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Photographs by Suellen Parker for The New York Times

Published: July 1, 2007

Doctor or Drug Problem

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Letters should be addressed to Letters to the Editor, Magazine, The New York Times, 229 West 43rd Street, New York, N.Y. 10036. The e-mail address is magazine@nytimes.com. All letters should include the writer's name, address and daytime telephone number. We are unable to acknowledge or return unpublished letters. Letters may be edited for length and clarity.

Thanks to Tina Rosenberg (June 17) for shedding light on a serious issue for chronic-pain sufferers and the doctors who care for them. The fine line between helping and harming is emotionally taxing enough for responsible physicians without the threat of incarceration. These are matters too delicate and medically complex to be decided by those who don't negotiate this very narrow passage on a regular basis.

Dr. McIver's sloppy record-keeping and perhaps-overzealous prescribing may have breached medical standards sufficiently to warrant license suspension or revocation by the state medical board, but 30 years in prison is an outrage. Shouldn't issues of treatment be determined by medical boards and peers of practitioners?

Terry Shlimbaum, M.D.
Lambertville, N.J.

For a physician, a jury of one's peers is not a group of lay people who do not understand chronic pain. Physicians should expect a true jury of their peers, those who are educated to the same level in the field of medicine.

And shame on the patients who are now bringing civil suits, after lying to and manipulating the doctor for more narcotics. They and the lawyers who have taken their cases should be reprimanded and penalized.

Jennifer Miller-Davis, M.D.
Portland, Ore.

Tina Rosenberg's article made me shudder. Just how many times have I dodged the bullet of a 30-year prison sentence for doing my professional best to relieve my patients' intolerable chronic pain?

The crux of nontechnical medical caregiving — action with compassion — is based on an old adage: Listen to the patient; he is telling you his diagnosis. Thus the doctor-patient relationship is anchored in bilateral trustworthiness.

History is full of stories of scammers "gaming the system" of medical care. McIver's crime is that he trusted his patients, and he is serving 30 years in jail for doing so. That makes me want to become a lawyer.

Alan F. Carpenter, M.D.
Portola Valley, Calif.

I suffered severe back pain some years ago and remember well on several occasions being talked out of the opioid prescription I knew would work. Even though I had been prescribed opioid drugs before and shown no tendency to abuse or overuse, the doctors showered guilt and fear upon me until I gave into their safer preference. (Was that done for my benefit or their own?) Now I worry about liver damage from years of doctor-recommended high doses of acetaminophen.

"You may have to live with some pain," a doctor is quoted as saying. Some? I wonder how that doctor might feel if he had to live with a pain level of 5 or more every day for years and be told the pain was considered adequately managed.

Robin Kopel
Northbrook, Ill.

Despite all the various injections and sophisticated devices to treat patients with chronic pain, the single most important leap in pain management in the last decade is the increased use of opioids like methadone, morphine and OxyContin.

As our population grows older, we are seeing more patients with severe pain who, despite various therapies, need opioids to control their pain and allow them to perform at least some of their activities of daily living. If states begin to restrict nonspecialist doctors from prescribing elevated doses of opioids, many people, and disproportionately the geriatric population, will suffer needlessly.

Harris Bram, M.D.
Little Silver, N.J.

As an emergency-medicine physician, I routinely evaluate and treat patients in pain. Among this population are those seeking narcotic prescriptions inappropriately. While these patients can be difficult to distinguish on history and physical exam, an electronic medical record that quickly documents past clinical visits and medications is an invaluable objective tool. Multiple visits and narcotic prescriptions from different doctors are red flags that are easy to spot on the computer: yet another reason to implement a national electronic medical-record system.

Mark Thanassi, M.D.
Portola Valley, Calif.

Denying pain relief to persons who need it is sadism masquerading as morality. Who started this cruel and inhuman policy, and how do we get Congress to change it? Maybe it's time to call off the "war on drugs."

Bernice G. Rosenthal
New York

It was with heartbreak and frustration that I read Rosenberg's article. As a social worker who formerly worked for an in-home hospice program in New York, I have encountered numerous patients who described years of battling crippling pain associated with their disease, only to find comfort in the last days of their lives through comprehensive palliative care. It is too bad that society only considers those at the very end of life to be worthy of "living" pain-free.

Megan L. Sielken
Brooklyn