Archive for May, 2007

OxyContin: On the Fault Lines of American Healthcare

Tuesday, May 15th, 2007

Three executives of Purdue Pharma have agreed to pay fines totalling $635 million to resolve charges relating to the marketing of Oxycontin. The company admits to understating the risks involved with this potent drug and to deliberately misleading doctors and the public about its addictive qualities. From 1996 to 2001 the company claimed that Oxycontin was a “miracle” drug, safer than rival medications. Alas, it turns out that the drug was subject to abuse and led rapidly to addiction. And the company apparently knew this all along.
The pleas involved Michael Friedman, CEO, Howard Udel, the chief legal officer, and Dr. Paul Goldenheim, the former head of research. While claiming to have taken steps to prevent misstatements in the promotion of the drug, Mike, Howie and Paul pled guilty under the legal principle that holds high-level executives accountable for the improper acts of others. I’m sure that they privately berated their marketing department for the lies and deceptions, even as the dollars began to roll in.
Company revenues associated with OxyContin between 2000 and 2006 approached $10 billion. So the $635 million fine, while appearing hefty, is about six per cent of revenues. As a tax on criminal negligence, that isn’t bad. Even Al Capone would have approved.
You don’t achieve overwhelming market share by sitting around and waiting for doctors to discover you. It takes very aggressive marketing and, in this case, pretty dramatic misreprentation to dominate the market for pain killers. The company told two fundamental lies in their drive to sell their product:
1. That OxyContin was less addictive than other opiates. It’s not.
2. That the drug was less readily subject to abuse. Not true.
It turns out that OxyContin is highly addictive and the company knew it. In addition, they put a warning right on the label not to crush the pill and ingest/inject it. You might get stoned. You might, indeed. By crushing the pill, users circumvent the “time release” characteristic and access the full power in one overwhelming (and highly addicting) moment.
Purdue Pharma did a great job of pushing (that is the operative word) OxyContin deep into the medical system. Originally intended for treatment of extreme pain in cancer patients, the company’s marketers successfully presented it as the drug of choice for common ailments such as routine back pain. That’s why it rose to prominence in the workers comp system. (See our post here.)
The Great American Success Story?
In the ideal world, when a drug is created, it will be prescribed prudently and carefully, and only for the purposes for which it was intended. When you develop an effective product to manage extreme pain, you would limit its use to cases of extreme pain. That’s in the ideal system – not exactly how you would describe the current status of health care in America.
The real American way is achieving market saturation, market dominance, even if your product is best used by a limited population. And to dominate the market, you tell people what they want to hear: the product is extremely safe and effective. It works better than anything else. And heck, if you have a workers comp claim, the prescription won’t cost the employee a dime! We’ll even give them 50 tabs, 40 more than they really need for their little back strain, so they can generate some income on the side.
This country has locked up more people for using and abusing drugs than any country in history. We have a real problem with people getting stoned. Nonetheless, when a legitimate company becomes a pusher, when their misrepresentations and outright lies lead to addiction and death, nothing much happens. If Mike, Howie and Paul sold a few ounces of marijuana or crack cocaine, or even a few tabs of OxyContin, to an undercover agent, they’d be going to jail for a long, long time.
But after their enterprise made billions, Purdue Pharma hired Rudy Giuliani Partners LLC to work out a deal with the prosecutors. In case you’re wondering, Giuliani Partners is “dedicated to helping leaders solve critical strategic issues, accelerate growth, and enhance the reputation and brand of their organizations in the context of strongly held values.”
Hmm. This drug scandal certainly became an embarassing “strategic issue” for Purdue Pharma. As for “enhancing the reputation and brand…in the context of strongly held values” – I’m still trying to figure out what the company’s core values are. Your guess is as good as mine. In any event, Guiliani Partners undoubtedly earned a hefty fee. Once you get beyond a few days of bad press, Mike, Howie and Paul are still very free and very rich. Overall, you’d have to say that Rudy’s boys cut them a pretty good deal, one that even the bootlegger Capone would appreciate.

