PITCHING RELIEF

A Physician With Firsthand Knowledge About Pain Advocates Opium-Based
Drugs Despite Fears of Abuse

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.