When a pharmacy sells the heartburn drug Zantac, each pill costs about 35 cents. But doctors dispensing it to patients in their offices have charged nearly 10 times that price, or $3.25 a pill.

The same goes for a popular muscle relaxant known as Soma, insurers say. From a pharmacy, the per-pill price is 60 cents. Sold by a doctor, it can cost more than five times that, or $3.33.

At a time of soaring health care bills, experts say that doctors, middlemen and drug distributors are adding hundreds of millions of dollars annually to the costs borne by taxpayers, insurance companies and employers through the practice of physician dispensing.

Most common among physicians who treat injured workers, it is a twist on a typical doctor’s visit. Instead of sending patients to drugstores to get prescriptions filled, doctors dispense the drugs in their offices to patients, with the bills going to insurers. Doctors can make tens of thousands of dollars a year operating their own in-office pharmacies. The practice has become so profitable that private equity firms are buying stakes in the businesses, and political lobbying over the issue is fierce.

Doctor dispensing can be convenient for patients. But rules in many states governing workers’ compensation insurance contain loopholes that allow doctors to sell the drugs at huge markups. Profits from the sales are shared by doctors, middlemen who help physicians start in-office pharmacies and drug distributors who repackage medications for office sale.

Alarmed by the costs, some states, including California and Oklahoma, have clamped down on the practice. But legislative and regulatory battles over it are playing out in other states like Florida, Hawaii and Maryland.

In Florida, a company called Automated HealthCare Solutions, a leader in physician dispensing, has defeated repeated efforts to change what doctors can charge. The company, which is partly owned by Abry Partners, a private equity firm, has given more than $3.3 million in political contributions either directly or through entities its principals control, public records show.

Insurers and business groups said they were amazed by the little-known company’s spending spree. To plead its case to Florida lawmakers, Automated HealthCare hired one of the state’s top lobbyists, Brian Ballard, who is also a major national fund-raiser for the Mitt Romney campaign.

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The Food and Drug Administration, overriding the advice of an expert panel, said Monday that it would not require doctors to have special training before they could prescribe long-acting narcotic painkillers that can lead to addiction.

But the agency said companies that make the drugs, like OxyContin, fentanyl and methadone, would be required to underwrite the cost of voluntary programs aimed at teaching doctors how to best use them.

The F.D.A. announcement came after several years of deliberations by the agency into the growing problem of prescription painkiller abuse and misuse. In 2010, a panel of outside experts assembled by the F.D.A. overwhelmingly rejected the agency’s proposal that physician training be voluntary.

Instead, that panel said that mandatory training was essential both to reduce the abuse of strong painkillers, or opioids and to make sure that pain patients were treated appropriately with them.

In introducing the plan on Monday, both Dr. Margaret A. Hamburg, the F.D.A. commissioner, and R. Gil Kerlikowske, President Obama’s top drug policy adviser, said they were hopeful that Congress would eventually enact mandatory physician training.

But the Obama administration has yet to draft legislation, despite voicing support for more than a year.

Major doctors groups like the American Medical Association have fought the idea of mandatory training, saying that the programs would be burdensome and could reduce the number of physicians who treat pain patients.

Over the last decade, overdose deaths related to the abuse and misuse of long-acting narcotics have reached epidemic proportions.

There are also growing concerns that long-term use of the drugs can cause a variety of problems, such as sharply reduced hormone production, sleep apnea and increased falls and fractures in people over 70.

Dr. Scott M. Fishman, a pain specialist, said he believed that the public health issues surrounding opioid use had reached a point at which doctor training was essential.

“The problem of prescription drug abuse has become so severe, I believe that the time has come to make that training mandatory,” said Dr. Fishman, a professor at the University of California, Davis.

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