was marked. The board kept periodic checks, which grew more
persistent as the pain drugs became more prominent.

In its complaint last October, the state medical board alleged, among other
things, that Talley failed to perform physical examinations before
prescribing narcotics, failed to get medical histories, failed to properly
assess patients' claims of pain, failed to offer alternatives to opioids.

He'll answer those allegations at a hearing on March 22.

After the board took action, the DEA swept in. On the Wednesday before
Christmas, four agents arrived at Talley's office with crates and began
pulling every patient chart on the shelves, 4,000 in all. Almost every last
one was a pain patient, because Tally's practice had evolved exclusively
into treating pain.

That visit resulted in last month's move by the DEA to pull Talley's
certification number, which authorized him to write prescriptions for
scheduled drugs.

"I can't tell you how pitiful the last few days have been," Talley said,
tipping back in his chair and crossing his arms across the platform of his
stomach. "People I've known for 20 years, I've had to send away. And I'm
having to send them to nothing. Nobody wants them."

Bucking the Establishment

Finding new doctors for his patients is a complicated matter because of the
narcotics. Talley said doctors balk at the notion of maintaining his
patients on his narcotic regimens, for fear they'll draw DEA attention.

Patients held out hope. The first arrived at 6:30 a.m. all last week and
the last left after 7 p.m. He handed out his home telephone numbers,
sometimes jotting the digits onto a paper towel he'd yank from the
dispenser: One number rings in the house, the other rings in his
woodworking shop out back, where he carves intricate trains out of blocks
of wood.

His handiwork fills the shelves throughout his office. Trains, in fact,
have always been his first love. He still gets a charge out of watching
them roar through town. On sunny days, he heads to a spot by the railroad
tracks at the edge of Grover, unfolds a lawn chair he keeps hidden in the
kudzu, and dictates patient charts while he waits for the familiar clank of
steel.

Medicine an Early Dream

"I never thought I'd be anything other than a doctor," Talley said. As a
kid growing up in Roanoke Rapids, he admired the way doctors walked into
rooms and immediately commanded respect, even awe.

But he had a wide anti-establishment streak, and he nearly derailed his
chance. After distinguishing himself at Wake Forest University -- taping
Playboy Bunny films to microscope slides and perpetrating other such tricks
against the Baptist authorities -- he was denied admission to the medical
school.

He headed out of state instead, earning his medical degree from the
University of Virginia before returning to North Carolina to practice.

In 1969, while working as an emergency room doctor at a hospital in
Greenville, he heard about the owner of the bedspread factory in Grover who
was recruiting a new doctor to treat mill workers. The owner offered $1 a
year rent on the tiny brick office across from the plant, plus $1 a year in
rent on a house.

Talley agreed to the arrangement, bringing in another doctor, and
eventually a third.

The small-town practice thrived, and Talley reveled in his role as healer.
Folksy and blunt, he also cultivated a reputation for risk-taking. He took
on the treatment of depression as his first cause because of his sense that
Freudian techniques were impractical. Psychoanalysis sessions simply didn't
fly in small towns such as Grover. Drugs did better. In 1987, he published
a book, "Treating Depressive Illness," to tutor other family practitioners
in the use of antidepressants. In a chatty style uncharacteristic of
medical manuals, Talley laid out his philosophy: "When therapeutic miracles
appear to be within our grasp, we ordinarily need no exhortations to go for
them. None of our infectious disease textbook writers have felt the need to
plead for the more aggressive use of antibiotics. ... The outstanding
exception to this rule is the antidepressant."

Even after the medical board questioned his dependence on drug therapies,
Talley's regard for the pharmacological solutions remained unshaken.

And then came some interesting research on pain management.

Pain Relief Gains Ground

The first rumblings were that doctors didn't do enough to manage pain,
particularly in light of research that disproved long-held beliefs about
the dangers of opiates and opioids.

Eventually, as the hospice movement pushed for better pain management in
terminal cases, the use of narcotics grew more acceptable. That acceptance
spread to people suffering from chronic pain -- backaches, arthritis, nerve
damage and other conditions.

Research showed that people could use the drugs and not slip into
addiction, although they became physically dependent. The distinction was
huge: Addiction was defined as the use of a drug despite its harmful
social, physical and psychological effects. Dependence was strictly a
bodily function. Such results had great resonance with Talley.

"I heard that and I thought, what's to stop us from giving these drugs
until doomsday?" Talley said.

And so he began prescribing with enthusiasm. By last year, all but a few of
the 100 patients who streamed into his clinic each day were seeking pain
medication. They found their way to tiny Grover -- on the North
Carolina-South Carolina line -- through word-of-mouth.

The town is no destination. Fast-food chains, truck stops and casino-style
video poker parlors line up along the edge of the old mill village like a
gaudy fringe tacked onto a worn bedspread.

But the little town was famous among the network of chronic-pain sufferers
and similar-minded doctors who communicated on the Internet. Talley said
his practice grew precipitously when other doctors were shut down by the
DEA and their patients flocked to him to continue their therapies.

