I have a problem with some of the continuing medical education courses offered by large health care institutions, even those like Harvard and Mayo, which have outstanding reputations for evidence-based medicine. That’s because what they teach, although scientifically sound and in line with the Department of Health and Human Services and CDC recommendations, can get you prosecuted and convicted by the DEA. If you get targeted for practicing the way you have been trained, the doctors who made these recommendations almost universally refuse to appear in court on your behalf.
I have personally experienced this, and I’ll relate those events while protecting the doctor’s privacy since it seems to have been fear of being targeted that influenced his decision. This fear is not unfounded, as many true medical experts are now terrified. When I say true medical experts, I’m talking about the doctors in the trenches treating these conditions on a daily basis—not someone who has taken a big paycheck to call themselves an expert who does not treat these disorders or prescribe the medications they are supposedly experts on. As any soldier will confirm, there is a gulf between theoretical and practical experience.
In my case, a psychiatrist from the largest teaching hospital in our state spoke during an education conference held by our state medical society. Standing in front of a mostly primary care physician crowd, he told us that if we have a drug screen with an unexpected result from a patient on opiate therapy, do not just cut them off or think that a taper is mandatory, as this puts the patient at extreme risk of overdose, addiction, and death. The reasoning was that most people cannot tolerate severe pain indefinitely and will seek relief. Having no source of safe medications makes them subject to unsafe ones.
This is a very reasonable argument and extremely effective for those of us who prioritize keeping our patients alive over politically correct considerations. We had all seen the death rates of fentanyl poisoning skyrocket as the DEA’s restrictions on controlled medication production, combined with a surge in physician prosecutions, left those patients abandoned. Our state medical board had also developed a “red flag” notice so we could all be on the same page. This document said that more than two unexpected urine drug screens in six months were a “red flag,” and opiate use disorder should be considered.
This would imply that one in a six-month period was perhaps a “yellow flag.” My clinic established the policy of holding medications when there was an unexpected result and investigating to see what might have happened. It’s not uncommon for patients who are constantly told to use the minimum amount of medication necessary to control their pain to have a good couple of days and test negative, or to have surgery and test positive for something. Or false positives and negatives were occurring. This all seems reasonable until you run into a problem and come to the attention of the DEA. How does this happen?
I’ve written about them, but the three most common ones are: you must tell a patient on controlled medications they can’t have them anymore because they kept breaking the rules; you must fire an employee for ineffectiveness or misbehavior; or a jealous competitor complains that you’re busier because you give patients “what they want” (and not that the complainer is a jerk). I must now add one more. It has become extremely common for jails to report any death they are responsible for as an “overdose” to the family. This stigmatized manner of death causes the family to feel shame and not look further.
This happened when a young father in his twenties, in jail for minor offenses, was sexually assaulted and beaten over several days while tied up. The jail guards must have seen what was happening on their rounds but did nothing. When he became unresponsive, they sent him to the hospital and did not notify the family for a week, letting the bruising heal while he was on life support. Telling the family he had suffered a drug overdose and not letting them see him. He died, and his family saw the medical notes on his condition at admission and, despite the lies they were told, started asking questions. Details are here.
So why is this now threat number four? Once the family is told their loved one died of an overdose, they turn their ire from the jail to the doctor, calling the DEA and demanding “justice.” The DEA these days is only too happy to ignore law enforcement crimes and lock up doctors, as these outcomes are politically popular right now. They would probably fail if the state tried this, but federal courts are very different from state courts. The federal government controls access to evidence, can threaten or reward witnesses, and has access to millions of dollars to hire “experts” and make a physician look guilty of something.
Now, add into this minefield that we have CME courses recommending “bridging” when going from a full opiate agonist for pain treatment to buprenorphine, a partial agonist, when the patient is believed to be in danger of developing or has developed opioid use disorder. What does this create? Essentially, it is a confession that the DEA can use to put you in prison. When there is a single drug screen with an unexpected result, which is usually what makes you start thinking of OUD, the DEA can use any prescription written after to argue to a jury that you put the patient “at risk” of OUD by continuing to treat them.
This ignores the risk of a patient with untreated pain developing an OUD after being abandoned, but there you go. If they have no doctor, there’s no one to lock up. That makes the only legally safe choice to “fire” the patient. This makes almost everyone happy, particularly the DEA and the local undertaker, but makes the doctor complicit in the patient’s death. Taking the advice of the psychiatrist who spoke at the conference, I followed his advice, holding prescriptions for two negative drug screens at least a week apart and educating my patients about the risks of illicit drug use or overuse.
This is excellent medicine. When I was targeted and asked the psychiatrist to repeat in court what he told us in the CME, he initially seemed receptive. Then he came back and said that, as his institution received federal grants, it was a “conflict of interest,” and they wouldn’t let him. I could not, in fact, find any organization willing to stand behind their CME. I’ll be sentenced next week. Now, as an eternal optimist, I’m still taking CME and listening to very knowledgeable physicians from my alma mater, the Mayo Clinic, talk about starting low-dose buprenorphine therapy while someone is on a full opiate agonist.
This makes perfect medical sense, as the buprenorphine binds stronger than even fentanyl, and as a partial opiate agonist at about 60 percent efficacy at activating the mu opiate receptors, it is indeed a smart way to help someone step down. Until you get to court. Then, your notes about OUD concern will be used to convince the jury that you knew the patient was at “high risk,” which the DEA has been able to convince juries means you cannot treat the patient with controlled medications. Again, this is accomplished using what I consider mercenary “experts” who argue whatever the DEA asks them to. For a price, of course.
I say mercenary because, while two experts can have differing opinions, no true expert’s opinion should contradict what is taught in textbooks and CME. That’s because holding a physician to the standard of whatever is in the mind of an outlier medical professional’s personal opinion creates an impossible barrier to knowing what will and will not be considered criminal. Everything I just heard while listening to 10.5 hours of CME through Mayo.edu’s online DEA requirement course seems reasonable. But doctors around the country have gone to prison for practicing exactly according to the training they present.
Now, the doctors at Mayo are protected by a multibillion-dollar operation ($16.3 billion in revenue in 2022 and $20.3 billion in assets as of 2021), which protects them from being held to the same nonstandard as independent physicians. I cannot, in fact, find a single case of a corporate physician being held to the same standards as independent doctors targeted for prosecution. Now, don’t get me wrong. If there is an independent health care corporation worth a few hundred million, the DEA may pounce. Just look at Done Health. But this is rare, and in the case of telemedicine (Done), the government is trying to make a point.
A new commandment is in effect: thou shalt not innovate and outperform our corporate masters. But when it comes to opiates, the disparity is even more pronounced, with major health care corporations being able to practice as they see fit, according to their education, training, and experience, while independent doctors are sent to prison for following the very education provided by those large health care corporations. My question is this: if a professional medical organization markets education that is touted as meeting the DEA’s opioid prescribing education requirements, shouldn’t it have to support that CME in court?
L. Joseph Parker is a research physician.
