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Well, isn’t this just super. Despite the increased attention being paid to the gender pay gap in the legal profession, there’s new data that suggest the problem is getting worse, not better.

According to Equilar’s latest General Counsel Pay Trends study, which crunches pay data from publicly traded companies in the U.S., male General Counsels make on average 18.6 percent more than women in the same roles — which is the largest gap recorded since Equilar began studying the metric in 2014. Ugh.

Previous iterations of the study placed the pay gap for GCs at around 11 percent. However in the 2017 to 2018 period, median GC compensation for men increased — from $2.52 million to $2.63 million — while median pay for women GCs fell — from $2.44 million to $2.21 million.

As John Gilmore, managing partner at consulting firm BarkerGilmore, told Corporate Counsel, clients in the space are attempting to hire more diverse candidates, but, well getting rid of the pay gap is hard work:

Despite the discouraging stats, Gilmore said in an interview Wednesday that “clients are out actively trying to attract more women and minorities to the GC ranks.”

But he acknowledged that, in general, when “you’re looking at some of the larger companies you’re finding a lot of men in those roles and they’re being extremely well-compensated because they’re [named executive officers] and they have a seat at that table.”

And maybe some good old-fashioned outrage will help move the needle.

Kathryn Rubino is a Senior Editor at Above the Law, and host of The Jabot podcast. AtL tipsters are the best, so please connect with her. Feel free to email her with any tips, questions, or comments and follow her on Twitter (@Kathryn1).

Pain, like death, is a universal phenomenon.

The sour grimace on the woman’s face, registering her bodily complaints to Dr. G.P. Dureja in his East Delhi office, would be recognized anywhere. Slouched shoulders, pinched forehead. She wore a willowy black kurta and cast a disapproving glance at the five pain physicians-in-training huddled behind Dureja, founder of Delhi Pain Management Centre and one of India’s pioneering pain physicians.

The five trainees, participants in the center’s acclaimed pain fellowship program, recorded the woman’s consultation on their smartphones, eager to see India’s famous pain doctor do his work. After their fellowships, they will return home, to Chennai, Kashmir, Rajasthan, ready to forge careers in India’s exploding pain industry.

The woman had been under Dureja’s care for some time now; he diagnosed her with fibromyalgia, a chronic neurological disorder of mysterious origin that causes pain throughout the body. But the regimen of Paracetamol and tramadol, an opioid analgesic, was not working and she was beyond fatigued. She wanted more relief.

Dr. G.P. Dureja, surrounded by medical trainees, consults with a patient in his office at Delhi Pain Management Centre, a chain of specialized medical centers dedicated to the minimally invasive treatment of chronic pain.

Indians once thought of pain relief as an indulgence of the West, Dureja said after the woman left his office gripping her new prescriptions. The old way of thinking was, “Nobody has time to complain about pain in our country. But I’m getting five to seven new patients per day.”

Storefront for-profit pain clinics like Delhi Pain Management Centre are opening by the score across Mumbai, Kolkata, Bangalore and other cities in this teeming nation. After decades of stringent narcotics laws, borne of debilitating opium epidemics of centuries past, India is a country ready to salve its pain.

And American pharmaceutical companies — architects of the opioid crisis in the United States and avid hunters of new markets — stand at the ready to feed and fuel that demand.

For Indian cancer patients who once writhed in agony, there are fentanyl patches from a subsidiary of Johnson & Johnson.

For the country’s vast army of middle-class office workers wracked with back and neck pain, there is buprenorphine from Mundipharma, a network of companies controlled by the Sackler family, owners of Connecticut-based Purdue Pharma.

And for the hundreds of millions of aging Indians with aching joints and knees, there are shots of tramadol from Abbott Laboratories.

Palliative care advocates, who recount stories of patients enduring excruciating cancer pain or dying in agony, have persuaded reluctant government officials to allow high-powered opioid painkillers into doctors’ offices and onto chemists’ shelves in this nation of 1.37 billion people.

But what began as a populist movement to bring inexpensive, Indian-made morphine to the diseased and dying poor has given rise to a pain management industry that promises countless new customers to American pharmaceutical companies facing a government crackdown and mounting lawsuits back home.

The lure of a pain-free life is a revelation in a country where incomes are rising for many city dwellers and 300 million to 400 million people are approaching the middle class. Like other markers of the country’s post-colonial sprint into modernity, newly minted pain doctors promise aspiring Indians that life has more to offer in a body free from pain, and foreign brands are worth the extra rupees.

Dr. G.P. Dureja performs a short procedure on a patient at the Delhi Pain Management Centre.

