In the state of New York (you already know it’s going to be bad), a doctor and a pharmacist were arrested in a sting operation conducted by a joint task force of the DEA, FBI, IRS, and probably CIA and CBS, though I have no proof of the latter two. The doctor, Mordechai Bar, and the pharmacist, Feroze Nazirbage, have been accused of “violating their oaths,” something you almost never hear said about a prosecutor who hides evidence, but I digress. They are charged with operating in a manner “no different than common drug dealers.” Is there truth to this, or is it more federal overreach?
Let’s take a closer look at this case. The DEA claims that a confidential source obtained medications from Dr. Bar that were both medically unnecessary and issued under other people’s names. The first accusation is subjective and requires solid evidence. However, the second issue raises more significant concerns for the doctor. It’s important to remember that people may lie to obtain prescriptions, and when the DEA sends in individuals to falsely claim pain, it feels unjust. If the doctor is genuinely involved in illegal activities, then providing a substantial cash incentive for an off-the-books prescription would be more telling. If they say yes, that’s probably still entrapment, but it’s on them to make that argument. Entrapment has gone from a forbidden tactic to standard operating procedure anyway.
The allegations continue, stating that since 2012, a confidential source (read: someone caught selling their medications with charges being held over their heads) bought prescriptions at Dr. Bar’s office. He is accused of prescribing oxycodone, amphetamine, and alprazolam without any medical exams or testing in exchange for cash. Working backward, cash is not illegal tender; it says so right on the bill. The patient was in front of the doctor, a requirement for Schedule II medications like oxycodone and amphetamine. Alprazolam, or Xanax, is Schedule IV, I believe, and often abused, so the doctor should be cautious. It doesn’t look like these doctors were—if these statements can be trusted.
I have seen absolute lies told by federal agents and attorneys who knew, should have known, or were willfully blind to the fact that their statements were false. I also try to look at these cases, as much as possible, in a light favorable to the accused since no one else—definitely not the media or court—bothers to do so. All that being said, this is starting to look bad. The source did say that blood pressure checks were sometimes done, and a single drug screen, but no other exams or tests were conducted over several years. This is not criminal, as there is no law saying that these must be done, but it is not good medicine. This type of behavior would almost certainly lead to a loss of your medical license. Here’s what I recommend.
Do vital signs on every patient, every visit, and do not see a patient without this in the record. Update the patient photo in the record every visit—this is proof that they were there, in case they wrongfully claim you didn’t see a patient, as they did with Dr. Rifai. I now recommend that you take pictures of the antecubital fossae of every patient on controlled medications every visit. Documenting no track marks shows you were looking for signs of addiction. If there are visible scars or healing wounds, document them with photos. A picture is worth a thousand words. And dictate your notes; don’t use templates. I know that’s time-consuming, but they will use templates against you in court.
Drug screens are problematic. If you do them every time on every patient, do you use simple antibody-based tests that are always giving false positives and negatives? If so, do you yank somebody off their medications when the test is inconsistent with their prescription? If you don’t, they’ll lock you up, saying you “ignored” clear signs of diversion and drug use. You may think you can argue otherwise in court, but no one will care what you have to say. By the time the media gets done beating you to death, you wouldn’t be trusted to recommend Tylenol. Comprehensive, well-documented notes are a good idea. Not that they won’t be twisted against you, but give your attorney something to fight with.
Order lots of tests that you profit from, and they’ll say you are committing fraud by ordering “unnecessary tests.” Don’t order enough drug screens, and you are “enabling diversion and addiction.” If you don’t make profits on the tests but instruct the labs not to send patients to collections, they will argue that you are just “making sure they have more cash to pay you.” In short, you are damned if you do and damned if you don’t, but that’s the goal. As an independent physician, you are a minority holdout from a bygone era. Just become an employee of one of the giant health care cartel members buying up all the practices, and they’ll leave you alone. Those guys just pay fines—no prison for them.
And what other things cause “bad” drug screens? Let’s look at a simple medication like codeine. In “normal” metabolism, 5 to 10% of codeine is metabolized by CYP3A4 to norcodeine, a weaker analgesic, and another 10 to 20% by CYP2D6 to morphine, a stronger analgesic, with more being converted by UGT2B7 to codeine-6-glucuronide (C6G), which is also considered a weak analgesic. But there is a minor pathway where the norcodeine can be converted to hydrocodone. This is usually subclinical, but many things can affect these processes, like rifampin, phenytoin, and even the supplement St. John’s Wort, which induces metabolism, and inhibitors like ketoconazole, erythromycin, and grapefruit juice.
