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 MD
Chairman
Department of Pain Medicine and Palliate 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