“Don’t listen to your forefathers,” Dureja said, a mantra for the shifting mindset. “They said you should tolerate pain, you should not complain, you should not take painkillers. Now, everybody wants a better quality of life, and everybody wants to get rid of pain early.”

As major pharmaceutical companies look to capitalize on the opportunity, the playbook unfolding in India seems eerily familiar. Earnest advocates share heartbreaking stories of suffering patients; physicians and pharmaceutical companies champion pain relief for cancer patients and persuade regulators to grant greater access to ever more powerful opioids; well-meaning pain doctors open clinics; shady pain clinics follow; and a spigot of prescription opioids opens — first addressing legitimate medical uses but soon spilling into the streets and onto the black market.

A looming deluge of addictive painkillers terrifies some Indian medical professionals, who are keenly aware that despite government regulations most drugs are available for petty cash at the chemist shops that occupy nearly every city block and village center.

“Are people going to figure out every trick in the game to make [opioid painkillers] widely available?” asked Dr. Bobby John, a leading Indian public health expert based in New Delhi. “Of course it will happen.”

Shops advertise their drug supplies along a busy street in Old Delhi, India.

‘The Market For Pain Is Good’

The headquarters of the Pain Clinic of India operates out of a closet-size office in Chembur, a tree-lined suburb in eastern Mumbai. The company’s presence on the internet is so prominent that Dr. Kailash Kothari, the clinic’s founder, has turned down requests from people in South Africa, Australia, Europe and the United States seeking prescription opioids.

Down an alleyway, the clinic’s small white-red-and-blue sign is difficult to spot. Around the side of a faded-pink building is a larger sign showing a shirtless, muscular white man gripping his back, another gripping his neck, another clutching his knee; a white woman with an excruciating headache presses her forehead and another grabs her shoulder. Back Pain. Neck Pain. Headache. Knee Pain. Shoulder Pain. Cancer Pain. The sign promises “Towards Pain Free Life.”

One of the principal architects of pain medicine in India, Kothari runs several clinics in Mumbai, consults at numerous hospitals and flies to his clinic in Goa once a week. He co-founded the Indian Academy of Pain, an educational branch of the Indian Society for the Study of Pain that aims to create standardized training for pain medicine, in part by offering qualifying exams to prospective physicians. “This program is going to change the scenery of what we have in pain management,” Kothari said.

Asserting control over who can call themselves a “pain medicine doctor” in this fledgling industry is an urgent question. Spread across the subcontinent are nearly 10 million licensed physicians and a massive number of untrained medical providers. (In rural India, 70% of health care providers have no formal medical training.)

A man carries boxes of medicine through the Bhagirath Palace pharmaceuticals market in Old Delhi, India.

“General practitioners have started prescribing these drugs,” Dureja said. “And we’re not educating the population on when to use and not to use.”

At Dureja’s clinics, as at most medical offices in India, patients pay cash for services and prescriptions. Delhi Pain Management charges $10 for a consultation; $10 for a Johnson & Johnson fentanyl patch; $10 for a Mundipharma buprenorphine patch. Dureja’s office takes a 15% cut of sales.

There are hints of American pharma’s fingerprints in a glass cabinet in the waiting room of his East Delhi clinic: awards from Johnson & Johnson honoring Dureja for symposia on pain management; a plaque for “his valuable contribution as a speaker” about tapentadol, an opioid marketed by Johnson & Johnson in 2009. The dispensing counter does a brisk business in Ultracet, branded tramadol tablets made by a Johnson & Johnson subsidiary.

Dureja’s training fellowships, like Kothari’s, are broadly considered on the level; but many others are shady, and none are regulated.

Each year, some 20 fellows attend Kothari’s three- to six-month training programs, and by his calculation, he has trained 150 aspiring pain doctors. “There are more than 50 people who already have their pain clinics in different parts of India,” he said. Of those clinics, five or six “are training people, and it’s a chain reaction, which is going to benefit pain management as a specialty.”

Kothari remembers when only a few hospitals in Mumbai treated cancer patients and had access to opioids. “But every year, we are accessing more of these kinds of drugs,” he said. “Many chemists, hospitals and medical shops started acquiring the licenses for keeping these drugs, and availability is much, much better. Opioids are available in not just oral, but injectable, patches, syrups.”

Most large Indian hospitals have added pain management as a specialty in recent years. At the insistence of the professional societies that accredit hospitals in India, Kothari said, nurses and doctors now are required to assess pain as a fifth vital sign, along with pulse, temperature, breathing and blood pressure.

