The DEA Inspects My Office

aaaadea

So last week I was going about my business, absorbed by the usual challenges of my week, when June called.

June is the Health Services Manager of my office practice, a title meant to indicate she is able to take payment from one patient while scheduling another patient on the phone, searching for a chart I have lost, faxing a prior authorization request, checking results of a urine drug screen, and amusing the toddler of the patient I’m talking to in my office…all at the same time. She has worked with Suboxone doctors for about five years, and worked in a big psychiatric practice for many years before that. She has a weird ability to stay calm yet firm when patients yell at her. Her unofficial titles are Patient Wrangler and Addict Whisperer.

June isn’t easily flustered. So when she called me on a morning she knows I’m working at another clinic, I knew something was up, because she usually just sends me a text.

“The DEA called and they want to come by and talk to you!” June said when I answered.

“Why? Is this a routine visit?”

“I don’t know but you’ve got to call them back.”

When I got the agent on the phone, he was very nice. He reassured me this was a routine inspection that the DEA does of Suboxone prescribers, and that I was on his list of doctors to visit before year’s end He was going to be in my area in the next few days and asked if I would be available. Of course I said yes. I don’t want to antagonize the DEA by being difficult, and I wanted to get it over with for my own sake. We made an appointment for him to come by my office a few days later.

Any doctor who prescribes buprenorphine (Suboxone, Subutex) can be inspected at any time by the DEA. It doesn’t happen very often because there are relatively few agents to inspect the growing number of doctors. I’ve talked to other doctors who’ve already had DEA inspections. Most said it went well with no problems, but I’ve heard a few horror stories about heavy-handed agents. The horror stories were from doctors in other states.

Two agents came to inspect my office. They came on my day off, so I didn’t have to worry about interruption of my work. Right away, I felt at ease because I recognized both of them from Addiction Medicine conferences held in North Carolina in the past. Both of them had done presentations on behalf of the DEA, to educate doctors about the law enforcement side of addiction, and the DEA’s requirements for doctors who prescribe buprenorphine (Suboxone). They knew a great deal about medication-assisted treatment in general and Suboxone in particular.

And no, they didn’t bring their guns, or if they did, I didn’t notice. They didn’t wear those jackets with “DEA” writ large across the back. They dressed in business casual, and would fit into any office setting. They did show me their DEA identification as soon as they arrived, and by the way, those badges look pretty cool.

Both were courteous, pleasant, and professional. They apologized for arriving a little later than we’d planned, and said they hoped their arrival wasn’t an inconvenience for me.  We chatted briefly, and then they asked to see my list of Suboxone patients. After making sure I didn’t have more than my allowed one hundred patients, they asked if I dispensed on site (I don’t) or kept any medication on site (I don’t). They asked if I did random urine drug testing (of course I do) and if I had a patient monitoring agreement (yes again.) They asked if I had a way to provide counseling and I said yes, I have a licensed professional counselor on site who also has a master’s in addiction counseling, but if a patient already has a therapist she prefers, I’m OK with that too, as long as she agrees to let me speak with the therapist from time to time. They wanted to see copies of the Suboxone prescriptions that I wrote for patients, and I showed them my computerized file with a copy of every patient’s prescription, organized by patient name.

Then the agents asked to see my registration with the NC department of Health and Human Services. I showed it to them, and they said many of the doctors they visited didn’t have this needed registration. They were pleased I had it. Well of course I have an up-to-date registration, I told them.

Ironically, in a random email conversation during the preceding week, someone mentioned that a registration certificate was mailed from the state when a doctor registered. I had registered, but never received a certificate. When I contacted the state, it turned out my application hadn’t been processed because the state still needed some information. I got that to them in a hurry and received my registration in the mail the day before the DEA came to inspect my office. How’s that for good luck?

They asked a few other questions, and I asked them if they’d like to see where I store charts, they said no, not really, and then they politely said good-bye. The whole thing took maybe fifteen minutes. They were friendly, and I had the impression they thought I was doing a good job.

