Chapter 11: Pain, Opioids and the Challenge of Working with Patients –and with Government Regulations
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Description
Dr. Hill begins this chapter by explaining the problem that triplicate prescription forms present to pain management. Since one copy of a prescription for an opioid goes to the police, physicians can be reluctant to prescribe (adequate) pain medication for fear of legal prosecution. Dr. Hill then talks about his related work with Texas Lt. Governor Bill Hobby to write the “Intractable Pain Treatment Act” (1989), adding many observations about how politics can influence medicine. He also talks about lawsuits against physicians who prescribe opioids and the lengths patients will go through to acquire adequate medication. He discusses “My Word Against Theirs”…Narcotics for Cancer Pain Control (1990-’91), an award winning video ("Heart of Wisdom Award" SMF "Gold Award" [First Place] for the Eighth Biennial John Muir Medical Film Festival in the category of "Patient Care") he produced with the MD Anderson Media services and a 1996 episode of 60 Minutes, during which he discussed a lawsuit against physician William Hurwitz for prescribing narcotics. Dr. Hill then talks about obstacles that still prevent the medical profession from adequately treating chronic pain. He also discusses the need to teach pharmaceutical companies how to tailor medications to maximize pain relief and avoid toxicity.
Identifier
HillCS_02_20120217_C011
Publication Date
2-17-2012
City
Houston, Texas
Interview Session
C. Stratton Hill, MD, Oral History Interview, February 17, 2012
Topics Covered
The Interview Subject's Story - Overview; Overview; MD Anderson and Government; Activities Outside Institution; The Clinician; The Administrator; The Leader; Discovery and Success; Human Stories; Offering Care, Compassion, Help; Patients
Transcript
Tacey Ann Rosolowski, PhD:
I was going to ask you about the triplicate issue because I was reading in some of the articles and editorials and also in the guidelines that you worked on that that whole issue of prescribing on triplicate forms was a huge barrier for physicians. Could you talk a little bit about how that was a barrier to the prescription of these drugs?
C. Stratton Hill, MD:
Well, it was like every time you wrote a prescription it went to the police department, and that’s what it— Ross Perot was the one that got that all put into effect. He gave— I don’t know whether he gave them but he said— He’s in the IT business, and so he said this ought to be automated and we ought to keep up with it and so forth. So he’s the one that put that in. I mean, doctors didn’t like it that one prescription went to the Narcotics Division at the Department of Public Safety. Well, that was just part of the overall issue of regulatory control and barriers. We realized that— When I realized that doctors said, “Wait a minute, we’re not going to give medication outside of what the book says is the normal dose to give,” that’s when I first went to my friend Bill Hobby [former governor of Texas] and said, “Hey, we need to do something about the Medical Practice Act,” because I got a copy of the Medical Practice Act, and there was nothing in it that said that there was a legitimate use for these drugs. Any reference to opioids related to the abuse of them. I started with the Texas Medical Association, and they said, “Oh, no. We don’t want to do anything like that.”
Tacey Ann Rosolowski, PhD:
Why didn’t they want to?
C. Stratton Hill, MD:
See, you open up the Medical Practice Act, and you’re going to get all kinds of problems, because if you start messing with that, then the snake oil people will come in there and the rain dancers and all these different people, so let’s don’t touch the Medical Practice Act. I thought, “Well, how can I get around it?” Well, I get a call then from one of the lawyers at the Texas Medical Association. C.J. Francisco was his name, a super guy, and he said, “You want to help me write the Intractable Pain Treatment Act?” And I said, “What?” Bill Hobby, what he’d done, he just took the bull by the horns and he got the guy— See, the lieutenant governor is the president of the Senate, so he got the Dean of the Senate to sponsor a bill. He calls up the Texas Medical Association and says, “I need a bill.” Then C.J. Francisco called me, and so we wrote the bill.
Tacey Ann Rosolowski, PhD:
What was Bill Hobby’s interest in pain? Why did he champion this?
