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Join us as we delve into the intricate web of discrepancies surrounding pain medication availability and governmental oversight. Our guest, L. Joseph Parker, a research physician, sheds light on recent revelations regarding the White House Medical Unit’s actions, outlined in an Inspector General’s report. From Operation “Bottleneck” to the DEA’s prescription requirements, we explore the systemic biases and ethical implications at play.

L. Joseph Parker is a research physician.

He discusses the KevinMD article, “Elite access vs. public scrutiny: Medication disparities exposed.”

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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 back L. Joseph Parker. He’s a research physician, and today’s KevinMD article is “Elite access vs. public scrutiny: Medication disparities exposed.” Joseph, welcome back to the show.

L. Joseph Parker: Thank you very much.

Kevin Pho: So Joseph has been on multiple times. Go to KevinMD.com/podcast to hear his story and prior episodes. But today let’s get into a recent KevinMD article, “Elite access vs. public scrutiny: Medication disparities exposed.” For those who didn’t get a chance to read this one, what’s it about?

L. Joseph Parker: This is about the difference between the standards that the federal government, specifically the DEA, holds physicians, pharmacists, and citizens to, and the standards they hold themselves and other members of the federal government to. And there’s a huge disparity there.

Kevin Pho: All right. So tell us the story.

L. Joseph Parker: Well, it turns out that the White House has its own medical office. And so it has its own physicians, as everyone would understand, the people working there need access to medical care from time to time, the president has a personal physician, and these people need access to health care.

However, what was extremely surprising to me, and probably anyone who reads the story, is that there were huge amounts of Schedule II substances, fentanyl and other substances, that were being distributed from the White House medical office with no record of who it was going to, according to a report from the Office of the Inspector General.

Now, the Inspector General is kind of like, they’re not really the police of the federal government, the federal government does not have any police over them, but the Office of the Inspector General does sort of investigate and advise Congress and other agencies of the federal government, so that they can, if they choose to, take some action to correct things.

Kevin Pho: So give us some context. When did this happen? Tell us a little bit more about the report, and why don’t we start from there?

L. Joseph Parker: OK. Well, this occurred during the Trump presidency, but I would not be surprised if it doesn’t bleed over into other administrations also, and it just happened to be that one where complaints were made.

So some complaints were made from members of the White House staff to the Office of the Inspector General saying, they’re just handing stuff out to whoever wants it, basically. And so the Office of the Inspector General came and did an investigation and got the paperwork.

So military medicine and sort of federal medicine is a little different than state medicine. There’s no federal medical license, so every federal practitioner has to be licensed in some state, but then they can operate in any federal facility.

So let’s say the National Health Service. If they’re going to put someone on an American Indian reservation in Arizona, that doctor can be licensed in Massachusetts and they can transfer him over and let him on federally controlled land. Now of course the Native American land is owned by the Native Americans, but it’s controlled and policed by the federal government, so they can go there.

And the White House is of course federal property. The entire District of Columbia is federally controlled. The police force in Washington DC is not state police or local police, they’re federalized.

And so there’s a form where you fill out who’s getting something, what they’re getting, and the doctor is supposed to sign and actually print their name and put their DEA number, or their military number if it’s a military physician.

And this form was actually made available to the public through the Office of the Inspector General, through a Freedom of Information Act request. We were saying, hey, who got what? And I review some of that form for that story. In that article I go through some of the medications that were distributed and the amounts they were distributed in, and it was very surprising.

Kevin Pho: So give us some of those numbers, for those who didn’t get a chance to read it.

L. Joseph Parker: 500 micrograms of fentanyl was released to someone, we don’t know who. Something like 48,000 tablets of what are called Z medicines, sort of like Ambien, to help you sleep, but these are scheduled medications and they can be habit forming.

There was also a lot of Provigil given out. Now, Provigil is a stimulant. I don’t want to say it’s similar to Ritalin or Concerta, but it is based on that. It sort of turns up the volume on the reticular activating system, helps you stay awake more, and it doesn’t make you as jittery as most of the others. Even caffeine, to help you stay awake, it can make you a little jittery. So a lot of it was handed out.

