DR. FEELSCARED

Drug Warriors Put The Fear Of Prosecution In Physicians Who Dare To Treat
Pain

On February 1, 2002, Cecil Knox was seeing patients in his Roanoke,
Virginia, clinic when more than a dozen federal agents burst through
the doors with guns drawn.

Helmeted, shielded, and wearing bullet-proof vests, they terrified
waiting patients and employees.

One worker later told the Pain Relief Network, a patient advocacy
group, she thought she and her husband, who was helping her in the
office that day, would be shot. She looked on in horror as an agent
put a gun to his head and ordered, "Get off the phone!

Now!"

Knox, a pain management specialist who had been practicing medicine in
Roanoke for seven years, was dragged out in handcuffs and leg irons.

The local U.S. attorney's wife, a TV reporter, was among the journalists
tipped about the raid in advance.

She stood outside with a gaggle of other media people to announce her
husband's triumph.

Knox's assets were frozen and bond set at $200,000. He and several
employees soon faced a 313-count indictment, including charges of drug
distribution resulting in death or serious bodily injury, prescription
of drugs without a medical purpose, conspiracy, mail fraud, and health
care fraud.

Prosecutors said Knox had illegally distributed millions of dollars'
worth of OxyContin, a timed-release version of the narcotic painkiller
oxycodone. William Hurwitz, a McLean, Virginia, internist and
prominent pain specialist, received similarly heavy-handed treatment
when he was arrested last fall. Hurwitz, who is Jewish, was visiting
his children on Rosh Hashanah eve when federal agents descended upon
his ex-wife's house in McLean and took him away in handcuffs.

As with Knox, the government froze Hurwitz's assets; his bail was
set at $2 million.

He was charged with 49 felony counts, including drug trafficking
resulting in death or serious injury, conspiracy, and running a
criminal enterprise.

Like Knox, Hurwitz attracted attention largely because of his
OxyContin prescriptions. Attorney General John Ashcroft said "the
indictment and arrests in Virginia demonstrate our commitment to
bring to justice all those who traffic in this very dangerous drug."
Prosecutors said Hurwitz was "no better than a street corner crack
dealer" who "dispenses misery and death." Assistant U.S. Attorney Gene
Rossi had earlier declared that the feds would "root out" such doctors
"like the Taliban."

Knox and Hurwitz are just two recent targets of an aggressive push by
the Drug Enforcement Administration (DEA) and the Department of
Justice (DOJ) to impose their judgments about the proper use of opioid
painkillers (drugs derived from opium and synthetics that resemble
them) on doctors throughout the country. In their attempt to prevent
prescription drug abuse, the DEA and the DOJ in effect have taken
upon themselves the authority to regulate the practice of medicine,
traditionally the province of the states.

Worse, they have transformed disagreements about treatment decisions
into criminal prosecutions, scaring physicians away from opioids and
compounding the suffering of patients who have trouble getting the
drugs they need to relieve their pain. Drug Control vs. Pain Control
Few disagree that pain is already poorly treated in the U.S. "Even the
DEA admits that 30 to 50 million people are undertreated for pain,"
says Ronald Libby, a professor of political science at the University
of North Florida who has studied the issue.

A 1999 survey of 805 chronic pain patients conducted by Roper Starch
for the American Pain Society and Jannsen Pharmaceutica found that
roughly half of those with serious chronic pain could not find relief
- -- and that the more severe the pain, the less likely it was to be
alleviated. Other surveys have yielded similar results.

Only a tiny fraction of the nation's nearly 1 million health care
professionals licensed to prescribe controlled substances are willing
to consistently use opioid medications, recognized as the best drugs
for severe pain. A 2003 analysis by the Ft. Lauderdale Sun-Sentinel
found that less than 3 percent of Florida's doctors prescribed the
majority of opioids for Medicaid patients there.

During the 1990s, pain experts, patient advocates, and drug makers
sought to reduce exaggerated fears about opioids and increase
prescribing. Research and clinical experience had shown that few
patients without a prior history of serious drug abuse get hooked on
narcotics during pain treatment, resulting in addiction rates no
higher than those seen in the general population. In one important
study, reported in the journal Pain in 1982, the researchers surveyed
181 staffers of 93 burn units who had seen more than 10,000 patients
and worked in the field an average of six years.