C. Stratton Hill, MD:
Because I talked to him about it. We had lunch together lots of times on Saturday, and I had talked to him about this, so he just took the bull by the horns and started that. We got this passed—I mean—we got this drafted. I didn’t have a sponsor in the House of Representatives, so, boy, it sailed through the Senate. I mean, boom, it was passed.
Tacey Ann Rosolowski, PhD:
And this was in 1980—?
C. Stratton Hill, MD:
It was 1989. There was a doctor in the House that was from Centerville, Texas. I think Center or Centerville. He never practiced medicine after that. He became big in state politics. Anyway, at that time, the AIDS epidemic was just coming into play. The guy’s name was [Dr. Michael] McKinney. That was the doctor’s name. Somebody said, “Why don’t you get”—I forget what his first name was—“Dr. McKinney to be your sponsor in the House.” I went up, and I talked to him, and he said, “Okay, I’ll do that,” and so it started its journey through the House. Well, he also was the sponsor of a bill for AIDS treatment. The person who was chairman of the Public Health Committee in the House wanted a punitive bill, and the doctor just wanted a treatment bill because when AIDS first came out, it was mostly in homosexual males, and the evangelical right-wing, religious people wanted to punish anybody who had AIDS. The doctor just wanted something to treat the patient. Anyway, he got crosswise— Would you like another—?
Tacey Ann Rosolowski, PhD:
No, I’m good. Thanks.
C. Stratton Hill, MD:
He got crosswise with the chairman of the Public Health Committee because he was on the Public Health Committee. Well, the doctor prevailed with his AIDS bill, and so the guy in the—now, this is real politics—the Public Health Committee said, “You’ll not get anything else passed. I’ll guarantee you that.” At that time, you could call up, and you could get a bill status number. I’d call up every day to see how that was coming along, and it wasn’t moving, it wasn’t moving, it wasn’t moving. And one of these guys that was a lobbyist for the Texas and New Mexico hospice, I had become friends with him. We didn’t have a lobbyist, so I said, “Can you find out what’s going on with this thing?” He said, “Well, there’s the chairman of the Public Health Committee.” And I said, “Who is that?” and he told me. It turns out that he’s the brother-in-law of one of my good friends, so I called up my friend and said, “Hey, I’ve got a problem here. We need to get this bill out of that committee.” And he just says, “Consider it done. I’ll talk to him.” I said, “Okay, that sounds good.” What happened was he didn’t get it out of the committee, so the bill failed. I called up Bill, and I said, “Bill, there wasn’t anybody against that bill. Nobody was against that bill, but it failed.” He said, “How did that happen?” I said, “You’re the ones in this legislature. Tell me how it happened.” He found out that that’s what happened, and so he couldn’t believe it. And Bill Clements was governor, so he called a special session of the legislature that summer to deal with workers’ compensation because they had not been able to get anything done with workers’ compensation. I said to Bill, “You can’t do anything except what the governor asks them to do in a special session.” I said, “If you get a chance, see what we can do about getting this thing done.” He says, “Okay.” They were making zero progress on workers’ compensation, so the last week of the session Bill then asked Bill Clements “Can we do this bill?” He said yes, so bam, it goes through the Senate, and this time Bill had— See, the only person that can take a bill out of a committee is the Speaker of the House. If it’s held up in a committee, the speaker can reach over and say, “Here it is. We’ll talk about that.” Gib Lewis was the Speaker of the House. That’s still when everything was in Democratic hands. Bill had it arranged with Gib Lewis that if it didn’t go right through the Public Health Committee, he was going to reach in there and get it. I remember I was at a meeting in Madison, Wisconsin, at the University of Wisconsin, and I knew that was coming up. I called down, and I talked to the senator’s aide, and she said, “Dr. Hill, your bill just passed.” We got it passed in that special session. That’s just some of the politics that you have to—
Tacey Ann Rosolowski, PhD:
What was the essence of the bill?
