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Joining A.J. Reid Finlayson, a psychiatrist, Jeffrey A. Singer, a general surgeon, and Peter R. Martin, also a psychiatrist. We’ll be discussing the case of Dr. Ralph Thomas Reach, an addiction medicine physician whose medical license was revoked, leading to legal troubles, and the broader issues surrounding addiction treatment and the role of the DEA. Tune in as we explore the barriers to medication-assisted treatment, the historical context of federal intervention in addiction treatment, and the implications for health care professionals and individuals struggling with substance use disorders.

A.J. Reid Finlayson is a psychiatrist. Jeffrey A. Singer is a general surgeon. Peter R. Martin is a psychiatrist.

They discuss the KevinMD article, “The DEA’s war on addiction doctors.”

The white paper discussed on the show: “Cops practicing medicine”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Jeffrey A. Singer, Peter R. Martin, and A.J. Reid Finlayson. Jeffrey A. Singer is a general surgeon and a senior fellow at the Cato Institute. A.J. Reid Finlayson and Peter R. Martin are both professors of psychiatry, and together they co-wrote the KevinMD article “The DEA’s war on addiction doctors.” So I’m just going to ask each of you to briefly share your story and journey, then we’ll jump straight into the article. Jeffrey, why don’t you go first.

Jeffrey A. Singer: Well, I’m a general surgeon in Phoenix, Arizona. I’ve been in practice for 40 years, and I’m also a senior fellow at the Cato Institute in the Department of Health Policy Studies, and I do a lot of work in the area of the overdose crisis and harm reduction.

I co-wrote a white paper with a colleague about two years ago now called Cops Practicing Medicine, where we got into the whole business of how, over the past several decades, law enforcement has increasingly encroached upon how doctors treat patients for pain or for addiction. And because of that, and Reid will tell you in a few minutes, he read that white paper and was very impressed by it, and then contacted me and told me about a colleague of Reid’s and Peter’s in Tennessee who is a victim of cops practicing medicine. And that’s what led to our article.

Kevin Pho: All right, and we’ll certainly talk about that case of course. Reid, a brief word on your story and journey.

A.J. Reid Finlayson: Well, I’m a former family doctor who specialized in psychiatry, then later in addiction medicine, and for about the past 30 years I’ve been involved evaluating and treating physicians who have behavioral problems, including addictions. And I’ve been fascinated by the history of addiction treatment, which was really quite successful over 100 years ago in America.

And because of that interest I noticed the excellent paper that Dr. Singer did with a colleague called Cops Practicing Medicine. And I knew of a situation of Dr. Tom Reach, who is currently in federal prison in Virginia and has never had due process. He was raided in May of 2018. He ran a very successful operation of several clinics called Watauga Addiction Treatment Centers in the Appalachian tri-state area. He was doing really well, he was raided, shut down, forced into bankruptcy. He couldn’t get in front of a judge to explain that there were no real charges. All the felony charges were withdrawn, 44 different misdemeanor charges were mostly withdrawn. He got some legal advice that he should plead to something that was of minuscule importance, and he’s in federal prison.

With his history and expertise, he really should be guiding us in how to be more successful in preventing overdose deaths in Tennessee. But that’s the situation that we’re in.

Kevin Pho: All right, so we’re going to certainly talk more about that case. But Peter, I just want to hear a brief word about your story and journey. Of course both you and Reid are professors of psychiatry at Vanderbilt University Medical Center. But Peter, a word or two about your story and journey.

Peter R. Martin: Well, I have been in this field since the mid 70s. I am trained in internal medicine, psychiatry, and clinical pharmacology, and I am very interested in addiction as an illness that physicians treat like any other illness. It’s very important to me that we use all the armamentarium that is available to physicians to bring to bear on addiction as an illness, like all other illnesses.

My interest in this particular story began when Reid told me about how unfairly this physician was treated, and I felt that this would not have happened to an oncologist or to a cardiologist. It was particularly designated for a physician who treats patients with addiction. It brings to mind the tremendous stigma that this disease has faced, and the difficulty in dealing with it by the medical profession.

Kevin Pho: All right, so let’s talk about this case and use that case as a jumping off point for our conversation. So Jeffrey, tell us briefly about the case.