Most patients had been given opioids to cope with agonizing
debridement treatments, but the staff could recall no cases of
addiction in anyone without a prior history of it. A study of 100
people taking opioids for chronic pain over prolonged periods,
reported in the Journal of Pain and Symptom Management in 1992,
likewise found that none became addicted.

No new evidence has contradicted this research, and a study of
prescribing from 1990 to 1996, published in 2000 in The Journal of
the American Medical Association, found that massive increases in the
use of particular opioids were not associated with proportional
increases in misuse; in fact, as use of some medications rose,
emergency room "mentions" of them dropped. But in the minds of police
and prosecutors, such reassuring findings were overwhelmed by concerns
about what was dubbed the OxyContin "epidemic." Introduced by Purdue
in 1995, OxyContin was designed to deliver steady pain relief over an
extended period of time, avoiding the peaks and valleys of
shorter-acting pills that have to be taken several times a day. It
soon became a $1 billion blockbuster. When illegal drug users figured
out how to defeat its timed-release mechanism and get all the
oxycodone at once, street demand -- and media coverage -- soared. (See
"The Agony and the Ecstasy," April 2003.) Most news stories neglected
to mention that OxyContin abusers generally were not new addicts
freshly minted from innocent patients by irresponsible doctors.
Rather, they were drug aficionados who scammed physicians for the
latest media-hyped high. According to data from the federal
government's National Survey on Drug Use and Health, some 90 percent
of illicit OxyContin users have also used cocaine, psychedelics, and
other painkillers. The typical profile is a person who has abused
many drugs in many combinations for many years. OxyContin poses no
greater addiction risk than other opioids when taken as directed. But
the media helped teach addicts and thrill seekers how to do otherwise.
In 2002 the Charleston Daily Mail quoted former Surgeon General C.
Everett Koop as saying "exaggerated news stories" have "hyped
[OxyContin] for recreational use into being almost irresistible." In
some cases, OxyContin-related pharmacy robberies followed local
exposA(c)s. On February 16, 2001, less than a week after the Cleveland
Plain Dealer reported on the OxyContin "epidemic," someone robbed a
local pharmacy at gunpoint, taking only OxyContin. The Cleveland Free
Times quoted a drug dealer who said a customer had shown him a
newspaper clipping about OxyContin, asking where he could get it.
While the OxyContin panic does not seem to have deterred addicts, it
has scared doctors. "Every time there is one of these trials," says
Libby, "another 50 to 60 doctors drop off from prescribing." Among the
doctors recently targeted by federal or state prosecutors are Frank
Fisher of Anderson, California, charged with three counts of murder
and 24 drug- and fraud-related charges; Jeri Hassman of Tucson,
Arizona, charged with 362 counts of "drug dealing with a pen"; James
Graves of Pace, Florida, convicted in 2002 of causing the deaths of
four patients and sentenced to 63 years in prison; Denis Deonarine of
West Palm Beach, Florida, charged with 79 felony counts, including
first-degree murder, based on a patient's death from a
self-administered overdose; and Deborah Bordeaux of Myrtle Beach,
South Carolina, who in February was sentenced to eight years in
prison for working less than two months at a pain clinic targeted by
the feds as a "pill mill."

The sheer number of charges in these cases makes defending the doctors
difficult because it's natural for jurors to think that with so many
counts, some crime must have occurred.

But this impression is misleading. The essence of the prosecutors'
cases is that ordinary events in a doctor's office become criminal
when the doctor steps outside the bounds of legitimate medicine.

It's easy to generate lengthy indictments by portraying the
doctor's entire practice as a criminal enterprise and redefining
everyday activities related to the practice as offenses.

Each prescription of a controlled substance can be made into several
crimes. In addition to drug distribution, it can be described as
health care fraud because charging or billing third parties for
practices that aren't really medicine is illegal.

If the prescription or a bill has been sent through the mail, it can
also be mail fraud.

