Healthcare Professionals' Perspective
Fear of State Medical Board/DEA Investigation

Seven million people suffer intractable pain that requires opioids for pain relief; however, only 4,000 physicians in the United States are willing to prescribe opioids for these people.¹⁰ One of the key reasons for this nationwide hesitation to prescribe opioids results from the increasing fear that legitimate physicians will be investigated and disciplined by state medical boards and the DEA.^3,18,19,20

Investigating and disciplining physicians and pharmacists

State medical boards and the DEA monitor opioid prescribing patterns and sometimes mistake physicians treating pain patients with large amounts of opioids for physicians selling opioid prescriptions to drug addicts. These mistaken identities usually cost physicians their medical licenses, leaving them out of jobs and patients without adequate pain treatment. Because of regulatory scrutiny, physicians resort to learning regulatory avoidance tactics so as not to look suspicious and ultimately lose their licenses. Unfortunately, these avoidance tactics come at the cost of treating patients ineffectively and inappropriately.

Since most physicians already underprescribe opioids for intractable pain relief, whether due to unfounded fear of addiction or lack of knowledge of opioid pharmacological effects, the physicians who do prescribe the correct amount of opioids required to relieve certain levels of intractable pain look even more suspicious to authorities.²⁰ As a result, 900 physicians’ licenses were revoked or suspended in 1995 and 1996 because their state medical board deemed that they were prescribing too many opioids.²¹ The scare of medical board and DEA investigation has run so rampant that some doctors go so far as putting signs in their offices saying, "Do not ask me to refill pain medications" or "Don’t ask for opioids."¹⁰

Pharmacists are also investigated by the DEA for dispensing too many opioids. In a Department of Health and Human Services report, the American Association of Hospital Pharmacists, the American Pharmaceutical Association, and the National Association of Boards of Pharmacy said that pharmacists may fail to provide adequate levels of analgesia because they fear harassment or prosecution by enforcement agencies, usually at the local or state level.^15,20

Harmful alternatives and multiple copy prescriptions

One form of drug regulation in some states is multiple copy prescriptions. These programs were created by state medical boards to monitor prescribing patterns of several drugs, including opioids, in order to discourage drug diversion.

The problem with multiple copy prescriptions is that it points out the physicians who are prescribing correct amounts of opioids and allows state medical boards to interpret their prescribing patterns as inappropriate and reason for investigation.

The irony of these multiple copy prescription programs is that there is no proof that all physicians who prescribe "too many" opioids are contributing to drug abuse, but there is proof that physicians turn to less-regulated drugs as alternatives that are not indicated for moderate to severe pain and cause more side effects and deaths than opioids.⁴

The most prescribed alternatives for opioids are anti-inflammatory agents (drugs that are indicated only for mild to moderate pain not intractable pain). When taken over extended periods of time, as required for intractable pain, anti-inflammatory agents cause internal bleeding, ulcers, and kidney, liver, or stomach damage.^4,10 Even worse, one study showed that 17,000 deaths resulted from these alternatives in one year, whereas deaths resulting from opioids was described as "vanishingly small" by Dr. Brian Goldman, a University of Toronto researcher who has studied prescription drug diversion.¹⁰

DEA’s rationale for investigation

Why do state medical boards and the DEA continue to investigate physicians and pharmacists when it seems so obvious that most are providing opioids to relieve intractable pain? Some say that the DEA’s war on drugs has found an easy target with healthcare professionals who prescribe and distribute opioids because the authorities can monitor prescribing patterns; they can’t monitor drug dealers as easily.

As logical as this type of monitoring and investigation of physicians’ prescribing to discourage diversion may seem to state medical boards, the fact of the matter is, there is little evidence that suggests the opioids physicians and pharmacists provide are those that are ultimately sold on the streets. In fact, DEA officials have stated that most of the drugs in the black market are those that originated from illegal, foreign manufacturers.¹⁰