This visit went well because I had been preparing for a DEA visit since the first day I opened my office. I made sure I always had a patient list and copies of the patients’ Suboxone prescriptions quickly available. I don’t run the most stringent Suboxone program around, but I am reasonably sure my patients are doing well. I do drug screens, use the prescription monitoring database before every patient visit, and insist patients get some sort of counseling. If patients start having problems, we talk about solutions together before the addiction worsens.

Also, the visit went well because the agents and I viewed each other as allies and not as adversaries. I appreciate these agents’ willingness to be educated about addiction, and how they at least appeared to support medication-assisted treatment for patients who need it. If this type of collaborative spirit could be duplicated across the nation, just think how much efficiently we could identify and treat addiction.

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7 responses to this post.

  1. Posted by dbc913202819276813 on December 16, 2012 at 3:26 pm

    The DEA did visit recently to a doctor I know around here – I made a comment a couple weeks ago that referenced this. For some doctors, this is scary news. For even the most squeaky clean, it is still surely an unpleasant experience! For my doctor, he asked what he ‘scored’, and without giving the exact number, they responded: 98. Thankfully, there are still mostly legit, caring doctors out there, and this monitoring has kept kept the profiteers from doing [some] unethical things. There are still cases where this has a negative impact, such as a doctor pushing people off their roles at a predetermined time, and not being as understanding of a failed drug test or two during the early stages, in order to have their records look good.

    Reply

    • Posted by dbc913202819276813 on December 16, 2012 at 3:27 pm

      Oh, and he also commented how they had asked a lot of questions about addiction and such .. dunno if they wanted to know, or were testing him.

      Reply

  2. Posted by Jay on December 16, 2012 at 3:41 pm

    Hi my name Jay and I think what you do with your blog is great. I loss my job as a law enforcement officer some years ago but I was not ready to get clean. I wish all law enforcement tried to undrstand that not all addicted personailty people are bad people. And that programs like sub subox should be more affordable in nj. I cannot find a doctor who will take medicare but I cannot afford the 200 visit because I’m on SSD. Thank you

    Reply

    • You may want to call opioid treatment programs in your area – some are able to offer the generic suboxone at relatively affordable prices. It may cost more per month, but in OTPs you can pay as you go, one day at a time. In some states OTPs do accept Medicaid/Medicare, I think.

      Reply

  3. I inform our clients from time to time about the rules & regs that govern our clinic’s operation. And we also have discussions about the steps our agency takes to properly authorize clients to receive our services. Authorization is enormously tedious and time consuming. Most people, particularly local community folks, have no idea how labor-intensive it is to provide quality opioid treatment services. There are many parts moving in unison that go on behind the scenes.

    We are providing an on-site holiday breakfast tomorrow morning for our 200 clients and their families. The families will have a chance to tour our agency and to hopefully feel more confident in the value of the staff, agency, and treatment model that their loved one is accessing.

    Reply

  4. Posted by Michael McCeney MD on December 25, 2012 at 12:20 pm

    I’m a pain anesthesiologist and write for s in cases where patients demonstrate abherent opioid behavior but not necessarily “addiction”. I did obtain the X number and used it mostly because the pharmacists said they needed it. I also found the training useful and informative. I too had the Dea visit me and they told me NOT to use the x number if I wasn’t treating addiction and urged me to give up the x number if I only do pain management. I believe Suboxone and B are great, safe alternatives to pure opioid agonists and don’t understand why the DEA is expending resources on enforcing theses regulations when there are so many other pressing issues.

    Mike McCeney MD
    Denver, colorado

    Reply

    • You can use buprenorphine in the patch form to treat pain, without using an “X” number. The brand is Butrans, and it’s a weekly patch. I too think the medication is safer, and if you have a pain patient for whom it works, it would be nice to use the tablets/film.

      But the DATA 2000 act was politially a big deal, because for the first time in about 80 years it meant a doctor could legally prescribe an opioid in an office setting to treat opioid addiction. Prior to that legislation, the Harrison Narcotic Act of 1914 was interpreted to prohibit a dotor from treating addiction in an office setting. I’m guessing because it is a kind of experiment, and because there was opposition to DATA 2000, governmental agencies want to control the extent of use of the medication, to avoid a debacle of overuse/misuse. Too much negative publicity would endanger this relatively new treatment.

      Reply

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