Avoiding the DEA

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

painconfidential

Full Member
Joined
Oct 8, 2018
Messages
15
Reaction score
2
Hey guys more questions here:

How can I avoid any issues with the DEA in the busy private practice I joined? I honestly can't do a full proper exam on every patient and honestly most of the times its pointless especially if they are follow ups or just here for refills. My clinic has started to wean all people <90 PO morphine equivalents as a rule so thats a good positive step. One issue I have is my clinic does a ton of Personal Injury and on occasion these patients will be prescribed narcotics (albeit rare) and we are not testing Urine because the attorney doesn't want urine tested or something like that or they won't pay for the UA. So sometimes I just have to spot test. Does that even make sense?

What are other things that a good ethical pain doctor can do to avoid the eye or the DEA or some under cover agent? Honestly because I inherited some pretty high dose opioid patients I feel uncomfortable writing them anything but so far I've been sticking to my instincts and tapering everyone down to <90 PO Morphine equivalents. I usually do a brief exam when they come in for the first time : See them walk, walk on toes, heels, palpate back, quick straight leg/Faber/Spurlings/ Reflexes brief strength test. Is that enough?

Now that Im out of fellowship Im kind of paranoid the DEA will have some undercover agent and like the 1 patient out of the 30-40 I saw that day I didn't do a full exam will be an agent and will write me up even though Im weaning them off of an already high dose narcotic.

Also Im being put in a position where Im seeing these PI patients and they are requesting narcotic and I never have any urine sample on them. Im not sure how to handle that. I think Im just going to refuse to give them any narcotics unless they have a urine from now on. I don't care how expensive it is. The only problem is this will probably piss off my boss and office manager because they tend to cave in to whatever that attorney wants.

Members don't see this ad.
 
  • Like
Reactions: 1 user
Hey guys more questions here:

How can I avoid any issues with the DEA in the busy private practice I joined? I honestly can't do a full proper exam on every patient and honestly most of the times its pointless especially if they are follow ups or just here for refills. My clinic has started to wean all people <90 PO morphine equivalents as a rule so thats a good positive step. One issue I have is my clinic does a ton of Personal Injury and on occasion these patients will be prescribed narcotics (albeit rare) and we are not testing Urine because the attorney doesn't want urine tested or something like that or they won't pay for the UA. So sometimes I just have to spot test. Does that even make sense?

What are other things that a good ethical pain doctor can do to avoid the eye or the DEA or some under cover agent? Honestly because I inherited some pretty high dose opioid patients I feel uncomfortable writing them anything but so far I've been sticking to my instincts and tapering everyone down to <90 PO Morphine equivalents. I usually do a brief exam when they come in for the first time : See them walk, walk on toes, heels, palpate back, quick straight leg/Faber/Spurlings/ Reflexes brief strength test. Is that enough?

Now that Im out of fellowship Im kind of paranoid the DEA will have some undercover agent and like the 1 patient out of the 30-40 I saw that day I didn't do a full exam will be an agent and will write me up even though Im weaning them off of an already high dose narcotic.

Also Im being put in a position where Im seeing these PI patients and they are requesting narcotic and I never have any urine sample on them. Im not sure how to handle that. I think Im just going to refuse to give them any narcotics unless they have a urine from now on. I don't care how expensive it is. The only problem is this will probably piss off my boss and office manager because they tend to cave in to whatever that attorney wants.

In many states, your statement is an admission of guilt as you are breaking the law. If it seams wrong, it probably is. Not getting UDS based on atty request is just stupid.
 
Focused physical exam. You don't need to check CN 2-12 for an L5 radic. Do your exam while you're getting the HPI. Always check urine for someone on chronic opiate therapy, and it truly doesn't matter what the attorney wants. You'll learn to be efficient. Most importantly, you're not the pts friend, so don't act like it by making small talk if you're busy.
 
  • Like
Reactions: 1 user
Members don't see this ad :)
Hey guys more questions here:

How can I avoid any issues with the DEA in the busy private practice I joined? I honestly can't do a full proper exam on every patient and honestly most of the times its pointless especially if they are follow ups or just here for refills. My clinic has started to wean all people <90 PO morphine equivalents as a rule so thats a good positive step. One issue I have is my clinic does a ton of Personal Injury and on occasion these patients will be prescribed narcotics (albeit rare) and we are not testing Urine because the attorney doesn't want urine tested or something like that or they won't pay for the UA. So sometimes I just have to spot test. Does that even make sense?

