Pill pusher or a lifesaver?

I came across the following articles while doing some research on an article that was sent to me via Email. After reading the article below I then read the comments that followed that article. Which in turn led me to research a little further into the second article.

After reading the following article's your comments are most welcome, as long as they are respectable of course.

DR. CLAUDE Curran sees himself as a thorn in the side of the medical establishment. If the state Board of Registration in Medicine makes its case, he may soon be removed.

Curran, who practices out of a ramshackle house in Fall River, is a relentless pill pusher, according to a 50-page board complaint. It alleges that the 56-year-old psychiatrist “inappropriately prescribed’’ Vicodin or benzodiazepine tranquilizers to at least 25 patients, often without conducting proper tests or medical histories. To his patients, however, Curran is a lifesaver who has snatched them from the horrors of heroin and OxyContin addiction.
On a recent weekday, addicts filled Curran’s waiting room. Some had their kids in tow. Some were on lunch breaks from work. Others haven’t worked in years. A burly man with two skull tattoos on his forehead stood apart from the other patients. Crowds, he said, make him nervous after serving 22 years in prison for “everything but murder.’’ Eventually, they all get ushered into Curran’s cramped office where Elvis memorabilia hangs on prime wall space normally reserved for medical diplomas.
Massachusetts is in the grip of a drug epidemic. Heroin is cheap, pure, and abundant. The addiction rate for OxyContin, a powerful pain killer, has jumped 950 percent in the last decade, according to a recent legislative report. And public health officials and police can’t seem to get a grip on the diversion of prescription pain medications. Where does the unorthodox Curran fit into this picture? Is he just a so-called “croaker’’ who prescribes drugs irresponsibly to addicts? Would revocation or suspension of his medical license alleviate the drug problem in Fall River, or exacerbate it? While state fact finders prepare to hear the specific allegations against him, state public health officials should study the wider policy implications of his case.

Curran is also in hot water over his enthusiasm for Suboxone- A cutting edge drug containing buprenorphine that offers maintenance therapy to opiate addicts. The drug, he says, has fewer side effects and less potential for abuse than methadone, a synthetic opioid that blocks the effects of heroin. It’s also cheaper. Despite such advantages, federal drug regulators place tight restrictions on its use. Physicians are required to take a special course before offering the drug, and even then each doctor can prescribe it to no more than 100 patients. Curran thinks such restrictions are ridiculous.
The cap was just 30 patients in 2005 when he lit up the radar of the Drug Enforcement Administration by prescribing buprenorphine to more than 700 patients.
The feds cracked down. Curran, in turn, organized a protest by addicts and their families at the JFK Building in Boston. Whatever might be said about Curran’s practice of medicine, it isn’t furtive.
Curran acknowledges that he is seen as a “cowboy’’ in his field. But his belief in Suboxone is quite mainstream. Dr. Kevin Hill, a psychiatrist at McLean Hospital, considers Suboxone, combined with behavioral therapy, to be the best his field has to offer for opiate addiction. Hill thinks the 100-patient cap is reasonable.

The bigger problem, he says, is that too few doctors in the state have chosen to undergo the specialized training needed to prescribe the drug to addicts. Doctors aren’t exactly lining up to treat such challenging patients, especially at Medicaid rates. About 900 of the roughly 24,000 active physicians in the state can prescribe Suboxone, but only 343 of them list their services on an easily searchable data base.
Curran’s door, however, is always open. Amanda, a 28-year-old addict, tells him that she is desperate to get off methadone. She and other addicts say methadone is murder on their teeth due to the side effects of extreme dry mouth. Yet she lines up at a Fall River methadone clinic for her daily dose to avoid getting “dope sick.’’ Curran is dismissive of methadone clinics, which he says can “trigger’’ illicit drug use by forcing daily contact with other addicts. But he can’t prescribe Suboxone in his private office for Amanda without exceeding the cap.
The allegations against Curran are disturbing, but so is the difficulty of finding effective drug treatment. Most doctors in Massachusetts are allergic to treating addicts. Does the Board of Registration in Medicine have a prescription for that?


I found the following among the comments that followed this article:

Claude A. Curran: Physicians and the problem of pain

09:37 AM EDT on Friday, October 30, 2009

CLAUDE A. CURRAN

The situation of my friend and colleague James Urban, M.D., (“East Greenwich doctor’s license suspended over drug sales,” news, Sept. 20) is unfortunate. I’ve known Jim for over 25 years. I trust his medical knowledge, his clinical skill and judgment and I have referred patients to him. I was not surprised to read, however, that he was willing to treat people for pain. Jim’s just the sort of doc to do that, and there aren’t too many of them out there.

Most of my colleagues stopped treating pain years ago. No one treats pain anymore. Even so-called pain clinics will not adequately treat pain. On one level it’s understandable. There are no consistent established national guidelines for pain treatment. Even if there were an established protocol it would probably fail to address the subjective nature of pain. If you’re sued for causing someone’s addiction there will be a mile-long parade of expert witnesses criticizing your work and telling the jury what you should have done. To add more confusion, there is no way to accurately assess if a patient actually has pain; there’s no test for pain. And drug addicts will tell you that everything hurts and that they’re in constant pain.

