Are the DEA and the Medical/Pharmacy Board Working Together?

The Cooperation You Were Not Informed Of

The answer is yes, and the coordination is older, more formal, and more consequential than the practitioners who become its subjects tend to realize before they become its subjects.

A physician receives a letter from the state medical board requesting documentation of prescribing practices. A pharmacist receives a visit from a Diversion Investigator who asks to examine the dispensing log. These appear to be separate events originating from separate authorities with separate concerns. In nine of the fourteen cases we reviewed in the past eighteen months, the board inquiry and the federal investigation were not separate. They were concurrent. The board knew about the DEA. The DEA knew about the board. The practitioner knew about neither relationship.

Whether this cooperation serves the public interest or produces a machinery of compounding jeopardy in which administrative and criminal proceedings reinforce one another to the detriment of practitioners who have not been convicted of anything is a question the system has not paused to consider.

The Formal Architecture of Information Exchange

In April 2018, the Department of Justice announced that the DEA had reached data sharing agreements with the attorneys general of 48 states, Puerto Rico, and the District of Columbia. The agreement was bilateral. The DEA provided state officials with data from its Automation of Reports and Consolidated Orders System, known as ARCOS, which collects approximately 80 million transaction reports each fiscal year from manufacturers and distributors of controlled substances. In return, the attorneys general provided the DEA with information from their state Prescription Drug Monitoring Programs, the electronic databases that track controlled substance prescriptions by flagging suspicious prescribing and dispensing patterns at the patient, prescriber, and pharmacy level.

That exchange created a closed informational circuit. The federal government sees what the states see. The states see what the federal government sees. A prescribing pattern that generates a flag in a state PDMP is visible to the DEA. A distribution anomaly that appears in ARCOS data is visible to the state AG. And the state AG, in most jurisdictions, shares investigative information with the state medical board and the state pharmacy board through formal or informal channels that predate the 2018 agreement by decades.

The practitioner who believes the state board inquiry and the federal investigation are unrelated proceedings conducted by unrelated agencies is operating under an assumption the agencies themselves abandoned years ago.

The PDMP is the connective tissue. Every state and the District of Columbia now operates a prescription drug monitoring program. In most states, prescribers and dispensers are required to check the PDMP before prescribing or dispensing a Schedule II controlled substance. The same data the practitioner is required to consult is available to the medical board, the pharmacy board, and, through the data sharing agreements, to federal law enforcement. The obligation to check is also the mechanism by which the practitioner’s conduct becomes visible to every entity authorized to review the record.

How the Referral Operates in Practice

The DEA’s Diversion Control Division works, in the agency’s own language, “in cooperation with state professional licensing boards and state and local law enforcement officials.” That cooperation is not ceremonial. In states such as New Jersey, Pennsylvania, and Virginia, medical board investigators and DEA Diversion Investigators have constructed working relationships close enough that the term “team” is not inaccurate. In other jurisdictions, the coordination is less integrated but no less real. It operates through referral.

The mechanics are straightforward. When the DEA initiates an administrative action against a registrant, whether an Order to Show Cause under 21 U.S.C. 824 or an Immediate Suspension Order under 21 U.S.C. 824(d), the state board receives notification. The notification is, in most states, automatic. It does not require a request from the board. It does not require a judgment call by the DEA field office. The administrative action generates a report, and the report is transmitted. The board then opens its own inquiry, applies its own standard, and reaches its own determination, which may precede, accompany, or follow the federal proceeding on an independent timeline.

The reverse is also true, or close to it. When a state medical board or pharmacy board revokes or suspends a practitioner’s license, the DEA receives notice. The agency will then request the voluntary surrender of the practitioner’s DEA registration, and if the surrender is not forthcoming, it will initiate revocation proceedings. The logic is circular by design. A practitioner whose state license has been revoked lacks the state authorization upon which the DEA registration depends. A practitioner whose DEA registration has been suspended or revoked has triggered the board’s reporting obligation. Each action by one body produces a predicate for action by the other.

The Evidentiary Asymmetry

This is where the coordination becomes, if we are being precise, something closer to a structural disadvantage for the practitioner.