Free Web seminars: Standard/Universal Precautions and Communicating with Spanish Speaking Employees

Monday, May 14th, 2007

We’ve learned about a few free seminars that we thought we would pass along to you. We don’t have any connection with either of these groups, but they are both sponsored by reputable organizations and sound interesting.
Standard/Universal Precautions: Compliance, Beliefs, and Barriers – Wednesday, May 16
The North Carolina Occupational Safety and Health Education and Research Center is sponsoring a free NORA Interdisciplinary webcast on Wednesday, May 16 from 1:00 – 2:30 pm EST. Kathy Kirkland, Executive Director, Association of Occupational and Environmental Clinics in Washington, DC, will present “Standard/Universal Precautions: Compliance, Beliefs, and Barriers.” The seminar can be viewed live via webcast, or an archive link will be available a few days after May 16 for viewing at your convenience.
Access the seminar here at 1 pm EST on May 16, and log in as a guest. Type in your first and last name and click the “Enter” button to launch the OSHERC meeting space. You may need to download the meeting plug-in (Flashplayer). There will be an interactive question and answer session. Slides and an evaluation form are available.
The seminar topic has been approved for 1.5 contact hours or 0.15 CEUs through the University of North Carolina. To receive the CE credit, you must complete a registration form (hard copy available only) and send a $4.00 check payable to *Friday Center for Continuing Education* to Susan Randolph by *May 25, 2007*; you must also complete an evaluation form after the seminar.
More info: Susan A. Randolph, FAAOHN Clinical Instructor Occupational Health Nursing Program University of North Carolina at Chapel Hill 1700 Airport Road, CB #7502 Room #337 Chapel Hill, NC 27599-7502 – Phone: 919-966-0979
Improving Communication with Spanish Speaking Employees – May 24
Benefits Management Online Forum & Expo is sponsoring this free online forum on Thursday May 24 at 2:00pm EST. Register for attendance here
The notice for this forum states:
If you are an employer with Spanish-speaking employees, an HR director responsible for the success of Spanish-speaking teammates, or a benefits specialist who must communicate plans to Spanish-speakers, this online forum is for you.
Spend an hour with Melissa Burkhart, founder and president of the consulting firm Futuro Solido USA, as she shows why developing Spanish straight talk es muy importante. Melissa will explain the different workplace behaviors and values held by English-speaking and Spanish-speaking workers and reveal the secrets to successful trouble-shooting and team-building with Spanish-speaking employees.
In this presentation, you will learn about:
* Culturally rooted beliefs
* Common pitfalls and employer frustrations
* Strategic solutions for optimizing communication and building more effective teams

News Roundup” Cavalcade of Risk, networks, docs & drugs, scandal watch & more

Friday, May 11th, 2007

Carnival timeCavalcade of Risk #25 is posted at Getting Green. Among other fine entries, we note there are two posts about data security. In one case, the Transportion Security Office lost the records of 100,000 workers – great, that speaks well to their ability to protect us! And in another item, we learn that Chase is careless in disposing of sensitive client materials – and they are obviously not the only ones. Not good. Is your agent, insurer or TPA properly disposing of any claim-related data and records for your organization? You may want to add this item to things you check for in renewals or RFPs.
WC networks – Joe Paduda has some thoughts on the future of workers compensation networks. After meeting with several network executives at the recent RIMS meeting, he sees a definite continuation of the trend away from the national broad-based, discount-oriented networks to regional hybrid networks. Not sure what a Hybrid network is? Joe offers a good explanation in his post. His expert analysis on these matters is worth your attention.
Docs & Drugs – Those free drug samples that physicians hand out may not be such a good idea after all, or so says a recent article in the New York Times. Critics see these as just another example of the close ties between physicians and drug companies, and say that ” … they may actually drive up the cost of health care in the long run, because the drugs being promoted are the most expensive brand-name medications.” We’ve talked about docs and drugs a few times before. (Thanks to HealthLawProf Blog for the pointer to the article)
Scandal watch – We’ve written quite a bit about the Ohio Bureau of Workers Compensation Coingate scandal. Today we learn that the BWC’s former CFO faces 5 years in prison. His sentence was reduced based on cooperation with authorities, so there is the potential for further shoes to drop. There have been 16 public officials and money managers convicted of various offenses thus far. In other state news, trouble is brewing in the North Dakota workers comp system too.
Geek safety25 Free health Tips for Computer nerds This blog may focus on work-related risks, but play can be dangerous too – In 2005, a 28-year-old South Korean man who played computer games for straight 50 hours died of heart failure. Pass this article on to your IT folks and the bloggers in your life. Via Ergonomics In the News
Notes from the Blogosphere – Congratulations to Michael Fitzgibbon at Thoughts from a Management Lawyer ob his 4-year Blogiversary. Michael is a Toronto-base attorney and professor who keeps us informed about the employment-related goings on in our neighbor to the North. And speaking of Canadian bloggers, we told you that rawblogXport had announced the blog was winding down, but we are happy to note that items are still being posted daily.