The pharmaceutical industry has kept pace. Twenty years ago, only a few pharmaceutical companies marketed pain medicines in India, Kothari said. “Today, almost every company is having pain management as a separate division. In the last five years alone, I must have met more than 15 or 20 companies that have started separate pain management divisions.”

A salesman for Sun Pharma, India’s largest drugmaker by sales, echoed the point during an interview in Chandigarh, the capital of Punjab and Haryana. The market for pain medications “has totally changed” in the past five years, he said. He shifted nervously and agreed to speak frankly only if his name wasn’t published, for fear of losing his job.

“Now everyone has a car, and [they get] back pain, and now they take medication.” Growing obesity rates in India were also fueling demand, he said, as patients look for relief from weight-related knee and back pain. “So the market for pain is good.”

Abbott Laboratories and Johnson & Johnson did not respond to requests for comment for this report.

Manmohan Singh, a vice president at Modi-Mundipharma in New Delhi, said opioid pain medications are an important therapeutic option, especially for cancer pain. He also said company promotions stress that physicians should familiarize themselves with product safety information. “Patients should be made aware of the clear treatment goals related to pain and function, as well as the potential opioid side effects and the potential for misuse, abuse and addiction,” he said in a written statement.

A man buys medicine from a pharmacy shop at the Bhagirath Palace pharmaceuticals market in Old Delhi.

One False Step

The ascendance of pain management in India comes at a fortuitous political moment. Ahead of his reelection earlier this year, Prime Minister Narendra Modi invested heavily in health care. Last fall, the Indian government launched the world’s biggest public health insurance program, called Ayushman Bharat. Dubbed “Modicare,” it guarantees half a billion poor Indians nearly $7,000 in hospital expenses, paid to private insurers, and, by 2020, the government is to open 150,000 primary care centers. The government has set aside $484 million to fund Modi’s signature program.

None of this would have been possible without the loosening of India’s strict narcotics laws.

The International Narcotics Control Board, established in 1968, and the Narcotic Drugs and Psychotropic Substances Act of 1985 codified the bureaucratic thicket for any doctor who wanted to prescribe opioid painkillers. Physicians feared fines, jail sentences and losing their medical license if they skirted regulations. While the government granted licenses to Indian farmers to grow poppies, most of the morphine produced from the crops was exported.

Dr. M.R. Rajagopal was a young medical student in Thiruvananthapuram at the time and remembers a neighbor with advanced cancer. “I [had] seen him screaming his way over weeks to death,” Rajagopal said. “It was horrendous, and there was nothing being done about it.” He chose to become an anesthesiologist because it was the only specialty then focused on pain.

Rajagopal is widely viewed as the father of palliative care in India; whispers of a Nobel Prize follow him. For decades, he has worked assiduously to convince national and state lawmakers that opioid medicines are not an indulgence but a humane refuge, and it is largely a function of his advocacy that morphine and other painkillers can be prescribed in India. “Two generations of doctors had not seen a tablet of morphine,” he said.

A pharmacy in New Delhi stocks painkillers.

The Narcotic Drugs and Psychotropic Substances Act, as amended in 2014, recognized that the need for pain relief was “an important obligation of the government.” The revised law created a class of medicines called the “essential narcotic drugs” list, which includes morphine, fentanyl, methadone, oxycodone, codeine and hydrocodone.

Rajagopal’s days are filled with the tedious work of building a movement: speaking at colleges and public forums, penning editorials and medical papers about palliative care and overseeing Pallium India, a nonprofit medical center and training institute that is singularly focused on palliative care.

Pallium’s pharmacy is a testament to Rajagopal’s persistence. Drugs once banned now fill the shelves: fentanyl injections and patches, oral morphine and, most recently, methadone, approved for pain relief in 2018.

Rajagopal seems aware that one false step would invite the government to clamp down on the availability of opioids, reversing decades of his work. He does not advise using oxycodone or hydrocodone, though they are included on the “essential narcotic drugs” list, and he does not accept funding from pharmaceutical companies, instead putting his hand out to temple trustees and for donations from families cared for by Pallium’s home visiting teams.

But the pharmaceutical industry is a wily adversary. American activists made many of the same arguments decades ago as they sought relief for dying patients. Drugs now commonly prescribed for chronic pain first were approved for use by cancer patients. One of the first formulations of fentanyl, for example, was a lollipop because chemotherapy left cancer patients too nauseated to eat. In India, pain physicians now prescribe fentanyl patches to patients with chronic muscular pain.