Every deposit of the physician's paycheck becomes money laundering.
Seeing a patient who turns out to be a drug dealer or addict can lead
to a conspiracy count, as can working with one's colleagues. Most
shocking of all, any death that can in any way be connected to use of
the doctor's prescriptions becomes a charge of drug dispensing
resulting in death or serious injury -- even if the person who died
stole the drug from a legitimate patient, lied to get the drug, used
it with other drugs or alcohol, or expired while suffering from a
potentially fatal illness. Physicians face these daunting indictments
with their assets frozen, their bail set as if they were drug
kingpins, and their livelihoods ruined by license suspensions or bail
conditions. In these circumstances, mounting a defense is extremely
difficult. "It makes it impossible to retain private counsel," says
Virginia attorney James Hundley, who represented William Hurwitz prior
to his indictment. (He is now using a public defender.) California
attorney Patrick Hallinan, who has represented Frank Fisher and has
advised Hurwitz, says, "They're throwing the entire penal code at
them." The tremendous pressure that such charges bring to bear is
illustrated by the 2002 federal indictment of eight doctors who worked
at the Comprehensive Care and Pain Management Center in Myrtle Beach,
South Carolina. Threatened with hundreds of years in prison and
fearful that his wife (an employee) could also be indicted, clinic
owner Michael Woodward pleaded guilty and testified that he had
schemed with the other doctors, including Deborah Bordeaux, to sell
drugs. South Carolina is a conservative state, and Woodward had seen
his clinic repeatedly attacked in the news media.

The Woodwards may also have feared that their young children could
lose both parents to long prison terms. Another clinic doctor,
Benjamin Moore, told Siobhan Reynolds, founder of the Pain Relief
Network, that he and his colleagues had done nothing wrong.

When he, too, found that he faced life in prison, he pleaded guilty
in desperation. But according to his brother, he could not go through
with testifying against co-workers he believed to be innocent.

Instead he hanged himself from a tree in his mother's backyard.

Doctors As Dealers In fiscal year 2003, according to the DEA, the
federal government investigated 557 physicians and arrested 34. Betsy
Willis, chief of the Operations Section of the DEA's Office of
Diversion Control, says "the numbers of federal prosecutions have
been relatively consistent for the last four years." The DEA reports
81 arrests in fiscal year 1999, 83 in fiscal year 2000, 78 in fiscal
year 2001, and 68 in fiscal year 2002.

Even if the number of federal prosecutions has declined, they have
received much more attention since the news media began highlighting
OxyContin abuse in 2001. And the alarm about OxyContin clearly has led
to increased enforcement efforts: Last year the DEA doubled controlled
substance licensing fees for health care providers to fund more
investigations, and in March the Office of National Drug Control
Policy unveiled "a coordinated drug strategy to confront the illegal
diversion and abuse of prescription drugs." The strategy includes
closer monitoring of prescriptions, coupled with "outreach" and
"education" aimed at making doctors more skeptical of patient requests
for painkillers.

Until recently, investigators would approach a physician if they
suspected a patient of diversion; now they try to build a case against
the doctor. "This is new in my experience, and I have been doing this
for 25 years," says David Brushwood, a professor of pharmacy at the
University of Florida. "I've always seen drug control and health
care work together....They were never really at odds until the last
two years....The way it used to be was that when drug control
officials saw the beginnings of a pattern of diversion, they would say
to the doctor, It looks like a problem is developing; let's work
together to fix it. Now when they see a small problem, they
conduct surveillance and wait for it to be-come big, then swoop in
with a massive show of force." Even when there is no direct evidence
of diversion, investigators and prosecutors may decide a doctor is
being too generous with painkillers because they are influenced by an
outmoded view of addiction.

According to this view, the essence of addiction is "physical
dependence," changes in the body that result in withdrawal symptoms
when drug use is halted.

Based on this criterion, all pain patients become addicts when they
take opioids long enough. In recent decades, researchers have
recognized the inadequacy of this definition. On the one hand, some
drugs that don't cause physical withdrawal symptoms (for example,
cocaine) clearly can produce a potentially self-destructive desire
for more. On the other hand, the vast majority of those who try even
the most addictive substances don't develop lasting habits.
Researchers therefore redefined addiction to emphasize craving and
negative consequences rather than withdrawal symptoms.

The diagnostic manual of the American Psychiatric Association now
recognizes that physical dependence is neither necessary nor
sufficient for addiction, which is characterized by continued use of
a substance despite ongoing drug-related problems.

For pain patients, of course, the drug produces fewer problems and
greater functioning, rather than the reverse. Some patient advocates
say drug warriors can't accept this reality because it undermines
the logic of prohibition: If most people don't get hooked when
exposed to the "hardest" of all categories of drugs, if patients'
lives get dramatically better and they function perfectly well on
doses that are supposed to incapacitate, stupefy, and derange, why is
it so important for the government to protect us from these
substances? From this point of view, the DEA must fight pain control
because functional patients on high doses of opioids threaten its
authority.