Comp Fraud Follows a Different Drummer

Thursday, May 10th, 2007

Let’s get down and funky. Valerie Scroggins is a drummer for ESG, a group she founded in the South Bronx with her sisters some 25 years ago. According to Wikipedia, ESG has been influential in a wide range of musical genres, including hip hop, post punk, disco, and dance-punk. Not exactly my taste in music, but who cares. Let’s get down!
We read in the New York Times that Valerie, in her working life, drives a bus for the New York City Transit Authority. Or at least she did until last September, when she hurt her shoulder and went out on workers comp. Then the band went to Europe on tour – and Valerie went with them. An investigator for the self-insured Transit Authority drew the lucky straw and followed the band to Amsterdam and Dublin, where he filmed Valerie happily playing her drums.
“She’s pretty good,” remarked Charles Hynes, the District Attorney. Alas, the party-pooping Hynes has indicted Scroggins on charges of grand larceny and insurance fraud.
Ms. Scroggins lawyer, Stacey Richman, points out that Valerie had been put out of work by two doctors. As for the drum playing, Ms. Richman responded with a classic line that belongs in a Bartlett’s for Attorneys: “I don’t believe there’s any movement that conflicts with the medical diagnosis.” Heck, banging the skins just might be what the physical therapist ordered!
This slightly sordid tale brings to mind the original quote from Henry David Thoreau:

If a man does not keep pace with his companions, perhaps it is because he hears a different drummer. Let him step to the music which he hears, however measured or far away.

Which we paraphrase:

If a chick gets tired of driving the bus, perhaps she really is a drummer. Let her boogie to the music she makes with her sisters, very loud and very far away indeed.

At least until she’s indicted. Makes me want to turn up the volume and play a couple of tracks from an old ESG album: “I can’t tell you what to do” and “Crash.”
Which brings to mind another Thoreau quote: Go confidently in the direction of your dreams. Live the life you have imagined. With one caveat: try to do it within the law.

Fleece on Earth, Ill Will to Independent Contractors?

Wednesday, May 9th, 2007

Fleece on Earth (FOE) makes clothing for babies and children. Pretty cute stuff, if you’re into knit caps with lobsters on them. This is a small, Vermont-based business, relying in part on knitters working from their homes. FOE provides the patterns and the yarn. The knitters work at their own pace, with their own tools, and are even free (to some extent) to make changes in the patterns. They are paid for each finished product. So are these home knitters employees of the company or independent contractors? Yes, it’s “independent contractor versus employee” – the issue that simply won’t go away.
The Vermont Department of Labor stumbled upon this situation when one of the knitters was laid off from an unrelated job (in respite care). In questioning her about her employment, they learned of her work for FOE. She was not seeking unemployment from FOE, but the state bureaucrats included FOE in their analysis. They found that the knitter, along with 3 fellow knitters and one sewer, were indeed employees of FOE. As a result, they sent a bill for unemployment insurance to the company. The company appealed and the case went all the way to the Vermont Supreme Court.
It’s interesting to note that this ruling has nothing to do with the wishes of the knitters themselves. They don’t want to be employees. They prefer being independent.
An amicus brief was filed on behalf of the employer by the National Foundation of Independent Businesses. NFIB argues that the knitters are truly independent. In their extensive brief, they cite among many other things the 1921 case of Kelley’s Dependents v. Hoosac Lumber:

If the employer may specify the result only, and the worker may adopt such means and methods as he (sic) chooses to accomplish that result, then the latter is not an employee, but an independent contractor.

A divided Vermont Supreme Court found that the knitters are indeed employees of the company. (Can FedEx be far behind?) Three justices in the majority ruled, with two additional justices dissenting. The split verdict probably indicates that there will be additional litigation in the Green Mountain state.
Repetitive Motion?
Having opened the door to unemployment insurance, the court has not specifically addressed the possibility of workers compensation coverage for the knitters. (Knitting, I hardly need add, is highly repetitive work.) Erin Gallivan, the company’s attorney, believes that workers comp is calculated under a different criterion. I’m not so sure. The Department of Labor has determined that the workers are employees. The knitters could (but most likely won’t) seek protections and benefits under Fair Labor Standards, workers compensation and discrimination laws. It will be very interesting to see what happens when the comp insurer completes its audit at the end of the policy year: my guess is that the auditor will add the 1099 forms for the knitters to the company payroll, thus retroactively increasing comp premiums.
These knitters are caught up in a very big and very broad net, one that seeks to eliminate long-standing practices for avoiding payment of insurance premiums on workers who really do not meet the criteria for independence. I am sympathetic to the argument that these knitters are really independent, but such disputes do not occur in a vaccuum. The solution for the bigger problem has overwhelmed these home-based workers in Vermont and it is likely to do the same for thousands of small artisans across the country. In the warp and weave of employment, you can probably make the case that most of us are employees at least part of the time.
We’ll keep you posted.

Celebrating American workers

Tuesday, May 8th, 2007

U.S. Steel - female workersThe website for National Archives is a national treasure. The National Archives and Records Administration (NARA) is the Government agency that preserves and maintains important historical materials and makes them available for research or public access. Many records have been digitized and the site has an extensive array of exhibits that range from the educational to the entertaining.
One that we chanced on recently that may be of some interest to readers of this blog is The Way We Worked. This is an extensive exhibit, primarily photographic, that offers a glimpse of American workplaces spanning the mid 19th to the late 20th centuries. The exhibit graphically depicts how the nature of the work that we do has changed and offers this commentary:

… In 1870 only a handful of factories employed over 500 workers. By 1900, 1,063 factories employed between 500 and 1,000 people. During the first half of the 20th century, many African American women worked as domestics in private homes, but during World War II, they took advantage of new opportunities at shipyards and factories.
By the end of the 20th century, a dramatic shift took place, sending individuals who had worked in factories, plants, and mills into jobs in offices, stores, and restaurants.

The site has exhibits on what people wore to work and what tools they used. Also, in a section about “conflict at work” there are photos focusing on labor issues. The section that attracted our attention is a compilation of photos on dangerous or unhealthful work. Each of the photos are captioned and offer interesting commentary. The photo of the women that we’ve used in this post depicts workers at U.S. Steel’s Gary, Indiana Works, taken sometime between 1941 and 1945. The caption refers to the workers as “top women” and states that, “Their job is to clean up at regular intervals around the tops of twelve blast furnaces. As a safety precaution, the girls wear oxygen masks while they are doing the clean-up job.”
The photos are also available for purchase in book form and can be viewed at the following locations in a traveling exhibit:

  • Morrow, GA., March 10 – May 20, 2007
    –National Archives and Records Administration – Southeast Regional Archives

  • Kansas City, MO. , June 9 – August 19, 2007
    –Kansas City Public Library

  • Ocala, FL., September 8 – December 18, 2007
    –Central Florida Community College

California Apportionment: Pennies for your Pain?

