DEA/Physician Cooperation
Cooperation, not antagonism, between the DEA and physicians is necessary for opioid diversion and abuse prevention. Physicians treating pain patients must become experts in diversion and abuse prevention and detection because they are on the front lines of contact with the opioid trafficker. I propose that physicians treating pain patients have a Drug Abuse Prevention and Detection (DAPD) program in their practices. Lawyers, knowledgeable in both health care law and criminal law, may set up DAPD programs. Patients' rights to confidentiality, as enumerated in the Health Insurance Portability and Accountability Act of 1996 (HIPAA), must be protected. The DAPD program should have a specialist in charge of implementing the program's goals. Such a person should have a minimal background equivalent to certified medical assistant, with additional training in drug abuse detection and prevention. The DAPD specialist should report to the prescribing physician, and a healthcare attorney should supervise the DAPD program.
While full implementation of a DAPD program may be feasible only in a practice with at least one full time equivalent pain practitioner because of cost, a scaled-back version of a DAPD program should be implemented in any practice prescribing opioid medications. This would help avoid prescribing opioids to the minority of patients who engage in medication diversion, abuse, or misuse. Such a program should, at the minimum, consist of physician-patient opioid contracting, electronic prescription monitoring, and quantitative urine drug testing to find out which patients are diverting, misusing, or abusing opioid medications. Physician-patient opioid contracting serves to educate patients about safe opioid use, obtains informed consent for opioid use, and lays out specific patient responsibilities (such as safeguarding their medication supply, receiving their medications from a single medical provider and pharmacy, submitting to random urine drug screens, and taking their medications exactly and only as directed). Opioid contracting is well accepted by pain patients seeking medical attention and does not seem to be a detriment to seeking care, even though insufficient data are available on the numbers of pain patients who never seek care and their reasons for not doing so. Many chronic pain patients who have personally experienced or learned of a pain management practice being shut down by the DEA are pleased to see their pain management provider taking full precautions to avoid DEA scrutiny and sanctions, which could include the shutting down of the practice, leaving its patients without a physician.
Of note, seven states have yet to pass electronic prescription monitoring legislation. These electronic prescription monitoring programs are crucial to DAPD because they allow physicians and pharmacists to see all of the opioid prescriptions filled by a given patient within that state, to find patients receiving redundant opioid medications from multiple providers. Urine drug screen indications of diversion, misuse, or abuse include the following: a negative or quantitatively lower than expected urine toxicological screen, which could indicate that the patient is not ingesting the medication as directed but rather diverting the opioids illicitly; or a urine screen positive for substances not prescribed, indicating illicit procurement of drugs or procurement of different opioids from multiple physicians. Opioid contracting, electronic prescription monitoring, and quantitative urine drug screens are needed to ensure the prescribed opioid medications are not being diverted to illicit channels or abused by the patient. Such diversion and abuse is a significant problem in a minority of patients in any pain practice, and can only be adequately redressed by the combination of opioid contracting, electronic prescription monitoring, and quantitative urine drug screens.