"It completely puts the lie to the whole criminal approach because it
shows that these molecules are not evil, that people can and do
function well on them," says the Pain Relief Network's Siobhan
Reynolds. "It undermines the whole basis for the war on drugs and
makes it a strictly scientific/medical issue." Whatever their reasons,
law enforcement officials (along with most of the public and many
physicians) still cling to the old-fashioned view of addiction as a
biochemical process that inevitably results from extended use of
certain drugs. In the Myrtle Beach case, federal prosecutors said in
court (before being forced to retract their claim due to contrary
testimony) that none of the clinic's 3,000 patients was
"legitimate"; in other words, in their view every pain patient of all
eight doctors was an addict. The DEA defines addicts as "habitual"
users of narcotics who have "lost the power of self control with
reference to [their] addiction" or whose use "endangers the public
morals, health, safety, or welfare." From this perspective, pain
patients could be considered addicts who have "lost control" in the
sense of needing the drug to function.

Many prosecutors do not understand the distinction between addiction
and physical dependence or recognize the growing acceptance of opioids
in medicine. Says John Burke, vice president of the National
Association of Drug Diversion Investigators, "Do I think some
prosecutors and law enforcement officers are not well educated?

Absolutely." A 2003 study published in the Journal of Law, Medicine,
and Ethics found that nearly three-quarters of prosecutors in four
states believed simply taking opiates poses a moderate or high risk of
addiction. Holding that view was one of the best predictors of who
would choose to prosecute physicians in a hypothetical case designed
to reflect good pain practice. Just under half of prosecutors surveyed
said they would recommend a police investigation merely on the basis
of evidence that a physician was prescribing high doses of opioids to
some patients for more than a month, something that is perfectly
legitimate in cases involving severe chronic pain. Prescriptions for
Trouble Frank Fisher seems to have been targeted based on just this
sort of suspicion. At his Northern California clinic, the Harvard
Medical School graduate accepted patients on Medicaid and Medi-Cal
(California's health insurance for the poor) that most other
physicians refused, and he tried to treat their pain as aggressively
as he would treat anyone else's. In February 1999 state law
enforcement agents raided Fisher's clinic and arrested him for drug
dealing, fraud, and murder.

His bail was set at $15 million.

State prosecutors accused him of "creating a public health epidemic"
of OxyContin abuse and death.

They implied that he must be a drug dealer because he was the largest
prescriber of the drug under Medi-Cal.

But in a context where fear of prosecution leads most doctors to
under-prescribe, anyone who prescribes what is necessary for severe
pain will be a top prescriber. Even Burke admits that prosecuting
doctors has a chilling effect on their colleagues' treatment
decisions. "I know from lecturing thousands of physicians that there
is no question but that it does," he says. "The thing we don't want
to happen is that physicians don't prescribe appropriately because
of these cases, but I know that it happens.

I have to be honest." Burke also recognizes that there is no ceiling
on opioid doses: When patients develop tolerance, they may need
massive doses that would kill someone who had never taken the drug.
"Physicians should not be targeted simply on volume," he says. "That
can be a huge mistake."

The DEA insists physicians aren't targeted based on volume alone.

But Fisher believes he was. While patients with moderate pain can be
treated effectively with low doses of opioids, he explains, severe
pain requires that the dose be adjusted ("titrated") to a level that
maximizes pain relief and minimizes side effects. "To get a sense,"
he says, "I titrated about two dozen patients, and they ended up
taking almost half of the OxyContin 80-milligram pills prescribed in
California in 1998. What that tells you is that nobody else titrated."
Fisher was jailed for five months, during which time the
prosecution's case began to evaporate.

First, the murder charges were reduced to manslaughter by the judge,
who saw no proof of intent.

Then the truth about these "killings" came out. One death involved a
passenger who died when her spine was severed in a van accident.

Fisher was charged with her "murder" because she had high levels of
OxyContin in her blood.

Another "victim" had taken drugs stolen from a patient, while a third
died of a self-administered overdose two weeks after Fisher was
incarcerated.

