As the nation grapples with a record number of overdose deaths, it might not seem like the ideal time for a physician convicted of illegally prescribing opioids to push for liberalized drug laws.
Dr. Jay Joshi is taking his shot anyway.
Joshi, 37, who lives in Chicago’s western suburbs but practices in northern Indiana (and is not to be confused with a pain doctor of the same name who works out of Vernon Hills), served 11 months in federal prison after pleading guilty to prescribing controlled substances without a legitimate medical purpose.
Prosecutors said Joshi gave an undercover agent prescriptions for 246 hydrocodone tablets over four visits without performing a proper exam or seeking the man’s medical records. Though he expressed regret at sentencing, Joshi now says his guilty plea was a mistake, and that his prosecution was the product of government hysteria over opioid painkillers.
“If you want to question my decision making, then let’s work together to create guidelines and optimize decision making,” he said in a recent interview. “But to state that a (medical) decision you may not agree with is a criminal decision is, I believe, a step too far.”
Indiscriminate prescribing is often viewed as a main cause of the opioid epidemic. Just this month, the nation’s attorneys general announced a $26 billion deal with pharmaceutical manufacturer Johnson & Johnson and three drug distributors, all accused of enabling the misuse of addictive painkillers.
But there is a growing sentiment among critics that the pendulum has swung to a dangerous extreme. They say federal prosecutors and the Drug Enforcement Administration have frightened doctors away from making legitimate opioid prescriptions, subjecting patients to needless suffering and prompting some to seek dangerous alternatives.
“Every time a doctor is prosecuted and the prosecution is prominently announced, the DEA is saying: ‘We’re going to get you and we don’t care how long it takes; we’ll put your (behind) in prison if you continue prescribing and we don’t care if the science disagrees,’” said patient advocate Richard Lawhern.
The DEA grants licenses that allow doctors to prescribe controlled substances, and Joshi is circulating a petition that aims to restrict its oversight (he made a similar argument in a letter to U.S. Attorney General Merrick Garland). He argues the agency has abused its authority and doesn’t have the medical expertise to make appropriate decisions.
That might sound self-serving given the loss of his own DEA license. But Joshi, who has returned to practice in Merrillville under the supervision of another physician, said law enforcement shouldn’t second-guess doctors.
“They’re co-opting the patient-physician encounter as another aspect of the war on drugs,” he said. “They’re using the Controlled Substances Act, which is the same law used to restrict illicit drug transactions, and applying it to health care.”
Joshi grew up in the Chicago suburbs, and after medical school established a practice in Munster called Prestige Clinics. Many of his 1,500 or so patients had issues related to pain, he said, but he was well aware of the potential danger of opioids: One of his specialties was treating drug addiction.
His trouble began when Munster police received an anonymous complaint about suspicious people patronizing the clinic. The DEA got involved and found that Joshi’s small practice was among the state’s top opioid prescribers (Joshi disputes that, saying an employee was forging prescriptions behind his back).
In 2017, according to court documents, an undercover federal agent posing as a truck driver came to the clinic complaining of leg pain and asked for Vicodin, a brand of hydrocodone.
Prosecutors said the agent purposefully modeled drug-seeking behavior, and that Joshi did only a cursory exam before agreeing to prescribe 60 tablets. He wrote similar prescriptions for the man three more times before he was arrested.
Joshi said in a court filing that he tried to cut the risk of abuse by ensuring the man wasn’t getting the medication from other doctors, and by giving him a coupon for Suboxone, a medication used to curb opioid craving.
He also said he relied on “rapport” to discern whether the man might misuse the tablets.
“More than any imaging test, any physical exam, any urine drug screen, any evaluation of a prescriber database, trust is the biggest determining factor as to whether a patient will abuse opioids,” he wrote.
Dr. Andrew Kolodny of Physicians for Responsible Opioid Prescribing, a group that promotes what it calls cautious use of the medication, said that rationale makes little sense.
“Rapport isn’t relevant,” he said. “What’s relevant, when prescribing a treatment with serious risks, is to make sure that in your patient, the benefits of the treatment outweighs those risks.”
Joshi’s reasoning wasn’t much help in his legal case. At sentencing, the judge said it was clear Joshi wrote opioid prescriptions for someone who “absolutely did not need that.”
But a counterargument to stingy opioid prescribing has grown in recent years, contending that pain patients are being hurt by doctors scared of federal heat. The Centers for Disease Control and Prevention says opioid prescriptions, which peaked at 255 million in 2012, have since dropped by more than 100 million.
Some critics attribute the plunge to the CDC itself, which in 2016 published guidance saying doctors should avoid prescribing large doses to chronic pain patients. Many doctors took that as a warning and stopped prescribing the drugs entirely, said patient advocate Claudia Merandi, who has joined Joshi in his petition effort.
She said she has heard from many desperate patients whose pain is no longer under control. Some, she said, have sought relief via fentanyl-tainted street drugs, which were responsible for most of the record 93,000 fatal overdoses last year.
“Doctors are afraid to speak out,” Merandi said. “The CDC guidelines are a million percent responsible for doctors being targeted, a million percent responsible for the fentanyl overdoes and a million percent responsible for pain patients’ suffering.”
The CDC is now reconsidering those guidelines. At a hearing July 16, some doctors endorsed keeping a strict stance while pain patients appealed for a new approach.
“Our conversation has gone from the best types of treatments to what our suicide plan is like when we are untreated,” one said. “The situation is desperate.”
Austin Wynn has a different perspective. The Munster-based founder of Never Alone Recovery, which connects patients with rehab centers, said that when he was a teen, he received liquid hydrocodone following sinus surgery and “conned” doctors into giving him more. He said that eventually led to a heroin addiction, from which he has recovered.
Though he doesn’t know Joshi, he said his own experience taught him that doctors should be skeptical and strict when it comes to opioids.
“That errant prescription that maybe shouldn’t have been written can rip a family apart,” he said.
A new quest
Joshi pleaded guilty in 2018, but before he was sentenced, he was sued by the pain doctor who shares his name; the other Dr. Jay Joshi alleged his practice suffered when patients confused him for his Indiana counterpart. According to court records, the physicians agreed last year to dismiss the case.
That has freed the Indiana-based Joshi to focus on his new quest. His petition, which has more than 3,500 signatures, aims to limit the DEA’s regulatory power over opioid prescriptions, alleging the agency is engaged in a “war against physicians who prescribe (the medication).”
Asked for comment, the DEA did not address the petition but defended its role in overseeing the prescriptions, saying it is charged with protecting public health and safety.
Joshi’s suspended DEA license means he can prescribe neither opioid painkillers nor Suboxone, but the Indiana Medical Licensing Board has otherwise allowed him to resume practicing on a probationary basis. A supervising doctor must review all aspects of his practice for at least one year.
One longtime patient, John Wielogourski, a retired well driller, has followed Joshi to his new office. He said the doctor got a raw deal from the government.
“He does everything by the book,” Wielogourski said. “He was not just handing (opioids) out. He’s a good doctor, I don’t give a (hoot) what anybody says.”
Joshi said he’s optimistic he’ll get his controlled substance license back, which would allow him to prescribe a full range of medications. Asked whether his campaign against the DEA might endanger that goal, he said he’s willing to take the risk.
“Other physician colleagues have warned me about that,” he said. “(They say) just lay low and try to get back on your feet. I’m choosing to talk about the issue. I’m choosing to create awareness about it, because I feel passionate enough that whatever (consequences) come to me, it’s less than the broader benefit that would come from speaking out.”