Contraindications: Dr. Jayam Krishna-Iyer

Those of us lucky enough to attend New York Medicaid Inspector General Jim Sheehan's talk Saturday at the Association of Health Care Journalists conference in Seattle heard him make reference to Dr. Jayam Krishna-Iyer. I was curious about the back story. Here it is:

Krishna-Iyer of Clearwater, Florida, had her DEA certificate, which allows her to prescribe controlled substances like painkillers and anti-psychotic medications, revoked in September 2006. The DEA gave the doctor three chances to do the right thing. It sent three undercover officers to her to request painkillers. In all three cases, the DEA said, the agents told her that they were not actually in pain and that they already had scored some painkillers from other sources, including their friends. Krishna-Iyer did not examine the patients but marked in her records that she did.

"Moreover, during each of the visits, Respondent made statements that indicated that she knew the patients were seeking the drugs to abuse them and not to treat a legitimate medical condition," wrote Michele M. Leonhart, DEA deputy administrator.

The story then takes a legal turn, and the DEA does a nice job of compiling the records for you. Krishna-Iyer appealed the decision. And the U.S. Court of Appeals for the Eleventh Judicial Circuit vacated the DEA's decision in September 2007.

"In considering Petitioner's experience in dispensing controlled substances under factor 2, the DEA identified only four visits by three undercover 'patients,' who were all attempting to make a case against her. The DEA failed to consider Petitioner's experience with twelve patients whose medical charts were seized by the DEA, or with thousands of other patients. In short, the DEA did not consider any of Petitioner's positive experience in dispensing controlled substances."

This would make for an interesting story. Because a doctor has done a good job treating the pain for most of her patients, does that negate the finding that she, according to the DEA, knowingly gave drugs to patients who were clearly just trying to get drugs any way they could? How often are the courts preventing the drug agency from shutting these diversion pipelines down? And are there particular judges who seem averse to stopping bad prescribing practices?

Because of the court's ruling, the DEA had to take another look at her case. After monitoring her practice, the agency found that, after being warned by the DEA about what she was doing, the doctor, perhaps not surprisingly, started to shape up. In December 2008, she was able to start prescribing drugs again but was required to provide monthly reports to the DEA.

"The reports shall list all controlled substances prescribed by the patient's name, the date, the name of the drug, its strength, the quantity prescribed, and the number of refills authorized," the DEA demanded. "The reports shall be due no later than the tenth day of the subsequent month and shall list all patients in alphabetical order. Failure to comply with the terms of this Order shall be grounds for the suspension or revocation of Respondent's registration."