What are other things that a good ethical pain doctor can do to avoid the eye or the DEA or some under cover agent? Honestly because I inherited some pretty high dose opioid patients I feel uncomfortable writing them anything but so far I've been sticking to my instincts and tapering everyone down to <90 PO Morphine equivalents. I usually do a brief exam when they come in for the first time : See them walk, walk on toes, heels, palpate back, quick straight leg/Faber/Spurlings/ Reflexes brief strength test. Is that enough?

Now that Im out of fellowship Im kind of paranoid the DEA will have some undercover agent and like the 1 patient out of the 30-40 I saw that day I didn't do a full exam will be an agent and will write me up even though Im weaning them off of an already high dose narcotic.

Also Im being put in a position where Im seeing these PI patients and they are requesting narcotic and I never have any urine sample on them. Im not sure how to handle that. I think Im just going to refuse to give them any narcotics unless they have a urine from now on. I don't care how expensive it is. The only problem is this will probably piss off my boss and office manager because they tend to cave in to whatever that attorney wants.
I was taught (in the 1970's) to always do what is best for the patient, everything else being irrelevant. Obviously, that is no longer true. My suggestion is for you is to contact the DEA and your local state agency and ask them how to be legal in their eyes. Then do whatever they say. You cannot fight city hall.
 
document and perform an exam on every patient you give a prescription opioid medication. I do a lot more than that on my exam - I look for signs of overuse, and signs of opioid toxicity - ie look at pupils, look at wakefulness, cardiac and pulmonary exam, and feel the belly. yes, I have felt a few thousand people with severe obstipation...

document a clear cut definable reason for why you are prescribing. "back pain" is not enough.

always get a pretreatment urine before prescribing, and follow local state guidelines regarding how often to do them again.

if you are feeling that you are being railroaded in to prescribing, then you should contact the DEA.
 
  • Like
Reactions: 1 user
Excellent advice above. Above all, don't document an exam (or anything) you didn't do. I don't do a full exam on everyone. Often for simple, well known, repeats, it's just a multi-system eval I can visually see. How are they walking? How are they transitioning? How are they moving their arms? Posture? Are hand joints swollen? Swelling in legs? Do they make eye contact? Are they anxious? Are they depressed? Are they slurring words? Obviously if anything has changed or they need further intervention that's a different story.

You don't necessarily need to UDS everyone, but it's a requirement if they're on opiate therapy. If the attorney doesn't like that, either too bad or the patient doesn't receive opiates. Is the lawyer going to stand behind you (without a knife) if any law enforcement official raids your office? I doubt it.

Also, for what it's worth, everyone I've talked to, including boards of medicine, have stated that as long as you're not committing fraud and you're moving your patients in the right direction while explaining your rationale in your notes, you're fine.
 
Last edited:
sounds like your job will burn you out in a year. if you are asking these questions, this doesnt seem to be a good fit
 
  • Like
Reactions: 1 users
It's very hard to be a good ethical pain doctor if your employer is enforcing and suggesting you look the other way. I had two friends leave interventional pain and go back to anesthesia because their bosses made them uncomfortable. I know a guy who left just in time before the DEA shut down his old job. On the plus side, they didn't go after him as well.
 
  • Like
Reactions: 1 user
I hope that fellows pay attention to this thread. I see practices that are not owned by physicians looking for a new grad to "supervise" 8-9 midlevels at multiple offices. Don't fall prey to setups like this. Your license, career, and freedom is on the line.
 
  • Like
Reactions: 2 users
I hope that fellows pay attention to this thread. I see practices that are not owned by physicians looking for a new grad to "supervise" 8-9 midlevels at multiple offices. Don't fall prey to setups like this. Your license, career, and freedom is on the line.

I actually talked to a doc at a recent interview whom worked for a practice like this that was shut down after he found out that they had NPs doing spinal injections under him without his knowledge in a different state that he wasn't even licensed in. Once he found out he went to the medical board and the practice had several locations shut down and investigated. He left and many of the physicians and NPs lost their license for various reasons after the investigation. I was asked by my current practice to sedate for basically anything that the patient wanted to be sedated for (including TPI) and told them I will not and if they didn't like it to hire somebody else. They didn't hire somebody else, but the fact that they even asked this and the fact that several of the other docs in my practice are doing this is an issue to me. Along with some other red/orange flags I have decided to join a new practice and hopefully will be moving on in the near future. Never sacrifice what you think is right because your boss/practice manager wants you too. Managing opioids properly is important and if something bad happens the excuse that "my boss didn't want me to test" or "my boss wanted me to do that" isn't going to fly as you the physician hold the responsibility. If the practice won't test them, then tell them you won't write for those patients if you don't want to. As somebody that is a relatively new attending I know it can be intimidating to feel that you have to stand your ground this early on something, but if you feel that it is right then do it.