During cross-examination in pretrial hearings, it was revealed that
seven attempts by undercover agents to get drugs from Fisher had been
rebuffed. "I had a screening process for those who tried to get
controlled substances," he says. "I screened out 60 percent of those,
and apparently the agents were amongst them."

In January 2003, four years after Fisher's arrest, a state judge
dismissed all the charges against him because prosecutors had tried
repeatedly to delay the trial.

But this year prosecutors decided to pursue another set of charges
against him. Instead of homicide, drug dealing, and felony fraud
involving $2 million in Medi-Cal reimbursements, they charged him with
eight misdemeanor counts of fraud.

Prosecutors would not put a dollar value on the offenses, but Fisher
said they added up to $150. The jury agreed with Fisher's expert,
who said the billings in question didn't warrant civil penalties,
let alone criminal charges, and he was acquitted of all counts in
May. He still faces possible disciplinary action by the state medical
board as well as civil suits by patients' relatives.

Fisher forwarded an e-mail message from a juror who said: "Now that I
am home and can read about you on the Internet, my heart really goes
out to you...I was upset that the prosecutor wasted my time and the
court's time on such a weak case. But now that I know what you have
really been through I feel embarrassed and selfish to be thinking
about my own time. I hope you can reopen your clinic some day and get
back to practicing medicine...Thanks for doing the job most doctors
won't." Unlike Fisher, other doctors fighting prosecutions based on
their opioid prescriptions so far have enjoyed only partial victories.

Last fall Cecil Knox's federal trial in Virginia got off to an
inauspicious start for prosecutors when their first witness, who
claimed Knox had traded prescriptions for marijuana, couldn't
identify him in the courtroom or from photographs. The jurors
ultimately acquitted Knox of about 30 out of 69 charges.

But due to a single holdout who voted guilty, they hung on the
remaining charges, including the most serious.

In January prosecutors refiled the case, this time with 95 charges.
Also in January 2004, federal prosecutors agreed to drop 358 of their
362 charges against Tucson pain specialist Jeri Hassman, who pleaded
guilty only to four counts of failing to report patients for
infractions such as taking a recently deceased relative's OxyContin.
On the same day, a Florida judge rejected a first-degree murder charge
against West Palm Beach physician Denis Deonarine, based on the death
of a patient who succumbed to "polydrug toxicity" after a night of
drinking and drug use. But in March state prosecutors filed a new
murder charge under a different statute, and Deonarine also faces 79
other charges stemming from his prescription of OxyContin and other
opioids. Second Opinions Eli Stutsman, an appeals attorney who is
representing Myrtle Beach physician Deborah Bordeaux at the behest of
the Pain Relief Network, thinks he may have found a way to stop such
prosecutions, at least at the federal level. Stutsman also represents
the state of Oregon in its thus-far successful battle with Attorney
General Ashcroft over physician-assisted suicide, a dispute that
hinges on what the federal drug laws mean and how they should be enforced.

A federal appeals court's decision in that case suggests the DEA is
overstepping its statutory authority when it tells doctors how
controlled substances should be prescribed.

In 2001 Ashcroft tried to nullify Oregon's assisted suicide law with
a directive that declared the prescription of drugs for suicide a
violation of the Controlled Substances Act (CSA).

Under the CSA, a prescription is "authorized" if it is "issued for a
legitimate medical purpose by an individual practitioner acting in the
usual course of professional practice." If a doctor writes
prescriptions to order for money, trades drugs for sex, or prescribes
drugs for resale, he is operating outside "the usual course of
professional practice." In such cases, the CSA authorizes the DEA to
revoke the registration that allows physicians to prescribe
controlled substances and to pursue criminal charges. But Stutsman
concluded that in recent cases the DEA has taken the statute's
language out of context, improperly reading "for a legitimate medical
purpose" as a requirement separate from prescribing in "the usual
course of professional practice." Instead of claiming that the
accused doctors weren't sincerely trying to treat patients, federal
prosecutors have argued that the defendants wrote prescriptions that
weren't "medically necessary" or that had no "legitimate medical
purpose." Thus the DEA claims the authority to determine what doses of
which drugs a doctor may use and what medical purposes are
legitimate. Those are questions about the standard of medical care --
the sort of questions addressed in malpractice litigation and civil
actions by state medical boards. The DEA insists it is correctly
interpreting the law. "We're only looking at instances where we have
information [that] practices outside of the norm are taking place,"
says Pat Good, acting deputy director of the DEA's Division of
Diversion Control. "We're not talking about avant-garde medicine
where patients are doing really well. We're talking about cases
where patients are selling drugs on the street, using fictitious
names on prescriptions, overdosing, and getting arrested."

