Many chronic pain patients revile the Drug Enforcement Agency (DEA) for its role in shutting down many pain doctors, leaving their pain patients without access to needed pain medications. Increasingly, physicians are electing to no longer prescribe anyopioids at all; the major reason doctors give for this decision is fear of DEA scrutiny. After all, the DEA’s middle name is literally “enforcement”! Thus, many chronic pain patients blame the DEA for running a heartless, evil campaign to exterminate pain management. Furthermore, some chronic pain patients believe the DEA’s motivation for this is corruption, to extort money from pain doctors, or because the DEA is being rewarded by large pharmaceutical companies making huge profits off buprenorphine. Anger toward and hatred of the DEA is palpable in the chronic pain patient community on Twitter, where I have seen it firsthand.

There can be no question that many chronic pain patients have suffered greatly as a result of DEA actions, subjecting them to unspeakable injustices. I understand their anger, frustration, sense of betrayal by the government. I get it. However, if the DEA is the enemy, let us understand the DEA better.

Firstly, the DEA is a Law Enforcement agency tasked with controlling both legal and illicit uses of narcotic drugs, drug trafficking and distribution, etc. The DEA is not concerned with the practice of medicine because the DEA functions under the jurisdiction of the US Department of Justice and not the Department of Health and Human Services. The DEA’s mandate does NOT concern itself with the welfare of patients, or the human suffering of pain patients. To understand this perspective, if FBI agents (also under the US Department of Justice) arrests a criminal, they are not allowed to consider what becomes of the criminal’s dependent children or aged parents. As human beings, the agents involved might be concerned about the fate of dependents, but such concerns cannot and must not interfere with their duty in law enforcement. Heartless? I suppose they are, because compassion is not allowed to interfere with their work. Thus, we should understand DEA actions in light of their role in Law Enforcement. They cannot be patient advocates.

My personal experience with the DEA

I was raided by the DEA several years ago when three agents showed up unannounced at my office. The visit was triggered by a complaint from a disgruntled patient and from the fact that my opioid prescribing pattern had shown a huge upsurge in the months leading up to the DEA’s visit. The upsurge was related to the fact that a pain doctor in my area had retired suddenly, leaving a lot of patients without care. I inherited a lot of his patients because his office manager referred them to me. Since this doctor had the tendency to prescribe at relatively high doses, the average MED for my patients jumped sharply. Moreover, this physician relied heavily on methadone as an inexpensive long-acting opioid. Methadone attracts greater scrutiny from the DEA because using methadone to treat opioid addiction is highly illegal, even though it is legal to use methadone for pain. Since I also had my DATA 2000 waiver, which allowed me to use buprenorphine for the treatment of opioid use disorders, my sudden high usage of methadone must have looked worrisome to the DEA.

The three DEA agents interviewed/interrogated me for about 2 hours. I am not sure how true this is, but I heard later that the DEA usually sends only one agent if it is a fact-finding visit; sending three agents at once only happens if they are anticipating arrests, office searches and medical record seizures. Yet, I found the DEA agents conducted themselves professionally and courteously. After the extended interview, they left me alone with no action taken. They told me they would discuss the matter with their chief, who would decide if any further action was warranted. It was about 2 days later that the chief called me personally to let me know they would not be taking any further actions but gave me guidelines to follow to ensure my practice stays on the right side of the law.

I have known three other pain doctors who were also raided by the DEA. One doctor also suffered no actions and continued his normal practice; he told me later he was treated courteously and professionally as well. Another doctor was reprimanded and given guidelines to modify his practice but was not arrested or shut down. I know less about the third case, but that particular physician appears to have weathered the DEA raid without ill effect as well. He is also still in practice.

I have also attended conferences on how to prescribe opioids safely. Often featuring lawyers as well as pain experts, these conferences travel the country and include nationally recognized legal experts. They do not describe the DEA as a sinister organization out to persecute pain doctors. They recognize the DEA as necessary to place constraints on improper conduct by physicians. They are painfully aware of the DEA’s power to destroy physicians and their livelihoods. Conference attendees are strongly cautioned to respect the DEA and to comply with all applicable laws (not that difficult). These legal experts do not portray the DEA as a rogue agency functioning outside the rule of law with an agenda to extinguish pain management.

