Many physicians reading this forum treat pain and addiction and may wonder what criteria the DEA believes to be indicative of a pill mill. The following is from a motion filed in federal court regarding the prosecution of a physician:

The government claimed in the motion that pill mills, “have been found to have common characteristics, including some or all of the following”:

• Clinics are cash only and do not accept medical insurance
• Provide no variation in treatment by prescribing each patient the same or substantially similar narcotic or narcotics in the same or similar quantities
• Prescribe a “trinity” of drugs, including a narcotic, benzodiazepine/depressant combined with a non-controlled substance, such as an antibiotic or muscle relaxant
• Prescribe specific narcotics as requested by patients
• Provide little or no medical examination
• Possess no medical equipment or equipment that is not operational
• Serve a large number of patients per day
• Make no recommendations to patients for alternative therapy or X-rays, and physical therapy
• Direct patients to fill prescriptions at certain pharmacies
• Have patients who travel long distances for treatment and/or travel in groups to the clinic
• See the majority of patients without an appointment
• Employ armed security guards

First, let’s acknowledge that none of these are crimes, then look at each from a doctor’s point of view.

Cash. Many doctors choose to only accept cash, so they don’t have to employ the staff required for billing. More than half of psychiatrists are cash only. In the past, many addiction specialists were cash only because insurance would pay little or nothing for this treatment. However, cash is harder for the government to trace, and while it may not be illegal for a physician to take cash, they will absolutely target you for it and use it to imply to the jury that you are shady.

Rubber stamp. Establishing protocols and procedures for patient treatment is a recognized and usually smart way to establish care. This can help clinic providers and staff know where to start and be able to recognize if something is off base. An addiction clinic, for instance, might decide that all patients would be started on Subutex 4mg BID and adjusted in one week as needed, down or up, and perhaps changed to Suboxone if tolerated. This would be reasonable but, according to Dr. DEA, it would also be evidence of criminal practice, a pill mill.

Medication combinations. The DEA, with its extensive knowledge of medicine, has somehow determined that people with chronic pain should not also be afflicted by anxiety, muscle spasms, or apparently an infection. The real “Holy Trinity,” given that name by drug users, was oxycodone, carisoprodol, and alprazolam. A breakdown product of Soma enhances the activity of oxycodone. That is why very few doctors still prescribe this combination. Though some patients who have been on these for decades will still come in as legacy patients.

Getting what they want. Most chronic pain patients know what worked well in the past and what they had a poor response or reaction to. This is not automatically drug-seeking behavior. At least not to the doctor. But it is to the DEA.

Physical examination. The longer a doctor practices, the more focused and shorter the exam usually gets, especially for primary care and ER doctors. Watching the patient walk in, sit, and start to speak gives an experienced physician a wealth of information. Now, a pain specialist establishing a diagnosis will do an incredibly detailed physical examination, worthy of a PM&R and neurologist working together. These are very helpful for the primary care doctor treating that patient. But what the PCP will not do is try to replicate that examination on every visit, or indeed any visit. If a patient comes in from an orthopedist with a diagnosis of a fractured arm, we don’t take that limb from the cast, splint, or sling and move it all around to double-check everything, just in case the ortho was mistaken.

Medical equipment. I’m not sure what to make of this. Almost every physician prosecuted that I could find had working equipment. If something breaks, don’t keep it in the office, I guess.

Number of patients. Some medical boards set the limit at 640 patients per month. They came to that figure assuming that a good doctor would see one patient every fifteen minutes, so four per hour, eight hours a day, five days a week, four weeks a month. That seems reasonable at first glance. But what if you have a nurse practitioner, or a physician assistant, or a counselor? These people might see the patient and provide critical care and a second look, while the doctor closely reviews the record, reevaluating the need for controlled medications. The patient might then come in to see the doctor for five minutes. Now you are at 960! Almost a thousand patients a month! Clearly outside the “usual” practice of medicine. And off you go to the big house.

Imaging and alternative therapies. A true pill mill almost always does not do these things. Which is not why you should. You should do it because it is good medicine. Now, many chronic pain patients are going to come to you having been imaged so thoroughly you can see their future descendants in the scans. How much radiation and expense should you put them through, so you can say that you ordered an image and not end up on the pill mill list?

Single pharmacy. There are pharmacies that will still try to fill prescriptions for patients with chronic pain and anxiety and those that don’t. Keep a list of pharmacies on hand and give it to your patients. Do not have an in-house pharmacy.

Traveling. As fewer physicians are brave enough to treat pain or addiction now, patients must travel further to find one who does. That makes this criterion the gift that keeps on giving for the DEA.

Appointments. Patients may love this, but apparently the DEA does not. I also think it is not practical for chronic pain patients. Though exceptions must be made for cancer or unexpected events. Get the records and a drug screen when a patient applies to be a patient. Do not accept them for continued care until you have reviewed these.

Armed guards. Again, this is arbitrary. There are neighborhoods where not having an armed guard is inviting disaster. And what about the doctors who have been killed by angry patients? I guess the government’s advice hasn’t changed since the 1950s. Duck and cover.

So there you have it. The twelve criteria, straight from the horse’s mouth, on what makes your practice a pill mill. But this may not be enough. At a recent trial, the jury was told that a clinic was a new breed of stealth pill mill. One that knowingly did not break any of the rules to appear legitimate, while secretly, only treating legacy patients to keep them hooked on opiates. As ludicrous as this may sound to my fellow medical professionals, it worked. I wish you all the best and good luck!

L. Joseph Parker is a research physician.