THE BLURRY LEGAL LINE BETWEEN DOCTORS AND DRUG DEALERS.

• Author: Sullum, Jacob
• Position: DRUGS

XIULU RUAN, A board-certified Alabama pain specialist, was sentenced to 21 years in federal prison for prescribing opioid analgesics "outside the usual course of professional medical practice." According to the appeals court that upheld his 2017 conviction, it did not matter whether he sincerely believed he was doing what a physician is supposed to do.

That ruling, which is the focus of a case the Supreme Court heard in March, conflates negligence with criminal liability, invites the Drug Enforcement Administration (DEA) to usurp state medical regulators, and encourages prosecutions that have a chilling effect on pain treatment. If it is allowed to stand, doctors who already face intense pressure to curtail opioid prescriptions will be even more inclined to elevate drug control above pain control.

Ruan's trial featured the usual battle of experts. Defense witnesses portrayed him as a conscientious physician doing his best to serve patients in dire need, while prosecution witnesses portrayed him as careless and blind to "red flags" indicating abuse or diversion of the drugs he prescribed.

Some of this disagreement stemmed from dueling interpretations of Ruan's practices and lapses. Some of it stemmed from ongoing debates on issues such as the risks and benefits of long-term opioid therapy for chronic pain and, more generally, how to balance patients' needs against the government's demand that physicians prevent misuse of pain medication.

That demand puts doctors in a difficult position, since pain cannot be objectively verified. If they trust their patients, some people will take advantage of that trust; if they reflexively treat their patients with suspicion, some people will suffer needlessly from pain that could have been relieved safely and effectively.

The threat of regulatory sanctions and malpractice lawsuits already forces clinicians to weigh the risk to their licenses and livelihoods if they make questionable prescribing decisions. The threat of criminal prosecution ups the ante because it means that doctors also can lose their liberty if they make decisions that the DEA, a law enforcement agency with no medical expertise, views as medically inappropriate.

Criminal penalties traditionally are reserved for people who knowingly break the law. But the U.S. Court of Appeals for the 11th Circuit has held that a physician's "good faith belief that he dispensed a controlled substance in the usual course of his professional practice is...