Why the DEA regulates doctors

The DEA’s mandate includes regulating opioid prescriptions. Many chronic pain patients on Twitter want the DEA to get out of the business of regulating physicians. This might be reasonable if all physicians were saints, never breaking the law or acting unscrupulously. Sadly, that is simply not the case. As a physician, I know too many of my colleagues who are not always ethical and are driven by greed and lust. I have known physicians who were themselves addicted to opioids and buying or trading drugs in their offices. Having a medical degree cannot put us above the law. It is not the DEA’s place to regulate the practice of medicine, but they are necessary to protect the public from criminal acts by physicians.

Being active in the field of prescribing opioids, I knew many of the other high prescribers in the area who were also raided by the DEA, arrested and forced to close down their practices. I knew them primarily through inherited patients who had seen them previously but switched to me for any of a number of reasons, from insurance changes to dissatisfaction with treatment, being dismissed from the earlier practice, etc. I would hear of their practices from their patients, I could examine their prescription patterns and I could see their medical notes. In every case, news of their arrests came as no surprise to me.

One particularly egregious example involved a pain doctor who was shut down and charged with exchanging drugs for sex with patients. At the time he was arrested, he had $100,000 in cash in his office. Clearly, this doctor was not a good actor. Nevertheless, shutting his clinic down caused immense suffering for many of his patients. Despite his unethical behaviors, he also had a lot of legitimate chronic pain patients who were suddenly abandoned. Many of these patients did not hear of the arrest and just showed up for their appointments to find the office shuttered. They had already run very low on medications and had no time to find another pain doctor. Yes, all these innocent patients suffered greatly at the hands of DEA actions. Again, I would ask you to return to my earlier analogy of FBI agents arresting a criminal – that criminal might have young children whose lives are now torn asunder, but the suffering of those innocent children cannot concern the FBI agents involved.

Pain management became a very lucrative line of work in the 2000s. To illustrate this point, I moved from Canada to Indiana in the year 1996. At that point in time, there was only ONE pain clinic in the entire state of Indiana. In 2013, I googled “pain clinic Indiana” and pulled up more than EIGHTY separate clinics advertising pain management. During that same time frame, no other medical area had even doubled its practitioners – we did not have twice the number of family doctors, pediatricians, cardiologists, surgeons, etc. but pain management grew 80-fold.  Doctors were entering pain management from a variety of disciplines. The pain doctor mentioned above who was charged with exchanging drugs for sex was a plastic surgeon, who found pain management to be much more lucrative.

The point is that pain management came to be infested with many bad actors. I had one patient who told me her son was fathered by one of the pain doctors. Prescriptions were being written in large quantities. Patients would tell me stories about drugs being bought and sold in the doctor’s parking lot, that the parking lot would have many cars with license plates from neighboring states, that the doctors would only accept cash payments refusing to go through insurance, etc. However, even these shady practices helped a lot of chronic pain patients, who were left in a lurch when the DEA shut their doctor down. The affected doctors typically plead innocence and usually enjoy the support of their disenfranchised patients.

Every primary care practice raided by the DEA that I knew of, had become a high-volume opioid prescribing practice, functioning as de facto pain clinics, attracting clients expressly for opioids. In other words, opioid prescribing had become a lucrative side-line for them. They already had full family medicine practices and had no interest or room to take on new patients with diabetes, high blood pressure or heart disease that also needed medical attention. They could not accept pain patients on referral from other physicians because their NPI taxonomy (indicators insurance companies use to designate a doctor’s specialty) was listed as primary care. Insurance generally do not allow one primary care provider to refer to another primary care provider because the second provider is not listed as a specialist. In order to bill insurance, primary care doctors would have to accept them as primary care patients and take over ALL their care, which these doctors did not have the time to do. This is the real reason these primary care doctors accepted cash payments only. Opioid prescriptions became quick and easy money, a very lucrative side-line that attracted clients whose only reason was for being at the clinic was to get opioid prescriptions in exchange for cash. Furthermore, cash payments were sometimes not reported – tax evasion enhanced the lucrative nature of this side-business. These pain appointments were often very brief, lasting less than 5 minutes, and no longer comported with DEA notions of normal or usual medical practice.

The DEA is not out to persecute law-abiding primary care doctors conducting the normal business of medicine, prescribing pain relief for their own patients. There are simply far too many family doctors for the DEA to go after individual doctors prescribing opioids for their own patients’ legitimate needs.  