Purdue Pharma’s international affiliate, Mundipharma, “is very good at co-opting regulators,” said Keith Humphreys, a professor of psychiatry at Stanford University. “As happened in the U.S., they are easily converted into useful idiots.”

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

According to Online Paralegal Program’s ranking of the 30 law schools with the most to do for fun, which law school takes the top spot as the most fun?

Hint: To come up with their ranking, they “looked at a broad range of law schools in diverse locations, offering either thriving social scenes or easy access to stunning natural scenery – or ideally both.”

See the answer on the next page.

Happy August, new law grads! Whether you’re headed toward a clerkship, associateship, or your next big interview, it’s important to spruce up (or finally build?) your professional wardrobe. Whether your office is business-casual or closer to the camp that believes women need pantyhose, heels, and skirts only at trial, we’ve got you covered (well, minus the pantyhose.  It’s August.  In 2019).

Click through the slideshow for professional looks for everyone that won’t break the bank.  All individual pieces are less than $200 and can be paired with multiple other separates to maximize the mileage of each piece.

The Democrats’ amicus brief demonstrates that their court-packing plans are more than mere pandering. They are a direct, immediate threat to the independence of the judiciary and the rights of all Americans.…

For our part, we promise this: While we remain Members of this body, the Democrats’ threat to ‘restructure’ the Court is an empty one. We share Justice Ginsburg’s view that ‘nine seems to be a good number.’ And it will remain that way as long as we are here.

— Senator Mitch McConnell and Senate Republicans responding to an amicus brief sent by Senator Sheldon Whitehouse (D. RI) along with five Democratic senators urging the Supreme Court not grant cert to “political ‘projects” like a case from New York challenging gun regulations. The Democratic letter went on to warn the Court that is may be “restructured in order to reduce the influence of politics” if such cases found their way to the Court’s docket.

Kathryn Rubino is a Senior Editor at Above the Law, and host of The Jabot podcast. AtL tipsters are the best, so please connect with her. Feel free to email her with any tips, questions, or comments and follow her on Twitter (@Kathryn1).

Having already legalized the open carry of swords to protect the state from dragons, Texas is going to let people arm themselves with brass knuckles at all times like they’re extras in a 30s mob movie. There’s no way adding a brutal melee weapon will come back to haunt a state with more than its fair share of drunken bar fights. Nope, no siree.

The state is also ending police harassment of children’s lemonade stands, a move that, coupled with the brass knuckles law, strongly suggests that the Texas legislature is driving hard for a constituency of pre-teens. It’s all part of a huge slate of new laws going into effect in Texas over the weekend that’s also ending the panopticon of red light cameras throughout the state and raising DWI fines.

Bryan Wilson, the Texas Law Hawk, offers a quick rundown of the highlights coming to Texas law in the way only he can — by taking a pair of brass knuckles and smashing the hell out of some stuff.

Dick pics are also criminalized now, so if you’re planning on doing some modern-day wooing you might want to take off your monogrammed brass knuckles first.

Earlier: Next Week, Swords Are Legal To Carry Down The Street In Texas

Update 8/29/19: Utah Supreme Court Votes to Approve Pilot Allowing Non-Traditional Legal Services.

Faced with an ever-widening gap in access to legal services, a Utah task force has called for “profoundly reimagining the way legal services are regulated in order to harness the power of entrepreneurship, capital, and machine learning in the legal arena.”

Appointed by the Utah Supreme Court to study innovative approaches to increasing access to and affordability of legal services, the Utah Work Group on Regulatory Reform has proposed a new structure for the regulation of legal services that would provide for broad-based investment and participation in business entities that provide legal services, including non-lawyer investment in and ownership of these entities.

In a newly issued report, Narrowing the Access-to-Justice Gap by Reimagining Regulation, the work group recommended that regulatory reform occur in two ways:

• Substantially loosening regulatory restrictions on the corporate practice of law, lawyer advertising, solicitation, and fee arrangements, including referrals and fee sharing.
• Simultaneously establishing a new regulatory body, under the supervision of the Supreme Court, to advance and implement a risk-based, empirically-grounded regulatory process for legal service entities.

This new regulatory body would solicit non-traditional sources of legal services, including non-lawyers and technology companies, and allow them to test innovative legal service models and delivery systems through a “regulatory sandbox,” an approach that would permit innovation in designated areas while addressing risk and generating data to inform the regulatory process.

This Utah report comes on the heels of recommendations by a State Bar of California task force to make sweeping changes in the lawyer regulatory structure in that state. These moves and others signal increasing recognition by bar officials in the U.S. that addressing the justice gap will require significant changes in the regulation of legal services.