Jeffrey A. Singer: Well, the specific details of the case I think Reid and Peter know more about than me, but generally speaking, this is a doctor who had an impeccable reputation, and I’m told by Reid and Peter that he would occasionally give seminars over at Vanderbilt University Medical Center, had a long history of expertise treating addiction. He had gotten the X waiver, now of course there’s no X waiver required, but he was legally treating addiction in these clinics, and suddenly got raided in a very dramatic DEA raid. His practice was put on hold, he had to go through all of these legal traumatic experiences, never got due process.

And as is often the case with law enforcement in these situations, the prosecutors tend to kind of pile on a whole bunch of charges because of mandatory minimums and the like, so that they put the person they arrest in a position of either plead guilty to something you may not have done at all, or risk maybe 120 cumulative years in jail or something like that. And it’s up to you, do you feel like spinning the roulette wheel, or do you want to just go ahead and take the lesser charge even if you didn’t do it. And so that’s what happened to him.

Now, my interest in this is, two years ago, rightly, Congress repealed the requirement that anybody who wants to treat opioid use disorder using Suboxone had to go through this hassle of getting an X waiver, and they also had restrictions on even who was able to do it. Well, the X waiver restriction was lifted at the end of 2022, and even nurse practitioners can prescribe Suboxone.

And there’s been a lot of commentary in the press about how it’s disappointing not many doctors have jumped at this opportunity now that they don’t have to get an X waiver. And I argue that one of the reasons is that if you decide to get into the business of treating addiction, you’re under close scrutiny by law enforcement. Every state has a prescription drug monitoring program, or PDMP, and you’re being watched like a hawk. And when you hear stories like those that happened to Tom Reach, that’s so intimidating that the doctors are reluctant, even if they’re interested in treating substance use disorder they’re afraid to, because they don’t want to have a target on their back and get into the situation that Tom Reach got himself into.

We’re not only seeing that of course with treatment of addiction, we’re seeing that with treatment of pain. So a lot of people who really need pain medication are going undertreated or untreated for the same reason, because the doctors and the pharmacists know they’re under constant surveillance by law enforcement. And in my white paper Cops Practicing Medicine we offer some reform proposals, which maybe we can get into later, that are not panaceas but they would certainly help improve the situation.

Kevin Pho: Reid, tell us a little bit about Tom Reach, and you mentioned it earlier, what was his practice like and what were some of the allegations against him from the DEA?

A.J. Reid Finlayson: Well, there were, I forget exactly how many, but probably in the neighborhood of eight felony charges, which were just speculations. There was never any proof. He never had any opportunity to have a hearing in front of a judge or a court.

And the other complication in this case is, the state of Tennessee has seen fit to overrule the medical board in terms of whether he is permitted to regain licensure in Tennessee, because they passed a law, which is probably unconstitutional, that means that the medical board can’t approve of his practice and reinstate his license. So it’s kind of a tough situation.

And I would point out that Tennessee is one of the worst states to have an opioid addiction problem. In terms of overdose deaths, it’s a very sad state of affairs.

Kevin Pho: And Reid, did Dr. Reach have any inkling that this was about to happen to him, or was it a complete surprise on his part, to your knowledge?

A.J. Reid Finlayson: Total surprise. You can look up on YouTube the videos of the raid and his reaction. His concern has always been, what about the patients that I was looking after, what happens to them, who’s going to continue their Suboxone maintenance and look after them?

Yeah, the next day he was reassuring people that they would try and get open as quickly as possible, but of course it’s still been shut down. As I may have mentioned, he was forced into bankruptcy, his clinics were all sold off to medical business interests, and I guess are still going under the approval of the DEA.

Kevin Pho: So Peter, I’d like to hear, what are your impressions of Dr. Reach and what happened with him regarding the DEA?

Peter R. Martin: Well, I don’t know Dr. Reach personally, but there’s one general principle here, and that is that the medical profession has neglected addiction for very long, and there are very few physicians who are both qualified and eager to treat these patients. And instead of treating them so harshly and so badly, they should work very hard to maintain him in his practice, and determine if there is any problem with this practice, and if there is, there should be remediation, rather than pushing him into federal prison and thereby depriving all his patients of the capacity to get treated.

