AT TRIAL, PAIN HAS A WITNESS

ALEXANDRIA, Va. -- William E. Hurwitz, the prominent doctor on trial
here for drug trafficking, spent more than two days on the witness
stand last week telling a jury why he had prescribed painkillers to
patients who turned out to be drug dealers and addicts. But the
clearest explanation of his actions -- and of the problem facing
patients who are in pain -- came earlier in the trial.

It occurred, oddly enough, during the appearance of a hostile
witness, Dr. Robin Hamill-Ruth, one of the experts who was paid by
the federal prosecutors to analyze Dr. Hurwitz's prescriptions for
OxyContin and other opioids.

Dr. Hamill-Ruth, who noted that she never prescribed the
highest-strength OxyContin tablet, said some of Dr. Hurwitz's actions
were "illegal and immoral" because he prescribed high doses despite
warning signs in patient behavior that the opioids were being resold
or misused.

Then, during cross-examination by the defense, Dr. Hamill-Ruth was
shown records of a patient who had switched to Dr. Hurwitz after
being under her care at the University of Virginia Pain Management
Center. This patient, Kathleen Lohrey, an occupational therapist
living in Charlottesville, Va., complained of migraine headaches so
severe that she stayed in bed most days.

Mrs. Lohrey had frequently gone to emergency rooms and had once been
taken in handcuffs to a mental-health facility because she was
suicidal. In 2001, after five years of headaches and an assortment of
doctors, tests, therapies and medicines, she went to Dr.
Hamill-Ruth's clinic and said that the only relief she had ever
gotten was by taking Percocet and Vicodin, which contain opioids.

Mrs. Lohrey was informed that the clinic's philosophy "includes
avoidance of all opioids in chronic headache management," according
to the clinic's record. The clinic offered an injection to
anesthetize a nerve in her forehead, but noted that "the patient is
not eager to pursue this option." Mrs. Lohrey was referred to a
psychologist and given a prescription for BuSpar, a drug to treat
anxiety, not pain.

"You gave her BuSpar and told her to come back in two and a half
months?" Richard Sauber, Dr. Hurwitz's lawyer, asked Dr. Hamill-Ruth.
Dr. Hamill-Ruth replied that unfortunately, the clinic was too
short-staffed at that point to see Mrs. Lohrey sooner. Under further
questioning Dr. Hamill-Ruth said that she was not aware that BuSpar's
side effects included headaches.

Mrs. Lohrey looked elsewhere for help. Having seen Dr. Hurwitz on
television _ -- "60 Minutes" and other programs had featured his
controversial high-dose opioid treatments -- she sent him a letter
describing her pain and the accompanying nausea and vertigo.

"I have lost hope of retrieving my life as it was," she wrote,
because she could find no doctor to take her seriously. "I currently
have a physician who has said that I am psychologically manufacturing
my headaches, and that I am addicted to narcotic pain relief. This of
course is not the first time that I have been treated as a 'nut' or a
'junkie.' "

It was the kind of letter Dr. Hurwitz received from people across the
country. His office in the Virginia suburbs of Washington was like a
Lourdes for people with pain, one of the most widespread health
problems. Surveys have found that one in five adults deals with
chronic pain, and that it is treated adequately only about half the time.

Prescribing opioids was once taboo because of concerns over patients'
becoming addicted. But medical opinion gradually shifted over the
past two decades as researchers concluded that high doses of opioids
could sometimes be safer and more effective than alternatives like
surgery or injections.

Two of the leading pain experts, Dr. Russell K. Portenoy of
Beth-Israel Medical Center and Dr. James N. Campbell of Johns Hopkins
University, testified without pay as experts for the defense. They
said Dr. Hurwitz was widely known as a knowledgeable physician and
passionate advocate of giving patients full pain relief, unlike many
doctors who were reluctant to prescribe opioids because they feared
legal repercussions, particularly when dealing with patients who
sometimes used illegal drugs.

Such "problem patients" consumed so much time and energy that most
doctors refused to treat them "regardless of what the consequences
would be for the patient," Dr. Campbell testified. He said that he
had been initially skeptical of some of Dr. Hurwitz's high-dose
treatments, but was then impressed by the results in patients he sent
to Dr. Hurwitz.

He said some doctors might argue that Dr. Hurwitz was guilty in some
instances of negligence that would make him liable for damages in a
civil case. But Dr. Campbell contradicted the prosecution's experts
by testifying that all the prescriptions were clearly within the
"bounds of medical practice."

That legal phrase is the crucial distinction in this criminal case,
which the jury was deliberating as this column went to press: Did Dr.
Hurwitz knowingly prescribe drugs to be used for nonmedical purposes?
(For updates on the case, see www.nytimes.com/tierneylab.)

When Dr. Hurwitz testified last week, he spent hours going through
the histories of those he called his "misbehaving patients," telling
why he believed they all had genuine problems. "Ultimately, pain is
what the patient says it is," he told the jury, contrasting his
approach with what he called the traditional "Father Knows Best"
approach of old-school doctors.

In retrospect, he acknowledged, he should have been more suspicious
of patients who asked for early refills, reported losing
prescriptions and tested positive for illegal drugs. He did get rid
of the worst patients, he said, but he believed others were
reforming, and he feared they would not get help anywhere else if he
dismissed them.

"I felt that I had a duty to the patients," he said. "I hated the
idea of inflicting the pain of withdrawal on them." After the closure
of his practice in 2002, he said, two of his patients committed
suicide because they gave up hope of finding pain relief.

The most moving testimony came from Mrs. Lohrey and other patients
who described their despondency before finding Dr. Hurwitz. They said
they were amazed not just at the pain relief he provided but at the
way he listened to them, and gave them his cellphone number with
instructions to call whenever they wanted.

"I felt like I was his only patient," Mrs. Lohrey testified. "I think
he truly understood the nature of what I was going through." When she
lost her health insurance, she said, Dr. Hurwitz continued treating
her at no charge, and helped her enroll in a program that paid for
her opioid prescriptions. After Dr. Hurwitz's practice was shut down,
she could not find anyone to treat her for seven months. Eventually,
she found a doctor willing to prescribe small numbers of low-dose
Percocet, but she said she was not getting enough medicine to
consistently blunt the headaches.

"The last two weeks, I was pretty much in bed and sick with the
headaches and the nausea and the whole nine yards," she said,
explaining that she had deliberately undergone the two weeks of pain
in order not to use up any of her pills.

"I had to save up medication," she testified, "so I could be here today."