“The DEA is on the phone.” Those are words you really never want to hear. To my relief the call wasn’t about my practice. The next week I found myself meeting with two United States District attorneys as well as DEA agents. I was asked to be an expert in a case against two pain specialists in Alabama. The facts revealed a level of depravity I have never seen in medicine.
Imagine you are a patient referred to this clinic. Your first visit consists of a physician visit that lasts for 43 seconds. The physical examination consists of bending forward. In less than a minute you have scripts for the Holy Trinity (Percocet, Soma, and Xanax). Time is of the essence. The two physicians wrote more than 200,000 opioid prescriptions in three years. Bets were placed on who could write the most. During your follow-up you provide a drug screen. The drug screen shows cocaine, amphetamine, and marijuana. No need to worry. As the accused physician explained to a resident in an email, inconsistent drug screens are simply a reason to order more frequent testing and make more money.
The next visit Subsys is prescribed. Subsys is a sublingual fentanyl spray, a drug so powerful any physician that prescribes it must go through a separate DEA registration program. It is approved for cancer pain only. This clinic is very experienced with this drug as it is one of the top five prescribers in the country—more than MD Anderson, Mayo Clinic, and Sloan Kettering combined. You must get the drug filled at their pharmacy for an average cost of $15,000. Since you do not have a cancer diagnosis, the clinic invents one so your insurance company will pay. In addition to the pharmacy profits, each doctor is receiving several hundred thousand dollars in “speaker fees” (usually dinner out with the staff and family). Occasionally you are switched to Abstral, a different sublingual fentanyl. This depends on which company is giving the highest profit margin that month.
Your follow-up appointments are with nurse practitioners that are not authorized to write prescriptions for controlled substances. The doctors pre-sign prescription pads to avoid any inconvenience. Today, the nurse practitioner seems sluggish, not surprising given that two of the three nurse practitioners are shooting Dilaudid intravenously throughout the workday.
The trial was an eye-opening experience. There were two defense pain experts, one was from Harvard, the other from New York City. Each testified that the medical records reveal a perfectly legitimate cutting-edge pain clinic. Nothing to see here. Before taking the stand, I was notified that I could not mention the over 250 overdose deaths that were associated with prescriptions from the clinic. In addition to general questions about standard of care, I was asked to specifically comment on ten charts; however, I could not mention to the jury that all of them were also dead.
The defense lawyers took issue with my criticisms, all day long and into the next. The 43-second initial office visit, which was videotaped by an undercover agent, was apparently a perfectly reasonable evaluation. The physician simply chose to adopt the physical examination findings of the referring chiropractor. “Dr. Vohra, where in the medical regulations does it specifically state that you cannot adopt a referring doctor’s physical exam as your own?” “Where is it written that you must discontinue controlled substances if a drug screen is inconsistent?” “Isn’t it just a matter of judgment even if all the drug screens are incompatible with the prescriptions?” “Can you show me in the state or federal regulations where you are prohibited from restarting the medication that a patient just overdosed on?” And on and on.
The doctors on trial received 20 years in prison for their crimes. Not nearly enough. At least it’s federal prison, so there will be no early parole.