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NATIONAL PAIN EXPERTS BLAST
ARBITRARY MAXIMUM DOSES AS ABSURD

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Six Past Presidents of American Pain Society Denounce Testimony of Prosecution's Key Witness in Hurwitz Case (12/20/04)

Six past presidents of the American Pain Society have denounced the testimony of Dr. Michael Ashburn, who testified for the prosecution in the recent Hurwitz. The doctors accused Ashburn, who is also a past APS president, of "factually wrong or serious misstatements of consensus in the field" and wrote that while they had previous regarded him as a "respected colleague" they were "stunned" by his testimony and felt "morally compelled" to speak up. Academic medicine tends very much toward caution, so this is an extraordinary move on their part. Their letter was addressed to one of Dr. Hurwitz's attorneys, and was printed on Beth Israel Medical Center letterhead. Following is the text of it, along with links to recent coverage and discussion of the Hurwitz case and related issues by DRCNet and others.

December 10, 2004
Marvin D. Miller, Esq.
P.O.Box 663
1203 Duke Street
Alexandria, VA 22313

Dear Mr. Miller,

We are Past-Presidents of the American Pain Society and have decided to take an unusual step in writing you about the expert testimony that you have heard at the trial of Dr. William Hurwitz. We are deeply concerned that serious misrepresentations in the testimony provided by the government's expert, Dr. Michael Ashburn, will undermine the welfare of patients who suffer in chronic pain.

Our concern is that the role of key government expert will lend credibility to Dr. Ashburn's statements about the treatment of chronic pain, many of which we believe to be factually wrong or serious misstatements of consensus in the field. The credibility accorded this testimony, when disseminated or used to justify future investigations, threatens the public good. We felt morally compelled to inform you of our profound concern.

There are several points of sharp disagreement:

- Dr. Ashburn repeatedly stated that the use of "high dose" opioid therapy is an indication of drug abuse in populations with chronic non-cancer pain. It is factually untrue that this is a consensus opinion of pain experts. We strongly hold the view that patients with non-cancer pain may benefit from opioid therapy and that the dose necessary to control pain may be high. Use of "high dose" opioid therapy for chronic pain is clearly in the scope of medicine.

- Dr. Ashburn asserts (page 23 of the transcript) that morphine at a dose of 195 mg/day constitutes a high dose. This statement is without foundation in the medical literature and we believe that it is, on its face, absurd.

- Dr. Ashburn implies that opioid treatment of a patient with a known addiction is medically wrong and worsens the addiction. This is not the view of experienced clinicians in the field. It is unacceptable to promulgate the view that the disease of addiction automatically denies patients with severe pain the possibility of relief through careful opioid therapy.

- He states (page 37) that high dose opioids produce hyperalgesia (increased pain) and therefore may worsen the clinical pain problem. Although this has been raised in the literature as a theoretical concern affecting some patients, neither the prevalence nor the clinical significance has been established and its putative risks have not led to any change in clinical guidelines.

- Dr. Ashburn speculates (page 37) that high dose opioids may compromise the immune system. Again, this is considered to be a theoretical risk, one balanced by the potential dysimmune effects of unrelieved pain itself; it has not found its way into any accepted guideline for opioid use in any population.

In the past, each of us perceived Dr. Ashburn as a respected colleague and his selection as an expert by the government as understandable. We are stunned by his testimony. As leaders in this field, we feel compelled to correct the errors in his testimony, lest it be used in the future in a manner that worsens the national tragedy of untreated pain. We will try to correct the public record after the trial concludes and sincerely hope that the government and the court will consider this information now.

Respectfully submitted,

Russell K. Portenoy M.D.
Chairman
Department of Pain Medicine and Palliative Care
Beth Israel Medical Center
New York, New York

Professor of Neurology and Anesthesiology
Albert Einstein College of Medicine
Bronx, New York
Chief Medical Officer
Continuum Hospice Care/The Jacob Perlow Hospice
New York, New York

James N. Campbell, M.D.
Director, Blaustein Pain Treatment Center
Johns Hopkins University Medical Center

Kathleen Foley, M.D.
Pain & Palliative Care Services
Memorial Sloan-Kettering Cancer Center

Charles Cleeland, Ph.D.
Director, Pain Research Group
U.T.M.D. Anderson Cancer Center

Christine Miaskowski, R.N. Ph.D. FAAN
Professor & Chair, Department of Nursing
University of CA San Francisco

Richard Payne, M.D.
Director, Duke University on Care at the End of Life
Duke University Divinity School

BOLDING IS BY DR. SCHALLER.

DR. SCHALLER AGREES WITH THE STATEMENTS OF THESE PAIN EXPERTS. ANYONE WHO DOES NOT AGREE WITH THEM IS TITANICALLY IGNORANT OF REAL PAIN CARE IN THE YEAR 2005 OR IS SIMPLY A SADIST. SOME MEDICAL BOARD MEMBERS AND DEA STAFF ARE SIMPLY OPPOSING THE GOOD STANDARD OF MEDICAL CARE DESIGNED IN PART BY THESE PAIN EXPERTS, AND THEY REALLY NEED TO GET OUT OF THE WAY OF PAIN CARE. WHY? BECAUSE THEIR VIOLENT INTERVENTIONS AGAINST PAIN CARE EXPERTS, WHICH FRIGHTEN ALL PHYSICIANS, ULTIMATELY LEADS SOME PEOPLE TO "PAIN RELIEF" BY SUICIDE, AND THEY INCREASE THE APPEAL OF EUTHENASIA TO STOP HORRIFIC PAIN. FINALLY, POOR PAIN CONTROL LEADS TO MARKED INACTIVITY, WHICH INCREASES DEATH DUE TO CLOTS, STROKES AND HEART ATACKS.


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