By L. Joseph Parker, MD

I have been writing for a while about how the DEA will run out of targets for opioid prosecutions because most doctors are too terrified to treat pain, and now it looks like it has happened. Three doctors in Tennessee were recently convicted of prescribing controlled medications “outside the usual practice of medicine” and “not for a legitimate medical purpose.” The interesting thing is that these doctors weren’t treating pain; they were treating an addiction.

All three were working at a company called EHC Medical, focusing on opioid addiction treatment, with offices in Jacksboro and Harriman, Tennessee, about an hour or so from the Kentucky border. The main medication prescribed by these doctors was Suboxone. Suboxone is a combination of buprenorphine and naloxone and is the most common treatment for substance use disorder. It is a Schedule III medication. Buprenorphine by itself is prescribed generically or as Subutex for mild pain or addiction.

Buprenorphine is a partial opiate agonist that binds and weakly activates the mu G protein-coupled receptors most associated with the euphoric and reward-seeking behaviors related to addiction. By binding them strongly but activating them partially, this medication can prevent withdrawals without generating euphoria in most people, allowing them a better chance to recover, about three times better by most accounts. Naloxone is Narcan, an opiate-blocking medication.

Naloxone does not displace buprenorphine but does displace other opiates, like morphine or even fentanyl, which are pushed away from the receptors, protecting the patient from overdose if they relapse. It’s used in the ER for overdose. This combination of medications is lifesaving, with a ceiling on respiratory suppression, meaning it would be extremely difficult for someone to overdose on this medication. It reaches a maximum effect and extra taken is just wasted.

The allegations were that EHC Medical was not a legitimate addiction clinic but a “machine to maximize profits without regard to the medical needs of each patient.” I would say welcome to the world of corporate medicine in America, but that would be cynical. It is wrong for any physician or associated business not to care about the welfare of their patients. That being said, doctors are not Shaolin monks who wander the streets treating the ill with a bowl. Making a good income should not be a crime.

The DEA alleged that the offices gained a reputation as a place where it was “easy to get drugs.” By drugs, they mean medications, so I guess to be safe, your clinic needs a reputation as a place where it is hard for those with addiction to get treatment. The authorities complained that the clinic “performed inadequate physical examinations.” Again, this is confusing to doctors. Buprenorphine can be prescribed by telemedicine or even by phone call. No physical exam is required.

The article notes that while Suboxone is a legal drug used to treat addiction, it goes on to say that it can be abused by “self-medicating against withdrawal” or “to get high.” First, medicating against withdrawal is the very purpose of Suboxone. I assume they mean self-medicating by someone other than the person the medication was prescribed for. This is not uncommon as drug users often share resources, but it is a crime. For the drug user, not the doctor prescribing it.

Second, it would be exceedingly rare to find any opiate drug abuser who got high off buprenorphine. It simply is not a strong enough agonist, even for a medication-naive person. When someone becomes addicted and seeks treatment, they have usually been using much stronger agonists for years, causing their opiate receptors to downregulate and cytochrome P450 enzymes like 2D6 and 3A4 to upregulate. 3A4 is the main metabolizer of buprenorphine, with a little help from 2C8, so no. Not likely.

The next complaint was that the doctors continued to treat patients who failed drug screens or showed “other signs that they were abusing or diverting drugs.” That’s kind of the definition of addiction. The uncontrolled use… etc. So, you can’t continue treating someone with addiction if they have clear symptoms of the very condition you are treating? That sounds like a Catch-22. I guess they need to be “cured” with the first treatment dose.

The complaints include that two Kentucky drug dealers acknowledged in guilty pleas that they used EHC as a source for drugs. OK. Book ’em, Dano, as they used to say. Was there a taped conversation proving that the doctors knew these guys were diverting their medications? All someone has to do is lie to the doctor and take something like heroin once to get a positive initial screen, then sell all their medications except a dose to use the day before the next visit so it’s in their system. The doctor will never know.

The funny thing is, the people testing positive for other stuff and sometimes negative for their medications may be even more likely to actually have addiction than the “perfect” patient who never does either. Addiction is a tough thing to fight, and most true addicts will relapse many times before succeeding. Selling their medications to get high. These criteria mean a doctor can be prosecuted if they don’t “fire” an addict as soon as they make a mistake. Which would be almost all true addicts.

The papers go on to say that “carloads” of patients would drive in from nearby states, so about an hour away in this case. It is common in rural states to drive several hours to get medical treatment, so this is a false metric the DEA uses to make clinics look illegitimate. The “carloads” is also a false metric. No doctor stands in the parking lot noting who drove in with whom, and even if patients come in the door together, they are seen one at a time in a steady stream. This is the usual practice of medicine.

The business was founded in 2013 and operated through 2018 by the supposed founder of this “drug ring,” Robert Taylor. He pleaded guilty, along with three other doctors and an office manager, and was given a sentence of thirty months and a $200,000 fine but also forfeited $13.8 million to the government. Not to imply that a good payoff helps, but three other doctors, Herrell, Grenkoski, and Cirelli, were not so fortunate, being convicted at trial and getting 10, 9, and 4 years, respectively.

The papers say that Harrell pocketed $3.7 million, Grenkoski $2.3 million, and Cirelli $903 thousand but it doesn’t say over what period of time. If that were ten years, it would not be unusual; if it were over three years, that would be uncommon for someone who did not own the clinic. Context matters, which we hope journalists will start providing. I’m interested in seeing what the jury was told by the government’s paid expert witnesses and if they had any evidence of true mens rea.

The Supreme Court said in Ruan that physicians must know that their actions are illegal and choose to do it anyway to be culpable. In true cases of drug-dealing doctors, the medications are sold per pill: $300 for 30, $600 for 60, etc. Simply charging for a patient visit is not the same. Suboxone doses don’t vary as much as other types of medication might, so this could be harder to disprove. Also, were jurors told that physical exams were mandatory? Or that other medications “should not be combined”?

This can be very effective, but it is not true. Xanax is mentioned, and it’s very reasonable that some addicts will suffer from panic disorder. My advice to addiction medicine providers would be to not prescribe them. Benzodiazepines can blunt some of the protective effects of buprenorphine. Let a psychiatrist deal with that. Two, I do not recommend that you profit from the labs you order, especially at addiction clinics. It may be legal, but that won’t stop them from putting you away for it.

Different doctors have different opinions on these matters, and as these are medical opinions, not crimes, by enforcing one over the other, the federal government is trying to influence the practice of medicine. Itself a crime, according to 42 USC 1395, which makes clear that the authority to regulate the practice of medicine is reserved to the states. For all the good that actually does. The only people who could arrest them are other federal agents, and they’re too busy helping the DEA arrest doctors to care.

So, the lesson to learn here is: Don’t treat addicts who can’t control their behavior; since that’s all addicts, I guess they’re done for. Don’t make money running your clinic; if you do, put back a big chunk for the federal payoff. Don’t treat anyone who crosses state lines. Addicts and doctors in border cities are also done for. Leave. Don’t treat anyone who drives over a certain distance. 45 miles in some prosecutions but 25 in others. And, I guess you need to make it hard for your patients to get treatment so you won’t be “too easy.” Good luck.