C. Stratton Hill, MD:
It had about three or four parts. First of all, it said these drugs had a legitimate use and that people who had intractable pain could be treated with these drugs, and third was that no medical organization could interfere with a physician who used these drugs to treat intractable pain. Fourth, the Board of Medical Examiners could not sanction a person, a doctor, for treating intractable pain with these drugs. We thought, boy, we’ve got this thing all squared away. But we found out we didn’t. The board kept acting just like it always did. So then we looked at the Medical Practice Act, and it was just really— It had such vague terminology and still does. But it’s pretty much universal across all states because medical practice in the bailiwick of states is not federal. There’s nothing federal on this, so we then went to the—let’s see. The Medical Practice Act is subject to the sunset law.
Tacey Ann Rosolowski, PhD:
To the—
C. Stratton Hill, MD:
Sunset law. Texas has a sunset law. You know what that is?
Tacey Ann Rosolowski, PhD:
I do not.
C. Stratton Hill, MD:
Okay, any agency of the state that’s subject to the sunset law means that that agency’s authorization to exist ceases at the end of 12 years unless the legislature reinstates it. That doesn’t mean that it can continue to exist under the legislation that’s there. It stops at the end of 12 years unless it’s been—and it’s got to go through the sunset process, and actually, that is a very, very good thing. Every state ought to have that. I didn’t know anything about the sunset, and it was time for the Medical Practice Act to come up for the sunset. There was a senator from Beaumont. The name was Carl Parker. He could have been Senator Claghorn because he was the typical good ol’ boy senator. I met with him, and he even came to MD Anderson to see me one time. He said, “Well, I’ll take care of that. I’ll take care of that.” I didn’t know any better, so when I talked to his chief of staff, it had already been through— I kind of talked to him and said, “How’s it coming along?” “Oh, it’s coming along fine.” And so when I found out, she said, “Yeah, it’s ready to go,” and I said, “Well, does it have this, this, and this and this in it?” She said, “No, it doesn’t have any of that in it.” I said, “Well, wait a minute. That’s what we wanted. Can we change that? Can we get it changed?” “There’s no way you can get that changed now.” We missed on that thing, and talking to Bill Hobby he says, “You know, really, that’s not what the sunset process is all about.” It was to change the laws, but obviously, it can be used that way.
Tacey Ann Rosolowski, PhD:
What were the specific changes you wanted to see made?
C. Stratton Hill, MD:
Well, we wanted to see the way that physicians were disciplined, for one thing. They had what they called the Informal Settlement Conference, and it was anything but informal. I mean, they just raked those guys over the coals. And by this time, I had been doing enough work and talking, and the board would get involved. When it would get sanctioned by the board, lots of times they’d call me. As a matter of fact, I got a call just a couple of days ago from a lawyer in Wichita Falls who said, “I had a case against a neurologist up here, and you were my witness.” I didn’t talk to him. He left a message. I’ve got to call him back. But it’s kind of interesting how all of this comes about. He said, “I have a daughter who is in occupational therapy school down there in Houston, and she wants to have an internship at MD Anderson.” He said, “You were my witness about 20 years ago, and we had a favorable outcome for that neurologist.” I don’t know whether he really meant this or not, but he said, “In all my 30 years of law practice, I think you were about the best witness I ever had.” I don’t know whether he wanted me to help him get his daughter in, but things like that. By that time, I was doing a lot of that.