Monday, May 7th, 2007

The plaintiff bar in California is very unhappy with the state’s (long overdue) reforms of 2004. One blogger calls for the abolition of comp and a return to the pre-comp days when employees sued their employers for work-related injuries. I would call that a bit emotional, counselor. To be sure, there are real problems in determining permanency benefits, and some adjustments in the current system are undoubtedly needed, but the issues are not so big that the solution is doing away with the entire system. Do you really want to go back to the days of the fellow servant rule, contributory negligence and the assumption of risk – the potent defenses that resulted in an 80 percent win rate for employers? I don’t think so!
While criticizing the payouts for permanent partial injuries, the plaintiff attorneys point to unusually high profits for comp insurers. These profits are the inevitable result of the delay between implementing reforms and adjusting the premiums. They are also the result of long overdue reforms that have significantly reduced losses in the state’s humongous comp system. Eventually, the bottom is going to fall out of the currently inflated premiums. Meanwhile, it’s a great time to write comp insurance in the California (see our prior blog here). And perhaps not such a great time to be a member of the plaintiff bar.
Addition by Subtraction
The state Supreme Court recently issued a ruling on a number of related cases involving the apportionment of permanency benefits. The court addressed this issue: when an employee who received a prior permanency rating and benefits for a work-related injury is subsequently re-injured, how do you determine the benefits?
Let’s take a specific case – emotionally charged, to say the least – involving Ken Welcher’s amputation. In 1990 Welcher was pulled into a conveyer belt, injuring his knee. He was awarded a 62.5 percent disability rating. Under CA law, he received a cash payment of four weeks of benefits for every point of disability: you multiply 4 times 62.5, plug in the wage, and you arrive at a settlement number.
Welcher eventually returned to work as a laborer. He suffered a work-related injury to the same right knee. This time the damaged leg had to be amputated. Under the state schedule, an amputation is calculated as a 71 percent permanent disability.
So how should Welcher be paid? Should you treat the injury as something new, by using the full 71 percent factor? Or should you subtract the original payment (62.5 percent) from the 71 percent, resulting in a new payment of about 8 percent? The court, citing precedent under the pre-2004 reforms, opted for the subtraction method. In terms of dollars, Welcher receives only $3,360 for his amputated leg. Yes, it sounds like chump change for an amputation, but the payment has to be viewed in the context of his substantial prior benefit.
The court cited a compelling argument for using the subtraction approach: if the most recent employer becomes liable for the full disability rating, employers would be very reluctant to hire anyone with a handicap. In effect, the court has limited the exposure of the most recent employer to the increment in disability. No double dipping. No multiple big-cash pay outs. (And no repeat pay days for the plaintiff attorneys.)
So the formula becomes a kind of addition by subtraction: by limiting the exposure of the current employer, the court opens the door to employment for thousands of workers who might otherwise be rejected. The dollar numbers of Welcher’s most recent settlement do seem trivial compared to his suffering, but the reduced amount may ultimately serve the greater good. Ironically, some future employer might look at the disabled Welcher not as unemployable, but as a worker carrying a 71 percent warranty.
Workers comp isn’t perfect, it may not be completely fair, but on the whole there is no better system for balancing the interests of employers and injured workers. Comp may always be in need of reform, but there is no reason at all to abolish it.

Health Wonk Review #31 – The Derby Edition

Thursday, May 3rd, 2007

HG Stern has a refreshing edition of Health Wonk Review up at InsureBlog and the post sports a jaunty look in keeping with Kentucky Derby week. Stop by to sample the fare – there are a few submissions from blogs that appear to be newcomers to HWR, as well as numerous posts from “the usual suspects.”
InsureBlog is one of the mainstay blogs in the insurance world, having been around for two and a half years. It features posts and contributions from insurance dudes from various parts of the country: OH, CA, GA, CT. Founder HG Stern and Bob Vineyard are the blog’s two most frequent contributors. Prof Stern is also noted in the blogosphere for having launched Cavalcade of Risk, our other favorite biweekly carnival. Just to give you a flavor of InsureBlog, here’s a sampling of a few recent posts that we found interesting:
One Woman’s story
Scammers and Fools
The Flipside of Empowerment…