The DEA’s criminal referral to the United States Attorney’s Office requires the government to prove, under Ruan v. United States, that the physician knew or intended that prescriptions served no legitimate medical purpose. The standard is proof beyond a reasonable doubt. The state medical board operates under the administrative standard: preponderance of the evidence, which requires only that the board’s position is more likely true than not. The distance between “more likely true than not” and “beyond a reasonable doubt” is the distance between the loss of a license and the preservation of a freedom, and the practitioner confronts both standards at once, arising from the same conduct, supported by the same evidentiary record, adjudicated by bodies that have been sharing information since before the practitioner received the first letter.

A physician acquitted of federal charges may still lose a medical license. This is not a theoretical possibility. It is an outcome we have observed. The board does not regard an acquittal as dispositive. It regards the acquittal as a determination that the government failed to meet the criminal standard, which is a different question from whether the practitioner’s prescribing fell below the professional standard the board applies. The physician who wins in federal court and loses before the board has won a proceeding and lost a career.

The pharmacy board operates under equivalent authority. A pharmacist whose dispensing practices attract DEA attention faces administrative proceedings before the board that apply the “corresponding responsibility” doctrine of 21 CFR 1306.04(a), a regulation whose boundaries are defined less by the text of the regulation than by the enforcement posture of the board and the agency in the year the dispensing occurred. The same conduct that was unremarkable in 2018 may be actionable in 2026. The pharmacist dispensed medications under the standard as it was understood at the time. The board evaluates the dispensing under the standard as it is understood now.

The National Practitioner Data Bank and Its Quiet Consequences

Behind the visible proceedings, another mechanism operates. The National Practitioner Data Bank, maintained by the Health Resources and Services Administration, collects reports of adverse actions taken against healthcare practitioners by state licensing boards, hospitals, professional societies, and federal agencies. Both DEA controlled substance registration actions and state board adverse licensure actions are reportable to the NPDB. The reporting obligation is mandatory. State medical boards that fail to submit reports of adverse actions face the removal of their reporting responsibility by the Secretary of HHS, which is a penalty no board has volunteered to incur.

An NPDB report follows the practitioner. Hospitals query the Data Bank when evaluating credentialing and privileging decisions. Insurance carriers query it when evaluating participation. The report does not expire. A board action that resulted from a DEA referral that originated from a PDMP flag becomes a permanent entry in a federal database that every institution with which the practitioner seeks affiliation is required to consult. The sequence from prescribing pattern to PDMP alert to DEA inquiry to board action to NPDB report is not a series of independent events. It is a pipeline. Each stage feeds the next, and the final stage feeds every institution the practitioner will approach for the remainder of a career.

Approximately 4,000 board actions are taken against physicians each year, according to the Federation of State Medical Boards. Controlled substance violations constitute roughly 27 percent of those actions. The FSMB’s Disciplinary Alert Service notifies boards within 24 hours when one of their licensees receives discipline in another state. The notification system ensures that a board action in one jurisdiction produces awareness, and often a parallel inquiry, in every other jurisdiction where the practitioner holds a license.

Emergency Powers and Their Convergence

The most acute expression of federal and state coordination occurs in emergency proceedings, where both the DEA and the state board exercise suspension authority on compressed timelines that permit little meaningful response from the practitioner before the consequences are complete.

Under 21 U.S.C. 824(d), the DEA may issue an Immediate Suspension Order when it determines that a registrant’s continued activity poses an imminent danger to public health or safety. The suspension takes effect upon service. There is no prior hearing. The Order to Show Cause that accompanies the Immediate Suspension Order affords thirty days to request a hearing before an Administrative Law Judge, but the hearing itself may not occur for months. The suspension persists throughout.

State boards possess equivalent emergency authority. Working in conjunction with the DEA, or on its own authority upon notification of a federal action, the board may issue an emergency suspension or a cease and desist order that terminates the practitioner’s authority to practice medicine or dispense medications before the administrative process has produced a finding. The 2025 National Health Care Fraud Takedown produced 93 administrative actions, many of which triggered parallel state proceedings. Whether the state boards initiated their emergency actions because their own independent review determined the public was at risk, or because the federal action created a reporting obligation they were bound to act upon, or because the institutional relationship between the board and the agency made inaction untenable, is a question the practitioner’s attorney must answer in real time while the practitioner’s ability to treat patients has already ceased.

The patient roster is the detail that receives the least attention. When a physician’s prescribing authority terminates without transition, every patient in the practice whose treatment involves a controlled substance must locate another provider who will accept the clinical history, evaluate the current regimen, and continue treatment without interruption. Some of those patients are in palliative care. Some are in medication-assisted treatment for opioid use disorder. The emergency suspension protects the public from one risk by creating another, and the created risk falls on the patients the system does not count.

