When Prescriptions Raise Fear, Not Relief

Authored by: Clarice Xu

Art by: Amy Em

Many controlled substances, including opioids and sedatives, are legally manufactured and can be prescribed for legitimate medical purposes. Although these drugs provide significant therapeutic benefits, the effects of substances such as temporary euphoria, have led some individuals to exploit legal loopholes and misuse them. Multiple U.S. policies, including the Controlled Substances Act, seek to ensure that patients have access to pharmaceutical controlled substances. The Act also aims to protect public health by preventing drugs from flowing into the illicit market [1]. The challenge in controlled substance policy is understanding whether strict penalties implemented to prevent frequent abuse have unintentionally restricted patient and healthcare provider access to life sustaining medication.

The frequent misuse of controlled substances has led to strict regulations, but unclear enforcement guidelines have created confusion among healthcare providers and prescribers. Under the Controlled Substances Act, certain medications are allowed only for legitimate medical purposes [2]. However, the term “legitimate medical purpose” was not clearly defined by the government. 

This lack of clarity creates confusion among different groups. Courts and prosecutors define the terms through case law, often during the prosecution of doctors crossing the line of what constitutes a “legitimate medical purpose.” For example, in the United States v. Moore, the Supreme Court held that physicians can be prosecuted under the CSA when their prescribing behavior falls outside the usual course of professional practice [3]. While physicians interpret the limit of “legitimate medical purpose” through professional standards, it may still be viewed as illegal by federal agencies like the Drug Enforcement Administration, who define them differently. The lack of a uniform definition, creates a legal ambiguity which increases the risk that prescribers may be accused of exploiting medications. 

Medical mistakes are usually treated as civil issues, not crimes. But under the Controlled Substances Act, certain prescribing decisions are seen as criminal. The problem is, the law doesn’t clearly define what counts as a “legitimate medical purpose", which makes it easier for doctors to cross legal lines and harder for them to know when they’re at risk of prosecution [4]. Critics insist that government agencies, such as the Drug Enforcement Administration, have been too aggressive in second-guessing doctors’ clinical discretion, to the extent of overreach [5]. This has resulted in a “chilling effect” among health providers, which means that the overly strict regulations have made doctors hesitant to exercise their professional judgment [6]. In this context, many doctors are afraid of being prosecuted for prescribing what might be considered “too much” medication. Research shows that between 2012 and 2018, the number of physicians providing first-time opioid prescriptions decreased from approximately 114,000 to just over 80,000 [7]. Furthermore, Adam M. Gershowitz from William & Mary Law reports that 40% of doctors refused to take on patients with chronic pain who required opioid treatment, because of the fear of legal repercussions [8].

The U.S. opioid crisis is complex as there is blurred accountability over whether drug users should be convicted or doctors who prescribe the substances should be held accountable. This issue affects multiple groups of people. First, are the patients who need medications that are on the restricted list of the Controlled Substance Act to sustain their lives. Prescription medications are often a much cheaper option compared to complex surgeries. [9] Patient who cannot get the medication may turn to street drugs. If they don’t have alternative options to get access to medicine, they might risk decreasing life expectancy [10]. Second, mistrust between patients and providers also increases; doctors may hesitate to prescribe necessary medications because they cannot see a patient’s intentions and worry they could get into legal trouble [11]. Simultaneously, some drug users take advantage of vague definitions of “legitimate medical purpose” to obtain substances, and continue to increase the flow of opioids into illegal markets [12]. 

The real problem is figuring out how to keep the public safe from illegal drugs without making it harder for patients to get access to the life-saving care they need most. From the interest of fairness, if the Controlled Substance Act is enforced too strictly, people who rely on these medications might be left without treatment, and doctors may feel afraid to perform their job. On the other hand, if the Controlled Substance Act is too lenient, it opens the door to misuse and addiction that would amplify the national opioid crisis. 