Agree with other docs that for stable follow ups I do a very basic exam that takes minimal time. All new patients or folks I haven't seen in a while get extensive exam. Any patient that tells me something new is going on gets full/focused exam depending on issue. If you have never seen them before get decent exams even if a follow up because I have found several myelopathies that other docs missed including one from a laser spine place that they just operated on. Grossly positive Hoffmans with severe multi level stenosis. Sent her to Neurosurgery and had multi-level fusion.
 
  • Like
Reactions: 2 users
Hey guys more questions here:

How can I avoid any issues with the DEA in the busy private practice I joined? I honestly can't do a full proper exam on every patient and honestly most of the times its pointless especially if they are follow ups or just here for refills. My clinic has started to wean all people <90 PO morphine equivalents as a rule so thats a good positive step. One issue I have is my clinic does a ton of Personal Injury and on occasion these patients will be prescribed narcotics (albeit rare) and we are not testing Urine because the attorney doesn't want urine tested or something like that or they won't pay for the UA. So sometimes I just have to spot test. Does that even make sense?

What are other things that a good ethical pain doctor can do to avoid the eye or the DEA or some under cover agent? Honestly because I inherited some pretty high dose opioid patients I feel uncomfortable writing them anything but so far I've been sticking to my instincts and tapering everyone down to <90 PO Morphine equivalents. I usually do a brief exam when they come in for the first time : See them walk, walk on toes, heels, palpate back, quick straight leg/Faber/Spurlings/ Reflexes brief strength test. Is that enough?

Now that Im out of fellowship Im kind of paranoid the DEA will have some undercover agent and like the 1 patient out of the 30-40 I saw that day I didn't do a full exam will be an agent and will write me up even though Im weaning them off of an already high dose narcotic.

Also Im being put in a position where Im seeing these PI patients and they are requesting narcotic and I never have any urine sample on them. Im not sure how to handle that. I think Im just going to refuse to give them any narcotics unless they have a urine from now on. I don't care how expensive it is. The only problem is this will probably piss off my boss and office manager because they tend to cave in to whatever that attorney wants.
If you are already in a job that's taking huge risks in their opiate prescribing, get out immediately, before you get caught up in a raid. I don't know if that's the case. Only you can decide that. But there are many cases of complicit doc's becoming collateral damage after only being at a bad location for only a few short weeks.

Rules of safety:

All patients are told by scheduler "You will not get a prescription on the first visit, no exceptions."

Exam all patients and document good imaging and diagnoses on every patient.

All patients get a UDS day #1 (LC/MS send out, no in office dip) and no Rx that day.

All patients must have a consistent UDS, old records sent from their previous prescriber prior to any first Rx, no exceptions. No hand carried old records accepted. If no records sent by your doctor, "Bye bye. Come back when we received them." Still no guarantee of prescribing.

No opiates started on opiate naive chronic non-cancer patients, ever.

Doses not escalated, ever.

No one gets over 90 MME/day, ever (preferably as low as possible; no dose better than zero).

Any history of drug abuse, addiction, diversion, alcoholism, then no opiates, ever (let addiction psych give them the opiate called suboxone).

Any significant aberrancy, opiates discontinued immediately, no taper.

Anyone on chronic daily benzos, cannot get a chronic daily opiate. Go back to benzo prescriber, taper off, then come back and we'll talk.

No methadone for pain, ever.

No roxicodone 10, 15 or 30, ever.

No soma.

No opiates if any illicit in UDS, ever, THC included.

When in doubt, no opiates.

When writing the RX makes you feel uncomfortable, no opiates.

When you feel manipulated, by anyone (patient, family, lawyer, PCP, referring doc) no opiates, no exceptions. That is co-dependency defined.

If discharged from a previous prescriber due to an Rx agreement violation, no opiates from me, ever.

No opiates if the only diagnosis is a pain syndrome not verifiable on imaging, or some sort of diagnostic testing (eg, fibromylagia, abominal pain of unknown cause in an abdomen with normal diagnostics and surgically untouched).

Simply look for any and ever reason to not start them, not increase them or to stop them.

This is the opposite paradigm from that of 10, 20 or 30 years ago, which was, "Prescribe first, ask questions later."

Check UDS at least once per year, preferably more, or more when needed.

For every patient have a prescribing agreement on file, including warnings and risks/benefits of opiates.

For every patient have some screening tool on file, indicating you assessed their appropriateness for opiates; examples, D.I.R.E, SOAP, SOAP-R assessments (none of them are great, nor validated, but they all show you tried).