Because believe me, in East Tennessee there are not that many physicians, and there are hardly any physicians who will treat these patients, and some of them I have known to travel 250 miles either way to get their methadone maintenance. So it’s really unfair to Dr. Reach, but mostly it’s unfair to the patients.

Jeffrey A. Singer: Well, the problem is that whether the so-called inappropriate prescribing of medication, whether it’s buprenorphine or pain medication for pain management, there’s no clear legal definition of what is inappropriate prescribing. And so law enforcement ends up rifling through the PDMP, and if they think a doctor is, in their opinion, inappropriately prescribing, they often consult a physician who aligns with their viewpoints on substance use and illicit drug use.

So in other words, the physicians they know in advance, just like in tort cases, they’ve got a physician who’s going to say what they want to say, which gives them justification. Then they move in and shut down a doctor’s office and arrest them. Oftentimes these doctors’ charges are never filed, and the doctors sometimes are able to go back to practice. But the point is, these are standard of care issues, these are not issues for cops to be deciding.

So this leads into the reform proposals. First, I think on both a state and federal level, law enforcement should be required to get a warrant to go through the PDMP, which is private medical information. 19 states, Tennessee is not one of them, have laws on the books saying that law enforcement needs to get a warrant. But even in those 19 states the DEA has ignored that, and they’ve cited that they’re a federal agency and those laws don’t apply to them, and so far courts have upheld that. So we need both state and federal law saying that any law enforcement, state or federal level, needs a warrant to show there’s probable cause that a real crime is being committed.

Number two, if in the process of going through the PDMP, once they get that warrant, they suspect quote unquote inappropriate prescribing, well, that’s a standard of care issue. They should be required in that case to refer to the state medical board, whose job it is to check into whether or not a doctor is violating a standard of care. And they get practitioners and experts from their state to review it, because every case is an individual case and there’s a lot of nuance, and they could look into that and they can make the decision. It’s not a matter for cops to decide. And those are two basic reforms that we think are necessary.

Kevin Pho: Reid, Dr. Reach, to your knowledge, did he practice within the standard of care?

A.J. Reid Finlayson: Yes. In fact, he has served several terms as the president of the Tennessee Society of Addiction Medicine. He’s presented nationally at ASAM meetings. I have a copy of the Watauga clinics handbook, which is a very thorough description of how the clinical practice operates, or operated, and it is a wonderful document. So yeah, Dr. Reach was eminently qualified and experienced in terms of addiction medicine.

Kevin Pho: And Reid, in your opinion then, why do you think he caught the attention of the DEA if he practiced within the standard of care?

A.J. Reid Finlayson: I’m not sure. I suspect because he was trying to treat everybody in the tri-state area, from women who were pregnant, people who were in jail, people who were insured, people who were on Medicare, people who were underinsured, people who were paying cash. And I think that he was suspected of financial problems, but the investigation didn’t turn anything like that up. And I believe that he was running an ethical practice, but I can’t prove that.

Kevin Pho: So Peter, tell us the reaction to this case among the addiction medicine clinician community.

Peter R. Martin: Well, I think in general people feel that when they prescribe buprenorphine, Suboxone, at least when it started, and I’m talking about, it’s been going around for 15 years now pretty much, and I remember when I first started prescribing it I was very frightened, and I was taking very meticulous notes, I had my nurses organize it. As time went on and we became more experienced with using it, I think we became much more comfortable, and we didn’t make a big deal, we treated it like we would any medication.

And I think that the trouble with addiction medicine and addiction psychiatry is, we’re sort of playing with fire according to the laws. It’s a notion that you are being supervised much more than other physicians would be. For example, as I said before, there is not this kind of oversight for oncology or cardiology or whatever other area of medicine that you would think of.

So the reality is that part of the problem is the drug. All of these drugs have liability, and it’s using them wisely and comprehensively, together with a comprehensive treatment program, where the efficacy lies. And these people have a different response to opioids than do people who are non-addicted, and we do have to use the medicine in order to allow them to go into treatment and have worthwhile lives and so on.