The trade-offs surrounding controlled substances eventually came from the complexity of overlapping policy changes. There’s no quick fix or single rule that can solve it. Instead, policymakers need to consider multiple stakeholders and find compromises. There should be a clearer definition of what constitutes a legal amount of substances for doctors to prescribe and for patients to access [13]. Prescription tracking should also be improved to minimize the risk that prescribed drugs end up on the illicit market [14]. By putting these kinds of safeguards in place, we can create a system that protects the public safety while upholding a person’s fundamental right of access to healthcare. 

References

1. U.S. Government Publishing Office. (2022, March). SUBCHAPTER I—CONTROL AND ENFORCEMENT. Retrieved October 9, 2025, from GovInfo website:  https://www.govinfo.gov/content/pkg/USCODE-2023-title21/pdf/USCODE-2023-title21-chap13-subchapI.pdf 

2. Oyez. (2019). Gonzales v. Oregon. Retrieved from Oyez website: https://www.oyez.org/cases/2005/04-623 

3. Gonzales v. Oregon - Brief (Merits). (2014, October 21). Retrieved from www.justice.gov website: https://www.justice.gov/osg/brief/gonzales-v-oregon-brief-merits

4. L. JOSEPH PARKER. (2024, March 19). DEA overreach: a threat to doctors’ freedom in American medicine. Retrieved October 9, 2025, from KevinMD.com website: https://kevinmd.com/2024/03/dea-overreach-a-threat-to-doctors-freedom-in-american-medicine.html

5. Sack, S. (2024, August 23). Difference Between Civil & Criminal Medical Malpractice | SSKB Law. Retrieved from Salenger, Sack, Kimmel & Bavaro, LLP website: https://sskblaw.com/understanding-the-difference-between-civil-and-criminal-medical-malpractice-cases

6. Sedney, C. L., Haggerty, T., Dekeseredy, P., Nwafor, D., Caretta, M. A., Brownstein, H. H., & Pollini, R. A. (2022). “The DEA would come in and destroy you”: a qualitative study of fear and unintended consequences among opioid prescribers in WV. Substance Abuse Treatment, Prevention, and Policy, 17(1). https://doi.org/10.1186/s13011-022-00447-5

7. Owens, B. (2019). Opioid prescriptions are down but some patients fear doctors are now too strict. Canadian Medical Association Journal, 191(19), E546–E547. https://doi.org/10.1503/cmaj.109-5748

8. Gershowitz, A. (2021). The Opioid Doctors: Is Losing Your License a Sufficient Penalty for Dealing Drugs? Retrieved from https://hastingslawjournal.org/wp-content/uploads/Gershowitz_13-Final.pdf

9. Socal, M. P., Cordeiro, T., Anderson, G. F., & Bai, G. (2022). Estimating Savings Opportunities From Therapeutic Substitutions of High-Cost Generic Medications. JAMA Network Open, 5(11), e2239868. https://doi.org/10.1001/jamanetworkopen.2022.39868

10. R. Friedman, S., Mateu-Gelabert, P., & Rossi, D. (2012). Has the United States Drug Policy Failed? And How Could We Know? Substance Use & Misuse, 47(13-14), 1402–1405. https://doi.org/10.3109/10826084.2012.705687

11. Merrill, J. O., Rhodes, L. A., Deyo, R. A., Marlatt, G. A., & Bradley, K. A. (2002). Mutual Mistrust in the Medical Care of Drug Users. The Keys to the “Narc” Cabinet. Journal of General Internal Medicine, 17(5), 327–333. https://doi.org/10.1046/j.1525-1497.2002.10625.x

12. Preuss, C. V., Kalava, A., & King, K. C. (2023, April 29). Prescription of Controlled Substances: Benefits and Risks. Retrieved from Nih.gov website: https://www.ncbi.nlm.nih.gov/books/NBK537318

13. D’Souza, R. S., Lang, M., & Eldrige, J. S. (2024). Prescription Drug Monitoring Program. Retrieved from PubMed website: https://www.ncbi.nlm.nih.gov/books/NBK532299

14. Gabay, M. (2013). Federal Controlled Substances Act: Controlled Substances Prescriptions. Hospital Pharmacy, 48(8), 644–645. https://doi.org/10.1310/hpj4808-644