What the Practitioner Sees and What Is Already in Motion

You receive an inquiry from the state board. It concerns documentation. It concerns a handful of patient charts. It asks questions that appear administrative in character, questions about recordkeeping, about the clinical rationale for a dosage, about whether you consulted the PDMP before writing a prescription you wrote two years ago. You respond because the board has asked and because you believe the inquiry is contained.

What you do not see is the Diversion Investigator who has already reviewed your ARCOS data. You do not see the PDMP report that flagged your prescribing volume relative to your specialty and your geography. You do not see the memorandum that transmitted the board’s findings to the DEA field office, or the referral from the field office to the United States Attorney, or the grand jury subpoena that has been served on the pharmacy that filled the prescriptions the board is now asking you to explain. You respond to the board in writing, under your own name, without counsel, because you believe you are answering a question about documentation.

You are providing a statement to one component of an investigative apparatus that includes the component you cannot see.

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This is not speculation. It is the operational reality of federal and state enforcement coordination in controlled substance cases, and it has been the operational reality since at least 2018, when the data sharing agreements formalized what had been occurring through informal channels for years prior. The board inquiry that appears routine may be routine. It may also be the visible surface of a proceeding whose depth the practitioner will not appreciate until the second letter arrives, or the third, or until the Diversion Investigator appears at the practice with an Administrative Inspection Warrant and a familiarity with the practitioner’s prescribing history that the practitioner did not expect a federal agent to possess.

The Compounding of Proceedings

Operation Profit Over Patients, part of the 2025 National Health Care Fraud Takedown, resulted in 51 arrests, 122 criminal charges, and 93 administrative actions. The administrative actions sought the revocation of prescribing and dispensing authority from pharmacies, medical practitioners, and companies. These administrative proceedings were independent of, and not in lieu of, the criminal prosecutions. The language is from 21 U.S.C. 824(a) itself: proceedings to deny, revoke, or suspend a registration “shall be independent of, and not in lieu of, criminal prosecutions.”

The statute mandates the parallelism. The practitioner who faces a DEA administrative action and a state board proceeding and a federal criminal investigation is not experiencing an aberration. The practitioner is experiencing the system as the statute designed it to function. Each proceeding operates on its own timeline. Each applies its own standard. Each produces its own consequences. And the consequence of one proceeding becomes evidence in another.

A DEA revocation of registration constitutes a reportable event to the NPDB, which constitutes a trigger for the state board, which produces a board action that constitutes grounds for CMS revocation of Medicare enrollment under 42 C.F.R. 424.535. The cascade is not accidental. Each agency’s action creates the jurisdictional predicate for the next agency’s action, and the practitioner stands at the center of a sequence that, once initiated, possesses its own institutional momentum. Whether any single agency intended the cumulative effect is irrelevant. The cumulative effect occurs.

The Consultation That Precedes the Coordination

The agencies are coordinating. That fact is established. The question for the practitioner who has received an inquiry from a state board, or a visit from a Diversion Investigator, or a subpoena, or a letter requesting the voluntary surrender of a DEA registration, is whether the practitioner’s response to the first contact will be informed by an understanding of what the first contact represents, or whether the practitioner will respond to a single proceeding without awareness that the proceeding is not single.

We have written about the importance of declining to provide statements to federal agents without counsel present. The same principle applies to board inquiries, with the additional complication that a board may impose adverse consequences for a failure to cooperate that the Fifth Amendment would prohibit in a criminal proceeding. The practitioner occupies a corridor between the obligation to respond to the board and the right not to incriminate oneself before a federal tribunal. That corridor narrows when the board and the tribunal are sharing information, and it narrows further when the practitioner does not know the sharing is occurring.

The consultation with counsel is where the scope of the coordination becomes visible. It is where the practitioner learns whether the board inquiry is isolated or connected, whether the federal investigation has commenced or remains latent, whether the response to the board will be read by the board alone or by the audience the board’s cooperation has assembled. That determination shapes every subsequent decision, from whether to respond in writing to whether to request a hearing to whether to surrender a registration the agency has not yet moved to revoke.

The agencies do not wait. The practitioner who delays the consultation does not delay the coordination. The coordination proceeds on its own schedule, with its own internal logic, and the practitioner’s awareness of it or ignorance of it does not alter the pace. What it alters is the practitioner’s capacity to respond before the options have been reduced to the ones the agencies prefer.