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Among clinicians seeking ways to safely treat chronic pain, Lynn Webster, MD, serves as a beacon -- a leading expert in the use of narcotic painkillers, who created an assessment tool to identify patients who are most likely to abuse opioids.

What they don't know is that Webster -- president-elect of the American Academy of Pain Medicine -- is under investigation by the U.S. Drug Enforcement Administration (DEA), which raided his Utah clinic in 2010. In an interview, Webster acknowledged that as many as 20 former patients of his clinic have died of opioid overdoses.

"That (overdoses) has always been something that's concerned me and has driven me to push for safer prescribing," he said.

Those who know Webster's reputation say the situation illustrates the often paradoxical relationship between pain specialists and the opioids they use to treat pain

"It is hard to know what you are doing is safe ... even if you are an expert," said Michael Von Korff, ScD, a Seattle researcher who has studied the risks of opioids and is a member of Physicians for Responsible Opioid Prescribing. "It's disturbing."

Studies have not shown the drugs are safe and effective for long-term pain, yet their use has often been promoted by leading professional organizations, many of which received funding from companies marketing those drugs.

The American Academy of Pain Medicine received nearly $1.5 million in 2011 from pharmaceutical companies, an investigation last year by the Journal Sentinel and 麻豆传媒 found.

That reporting and other stories helped prompt an investigation by the U.S. Senate Committee on Finance into financial relationships between opioid companies and several nonprofit organizations that had advocated for use of the drugs, including the academy.

The committee also sought records of payments from opioid companies to four doctors -- including Webster -- who are board members of the group.

Federal court records filed as part of an administrative inspection warrant last August indicate that Webster, who operated the Lifetree pain clinic in Salt Lake City, was under investigation by the DEA and other law enforcement agencies -- a fact Webster himself confirmed.

The investigation was started amid a growing epidemic of opioid addiction and overdose deaths in America fueled by dramatic increases in opioid prescriptions over more than a decade.

A report Tuesday in the Journal of the American Medical Association, indicated that overdose deaths involving prescription opioids increased to 16,651 in 2010, more than any other drug. That's four times the opioid-related deaths recorded in 1999, when there were about 4,000 such deaths.

For pain doctors, multiple overdose deaths and a DEA investigation are rare and potentially serious issues.

Martin Grabois, MD, the current president of the American Academy of Pain Medicine, labeled the situation Webster is facing as concerning, but asked: "What's the proof?"

"When you order medications like these you are prone to get potentially investigated," said Grabois, a professor at Baylor College of Medicine in Houston. "That does not mean you're doing something wrong. He's always been a stand-up guy, very interested in safety."

Gilbert Fanciullo, MD, an academy board member, said Webster is like a lot of pain specialists who get the most difficult patients, including those who may lie about pain in order to obtain a prescription.

"I'm surprised he's had 20 deaths out of his clinic, if that is indeed the case," said Fanciullo, a pain specialist at Dartmouth-Hitchcock Medical Center.

Phil Saigh, spokesperson for the AAPM, released this official statement:

"Physicians in the AAPM treat patients who have suffered horrific injuries or are terminally ill and in great pain. A small percentage of those terribly suffering patients die – not as a result of appropriate medical treatment, but in spite of it. As a society, we must care for the millions of people who suffer from pain, while preventing those same patients from ending their lives by overusing their medications. Dr. Webster is one of the most highly respected physicians in the field and has worked tirelessly to prevent the overprescribing and misuse of opioids as part of a pain treatment regimen."

Webster's opioid risk tool is used by thousands of doctors. He regularly lectures on preventing opioid abuse. He has also written about ways by which physicians who prescribe opioids can legally protect their practices from DEA and other regulatory investigations.

And he started a nonprofit to launch the "Zero Unintentional Deaths" campaign, designed to educate doctors and patients and help avoid overdose deaths.

Last year, Webster received the academy's Presidential Excellence Award for Education for major contributions in educating others about pain medicine.