Check state PMP database every Rx, document "consistent" and if not consistent, either document valid explanation, or discontinue opiates.

Document a narcan Rx for every opiate patient, no matter what dose, frequency or drug (even tramadol).

Don't prescribe opiates to cash-pay patients (no pill mill that ever existed could survive this policy).

Have a mindset of trying to minimize opiates as much as possible and think "How can I manage this patient with means other than opiates or dose escalation" in every patient.

If you ever get an anonymous phone call telling you a patient is abusing meds or selling, assume 100% truth and discontinue opiates immediately (your liability & risk in today's environment is drastically higher for an Rx written that leads to death, than an Rx written that angered a patient who's still alive. The former can lead to loss of license, jail time or high-award wrongful death settlement; the latter is unlikely to bring more than a patient complaint, easily dismissible board complaint or easily beatable lawsuit with no provable damages).

And if you're in a job where there's pressure to do anything other that what you feel is right, quit as soon as possible.



If you follow this protocol combined with practicing good, common sense medicine, I think your risk of significant trouble with drug regulators will likely be negligible. If you do all this, document well an still get in trouble, they have to throw us all in jail. And that's not going to happen.
 
Last edited:
  • Like
Reactions: 12 users
If you are already in a job that's taking huge risks in their opiate prescribing, get out immediately, before you get caught up in a raid. I don't know if that's the case. Only you can decide that. But there are many cases of complicit doc's becoming collateral damage after only being at a bad location for only a few short weeks.

Rules of safety:

All patients are told by scheduler "You will not get a prescription on the first visit, no exceptions."

Exam all patients and document good imaging and diagnoses on every patient.

All patients get a UDS day #1 (LC/MS send out, no in office dip) and no Rx that day.

All patients must have a consistent UDS, old records sent from their previous prescriber prior to any first Rx, no exceptions. No hand carried old records accepted. If no records sent by your doctor, "Bye bye. Come back when we received them." Still no guarantee of prescribing.

No opiates started on opiate naive chronic non-cancer patients, ever.

Doses not escalated, ever.

No one gets over 90 MME/day, ever (preferably as low as possible; no dose better than zero).

Any history of drug abuse, addiction, diversion, alcoholism, then no opiates, ever (let addiction psych give them the opiate called suboxone).

Any significant aberrancy, opiates discontinued immediately, no taper.

Anyone on chronic daily benzos, cannot get a chronic daily opiate. Go back to benzo prescriber, taper off, then come back and we'll talk.

No methadone for pain, ever.

No roxicodone 10, 15 or 30, ever.

No soma.

No opiates if any illicit in UDS, ever, THC included.

When in doubt, no opiates.

When writing the RX makes you feel uncomfortable, no opiates.

When you feel manipulated, by anyone (patient, family, lawyer, PCP, referring doc) no opiates, no exceptions. That is co-dependency defined.

If discharged from a previous prescriber due to an Rx agreement violation, no opiates from me, ever.

No opiates if the only diagnosis is a pain syndrome not verifiable on imaging, or some sort of diagnostic testing (eg, fibromylagia, abominal pain of unknown cause in an abdomen with normal diagnostics and surgically untouched).

Simply look for any and ever reason to not start them, not increase them or to stop them.

This is the opposite paradigm from that of 10, 20 or 30 years ago, which was, "Prescribe first, ask questions later."

Check UDS at least once per year, preferably more, or more when needed.

For every patient have a prescribing agreement on file, including warnings and risks/benefits of opiates.

For every patient have some screening tool on file, indicating you assessed their appropriateness for opiates; examples, D.I.R.E, SOAP, SOAP-R assessments (none of them are great, nor validated, but they all show you tried).

Check state PMP database every Rx, document "consistent" and if not consistent, either document valid explanation, or discontinue opiates.

Document a narcan Rx for every opiate patient, no matter what dose, frequency or drug (even tramadol).

Don't prescribe opiates to cash-pay patients (no pill mill that ever existed could survive this policy).

Have a mindset of trying to minimize opiates as much as possible and think "How can I manage this patient with means other than opiates or dose escalation" in every patient.

If you ever get an anonymous phone call telling you a patient is abusing meds or selling, assume 100% truth and discontinue opiates immediately (your liability & risk in today's environment is drastically higher for an Rx written that leads to death, than an Rx written that angered a patient who's still alive. The former can lead to loss of license, jail time or high-award wrongful death settlement; the latter is unlikely to bring more than a patient complaint, easily dismissible board complaint or easily beatable lawsuit with no provable damages).