Doug B. Scott, a former police officer in Jacksonville, Fla., was directed
to Talley by a California doctor who had been featured on the television
program "48 Hours." He first made the 415-mile trek up the interstate to
see Talley in 1995.

Plagued with back pain from a 1980 injury he suffered while arresting a
suspect, Scott said he tried every therapy around. He underwent an
operation that fused a steel rod in his spine, got epidural nerve blocks,
took steroid shots, tried behavior therapy.

"Nothing worked," Scott said. His pain kept him from playing with his two
sons and eventually cost him his career; he retired with a full medical
disability at age 38.

Scott said Talley was the last hope before he succumbed to his worst fear
- -- getting a morphine pump implanted on his hip to administer regular doses
of the narcotic.

Under Talley's care, Scott takes a high dosage of OxyContin and has no trouble.

"It's like I have a new life," he said. "He's a godsend. He gave me my life
back, and now they're going to take him away and I don't know what I'm
going to do."

The Problem with Pills

But pain experts have reservations about treatment plans that rely solely
on pills.

Dr. Michael Ashburn, the director of pain programs at the University of
Utah and president of the American Pain Society, said the organization has
issued guidelines in proper care for people in pain. Yes, he said, opioids
are helpful, but they need to be accompanied by physical therapy, stress
management, psychological evaluations and a host of other approaches.

"It's rare that a physician is prosecuted for inappropriate care," Ashburn
said, noting that he is not familiar with Talley's case. "In the cases I
have reviewed, the physicians have orders of magnitude outside the norm.
They are egregious."

Pain specialists worry that doctors such as Talley put their growing
specialty in a bad light.

Dr. Thomas Buchheit, director of the pain medicine fellowship at Duke
University, said that research and funding for pain treatments has only
recently gained acceptance, but that progress could easily halt under fears
that pain management is little more than pill popping.

"If it's not done right," Buchheit said, "it's going to get a bad
reputation -- and it will get less support and less funding. It's extremely
difficult to keep a pain clinic open as it is. Buchheit said he grows
suspicious when pills alone are used for therapy.

His colleague at the Duke Pain and Palliative Care Clinic, Dr. Veeraindar
Goli, said simply offering pills is like building a house with a single tool.

"For chronic pain management, there is only one modality that works, and
that is a multi-disciplinary approach," Goli said. "Pain is such a complex
problem, and there should be a team approach to treatment."

Talley acknowledges that his treatment philosophy isn't shared by doctors
certified as pain specialists. But he swears by the safety and
effectiveness of narcotics, and he is willing to lose everything to press
his point.

"If I say, 'All right, I resign,' I would be saying I was wrong, and that
what I have been doing all these years was wrong," Talley said. "And as
soon as I know that scientifically, I will be man enough to say that. But I
have not been convinced by the literature on the outcomes. I can't retire. No."

And although his pain patients agree with him, the DEA alleges in its order
Jan. 28 that Talley's conduct is connected to 23 deaths and that he has
either willingly or knowingly diverted narcotics to illegal uses. The
family of one of his former patients, David Barry Bailey, has recently sued
him for negligence for prescribing excessive amounts of narcotics against
the wishes of his family.

In another case outlined in the DEA's order, five former patients from
Union County, South Carolina, died -- four of them allegedly from drug
overdoses. Talley said he could not comment about specific cases, but he
said that deaths can occur as a result of ignorance about different drugs
and their effects.

The potential for overdose from OxyContin is great because of the drug's
time-release feature. A legitimate pain patient can take a high dosage of
the drug because it is manufactured so that its effects are released over
time. But when drug addicts crush the pills to disarm the time-release
mechanism, they get the full effect immediately. Injecting a solution of
OxyContin makes an even greater, often lethal, impact.

"That's how deaths occur," Talley said. As for charges that his
prescription practices have not been as discriminating as they should be,
he answers:

"If you had a party, and invited 100 people to the party, 95 of them would
have a couple of beers and go home and be fine," he said. "The other five
would drink two six-packs and want a third. Do you not have the party just
because of those five?"

On occasion, he said, he may have been fooled by people who claimed to be
in pain but really wanted the drugs to get high or to sell. He said it's
impossible to tell who is legitimate and who isn't.

"Sure, I gave prescriptions to people who were a worry," he said. "I wish
they had fewer tattoos, they shaved their beards, and the girls didn't have
rings everywhere. But do I worry about them more than the preacher's wife
who's out there knitting with a Bible in her lap?" The person who turns out
to be a dealer or addict, he said, is often surprising.

"I'm going to make a mistake one way or another," Talley said. "Which is
more damaging to society and the patient -- if someone gets by who is
abusing drugs or selling, or if I have to tell everyone who comes in here
whose life is dominated by pain that I cannot help them?

"Which mistake am I going to make? How much is society hurt by one mistake
versus the other? To me, it seems like a no-brainer."

Staff writer Sarah Avery can be reached at 829-4882 or savery@newsobserver.com.