The main problem was that it was handed out with no record of where it went to. And there was even one annotation for cocaine hydrochloride. Now, cocaine is a medication used usually in rhinoplasty procedures. I don’t know if that was handed out or if it was just on the form, but it was definitely there, it was on the list. So if they keep cocaine in the White House I would wonder why. I don’t think they do too many rhinoplasties there, but perhaps it’s on every federal form.

But the fentanyl was definitely being handed out in 200 and 500 microgram batches, and that’s a really hefty dose of fentanyl. Of course, fentanyl is 100 times more powerful than morphine and all that, but it’s very potent stuff.

And supposedly we’re in the middle of an opioid crisis and everyone is supposed to be very strict about who gets what. If a pharmacist had done this, if a doctor had done this, they would roll you up so fast it would make your head spin.

And this isn’t a matter of interpretation or medical opinion. This is not a doctor saying, I think this guy needs his sleep medicine, and the federal government paying some other expert to come along and say, I don’t think he did, and then trying to prosecute him for it. This is not tracking who got a Schedule II narcotic. You’re done, every time, if that happens.

If you distribute, I mean, that’s literally drug dealing. If you’re distributing a Schedule II narcotic without tracking who it goes to, and there’s no way to track who it went to if you don’t record it, then that’s drug dealing.

And apparently they said that there were basically party bags. People taking trips overseas, or who were going to go somewhere to do something, they would ask for a combination of medications, stimulants, sleep medications, depressants, and narcotics, opiates, to take with them. And these would be distributed to them and they would head out with this bag of, they call them party favors, I think.

I won’t speculate on if they were going to be used as, I don’t know, inducements. I have never been to like a big Hollywood party, in Studio 54 when it existed or anything like that, so I don’t pretend to know how the upper echelons, how the wealthier and more powerful people party. But from what I have seen and heard, it’s a lot more robust than how the rest of us might.

While I’m used to tailgate parties, my family would hold some of those with alcohol, and maybe perhaps if someone was bold there might be something of a cannabis nature there, that would pretty much be it for this section of the country. I do know in Hollywood and other places, parties, they might have cocaine, things like that.

I was shocked to see that a medical officer in charge of it, an active duty officer, that he would not have stricter controls over that. But apparently there were almost no controls at all.

Kevin Pho: Now, can you speculate, are there any legitimate medical reasons why that number of Schedule II fentanyl can be used legitimately?

L. Joseph Parker: The Office of the Inspector General looked into that, and they looked at other federal facilities to say, how much of this stuff do you guys issue? And the answer was zero, and they kept none on hand. They said, we let the military pharmacies handle that. We have non-narcotic stuff here, and if someone needs a narcotic we write a prescription and they go out and get it filled somewhere else. That way there’s a clear record and multiple checks and balances.

One of the reasons that we have doctors and pharmacists is so that a doctor is not responsible for writing the prescription and making sure you get the right pill. Everybody gets rushed, you need double and triple checks. So the doctor writes the prescription, the prescription goes to the pharmacist. The pharmacist is not an expert on who needs what medication, he’s an expert on what pills look like, how to prepare solutions, and how to make sure that the patient gets the right medicine that the doctor prescribed.

So I think it’s terribly unfair when pharmacists get rolled up and prosecuted for filling a perfectly valid prescription, on the argument that they should have known the patient didn’t need that. They’re not trained to know that, they’re not supposed to know that. Now, if it says a thousand hydrocodone tablets per day, of course they’re going to say, hey, wait a minute. But that’s not what’s been going on.

But in this case, unless a cancer patient, a patient with bone cancer, I have given like 200 microgram patches, that patch lasts three days. These were 500 microgram liquid solutions. That would drop a horse dead. I mean, that would probably kill three or four of me.