So, you’ll get a chance to explain all this before anyone is crazy enough to arrest you, right? No. You’ll get that chance—such as it is—after you have lost everything and are sleeping on a couch somewhere, if you’re lucky, probably at your mom’s house. I have heard physicians board-certified in pain medicine say that someone on codeine testing positive for hydrocodone is clear evidence that they are selling one to buy the other—proof of diversion and addiction. Nonsense. It might be, but it is by no means certain. So, do you have to “fire” the patient to be safe? Yes. I know it is unfair to the patient, but they will shut you down and probably convince a medically naive jury to lock you up otherwise.
I say the above in jest, but seriously, they will. Even though the patient can die from that choice. The DEA either does not understand or does not care about the complexity of these issues. They have been given a mandate to lock up a bunch of doctors, and if you come into their sights, they will absolutely use your due diligence in waiting for a trend as evidence of criminal conduct. On the other hand, your oath is to your patient, not the government. I personally follow Mark Twain’s admonition to support your country always and your government when it deserves it. That’s why I’m probably going to prison. The DEA does not enforce the Americans with Disabilities Act against doctors who abandon patients.
Some illegal prescriptions that Bar wrote were filled at QV Pharmacy, the DEA investigation claims. From December 2022 to May 30, 2024, prosecutors say Nazirbage, the pharmacist, illegally dispensed oxycodone in exchange for cash. Usually, when the government says this about a pharmacist, they are arguing that they knew, should have known, or were willfully blind to the fact that some overpaid government “expert” in the future would tell a jury that the patient didn’t really need the medication, and the pharmacist should have known. This is just insane. No pharmacist is trained to recognize and treat illness; they are trained to recognize and dispense pills. They do not “know” what medication a patient needs.
That’s why they cannot prescribe medications or dispense them without a prescription. And here is where things get bad for Feroze Nazirbage. According to the government evidence presented at trial, Feroze repeatedly sold controlled substances to a customer without a prescription in what is known as a “backdoor sale.” During one of those sales, Nazirbage gave a customer a handwritten menu of various prescription drugs and their per-pill cost for future backdoor sales. I want any DEA agent or federal attorney who reads this to take note: Good job. This is truly a crime. As a pharmacist is not trained to know who needs what medication, this would be dangerous if it were an antibiotic.
I bet you made this argument at his trial, too—that pharmacists are not trained or authorized to determine who needs which medication. If you did, you need to go release every pharmacist you locked up for filling a correctly written prescription for “too much” medication or for the “wrong” patient. Your putting them behind bars on this pretext is just as criminal as handing out a “menu” of backdoor prescriptionless narcotics. But I’ll bet you won’t. You’ll keep arguing one thing at one trial and another at the next, making sure that there is no clear standard or set of rules that anyone, a physician or pharmacist, can follow. While that makes your job easier, it is killing people all over this country. Stop it.
“The arrests today of Dr. Mordechai Bar and pharmacy owner Feroze Nazirbage are the result of the DEA’s commitment to pursuing those individuals who allegedly exacerbate the ongoing opioid crisis,” Tarentino said. “As alleged, these two health care professionals, who illegally diverted the highly addictive oxycodone for cash, had a responsibility to protect patients’ lives, not destroy them. The DEA will relentlessly pursue those individuals responsible for putting profits and greed over the health of their patients.” Bar is 71, and Nazirbage is 50. They will be looking at a long stretch in prison, barring the government having falsified evidence or testimony. I have no problem with that.
I have analyzed many cases now of physicians being prosecuted on nebulous charges, with the DEA arguing that a physical examination was insufficient or that a patient was “at risk” of addiction and overdose. In the first place, the physical exam is for the physician’s benefit—to figure out what’s wrong—and can be as comprehensive or focused as circumstances determine. While the state medical board has the right to say one is inadequate, the DEA does not, since this crosses over into “influencing the practice of medicine,” which 42 U.S.C. 1395 clearly prohibits. On the other hand, sometimes there is a clue indicating true criminal intent—not a difference of opinion or a false metric, but real evidence.
Now require that for every medical prosecution, as the Supreme Court ordered you to.
L. Joseph Parker is a research physician.