Tacey Ann Rosolowski, PhD:
Serving as a witness for physicians who were being sanctioned and you were—
C. Stratton Hill, MD:
That case was a— This was an interesting case. I’m pretty sure this was the case. This was a case of a guy who had migraine headaches. He was an oil man who was married to a girl whose father was a doctor. He could not get pain medication for his migraine headaches in Wichita Falls. He was an airline— He had his own airplane. He flew his own airplane, and he would go— He divorced his first wife, whose father was the doctor, but he kept on treating him. He moved to New Mexico or something, and he’d have to fly out to New Mexico to get something for his pain and then fly back. He had gotten a doctor, a neurologist, in Wichita Falls who would treat him, and he was out of town. That doctor was out of town, and this guy hated to go to the emergency room because they treated him like a dog. He had a girlfriend who was a policeman there. So he had this terrible headache. The headache started, and he called the doctor, and the doctor was out of town. But he called him and got in touch with him, and the guy said, “I’m going to order this stuff at the emergency room. You go to the emergency room. I know you don’t like to do that, but go there, and they’re going to give you this.” Well, he went there, and they gave it to him, and then the orders were if it was— And then the story is that the resident or whoever came in and quizzed him about this, and by innuendo he’s a morally reprobate drug addict and all this kind of stuff, and so it was that he could have another shot if it wasn’t out of there, if he didn’t get relief. He got the other shot, and he talked to his girlfriend. He said, “Call that ambulance.” I don’t know why he had to have an ambulance. He was very obese. He had to have an ambulance, and he signed himself out, and he went home, and she went with him. He was obviously pretty groggy, and it took two or three guys to carry him in because he was so obese. He fell down in the driveway, and they finally got him into bed, and she thought— His girlfriend thought he had stopped breathing. He may have, so she got on top of him and tried to resuscitate him and caused him to vomit, and he aspirated that vomitus and everything, and he died. The suit was against the neurologist. It was against the hospital, against all that stuff, and so I testified for that neurologist. He got off. So did the hospital. But that wasn’t— It was probably the fact that she got on top of him and gave him that stuff and caused him to vomit that made him—but that just illustrates what people have to go through.
Tacey Ann Rosolowski, PhD:
And it sounds like Texas certainly wasn’t the only state in which this was happening. When you were doing this work on the pain clinic, the Intractable Pain Act, and trying to get the medical legislation changed in Texas, were there other states doing similar things? Your movements to kind of treat pain in Texas, how was that part of the trend nationwide?
C. Stratton Hill, MD:
About that time, the people in Wisconsin— And that’s the reason I was in Wisconsin at that time was they organized the Wisconsin Cancer Pain Initiative, and so I got in touch with them. We started working together, and out of that—and started working with Kathy Foley. In 1981, we put on— Dr. Clark wanted to put on an international program here, and we put on one at the Shamrock Hotel. It was still there at that time. I had Kathy Foley on that program to speak about pain. That was the first cancer meeting to ever have anybody to talk about treating pain.
Tacey Ann Rosolowski, PhD:
Oh, I see, so this was an international program for cancer in general, but then it had a pain thing.
C. Stratton Hill, MD:
That’s right. So I decided I wanted that—because I was in charge of that program, and I was the coordinator, and that was another time we missed the boat by not publishing that particular program. We had two or three Nobel Prize winners on that program. That happened at that time, and then shortly after that— See, we were beginning to make some moves, because 1984 was when we had this program here on pain and—
Tacey Ann Rosolowski, PhD:
Just to back up a sec, what was the reaction from the attendees at that conference of the international program to Kathy Foley’s lecture?
C. Stratton Hill, MD:
Well, actually, it was blasé. Nobody took pain seriously at that time, and actually, that was one of the first cable satellite programs. We were on HBO.
Tacey Ann Rosolowski, PhD:
What?
C. Stratton Hill, MD:
I had people from all over say, “Hey, I saw you on HBO.” (laughs) But that kind of broke the ice, and then the American Cancer Society published a book on cancer. Art Holub was at Memorial when I was there. He was a surgery— He was in surgery at the time, and he had some kind of administrative job. Anyway, he came to MD Anderson and was kind of the head of education at MD Anderson for a while, and then he went back to be the head of the American Cancer Society. Then he moved back to New York. They wanted me to write the chapter on the thyroid in there, and by that time, I had already started doing this stuff in pain, so I said, “Okay, I’ll do that. But guess what, Art?” I called him on the phone, and I said, “If you just mention the word cancer, what are words that come to a person’s mind when you just throw out that word? Is it death?” “Yes, death.” “Okay, pain?” “Oh, yes, pain.” “Where’s the chapter on pain in the book that the American Cancer Society is going to put out?” He said, “Do we have one?” I said, “No, you don’t have one.” I said, “You get on the phone over there to Kathy Foley at Memorial and tell her to write you a chapter on pain.” That’s the first time that the American Cancer Society ever had anything on pain.
Tacey Ann Rosolowski, PhD:
Did that have an effect because the American Cancer Society suddenly recognized it as significant enough to put it in a—?