In an interview, Webster said he does not know precisely how many former clinic patients died of an opioid overdose. At most it could be 20, he said. Many of those probably were suicides, he added.

"I don't think any of the deaths were for scripts I wrote," he said. "They were from staff."

In some states, including Utah, nurse practitioners and physician assistants can write prescriptions if they are supervised by a doctor.

Webster said he does not know the status of the DEA investigation. He said he believes the DEA was looking at overdose deaths and the appropriateness of opioid prescribing for patients of the clinic.

No charges have been issued.

Sue Thomas, a spokeswoman for the DEA in Utah said that because the investigation still is active, she could not comment. A spokeswoman for U.S. Attorney's Office in Salt Lake City also would not comment.

In response to the DEA investigation and potential malpractice lawsuits, Webster's attorney asked another Salt Lake City pain specialist, Perry Fine, MD, to review a number of overdose cases from the clinic, Fine said. Fine, also is the immediate past president of the American Academy of Pain Medicine and has known Webster for years.

In most of the overdoses, the cases were handled appropriately, said Fine, a professor of anesthesiology at the University of Utah. In others where something "went awry," Webster was not aware of what was going on, though his name may have appeared on patient records, Fine said.

The prescribing in those cases may have been handled by a nurse practitioner or a physician assistant, Fine said.

"I did see (questionable) behaviors by individuals in the clinic who had prescribing privileges and were seeing patients," he said. "There was a certain amount of autonomy that was given to the practitioners."

Whatever the reason, Fine said, having as many as 20 deaths from one pain clinic is a troubling number. In his 30 years as a pain specialist, Fine said, he knows of only one of his patients who died of an opioid overdose.

Webster, who started the Lifetree pain clinic in the 1990s and sold it in 2010, now focuses on doing medical research. He said when he was operating the pain clinic it may have had about 2,000 active patients at any given time.

Webster said many of the people treated at his clinic were among the most high-risk pain patients in the state who often also had mental health issues, past substance abuse problems along with severe chronic pain.

Often times they may have died after taking opioids, but may also have had other drugs such as sedatives that contributed to their overdose, he said.

"We had people die (from) our clinic," he said. "Probably one or two a year for a number of years. Just because you have an opioid on board and just because the medical examiner says it's an overdose due to an opioid doesn't mean it is.

"But it is true, we had deaths," he said. "We had people die from old age, we had people with cancer who died who were taking opioids, and we also had some who overdosed, who should not have died in my estimation."

All of them took a lot more than was prescribed, he said.

Webster described opioids as powerful, dangerous medications, but until a safer alternative is found it won't be possible to prevent all overdose deaths, he said. For some patients, the drugs are needed, he said.

And the alternative -- not using the drugs or dramatically cutting doses -- can have deadly consequences as well, he said.

He recalled a patient who was on a very high dose of opioids for whom he decided to cut back the dose in 2008. The man tried the lower dose for awhile, but said it was not adequately controlling his pain, but Webster said he did not think he should restore him to the high dose.

The man then went home and killed himself with a gun, one of several of his patients who have done so, he said.

"If I don't treat them, will they commit suicide?" he said. "If I do treat them, will they be harmed? It's damned difficult. I don't know any field in medicine that is more challenging. We have to find better drugs."

Steven Pulley, MD, a pain physician, had just started working at Webster's clinic six months earlier when seven to nine DEA agents showed up in the fall of 2010.

"They came in, and I was shocked," Pulley said. "You had guys in Kevlar vests with badges and guns strapped to them. They were all over. They were taking pictures of offices. They were copying hard drives and looking through records."

Pulley bought the clinic and a few months later began operating it as Omega Interventional Pain.

One of the first things he did was review the opioid regimens of patients. Some of them had to have the drug levels reduced, he said.

He also put up a poster in the office that warned of the dangers of opioids, including that the drugs can actually make pain worse.

Over the last 2 years, more than half of the patients have left the clinic, he said.

This story was reported as a joint project of the Journal Sentinel and 麻豆传媒.

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