So no, I do not see any legitimate reason. I made a joke about someone falling through the trapdoor and landing in the hidden acid pit in the White House. You would have to have full body burns, be in the burn unit, and still be conscious enough to scream at a very high volume, before anyone would think about slowly giving you that amount over several days.

Kevin Pho: So to summarize, according to the Office of the Inspector General, the White House medical unit is prescribing large amounts of Schedule II and III controlled substances for what you speculate as non-legitimate medical reasons. This started during the Trump administration, and perhaps it’s persisting through the Biden administration. Is that correct?

L. Joseph Parker: I would suspect that if you were to scan all the administrations, you will find, to a lesser or greater degree, that some of this might have occurred in prior and maybe even current administrations. But I would also argue that it had to have been this specific military officer in charge of this office, because anyone else would be too terrified to do so. No complaint has ever been made against someone else, so something must have been exceptional for someone to go to the OIG and say, you need to look into this, because this guy’s out of hand.

It’s worse than them prescribing without a legitimate medical purpose, because they dispensed without recording who it went to. That is a totally different thing. A valid prescription, and again we can argue if someone needs or doesn’t need, that’s a matter of opinion. But when you take a Schedule II narcotic and you dispense it to someone with no record of who it went to, that is illegal.

Kevin Pho: Now, what was the response to the OIG’s report? Did it go public? What happened next?

L. Joseph Parker: It did go public, and there was, of course, a lot politically made of it. Or probably not as much as I would have expected to be made of it. But it’s kind of too late.

So the policing of these things, they occur instantaneously for the rest of the population, but for agencies, until they do something for so long that someone in a federal agency gets tired of it, it just continues. So by the time this was identified, investigated, and recognized, you’ve got a whole new group of people in there. And probably because of what had come out, the new people coming in are probably like, track everything, record everything, you would be insane not to. So probably it’s much more strict now because of that complaint.

But it does not appear like anything was done. I’m reluctant to say people need to be punished and hammered, but at the same time, if they set a standard that they enforce on every citizen, physician, and pharmacist in this country, and then they don’t apply that standard when it is one of their own, that is hypocrisy, that is unjust, and that is not following the law.

So they could at least take away the gentleman’s prescribing rights, which is always kind of a legitimate authority that the DEA has according to the Controlled Substances Act. And actually that’s the only authority they’re supposed to have, is to issue a certificate or withdraw that certificate. Withdrawing that doctor’s certificate would prevent him from being able to prescribe or distribute any controlled medication. And if he’s doing so in an unsafe manner, then that should be done, you would think.

The argument that the DEA can throw a doctor in prison because they don’t like the patients he’s seeing, or don’t agree with whether or not a particular patient needs a particular medication, that’s a violation of federal law in my opinion, 42 U.S.C. 1395. They’re not supposed to try to influence the practice of medicine. This is not the practice of medicine. This is someone going into a pharmacy, grabbing a solution of fentanyl, and handing it to someone without tracking who it went to and for what purpose.

Kevin Pho: And as far as you know, no repercussions to the prescribing clinician?

L. Joseph Parker: Nothing at all, as far as I know. There’s not even been a DEA investigation. It’s just the Office of the Inspector General.

Kevin Pho: We’re talking to L. Joseph Parker. He’s a research physician. Today’s KevinMD article is “Elite access vs. public scrutiny: Medication disparities exposed.” Joseph, as always, we’ll end with your take-home messages to the KevinMD audience.

L. Joseph Parker: There are two sets of laws in how they are enforced in this country. There is one set of rules for the powerful and the politically connected, the wealthy, and there’s another set of rules for everyone else. I would encourage everyone to always assume that they’re not on the lucky side.

But at the same time, if we as citizens do not hold those in power to account when they abuse that authority, then we’re neglecting our duties as citizens to petition our government for a redress of grievances and to correct their behavior. Ultimately, in any democracy, the government is a reflection of the citizens and what they tolerate. And I don’t think that this type of behavior should be tolerated.

Kevin Pho: Joseph, as always, thank you so much for coming on the show and sharing your perspective and insight.

L. Joseph Parker: Thank you very much.