C. Stratton Hill, MD:
The short answer to that is no. Nothing has had an effect. You still have a problem. That’s what this thing from the Institute of Medicine says, that we are torturing patients with chronic pain. Anyway, after we saw that the medical board was going to keep on doing what they were doing, then I thought, “Well, we need to go to the medical board and give them some lectures.” About that time, Ann Richards became governor of Texas. And one of her heroes was a woman out at Anderson by the name of Frances Goff. Frances was a legend at Anderson. Nobody knows who she is now, but she ran Girls’ State in Texas ever since World War II up until she died about 10 years ago, maybe. Well, it’s more than that, I guess, because she died when Ann was still governor. I was the token male pall bearer. The rest of them were girls from Girls’ State, including Ann Richards. Ann had arranged for Frances to be buried in the state cemetery in Austin, and she’s buried up there. And Ann gave the eulogy and the service at the grave site. But anyway, Ann Richards was the governor, and Frances had told her—because Frances and I were great friends—had told her what I was doing, and she got real interested in it. And actually, she invited a bunch of people up to the governor’s mansion for dinner, kind of a grassroots thing that Frances thought she ought to do. We got on a bus and went up there. I got to sit next to her, and I talked to her all about pain and everything. When she started speaking to everybody, she said, “Well, now, I’ve heard everything that needs to be known about pain, so I want some of the rest of you people to”—anyway, she made some appointments, recess appointments, and so we said, okay, the board has got to make some changes. We ran into—because we wanted—a doctor who was the executive director of the board at that time had trained with Bonica out in Washington, and he was a big behaviorist. He was an anesthesiologist, and here we were pushing narcotics, so he wasn’t too happy with what we were doing. And I had this student that I was telling you about that was working on his Master’s, and he was doing all this research on the stuff, and so I had to get— Let’s see, Bill Hobby, I think, was still lieutenant governor. Yeah, he was, and he wasn’t very cooperative until we kind of put a little pressure on him. And then we had another guy who was—on this doctor who was the chief of—who was the executive director of the board had developed a granulomatous disease of the sarcoidosis of the lungs, and he had to give up medicine, so he went to law school. He was a lawyer, too, but the legal counsel for the board then told him one day, “Look, I’m the lawyer. You’re the executive director. I’ll make the decision on how we do these things.” Then we got them to change to adopt the rules that corrected some of the vagueness in there, like saying what is inappropriate prescribing, defined that, and also what is legitimate use of the drug and things like that. That was in 1995. So we got that passed by the board, and of course, it was really interesting because then that guy who was executive director of the state board became the executive director of the Federation of State Medical Boards, the organization for all the medical boards. Then he takes the rule that we had for that and puts it up before the Federation of State Medical Boards as if he was the one that did it. We couldn’t care less. I couldn’t care less, but it was interesting to have to make him do something, and then he decided it was a great thing and he goes up here and puts it up before the whole—
Tacey Ann Rosolowski, PhD:
Did they accept it? Did they adopt it?
C. Stratton Hill, MD:
Yeah, they did, they did, and they’ve come a long way too. We’ve had to go up and speak before them. I went up to Boston. They were meeting in Boston, and it was amazing. He was head of the thing. “It never occurred to me that pain is not treated adequately.” He was a surgeon and so—
Tacey Ann Rosolowski, PhD:
That’s amazing. As you’re telling this story, I’m stunned because it just seems like such a no-brainer. I mean, here you have a disease that attacks the body in such dramatic ways. People are in pain. I mean, you watch movies, TV shows. You see people in agony. It’s like, okay, I get that that’s not fictional, and it seems like, don’t you treat the pain? It just never occurred to me that, A, it wouldn’t be done, and B, that trying to do it would be so difficult and be such a long haul.
C. Stratton Hill, MD:
Well, the thing was they were faced with a book that said this is the way you do it, and they knew that the image that these drugs had in our society is drugs of abuse, so they were between a rock and a hard place. If I do that, they’re going to say, “What’s the standard of practice, doctor?” “10 mg.” “You gave them 100 mg. You gave them 10 times the amount that the book says you’re supposed to give.”