Keeping up with RIMS from the sidelines

Wednesday, May 2nd, 2007

The Risk and Insurance Management Society’s annual meeting – the insurance industry’s equivalent of Woodstock – is currently in progress in New Orleans. For those of you who are sidelining things this year, our colleague Joe Paduda is blogging the event, so you might tune in to Managed Care Matters this week to get his perspective on things. And if you have a subscription to Business Insurance, you can follow along with daily video coverage of RIMS. You can keep up with some related headlines that hit the media by running a Google news search on RIMS, although this will also return some unrelated news on non-related “rims” matters, like things pertaining to tires.
You can also follow any media releases that RIMS issues. One of the more interesting releases to date is the 2006 Annual Benchmark Survey which notes that “the commercial insurance industry continued to experience an overall decline in total cost of risk in 2006.” According to the 1200 survey participants, although there was significant variation by industry segments, the average total cost of risk fell by 9.2 percent for all survey participants.

Managing Pain: Dr. Feelgood’s Hard Time

Tuesday, May 1st, 2007

A jury in Alexandria VA recently found Dr. William Hurwitz guilty of 16 counts of drug trafficking, determining that he prescribed massive quantities of medicine to patients in chronic pain. The 12-member jury acquitted Hurwitz on 17 other trafficking counts, but Hurwitz faces up to 20 years in prison for each count on which he was convicted. He will be sentenced July 13.
This was the second trial for Dr. Hurwitz. In the first, the judge improperly told jurors that they could not consider whether Hurwitz acted in “good faith” when he prescribed the large doses of medicine. So whether he acted in good faith or not, the good doctor is going where drugs are readily available, but prescriptions are never needed.
Hurwitz is a trusting soul who has become a lightening rod for the issue of pain management. He defines pain in a very simple manner: “Ultimately, pain is what the patient says it is…” In other words, as a doctor, he does not put himself in a position to question his patients. If they say they are in pain, he provides the strongest available medications. In large quantities. Repeatedly. If his patient “loses” the prescription, he immediately provides another.
During the four-week retrial, prosecutors argued that Hurwitz was a common drug dealer whose McLean waiting room was filled with sleeping and incoherent patients with track marks on their arms. The prosecution presented 41 witnesses, including 12 former patients who had been convicted of drug crimes.
“He crossed the line from a healer to a dealer,” Assistant U.S. Attorney Gene Rossi told the jury in closing arguments April 18.
Dealer as Healer
In an article by New York Times reporter John Tierney, we read of a compelling incident in support of Dr. Hurwitz:

It occurred…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.’ “

While I normally would lean toward Dr. Hamill-Ruth’s approach to pain management – minimizing the use of opiates – she clearly was no help to Mrs. Lohrey and may have exacerbated her condition (by prescribing a medication with a headache side-effect). Her cavalier approach may have been even less helpful than Dr. Hurwitz’s.
What is Pain?
There are no objective tests to validate or measure pain. It’s a very complicated issue, with extraordinary ramifications in the workers comp system (where Oxycontin is all-too-frequently prescribed – see our prior post here).
As Dr. Hurwitz says, pain is what the patient says it is. Ah, but patients can lie, especially those who are addicts, who will do anything and say anything to secure their next dose. Hurwitz, if nothing else, was phenominally naive. His “good faith” was trumped by his poor judgment. If pain is what the patient says it is, then we’d best have a very close look at the patient. That’s where good Dr. Hurwitz morphed into Dr. Feelgood. He was so focused on making the pain go away, he routinely prescribed pain relievers that all-too-quickly become problems unto themselves. And now he pays a price well out of proportion to his crime. In the matter of pain and pain management, there is very little middle ground.