The tremendous pressure that such charges bring to bear is illustrated by the 2002 federal indictment of eight doctors who worked at the Comprehensive Care and Pain Management Center in Myrtle Beach, South Carolina. Threatened with hundreds of years in prison and fearful that his wife (an employee) could also be indicted, clinic owner Michael Woodward pleaded guilty and testified that he had schemed with the other doctors, including Deborah Bordeaux, to sell drugs. South Carolina is a conservative state, and Woodward had seen his clinic repeatedly attacked in the news media. The Woodwards may also have feared that their young children could lose both parents to long prison terms.
Another clinic doctor, Benjamin Moore, told Siobhan Reynolds, founder of the Pain Relief Network, that he and his colleagues had done nothing wrong. When he, too, found that he faced life in prison, he pleaded guilty in desperation. But according to his brother, he could not go through with testifying against co-workers he believed to be innocent. Instead he hanged himself from a tree in his mother's backyard.
Doctors As Dealers
In fiscal year 2003, according to the DEA, the federal government investigated 557 physicians and arrested 34. Betsy Willis, chief of the Operations Section of the DEA's Office of Diversion Control, says "the numbers of federal prosecutions have been relatively consistent for the last four years." The DEA reports 81 arrests in fiscal year 1999, 83 in fiscal year 2000, 78 in fiscal year 2001, and 68 in fiscal year 2002.
Even if the number of federal prosecutions has declined, they have received much more attention since the news media began highlighting OxyContin abuse in 2001. And the alarm about OxyContin clearly has led to increased enforcement efforts: Last year the DEA doubled controlled substance licensing fees for health care providers to fund more investigations, and in March the Office of National Drug Control Policy unveiled "a coordinated drug strategy to confront the illegal diversion and abuse of prescription drugs."
The strategy includes closer monitoring of prescriptions, coupled with "outreach" and "education" aimed at making doctors more skeptical of patient requests for painkillers.
Until recently, investigators would approach a physician if they suspected a patient of diversion; now they try to build a case against the doctor. "This is new in my experience, and I have been doing this for 25 years," says David Brushwood, a professor of pharmacy at the University of Florida. "I've always seen drug control and health care work together....They were never really at odds until the last two years....The way it used to be was that when drug control officials saw the beginnings of a pattern of diversion, they would say to the doctor, 'It looks like a problem is developing; let's work together to fix it.' Now when they see a small problem, they conduct surveillance and wait for it to be-come big, then swoop in with a massive show of force."
Even when there is no direct evidence of diversion, investigators and prosecutors may decide a doctor is being too generous with painkillers because they are influenced by an outmoded view of addiction. According to this view, the essence of addiction is "physical dependence," changes in the body that result in withdrawal symptoms when drug use is halted. Based on this criterion, all pain patients become addicts when they take opioids long enough.
In recent decades, researchers have recognized the inadequacy of this definition. On the one hand, some drugs that don't cause physical withdrawal symptoms (for example, cocaine) clearly can produce a potentially self-destructive desire for more. On the other hand, the vast majority of those who try even the most addictive substances don't develop lasting habits. Researchers therefore redefined addiction to emphasize craving and negative consequences rather than withdrawal symptoms. The diagnostic manual of the American Psychiatric Association now recognizes that physical dependence is neither necessary nor sufficient for addiction, which is characterized by continued use of a substance despite ongoing drug-related problems. For pain patients, of course, the drug produces fewer problems and greater functioning, rather than the reverse.
Some patient advocates say drug warriors can't accept this reality because it undermines the logic of prohibition: If most people don't get hooked when exposed to the "hardest" of all categories of drugs, if patients' lives get dramatically better and they function perfectly well on doses that are supposed to incapacitate, stupefy, and derange, why is it so important for the government to protect us from these substances? From this point of view, the DEA must fight pain control because functional patients on high doses of opioids threaten its authority.
"It completely puts the lie to the whole criminal approach because it shows that these molecules are not evil, that people can and do function well on them," says the Pain Relief Network's Siobhan Reynolds. "It undermines the whole basis for the war on drugs and makes it a strictly scientific/medical issue."
Whatever their reasons, law enforcement officials (along with most of the public and many physicians) still cling to the old-fashioned view of addiction as a biochemical process that inevitably results from extended use of certain drugs. In the Myrtle Beach case, federal prosecutors said in court (before being forced to retract their claim due to contrary testimony) that none of the clinic's 3,000 patients was "legitimate"; in other words, in their view every pain patient of all eight doctors was an addict.
The DEA defines addicts as "habitual" users of narcotics who have "lost the power of self control with reference to [their] addiction" or whose use "endangers the public morals, health, safety, or welfare." From this perspective, pain patients could be considered addicts who have "lost control" in the sense of needing the drug to function.
Many prosecutors do not understand the distinction between addiction and physical dependence or recognize the growing acceptance of opioids in medicine. Says John Burke, vice president of the National Association of Drug Diversion Investigators, "Do I think some prosecutors and law enforcement officers are not well educated? Absolutely." A 2003 study published in the Journal of Law, Medicine, and Ethics found that nearly three-quarters of prosecutors in four states believed simply taking opiates poses a moderate or high risk of addiction. Holding that view was one of the best predictors of who would choose to prosecute physicians in a hypothetical case designed to reflect good pain practice. Just under half of prosecutors surveyed said they would recommend a police investigation merely on the basis of evidence that a physician was prescribing high doses of opioids to some patients for more than a month, something that is perfectly legitimate in cases involving severe chronic pain.
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