And if you're in a job where there's pressure to do anything other that what you feel is right, quit as soon as possible.



If you follow this protocol combined with practicing good, common sense medicine, I think your risk of significant trouble with drug regulators will likely be negligible. If you do all this, document well an still get in trouble, they have to throw us all in jail. And that's not going to happen.

Great stuff. I totally agree.
Sometimes in new patients, when I see a dangerous combination on the PDMP, I call the prescribers and let them know what I see on the PDMP. Many are PCPs that never check the PDMP and are surprised that their patient is getting other controlled substances somewhere else. They usually are very receptive and want to taper.
 
  • Like
Reactions: 1 user
Members don't see this ad :)
Why no oxy 10?
When I first started practice in the town I'm in, the local (state) drug control agent told me that roxicodone, in any form (10, 15, 30mg, plain oxycodone, no tylenol, no tamper resistant formulation) is the single drug with the greatest street value in my town ($1 per mg).

I'm not saying you can't prescribe it at all, ever, but it's just a matter of determining what the pill mills are doing and doing the opposite.

Go to the DEA/diversion website and read the indictments against doctors ("Cases Against Doctors") and study the common threads among the doctors that are in legal trouble. There are certain themes that recur over and over again. Determine what they are and set official policy that makes it impossible for you or anyone in your practice to intentionally or unintentionally do those things.
 
Try to find out what the standard of care is in your state, then exceed it. It sounds like you're feeling pressure to see lots of complicated patients on high doses of opioids who are new to you for short periods of time, just to keep things moving, and you should know that this puts you at a lot of risk. If you're not verifying people's diagnoses and histories and so on, you're just assuming that the doctor before you did the right thing with all these patients, and that's not a safe assumption at all. In fact, that pretty much guarantees that you're going to find out a lot of scary and bad things later on, the hard way, after you've been seeing these patients for a while and prescribing for them and your name is all over the chart, known throughout the community, known to the pharmacies, etc. This is not a good place to find yourself.
 
  • Like
Reactions: 1 user
Rules of safety:

No opiates started on opiate naive chronic non-cancer patients, ever.
No hand carried old records accepted.
Doses not escalated, ever.
Anyone on chronic daily benzos, cannot get a chronic daily opiate. Go back to benzo prescriber, taper off, then come back and we'll talk.
No roxicodone 10, 15 or 30, ever.
No soma.
Don't prescribe opiates to cash-pay patients (no pill mill that ever existed could survive this policy).

You're being too paranoid with some of these suggestions. Some of these have nothing to do with avoiding the DEA and will just lead to bad quality pain management. All they really care about is that you're examining each patient properly, checking their UDS, checking the PDMP, staying under 90MME for most patients, and using common sense. Basically just following the CDC guidelines. The guidelines say keep them at their lowest EFFECTIVE dose, not lowest dose possible no matter what....
 
Last edited:
You're being too paranoid with some of these suggestions. Some of these have nothing to do with avoiding the DEA and will just lead to bad quality pain management. All they really care about is that you're examining each patient properly, checking their UDS, checking the PDMP, staying under 90MME for most patients, using common sense. Basically just following the CDC guidelines. The guidelines say keep them at their lowest EFFECTIVE dose, not lowest dose possible no matter what....

Yeah I think emd is def paranoid. Prob the EM training in him/her. I totally agree COT for most patients long term is not great but I think there is a role for opioids in select patient populations that have non-cancer pain.
 
  • Like
Reactions: 1 user
You're being too paranoid with some of these suggestions.

Yeah I think emd is def paranoid.

This is exactly the space I want to occupy in today's environment. Just remember, that your "less paranoid" version of conservative practice was "too paranoid" practice of yesteryear. And as OD deaths continue to rise, causing societal, media and governmental paranoia to worsen, my overly conservative method of practice may be considered too lax 5 years from now. But if I'm on the "too conservative" end of the opiate spectrum, I'm very happy with that. I'm glad to hear that I am.
 
Everything about this sounds awful.
 
  • Like
Reactions: 1 user
This is exactly the space I want to occupy in today's environment. Just remember, that your "less paranoid" version of conservative practice was "too paranoid" practice of yesteryear. And as OD deaths continue to rise, causing societal, media and governmental paranoia to worsen, my overly conservative method of practice may be considered too lax 5 years from now. But if I'm on the "too conservative" end of the opiate spectrum, I'm very happy with that. I'm glad to hear that I am.