The Utah Supreme Court created the work group at the request of the Utah State Bar. It is chaired by Supreme Court Justice Deno Himonas and Salt Lake City lawyer John Lund, a past-president of the bar.

The bar’s request to the court, which came in the form of a letter from immediate past-president H. Dickson Burton, asked the court to appoint a working group “to promptly study possible reforms and make recommendations for revisions, possibly major revisions, to the rules of professional responsibility so as to permit lawyers to more effectively and more affordably provide legal services and do related promotion of those services.”

The working group’s report provides extensive details on the scope of the justice gap in the United States, noting that the U.S. ranks 99th out of 126 countries in access to and affordability of civil justice. At the same time, the report notes that we “live in an age when disruptive innovation is occurring non-stop,” including in the justice system. The potential for these disruptions to benefit access to justice, the report says, are significant.

“If legal services can be provided to litigants and those with potential legal problems in a much more cost effective way, then true access to justice becomes possible for millions of people who currently get no help and do nothing. Technology, especially online legal services, exponentially increases the potential to improve access to justice. But it also simultaneously increases the risk of legal and practical harm to users if those services are not of sufficient quality. However, the potential benefits are too large to pass up, so changing how legal services are regulated to both open the door to innovation and protect litigants and other users in responsible ways is critical.”

To that end, the report calls for fundamental reform of how legal services are regulation — steps, it says, that require “equal parts courage, caution, imagination and deliberation.”

As already noted, one aspect of that reform is to loosen restrictions on lawyers — specifically restrictions on lawyer advertising, fee sharing, and non-lawyer ownership of and investment in law firms. In particular, the report endorsed a recommendation recently made by an Arizona task force to get rid of Rule 5.4 — the rule that prohibits non-lawyer ownership — and to allow lawyers and non-lawyers to form alternative business structures.

The second aspect of the reform called for in the report is to create a new regulatory body whose purpose would be to ensure that consumers have access to a “well-developed, high-quality, innovative, and competitive market for legal services.”

“The explicit goal of this approach is to develop a regulatory framework that allows, supports, and encourages the growth of a vibrant market for legal services in Utah and, ultimately, across the United States.”

In fulfilling that mission, the regulator would focus on the evidence of risk to consumers of new approaches to providing legal services and ways to mitigate any risks.

The report further suggests that the new regulatory body be developed in two phases. In phase one, an implementation task force would develop the funding and framework for this new regulatory entity and establish a pilot program to evaluate its operations. In phase two, the recommendations that come out of the first phase will be implemented in the form of an independent, non-profit regulator with authority over some or all legal services.

As outlined in the report, a key component of the first phase is a so-called legal regulatory sandbox.

“The regulatory sandbox is a policy structure that creates a controlled environment in which new consumer-centered innovations, which may be illegal (or unethical) under current regulations, can be piloted and evaluated. The goal is to allow the Court and aspiring innovators to develop new offerings that could benefit the public, validate them with the public, and understand how current regulations might need to be selectively or permanently relaxed to permit these and other innovations.”

Examples of participants in this sandbox, the report says, could be an accounting firm proposing to offer legal services alongside its accounting services, a technology startup using AI to help consumers complete legal documents, or a non-profit proposing to allow paralegals to provide limited legal advice without lawyer supervision.

The report concludes with a request to the Utah Supreme Court that it adopt the recommendations and direct their prompt implementation. That would include establishing the phase one regulator and delegating regulatory authority to run the sandbox. It would also require the court to exempt providers chosen to participate in the sandbox from limitations on the unauthorized practice of law and to make clear that lawyers who work with such providers would not be subject to discipline.

In addition to the two chairs mentioned above, others who served on this working group were: H. Dickson Burton, the bar’s immediate past president; Thomas Clarke, who recently retired as vice president of research and technology at the National Center for State Courts; Cathy Dupont, deputy administrator of the Utah State Courts; and Gillian Hadfield, professor of law and professor of strategic management, University of Toronto Faculty of Law (and recent guest on my LawNext podcast).

Also: Margaret Hagan, director of the Legal Design Lab and lecturer in law at Stanford Law School; Steve Johnson, past chair of the court’s Advisory Committee on the Rules of Professional Conduct; Lucy Ricca, former executive director of and current fellow with the Stanford Center on the Legal Profession; Gordon Smith, dean of the J. Reuben Clark Law School at Brigham Young University and Glen L. Farr Professor of Law; Heather White, past co-chair of the Bar Innovation in Law Practice Committee; and Elizabeth Wright, general counsel to the bar.