But in Oregon v. Ashcroft, the assisted suicide case, U.S. District
Judge Robert Jones found Stutsman's reasoning compelling. Ashcroft
had argued that the CSA gave federal prosecutors the right to decide
that assisting suicide is not part of legitimate medical practice.

Jones disagreed: "The CSA was never intended, and the USDOJ and the
DEA were never authorized, to establish a national medical practice
[standard] or act as a national medical board.

To allow an attorney general -- an appointed executive whose tenure
depends entirely on whatever administration occupies the White House
- -- to determine the legitimacy of a particular medical practice
without a specific congressional grant of such authority would be
unprecedented and extraordinary." Last May the U.S. Court of Appeals
for the 9th Circuit affirmed Jones' decision, finding that "the
attorney general's unilateral attemp to regulate general medical
practices historically entrusted to state lawmakers...far exceeds the
scope of his authority under federal law."

Stutsman intends to use similar reasoning in his appeal of Deborah
Bordeaux's conviction. Her prescribing never exceeded
manufacturers' recommendations or those of her state medical board;
there was no exchange of drugs for sex or other evidence that she was
not practicing real medicine. "What makes this particularly
outrageous," says Stutsman, "is their confusion of civil and criminal
standards to start with. It's an excessive exercise of federal power
based on a misapplication of federal law."

Suicide Is Painless Kathryn Serkes, spokesperson for the Association
of American Physicians and Surgeons (AAPS), sees these cases as part
of a long-term trend toward increased prosecutorial power that
includes sentencing guidelines, mandatory minimums, and forfeiture
laws. The Coalition Against Prosecutorial Abuses, a group she is
organizing to fight this trend, declares: "There's still one group
of trial lawyers that has been left alone to go about their dirty
work with few restrictions -- and all at taxpayers' expense.

These are the government prosecutors."

The AAPS, along with the Pain Relief Network, has been vocal in
denouncing the federal and state doctor prosecutions. The group's
Web site warns: "If you' re thinking about getting into pain
management using opioids as appropriate: DON'T. Forget what you
learned in medical school -- drug agents now set medical standards."
The AAPS urges doctors inclined to ignore this advice to be aware of
the risks, including "years of harassment and legal fees," loss of
income and assets, and professional ostracism.

Despite increasing outrage from physicians and patient advocates, the
DEA maintains that people in pain have nothing to fear from the
crackdown. "A legitimate patient with legitimate medical problems
should have no problem getting another doctor if their doctor has
been arrested," says the DEA's Willis. Anti-pain activists
vigorously dispute that. "This is causing doctors not to prescribe,"
says the Pain Relief Network's Siobhan Reynolds, "and that means
patients will be in hell." Several of the prosecutions have been
associated with suicides by devastated patients who couldn't get
effective treatment elsewhere. Common Sense for Drug Policy reports
that one of William Hurwitz's patients killed herself on March 16.
Frank Fisher says one of his patients drove her car in front of a
train.

In a forthcoming documentary by Reynolds, pain patient Skip Baker
says, "It's a devastating health care crisis, to the point that
thousands are committing suicide that nobody knows about.

Most pain patients know -- everybody's planning to run into this
bridge abutment or that tree or whatever to make it look like an
accident." Ronald Myers, a Mississippi physician and minister who
founded the American Pain Institute, observes: "They want to talk
about deaths associated with OxyContin. But no one wants to talk about
these deaths.

There's been an epidemic of suicide." Laura Cooper, an attorney with
multiple sclerosis and a former patient of Hurwitz, moved to Oregon
when his practice was shutting down. Her new doctor "is also under the
microscope," she says. "All of these guys are on their way out -- if
not on their own, the government is on the way to putting them out.
Anybody who would treat me the way I need to be treated is not long
for American medicine.

When my doctor goes down, I don't know what I'll do." Since Cooper
lives in Oregon, she notes, "by law I can get drugs to kill myself,
but not to treat my pain. The doctor could say, in effect, I'm
not trying to treat pain; I'm trying to kill her, and that would
be more acceptable. Clearly, something's a little off kilter.

My medical needs are less important than their war on drugs."