Medical literature describes studies demonstrating normal MRIs in people who report severe back pain, and abnormal MRIs in patients who report no back pain. Fibromyalgia is another can of worms. I’ve treated many fibromyalgia patients (mostly women) sent to me (I’m a psychiatrist) because their fibromyalgia pain was thought to be “all in their head.” Thalamic stroke and kidney-stone pain are two other situations where there can be excruciating pain, little benefit from even the most powerful pain medications, and little to no evidence for the pain on imaging studies like MRIs and X-rays. So what does a doc do? Do you treat the pain or not?

Many years ago, during my clinical training, I had a middle-aged female patient addicted to pain meds. The treatment team thought that either her pain was psychosomatic or that she was simply an addict. As the psychiatry intern, I was assigned to her care.

She was horrible. Always complaining. She would page me around the clock. The story was that she had become addicted to pain meds years before and now would seek admission to the hospital to have access to opiates. Her chief complaint was severe abdominal pain. We tried everything to quell it, ordered every imaginable study, tried every pain med, even PCA — patient-controlled analgesia.

At my suggestion we gave her placebo pills, trying to trick her brain into thinking that the pain had gone away. Nothing worked. She was simply addicted to pain meds, that’s all.
Plus she obviously had a “personality disorder” — a diagnosis used as a flag to future treaters that she’s a pain in the butt. I was relieved when she was finally transferred to the surgical floor — for more probing and scoping studies. By then she was on a pain-med cocktail that kept her more sedated than pain-free. I remember wondering how much this one addict was costing the health-insurance pool — what a waste of money.

About one year had passed when I ran into one of the surgery residents who had taken over her care. The resident told me that she had heard that the patient had recently died but she didn’t know the details or any autopsy results. I called the attending physician and reminded him who I was and that I had treated his patient for a time. He remembered the patient well. Cause of death: pancreatic cancer. All the imaging and lab studies had been negative. Her pain had been real. We, I, never believed her.

The pain in cancer of the pancreas is one of the most horrible imaginable. The pancreatic enzymes back up and the person suffers the pain of “autodigestion” — the powerful enzymes dissolve anything they contact, causing the patient to digest his own organs. It’s agonizing. I learned an important lesson.

Again, the treatment of pain is a huge problem. I read that the Drug Enforcement Administration at one time had a pain treatment protocol on its Web site, but when a doc charged with a violation used the DEA’s own protocol in his defense, the protocol was removed. It’s safer for docs to just avoid pain patients. I remember one colleague who said to me: “Yeah, I see the bones rubbing together on the MRI and I know he could use something for pain, but I’m not going to become the ‘go-to guy’ for Vicodin.”

Certainly you can send all pain patients to the methadone clinic, but for most people methadone is more addicting than heroin. It can be sedating, cause weight gain and requires a daily trek to the clinic for dosing. Suboxone (Buprenorphine) can also be used to treat pain but there are inexplicable and indefensible federal limitations on access to it.

Opiate pain medications are a defective product. They help pain but accelerate the aging process and put patients at risk for a lifetime of addiction. There is no “safe” way to prescribe them. All of us have followed the addiction problems of celebrities and politicians. Unfortunately, the opiates remain the only reliable balm for severe physical pain.

Dr. Urban was a captain in the U.S. Army during the Vietnam War. Together, we ran the gauntlet of Italian medical school at the University of Rome, where only 12 percent of our freshman class graduated. I know what he has survived, I know what he sacrificed to become a physician.

Regarding Rhode Island Atty. Gen. Patrick Lynch’s charge that he is a “threat to the health, welfare, and safety of the public,” Dr. Urban, as far as I know, never worked as a lobbyist for the tobacco industry.

Below is the article that Dr. Curran is referring to:
East Greenwich doctor's license suspended over drug sales.

PROVIDENCE - An East Greenwich physician has been stripped, at least temporarily, of his license to practice medicine in Rhode Island, amid allegations that he coached an undercover agent how to sell drugs illegally without getting caught by police.
Dr. James R. Urban, who has been given until Sept. 28 to file an appeal of his suspension by the Board of Medical Licensure and Discipline, has gotten into trouble with the board at least twice before - once in 2007 when he allowed a physician whose license had been revoked in Massachusetts to practice in his medical office in East Greenwich and again last May for not taking steps to have his x-ray machine inspected.
But Dr. Robert Crausman, chief administrative officer for the medical board, said the allegations in the latest decree may result in something even more serious than no longer having a license, and may even lead to jail time.
According to Crausman, separate investigations into Urban's activities were conducted by the U.S. Food and Drug Administration's Office of Criminal Investigations, the Attorney General's Medicaid Fraud and Patient Abuse Unit and the East Providence and North Providence police departments.
In one probe, an undercover agent posing as a patient went to Urban's offices at Harbour Medical at 100 Division St. in East Greenwich and got a prescription for narcotics from the doctor without a proper assessment as to whether the medication was necessary.
Health officials say Urban continued to prescribe the narcotics for the "patient" even after being warned by an East Providence police officer, and then by the agent himself, that he was reselling the drugs illegally.
It is alleged that Urban even coached his "patient" on how to hide the narcotics sales from law enforcement agencies.
In an order signed Friday by state Health director David R. Gifford, the continuation of Urban's license was deemed to pose "an immediate threat to the health, welfare and safety of the public" and accordingly his license to practice medicine in Rhode Island "is hereby suspended."


References:
Boston Globe.com
Projo 7 to 7 News blog