You're not being paranoid at all. Unfortunately, physicians are increasingly seen under a guilty situation and branded as evil. Especially with lawyers, government, and everyone waiting for one goof up to screw over a physician for life. You have to be paranoid in today's climate. Sad but true, this is what these idiots wanted, and this is what they got. Hence why defensive medicine practiced to the Nth degree now.
 
  • Like
Reactions: 1 user
If you are already in a job that's taking huge risks in their opiate prescribing, get out immediately, before you get caught up in a raid. I don't know if that's the case. Only you can decide that. But there are many cases of complicit doc's becoming collateral damage after only being at a bad location for only a few short weeks.

Rules of safety:

All patients are told by scheduler "You will not get a prescription on the first visit, no exceptions."

Exam all patients and document good imaging and diagnoses on every patient.

All patients get a UDS day #1 (LC/MS send out, no in office dip) and no Rx that day.

All patients must have a consistent UDS, old records sent from their previous prescriber prior to any first Rx, no exceptions. No hand carried old records accepted. If no records sent by your doctor, "Bye bye. Come back when we received them." Still no guarantee of prescribing.

No opiates started on opiate naive chronic non-cancer patients, ever.

Doses not escalated, ever.

No one gets over 90 MME/day, ever (preferably as low as possible; no dose better than zero).

Any history of drug abuse, addiction, diversion, alcoholism, then no opiates, ever (let addiction psych give them the opiate called suboxone).

Any significant aberrancy, opiates discontinued immediately, no taper.

Anyone on chronic daily benzos, cannot get a chronic daily opiate. Go back to benzo prescriber, taper off, then come back and we'll talk.

No methadone for pain, ever.

No roxicodone 10, 15 or 30, ever.

No soma.

No opiates if any illicit in UDS, ever, THC included.

When in doubt, no opiates.

When writing the RX makes you feel uncomfortable, no opiates.

When you feel manipulated, by anyone (patient, family, lawyer, PCP, referring doc) no opiates, no exceptions. That is co-dependency defined.

If discharged from a previous prescriber due to an Rx agreement violation, no opiates from me, ever.

No opiates if the only diagnosis is a pain syndrome not verifiable on imaging, or some sort of diagnostic testing (eg, fibromylagia, abominal pain of unknown cause in an abdomen with normal diagnostics and surgically untouched).

Simply look for any and ever reason to not start them, not increase them or to stop them.

This is the opposite paradigm from that of 10, 20 or 30 years ago, which was, "Prescribe first, ask questions later."

Check UDS at least once per year, preferably more, or more when needed.

For every patient have a prescribing agreement on file, including warnings and risks/benefits of opiates.

For every patient have some screening tool on file, indicating you assessed their appropriateness for opiates; examples, D.I.R.E, SOAP, SOAP-R assessments (none of them are great, nor validated, but they all show you tried).

Check state PMP database every Rx, document "consistent" and if not consistent, either document valid explanation, or discontinue opiates.

Document a narcan Rx for every opiate patient, no matter what dose, frequency or drug (even tramadol).

Don't prescribe opiates to cash-pay patients (no pill mill that ever existed could survive this policy).

Have a mindset of trying to minimize opiates as much as possible and think "How can I manage this patient with means other than opiates or dose escalation" in every patient.

If you ever get an anonymous phone call telling you a patient is abusing meds or selling, assume 100% truth and discontinue opiates immediately (your liability & risk in today's environment is drastically higher for an Rx written that leads to death, than an Rx written that angered a patient who's still alive. The former can lead to loss of license, jail time or high-award wrongful death settlement; the latter is unlikely to bring more than a patient complaint, easily dismissible board complaint or easily beatable lawsuit with no provable damages).

And if you're in a job where there's pressure to do anything other that what you feel is right, quit as soon as possible.



If you follow this protocol combined with practicing good, common sense medicine, I think your risk of significant trouble with drug regulators will likely be negligible. If you do all this, document well an still get in trouble, they have to throw us all in jail. And that's not going to happen.

Someone give this guy a gold medal. You killed it. Thank you.
 
  • Like
Reactions: 1 user
Hey guys more questions here:

How can I avoid any issues with the DEA in the busy private practice I joined? I honestly can't do a full proper exam on every patient and honestly most of the times its pointless especially if they are follow ups or just here for refills. My clinic has started to wean all people <90 PO morphine equivalents as a rule so thats a good positive step. One issue I have is my clinic does a ton of Personal Injury and on occasion these patients will be prescribed narcotics (albeit rare) and we are not testing Urine because the attorney doesn't want urine tested or something like that or they won't pay for the UA. So sometimes I just have to spot test. Does that even make sense?