Tacey Ann Rosolowski, PhD:
So you really had to change the knowledge base to—
C. Stratton Hill, MD:
We had to change the knowledge base, and you’ll see back in that 60 Minutes thing, because that was the next thing. I remember one time I was testifying for a guy out in Los Angeles, and this lawyer said, “Doctor, do you realize that this doctor out there was giving him fifteen pills every four hours? That’s six times fifteen. That’s ninety pills a day.” I said, “Yes, I realize that, but it’s not the number of pills. It’s the dose that’s necessary to relieve the pain, and you have to use whatever you’ve got.” And the strength of the pills at the time that he was prescribing it was 5 mg. The pharmaceutical industry has risen to the occasion now so that now there’s a 30 mg tablet. So if he was prescribing for that patient now, he could give him two tablets and he would have the same amount. That was one of the big things that we had to fight. I remember Abbott Laboratories. I was talking to their chief medical officer, who is a woman, and she was in some other field. I’ve forgotten what field she was in. They had a 4 mg tablet of Dilaudid, hydromorphone, and they were the chief makers of that at that time. I said, “We need a 30 mg tablet of Dilaudid.” And she just—that’s the most ridiculous thing she’d ever heard, and that was the milieu that we were working in. To get almost every facet of this thing, it had to be addressed. And then they would do all kinds of things like, okay, we’re going to give twice as much oxycodone, and we’ll put twice as much acetaminophen. No, no, no. Don’t do that. But they didn’t ask anybody. They come along, and Abbott comes up with Vicodin ES, extra strength, and they put more hydrocodone in there and more acetaminophen. I said, “Come on. What you’re doing here”—they had one that was 500 mg, and they went to 750. I said, “If you take two of those, you’re taking a gram of acetaminophen.” Four grams is the beginning of a toxic dose a day in 24 hours, so if you take two of those tablets every four hours, that’s six doses. You are already into the toxic range. Now you’re going to put in that you’ve got a gram and a half into that. It’s worse. Then there was some private little company, and when they heard me saying that, they came down here and said, “Oh, look here, we’re just going to up the narcotic dose, but we’re going to keep”— I said, “That’s fine,” and they do that now. And then you’ve got all kinds of sizes in this tablet. In this My Word Against His, one of the guys says, “I take fifteen of those in the morning and fifteen of those in the evening.” They were 30 mg tablets. That’s all we had. We just made that film, and that was the Sackler family that owned Purdue Frederick. It’s now Purdue Pharma, and they still own it. They got sued, and people I know got fines, big time, because of their claims that they knew that it was bad. It’s crazy. But anyway, they were having their national meeting, and they asked me if they could take this tape up there and show them, and I said, “Sure.” They were all there. Representatives from all over the United States were at their meeting, the United States and Canada. It was in Montreal. When they heard that that guy was taking fifteen of those twice a day, of course, that means that’s good for them. Because if they get one of their doctors to do that, they use a lot of the drugs, and the more money they make for the salespeople. Those were the things that we were running into, and I testified for doctors all over the United States, still do. Well, I try to quit, but occasionally somebody— And I try to just do very limited stuff because it takes a lot of time. Okay, let’s see, I don’t know where that got us.
Tacey Ann Rosolowski, PhD:
Well, let me look at the time. We’re at ten minutes after 4:00, and I’m wondering if it’s okay if we quit today, and then maybe we can make an appointment for a final session next week just to finish up, because we haven’t talked about ambulatory care, which we really need to do. And maybe there are a few lingering issues with pain which we can follow up on as well. Would that work out for you?
C. Stratton Hill, MD:
Yeah, I think that’d be okay.
Tacey Ann Rosolowski, PhD:
Well, it’s about ten minutes after 4:00, and I’m turning off the recorder now. (end of audio session 2)
Recommended Citation
Hill, C. Stratton Jr. MD and Rosolowski, Tacey A. PhD, "Chapter 11: Pain, Opioids and the Challenge of Working with Patients –and with Government Regulations" (2012). Interview Chapters. 1050.
https://openworks.mdanderson.org/mchv_interviewchapters/1050
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