republished & reported in youarewithinthenorms.com
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Richard A. Lawhern, PhD
September 11, 2026
The Linguistic Divergence of Opioid Red Flags
Anyone working as a clinician or pharmacist in pain medicine these days has heard the term “red flag” to the point of personal nausea. In everyday practice, the term has multiplied like termites, with an equally destructive effect on the lives of patients and their doctors.
It is almost always applied as a reason (actually an excuse) for denying patients access to safe and effective prescription opioid analgesics and/or benzodiazepine medications. One bit of information that we do not hear, however, is any identification of published studies or trials that have validated such red flags against real-world outcomes in either medicine or law.
Who says that a patient who travels over 50 miles to fill an opioid prescription at a pharmacy that hasn’t filled for them before is any greater risk for substance use disorder than someone whom the pharmacist has known for ten years? Has nobody heard of the artificial drug shortages created by the Drug Enforcement Administration (DEA) and state attorneys general in the National Opioid Settlement?
Who says that a pharmacy customer who pays in cash is any more likely than any other customer to divert or resell their prescription? Has nobody heard of the millions who are losing Medicaid coverage because of work requirements imposed by the current national administration?
Who says that the top ten state prescribers monitored by a prescription drug monitoring program are more likely than any other doctor to overprescribe? In a hostile regulatory environment where thousands of doctors are leaving practice due to fear of being falsely accused or prosecuted, we should expect those who remain to be handling larger caseloads.
As readers of my previous work on KevinMD will know, I have an extensive peer-review network that reviews my work before it is ever submitted to journal editors. From this network, I recently received what I find to be an important insight that is largely missing from current clinical and law enforcement literature. Credit for this quotation goes to Daniel Harris, MD, HMDC. He is medical director of Lumina Hospice & Palliative Care.
“In medicine, a ‘red flag’ has always meant ‘caution.’ It is an indication that there may be a serious problem underlying the symptom one is assessing and treating, and greater care may be needed to rule out the serious problem. For example, if a patient with reflux symptoms has ‘red flags,’ they need to have an endoscopy promptly rather than a prescription for omeprazole and a follow-up appointment in four weeks.
“In law enforcement, the same term ‘red flag’ has commonly been used to indicate that a violation of the law has occurred. It does not mean ‘take a closer look’; it means ‘someone should be arrested and punished.’
“I believe that this difference in the meaning of the same term contributes to the DEA’s excessive prosecution of physicians and pharmacists. In medicine, we note there are ‘red flags’ for drug diversion, and we look to see if there is another explanation for the issue. The DEA hears there are ‘red flags’ and jumps to the conclusion that the doctor has written, or the pharmacist has filled, an illegitimate prescription.”
I would take Dr. Harris’s observation a step further. Not only do DEA, Department of Justice, and some state boards of medical examiners jump to this incorrect interpretation of red flags. They also improperly lead judges and juries to make the same leap with them. The result is that law enforcement has criminalized the practice of pain medicine on essentially false grounds. The same bad actors have forced the arbitrary and undeserved revocation of thousands of medical licenses and sent hundreds of doctors to prison on false grounds.
The same process has led a number of federal and state judges to ignore or directly contradict a landmark decision of the U.S. Supreme Court in the case of Ruan v. United States. Under this decision, it is no longer acceptable to convict a doctor of having violated some arbitrary standard of practice, or practice “guideline.”
JUSTICE IN PAIN MEDICINE
Following Ruan, the prosecution must demonstrate that the doctor knew of this standard and deliberately chose to violate it, for whatever reason. Ruan takes convictions out of the realm of supposedly “objective” standards (as if there could actually be such a thing), and forces judges and juries to consider the “subjective” state of the clinician’s choices.
The basis for a “red flag” in such proceedings is no longer that a government expert witness would not have done as the defendant did. Law enforcement must now prove beyond a reasonable doubt that the defendant knew what comprises acceptable medical practice and chose to violate that standard. This is a much more difficult burden of proof in adversarial proceedings. And it is one that should prompt near-term judicial reviews of doctor convictions in all state and federal jurisdictions, and the timely release and compensation of any defendant who has not been convicted under the subjective standards of Ruan.
Present law enforcement and state board misuse of “red flags” is yet another kind of insanity in the practice of pain management. And it’s past time that this insanity was stopped.
BACKGROUND
Richard A. Lawhern is a nationally recognized health care educator and patient advocate who has spent nearly three decades researching pain management and addiction policy. His extensive body of work, including over 300 published papers and interviews, reflects a deep critique of U.S. health care agencies and their approaches to chronic pain treatment.
Now retired from formal academic and hospital affiliations, Richard continues to engage with professional and public audiences through platforms such as LinkedIn, Facebook, and his contributions to KevinMD. His advocacy extends to online communities like Protect People in Pain, where he works to elevate the voices of patients navigating restrictive opioid policies. Among his many publications is a guideline on opioid use for chronic non-cancer pain, reflecting his commitment to evidence-based reform in pain medicine.
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FINDINGS, NOTES AND REFERENCES
Briefing Doc: Anthem’s Proposed Anesthesia Time Billing Policy Changes
Source: Letter from the American Society of Anesthesiologists (ASA) to Anthem leadership, dated November 12, 2024.
Main Themes:
- Strong Opposition to Anthem’s Policy: The ASA vehemently opposes Anthem’s proposed policy of using CMS Physician Work Time values to determine anesthesia payment, arguing that it is an inappropriate and inaccurate metric.
- Misinterpretation of Standards: The ASA accuses Anthem of misinterpreting established coding requirements and ASA standards related to anesthesia time billing.
- Patient Safety Concerns: The ASA raises serious concerns about patient safety, arguing that the policy fails to consider the varying lengths of surgical procedures and individual patient needs, potentially leading to underpayment for necessary anesthesia services.
- Call for Policy Rescission and Meeting: The ASA demands Anthem rescind the policy and requests an urgent meeting with Anthem officials to discuss their concerns.