From the above, including my own experiences, I find it difficult to accept that the DEA is a corrupt agency out to demolish pain practices or extort money from innocent doctors. If that were the case, I do not understand why they would not have pressed on with prosecuting myself and the other 3 doctors I mentioned above. Conversely, all the cases I am aware of where the DEA took drastic action did involve laws being broken. If you think a physician was targeted unfairly, I would suggest you look the case up on the DEA website, or even on Google. Prosecuting physicians is not done in a clandestine manner.

Many in the chronic pain community believe the DEA targets physicians for profit motives, to fill the DEA’s coffers. What they may not realize is the very high costs of litigation to bring physicians to court. I do not know if prosecuting physicians makes money for the DEA and thus, I cannot rule out a profit motive. However, anybody leveling this claim needs to prove physician prosecutions to be a revenue generator for the DEA. It is even possible that prosecuting physician costs the DEA more money than it recovers. Anyone who believes the DEA prosecutes physicians to make money should seek to examine the DEA’s books under the Freedom of Information Act. If it is tyranny for the DEA to be targeting physicians without due process (as is alleged), it would also be tyranny to try the DEA in the court of public opinion, or Twitter, without evidence. I am not categorically ruling out the possibility that the DEA really is attempting to profit but accusations need to be backed up. “Follow the money” is a great strategy for uncovering the truth but must be more than just a thought experiment.

Why am I defending the DEA?

Let me begin by stating categorically that I am an advocate for increasing accessibility to opioids for chronic pain patients. I am still prescribing opioids and will continue to prescribe opioids to patients who need them. I am actually NOT defending the DEA; I simply do not see the DEA as an evil agency conducting domestic terrorism targeting physicians and pain patients. It remains a possibility that the DEA division in the state of Indiana where I practice is particularly benign and not representative of other DEA jurisdictions, but I doubt it. No, I am not on the DEA payroll as an expert witness, as some on Twitter have suggested. No, I do not have any relatives working for the DEA. No, I am not immune from DEA action because I am an addiction doctor – addiction doctors can also get raided and besides, I also prescribe lots of opioids.

My reason for writing this article is because I believe demonizing the DEA is a counter-productive strategy. The DEA is NOT going away – it would literally take more than an Act of Congress to do that. They cannot stop investigating doctors because they are required to investigate physicians suspected of abusing their DEA license or other felonies. I cannot imagine any scenario under which blaming the DEA would actually improve patients’ access to opioid medications. The idea of a more compassionate DEA is a non sequitur, because the DEA is under the Department of Justice, NOT the Department of Health and Human Services. It isn’t going to happen. Instead, I believe that fanning fears of draconian DEA actions has the opposite effect of what we desire, reducing rather than improving access to opioids.

Overwhelmingly, doctors who have stopped prescribing opioids tell me it is because they are afraid of running afoul of the DEA. Portraying the DEA as an evil, agenda-driven, physician-devouring bureaucracy does not give any physician incentive or confidence to prescribe opioids. The only reason that I continue to prescribe opioids is precisely because I do not believe that narrative! If you could prove the DEA is out to get me, I would be insane to continue prescribing opioids. The more success you have in spreading the message of a corrupt and unaccountable DEA, the fewer opioid prescribers you will have.

What is overprescribing?

DEA action is predicated on laws being broken, but innocent doctors’ fears of the DEA tend to revolve around an undefined vague concept of “overprescribing”. Please understand that if “overprescribing” is not defined, it cannot be illegal per se. You can’t be charged with speeding if there isn’t a speed limit. The DEA cannot take any action unless there are actual laws being broken. Invariably, doctors are charged with prescriptions “not issued for a legitimate medical purpose” and “not acting in the usual course of professional practice”, in violation of the Controlled Substances Act and the False Claims Act.” Many prescribers believe the CDC’s 2016 guidelines for primary care to stay under 90 MED means going over this threshold amounts to overprescribing. In reality, the CDC only suggests 90 MED as a notional limit; prescribers can exceed this threshold but are cautioned to exercise great care, and to provide justification for the higher doses being necessary (see: CDC). Even in their own communications citing overprescribing, the DEA acknowledge that prescribers can exceed the 90 MED limit (see highlighted section in this DEA communication).

