Aaron Gilson, MS, MSSW, PhD

Disclosures

December 23, 2009

Question

Why are doctors the target of our country's war on drugs?

Response from Aaron M. Gilson, MS, MSSW, PhD
Senior Scientist, Paul P. Carbone Comprehensive Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison

This question addresses the prevalent perception that physicians, who frequently prescribe controlled substances (including opioid analgesics) for pain management and other chronic conditions, are targets not only of investigation and discipline from their professional regulatory bodies (ie, medical examining boards) but also of local, state, or federal law enforcement agencies. In particular, the US Drug Enforcement Administration (DEA) has received considerable attention from the public and professional media for its actions against physicians. To be sure, the DEA has the statutory authority to investigate and criminally prosecute violations of federal drug control laws by physicians who are registered to use controlled substances for medical purposes. However, it is aphoristic that learning of a physician's arrest because of his or her "prescribing practices" can have a chilling effect over the entire healthcare community, regardless of the specific characteristics or ultimate disposition of the case. Practitioners have expressed such concerns about law enforcement actions since the 1980s.[1,2,3] These very apprehensions motivated some state lawmakers to amend Intractable Pain Treatment Acts, which were originally created to protect from regulatory discipline those practitioners who prescribe controlled substances to treat pain, to extend that immunity to criminal prosecutions.[4]

Research suggests that both administrative sanctions and criminal charges against physicians for prescribing opioids are infrequent events.[5,6] In fact, a comprehensive review of cases occurring between 1998 and 2006 showed that 752 individual physicians (or 0.1% of active "patient care physicians") had faced criminal charges or administrative reviews, or both, because of opioid prescribing issues.[7] Despite the seemingly uncommon occurrence of physician prosecutions, DEA criminal investigations of controlled substances violations were found to increase almost 16% during the last 2 years of available data (ie, 2005 and 2006), whereas the number of state medical board cases actually decreased 22% over the same period. In addition, a recent survey of state medical regulatory board members showed that 35% believed that law enforcement agencies at the national level are increasingly investigating and prosecuting physicians for violations involving opioids, and another 33% thought that law enforcement had become more involved at the state level.[8]

Overall, law enforcement prosecutions of physicians seem to be a relatively rare event, but even the act of investigation can suggest a significant risk for formal DEA action. At the same time, medical regulators perceive law enforcement as increasingly involved in prescribing cases, which further contributes to the view that physicians who prescribe controlled substances are likely casualties of the US "War on Drugs." These issues converge to create an environment in which physicians often feel threatened when considering whether to provide pharmacologic treatment, which is legitimate medical practice -- this chilling effect often creates an unwillingness to prescribe and can result in inadequate pain control. Discord among law enforcement members, regulators, and healthcare professionals is an untenable situation, with a direct and deleterious consequence for patients with chronic severe pain. For its part, law enforcement can anticipate the impact of its activities to avoid encroaching on the practice of medicine and also to prevent actions that send intimidating messages to clinicians. Such an approach can serve to enhance the acceptability of opioid therapy for the physicians who prescribe and the patients who use these important medications.

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