Fear and loathing in the pain clinic.

The piece by Jung and Reidenberg presents updated information on U.S. Drug Enforcement Administration (DEA) activities against physicians that we have heard reported on multiple occasions over years as pain professionals, both attending and speaking at conferences. Often presented by active or retired members of law enforcement, such data were nearly believable enough to be taken at face value during the Hutchinson years at the DEA, when balance and collaboration were the stated goals of the agency in its interactions with pain professionals. “The DEA is not after you; the DEA does not want to tell you how to practice medicine” was often the theme. Never mind the fact that at every advisory board or meeting there was always at least one physician in attendance who had been the subject of an investigation, their life, reputation, and practice disrupted or ruined, pointing out the platitudes inherent in such comments. Always there appeared to be an undertow of fear related to the suggested disconnect between the preaching in Washington at the top of the agency and what was “really happening in the field,” where agents and prosecutors often see things differently. In recent years, reassurances related to data suggesting a miniscule number of investigations, arrests, and sanctions ring hollow. These numbers seem particularly tiny when the “denominator” utilized is the total number of physician-registrants in the United States, all 936,385 of them. It makes any fear of DEA action appear to be nothing more than a collective neurosis shared by physicians who treat pain and/or prescribe controlled substances. However, the presentation of these data begs the question: what is the denominator? Also, why are so many physicians and organizations involved in the treatment of pain worried when they have been specifically told that they will not be sanctioned for prescribing opioids [1,2]? The denominator is the key to a better understanding of the fear.