So on one hand we’re dealing with something that’s illicit, that’s illegal, and on the other hand we know that we will help the patient with it if we use it properly. And there’s a shortage of physicians. So these all go together with being counter to what I would do with Dr. Reach.

Jeffrey A. Singer: If I may interject as the non-psychiatrist in this group, it’s analogous to when you’re seeing a patient, let’s say, for a different behavioral disorder, because addiction is a behavioral disorder. So you’re seeing somebody, for example, who is so clinically depressed that you can’t even really begin to make headway in things like talk therapy. You need to first stabilize their situation so that you can now investigate the root causes of their problem and help them with it. So you put a person on a medication to assist in that.

It’s the same thing with addiction. So when you put a person on something like Suboxone or methadone, these are two proven for decades forms of medication assisted treatment, the first thing you’re doing is getting the person’s life stabilized, because they’re spending most of their waking hours either trying to come up with the money to purchase the drug on the black market or to find the person to get it from. And now all of a sudden they don’t have that issue, and now their relationships can be rekindled, and now you can have conversations with them about why they have this relationship with this particular drug.

So this is an essential tool in treating opioid use disorder. And when doctors want to engage in this, and then they suddenly realize that just the fact that they’ve chosen to do this makes them come under the watchful eye of law enforcement, that would frighten most people.

Peter R. Martin: Yeah, I should also add that it’s a legal statement that these drugs are illicit. For example, alcohol is probably just as harmful, but it’s a highly profitable business. We’re playing the same game with marijuana.

And back in the late 1800s opioids were used pretty openly in medicine, there was no regulation, and it’s really in the late 19-teens that the Harrison Act came into being. And that’s basically where you took an illness and you declared it a legal problem rather than a medical problem. And I don’t think the problem has changed, it’s been with us since biblical times. It’s just we, in terms of the way we treat it, that have changed.

Kevin Pho: We’re talking to Jeffrey A. Singer, A.J. Reid Finlayson, and Peter R. Martin. They co-wrote the KevinMD article “The DEA’s war on addiction doctors.” So we’re going to end quickly with just some of your take-home messages to the KevinMD audience. Reid, why don’t you go first?

A.J. Reid Finlayson: I think my take-home message is that we have to do a much better job of ending the stigmatization of this problem. It is a medical illness, it has been for centuries a medical illness. And the law in theory is good. The Supreme Court, when they hear cases, they always defer to a medical judgment, and the issue of mens rea, in other words, to be convicted of a crime Dr. Tom Reach would have to have planned to hurt somebody with prescribing buprenorphine.

But what the DEA tends to do is sort of skirt around that, and really has bullied physicians for over a century. It’s been studied that at least 1,500 doctors a year from 1919 on have been penalized for trying to help people who are suffering from the disease of addiction.

Kevin Pho: Peter, why don’t you go next with some of your take-home messages?

Peter R. Martin: I guess my take-home message, as an educator for decades, is that we need to have our colleagues be very much like Jeff. He, as a surgeon, understands that this is an illness. And we need to motivate young physicians to become interested in helping these people, because the problem is so immense and so many people die as a result of it.

And I guess the analogy I would like to bring out, and I said this to Jeff before, I mean, a surgeon uses a knife to heal people. You can also use a knife to kill people. And the analogy to opioids is there. And I think we need to use the opioid skillfully, and we need to teach young physicians how to do that, to help patients.

Kevin Pho: And Jeff, we’ll end off with you, your take-home messages to the KevinMD audience.

Jeffrey A. Singer: Yeah, I think the take-home message is that opioid use, whether it’s treatment for pain or treatment for addiction, is a medical issue, not a law enforcement issue. There’s no place for law enforcement in this picture. The only role for law enforcement is to enforce actual laws that have to do with the selling of these drugs illegally on the black market and those kinds of things.

And they should stay out of the way doctors practice medicine, either to treat pain or to treat addiction. And a whole lot of people, both in pain or suffering from opioid use disorder, are undertreated or untreated or improperly treated, all because of the interference by law enforcement into the practice of medicine. Many of them are in jail or dead.

Kevin Pho: Jeffrey, Reid, and Peter, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Jeffrey A. Singer: Thank you, Kevin, appreciate it.