Let us examine the notion of overprescribing. In speaking with other doctors, I believe there is generally very poor understanding of what overprescribing means or does not mean. For the most part, overprescribing is not determined by how much opioid any given single patient receives. The way the DEA or other regulatory bodies look at overprescribing is to look at a prescriber’s total volume of opioid prescriptions as well as the average dosages prescribed. For instance, a physician who appears to be seeing 100 patients a day would look suspicious because it is difficult to see how legitimate medical visits could last less than 5 minutes on average for an entire 8-hour day. Also, a physician whose average patient appears to be on very high dosages might warrant the DEA taking a closer look. However, as with my case, a closer look does not always translate into prosecution. Keep in mind that my practice looked quite suspicious on paper when the DEA raided me. From my personal experience, I can tell you that the DEA does not appear to function on presumption of guilt. Often, there are understandable reasons for higher average doses; for example, oncologists or palliative care doctors looking after patients at the end of life would typically be writing opioids at higher doses. In my case, I had just inherited a large cohort of patients from a retiring doctor who had most of his patients at high doses of methadone. “Overprescribing” does not refer to a certain numeric threshold being exceeded, but excessive in context of other aspects of the doctor’s practice.

High doses are not the only thing that attracts the attention of the DEA. Certainly, multiple overdose deaths among the same doctor’s patients would earn scrutiny, as it should. Other indicators of suspicious practices include patient complaints of unethical behaviors, physicians refusing to bill insurance but demanding cash only, or if a physician’s colleagues report questionable practices.

Future Direction

I feel strongly that government efforts to drive down opioid prescriptions has been a terribly misguided strategy for dealing with the opioid crisis. Restricting access to legitimate opioid prescriptions has had little or no impact on opioid abusers, who have the easy option of switching to much cheaper and readily available alternatives, namely heroin and fentanyl. Essentially, the only people truly affected by restricting opioid access are those chronic pain patients who refuse to break the law, refuse to turn to illicit opioids.

Chronic pain patients have been described as “collateral damage” in the war on the opioid crisis. The truth is actually far uglier. With collateral damage, the intended enemy suffers most of the heavy consequences, with some innocent bystanders inadvertently affected. However, to continue the war analogy, the plight of pain patients is more aptly compared to a bomb being dropped on the wrong building, housing only innocents and no enemy. None of the intended targets were dispatched, only innocent bystanders. It is a failed strategy and a tragedy of unspeakable injustice. I am appalled by what we, as a society, have done to the most unfortunate, vulnerable and defenseless of us, our pain patients. Many of them are disabled or elderly. Some are veterans whose chronic pain are the result of serving our country. All of them are victims and all of them are suffering. Restricting opioids only punishes the innocent with no benefit for society, as evidenced by the unmitigated rise of the opioid crisis despite plummeting opioid prescriptions.

I write this article not to defend the DEA, but because I want physicians and other prescribers to not fear the DEA needlessly. I firmly believe that primary care physicians prescribing opioids in the normal course of medical practice have nothing to fear from the DEA.

I would like physicians to take a stance against the injustice done to chronic pain patients, and to return to prescribing opioids where needed. When a physician is afraid to prescribe medications his/her patients need because of the physician’s insecurity, they are putting their self-interests above those of the patients. This is by definition, conflict of interest.

Steps to safe prescribing

  1. Make sure the focus of opioid prescribing is on patient care rather than making money.
  2. Document your rationale for using opioids. Document that non-pharmacologic and non-opioid treatments have been considered, tried and deemed inappropriate or failed. (e.g. NSAIDs in renal disease or peptic disease)
  3. Make the effort to familiarize yourself with all applicable rules in your state.
  4. Take necessary precautions to prevent opioid diversion, including urine toxicology, reviewing Prescription Drug Monitoring Programs (PMDP) for your state.
  5. Get some CME (continuing medical education) credits on safe opioid prescribing.
  6. Develop policies to deal with aberrant behaviors.
  7. Document attempts to stay under 90 MED whenever possible. It can be completely appropriate to go above 90 MED, but make sure you document why you need to do so, as well as other steps you have taken to avoid increasing the dose.
  8. Refer out to addiction medicine or pain management when necessary.

If the above guidelines are followed, it would be exceedingly unlikely for the prescriber to get in trouble with the DEA, licensing boards, or malpractice suits. The key is to be conscientious, law-abiding and focused on patient care.

Come on doctors, let’s do the right thing! Do not deprive your patients of necessary medications and subject them to unnecessary suffering because you are afraid of the DEA. It doesn’t take much to learn how to prescribe safely. If you do not feel comfortable prescribing more than 90 MED, at least prescribe to your level of comfort while you try to locate a specialist to help better manage their pain. There should be no reason to categorically refuse to utilize opioids for chronic pain when non-opioid options have been exhausted.

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