What are other things that a good ethical pain doctor can do to avoid the eye or the DEA or some under cover agent? Honestly because I inherited some pretty high dose opioid patients I feel uncomfortable writing them anything but so far I've been sticking to my instincts and tapering everyone down to <90 PO Morphine equivalents. I usually do a brief exam when they come in for the first time : See them walk, walk on toes, heels, palpate back, quick straight leg/Faber/Spurlings/ Reflexes brief strength test. Is that enough?

Now that Im out of fellowship Im kind of paranoid the DEA will have some undercover agent and like the 1 patient out of the 30-40 I saw that day I didn't do a full exam will be an agent and will write me up even though Im weaning them off of an already high dose narcotic.

Also Im being put in a position where Im seeing these PI patients and they are requesting narcotic and I never have any urine sample on them. Im not sure how to handle that. I think Im just going to refuse to give them any narcotics unless they have a urine from now on. I don't care how expensive it is. The only problem is this will probably piss off my boss and office manager because they tend to cave in to whatever that attorney wants.

Sorry, I just have to get back to this again. Because I went through something similar in a job process where most of what I was finding was super shady positions like this. The bolded part to me spoke volumes and is what inherently pisses me off. Dude, you didn't go through 4 years of undergrad, 4 years of medical school, 4 years of residency, and one year of fellowship to be treated like some piece of trash by a money hungry attorney and an office manager or boss. Screw that, your dignity is worth more than that. I would leave, and find another job, as difficult as it sounds because believe me, I know it's not easy to be unemployed. But better that than your license. All these guys see you as a mere vehicle for money driven profits - they could care less about you, your license, your life, your reputation, etc. The fact that medicine as a whole, and pain management in this case, got to this very state is pathetic. Doctors are a joke, we're such timid book nerds that we've let others run our lives and dictate to us what to do. What an absolute joke.
 
  • Like
Reactions: 2 users
You're being too paranoid with some of these suggestions. Some of these have nothing to do with avoiding the DEA and will just lead to bad quality pain management. All they really care about is that you're examining each patient properly, checking their UDS, checking the PDMP, staying under 90MME for most patients, and using common sense. Basically just following the CDC guidelines. The guidelines say keep them at their lowest EFFECTIVE dose, not lowest dose possible no matter what....
Some of these have nothing to do with avoiding the DEA and will just lead to bad quality pain management.
If you believe opiate reduction = "bad quality pain management" then I disagree, in fact, I believe it's the opposite. It's good quality pain management. But regardless of whether you or I am right about that, the powers that be are pushing this pendulum to a point where "opiates don't help chronic non-cancer pain at all." Once we're there, then you have a drug that kills people and ruins lives with no benefit. In that setting, it's hard to justify anything but the strictest restrictions.

I'm not saying "my way is the only right way." I think if you do the required things, as you've listed them, then most likely you'll be fine. And I personally do think opiates (low-mod dose) help some people and are safe in some patients and that's why I do prescribe some patients low-moderate dose opiates, albeit under very restricted criteria. But the less and less they're accepted as an effective treatment for CNC Pain, the thinner the ice we're skating with anything but the most conservative of approaches. So we have to be careful and be pro-active based on where things are going, as opposed to reactive. Read about Lynn Webster, Lifetree clinic, and about how he had a run of patient overdose deaths and was ultimately cleared, by not until he had to go through a painful DEA raid, clinic shut down and years long investigation under the threat of possible federal indictment. Keep in mind that he was President of American Academy of Pain Medicine at the time.

I definitely think I'm much more conservative with opiate prescribing than the average Pain MD, except for of course those that prescribe none. It's just because of the direction things are going, because I can guarantee you, OD deaths are going to continue to rise and the regulators will twist the nuts of the easiest victim, and that's the powerless weaklings in white coats with their traceable DEA numbers and no ability to pay legal fees once their practice is shut down and under investigation. It's much more difficult to go after the real problem, that is the secret, hidden fentanyl factories in China, that are supplying most of the opiates now. The Feds are even less likely to blame their own US mail service which transports most of it to the country without inspection.

"An ounce of prevention is worth a pound of cure. "
- Ben Franklin.
 
Last edited:
  • Like
Reactions: 1 users
If you believe opiate reduction = "bad quality pain management" then I disagree, in fact, I believe it's the opposite. It's good quality pain management. But regardless of whether you or I am right about that, the powers that be are pushing this pendulum to a point where "opiates don't help chronic non-cancer pain at all." Once we're there, then you have a drug that kills people and ruins lives with no benefit. In that setting, it's hard to justify anything but the strictest restrictions.

I'm not saying everyone needs to follow my policies to "stay out of trouble" with the DEA. And I'm not saying "my way is the only right way." I think if you do the required things, as you've listed them, then most likely you'll be fine. And I personally do think opiates (low-mod dose) help some people and are safe in some patients and that's why I do prescribe some patients low-moderate dose opiates, albeit under very restricted criteria. But the less and less they're accepted as an effective treatment for CNC Pain, the thinner the ice you're skating with anything but the most conservative of approaches. So we have to be careful and be pro-active based on where things are going, as opposed to reactive. Read about Lynn Webster, Lifetree clinic, and about how he had a run of patient overdose deaths and was ultimately cleared, by not until he had to go through a painful DEA raid, clinic shut down and years long investigation under the threat of possible federal indictment. Keep in mind that he was President of American Academy of Pain Medicine at the time. Pro-active = prevention. Reactive = life and career destroyed, and maybe get a pat on the back and "you're cleared" at the end of 3 years, if you're lucky, or if not lucky, life and career destroyed with a federal indictment.

I definitely think I'm much more conservative with opiate prescribing than the average Pain MD, except for of course those that prescribe none. It's just because of the direction things are going, because I can guarantee you, OD deaths are going to continue to rise and the regulators will twist the nuts of the easiest victim, and that's the powerless weaklings in white coats with their traceable DEA numbers and no ability to pay legal fees once their practice is shut down and under investigation. It's much more difficult to go after the real problem, that is the secret, hidden fentanyl factories in China, that are supplying most of the opiates now. The Feds are even less likely to blame their own US mail service which transports most of it to the country without inspection.

"An ounce of prevention is worth a pound of cure. "
- Ben Franklin.

Keep doing what you're doing man. You're doing the right thing. We need more people like you. You need to dictate pain management on your own terms, and in the way you feel is best practiced and safest. You don't need some people telling you that you're being too cautious and over-doing it. The system has made it a mockery, you're merely practicing on top of the absurdities that are already established in the best manner for yourself.
 
  • Like
Reactions: 3 users
Keep doing what you're doing man. You're doing the right thing. We need more people like you. You need to dictate pain management on your own terms, and in the way you feel is best practiced and safest. You don't need some people telling you that you're being too cautious and over-doing it. The system has made it a mockery, you're merely practicing on top of the absurdities that are already established in the best manner for yourself.
Thanks.
 
You're being too paranoid with some of these suggestions. Some of these have nothing to do with avoiding the DEA and will just lead to bad quality pain management. All they really care about is that you're examining each patient properly, checking their UDS, checking the PDMP, staying under 90MME for most patients, and using common sense. Basically just following the CDC guidelines. The guidelines say keep them at their lowest EFFECTIVE dose, not lowest dose possible no matter what....

I disagree. His "paranoia" is dialed in to the right level. This is all 100% real.
 
Hey guys more questions here:

How can I avoid any issues with the DEA in the busy private practice I joined? I honestly can't do a full proper exam on every patient and honestly most of the times its pointless especially if they are follow ups or just here for refills. My clinic has started to wean all people <90 PO morphine equivalents as a rule so thats a good positive step. One issue I have is my clinic does a ton of Personal Injury and on occasion these patients will be prescribed narcotics (albeit rare) and we are not testing Urine because the attorney doesn't want urine tested or something like that or they won't pay for the UA. So sometimes I just have to spot test. Does that even make sense?

What are other things that a good ethical pain doctor can do to avoid the eye or the DEA or some under cover agent? Honestly because I inherited some pretty high dose opioid patients I feel uncomfortable writing them anything but so far I've been sticking to my instincts and tapering everyone down to <90 PO Morphine equivalents. I usually do a brief exam when they come in for the first time : See them walk, walk on toes, heels, palpate back, quick straight leg/Faber/Spurlings/ Reflexes brief strength test. Is that enough?

Now that Im out of fellowship Im kind of paranoid the DEA will have some undercover agent and like the 1 patient out of the 30-40 I saw that day I didn't do a full exam will be an agent and will write me up even though Im weaning them off of an already high dose narcotic.

Also Im being put in a position where Im seeing these PI patients and they are requesting narcotic and I never have any urine sample on them. Im not sure how to handle that. I think Im just going to refuse to give them any narcotics unless they have a urine from now on. I don't care how expensive it is. The only problem is this will probably piss off my boss and office manager because they tend to cave in to whatever that attorney wants.

If you are writing opioids for patients without getting UDS, you will lose your license. If the people running your practice don't know this, they will soon.
 
  • Like
Reactions: 1 users
Top