11-15-18

We will be closing the fort smith office permanently in January and no longer providing buprenorphine management.  We are in the process of delisting ourselves from addiction help websites.


This is a difficult business due to the constant risk of diversion and risk of being targeted by law enforcement.    We had the lowest prices anywhere in Arkansas but unfortunately attracted some bad actors and now have informants approaching our patients for entrapment.   I have to assume that I am personally targeted.  This was only 8 hours a week of my entire practice and we do not generate any significant revenue to be worth the risk.  For example last year our gross was $18000 approximately.  This year is probably a little higher.  It is unfortunate that we weren't able to catch all the diversion before it attracted attention of law enforcement.  


I have tried to constantly exhort my patients that even selling  just a few pills  of schedule 3 buprenorphine in the jurisdictions around here  is treated the same as distribution of oxycodone and heroin, but apparently some did not listen.  


I have learned quite a bit since starting in buprenorphine management.   If a buprenorphine prescriber happens to stop by I have some useful advice here.  I will be blogging about my experiences in the future.  Hopefully I have no future experiences to blog about.  


These are  the same procedures used to target pain doctors too, or anybody who provides real pain treatment instead of placebos like gabapentin.  One might want to assess how many prescriptions one has out there and start cutting off your patients if you live in a high risk jurisdiction or have already had law enforcement complain to you.  That was your warning.  Heed it .  Stop the prescriptions and get out.


The first and probably most important thing someone needs to know is that in some jurisdictions it isn't safe to dose by guidelines which suggest individualizing the dose of buprenorphine to the point the person has no cravings or desire to use other more dangerous opiates.  Word gets around that you are "easy" when you are merely following dosing recommendations.  The bad actors will start scheduling at your clinic.  In order to survive as a buprenorphine prescriber in a small solo office (which automatically makes you look suspicious)  in some jurisdictions one has to deny all dose increase requests.  


I did wonder why the other guy in town was forcing dosage reductions on his patients.  The general standard of care is to provide sufficient medications for an indefinite period of time in order to prevent relapse to more dangerous illegal drugs.  If you try that then you will attract  people who know each other and find the "easy" doctor.  The bad actors will then ask for three tablets per day, take two per day, and sell 30 per month for a little extra income.  


 In some jurisdictions where there is zero tolerance for any level of buprenorphine  diversion if you are the only doctor acceding to requests to "provide enough medication so I don't crave drugs or relapse" then your career will be very short.  You will need to figure out your "jurisdictional profile," your personal profile within that jurisdiction, and  decide if you can  provide individualized maintenance treatment within the entire acceptable dosing range.  You should  figure this out before informants start to entrap your patients, not after like I did. Paul Smith is on record as blaming doctors for the heroin epidemic if that tells you anything.  


http://www.swtimes.com/news/20180318/dtf-director-details-history-of-sebastian-county-opioid-abuse


Sebastian County leads the state in "drug distribution arrests."


http://www.swtimes.com/news/20180826/respondents-heroin-has-presence-in-sebastian-crawford-counties


No doubt that is true.  However that includes a lady who was worked by a family member informant for a month to sell a few tablets of hydrocodone left over from a procedure.  She has never had a previous arrest.  After she and her public defender pleaded to 4 in and 16 out they should have informed the judge of the particulars of the case.  Apparently an informant can target any one and there is no limit to how they approach you or how many times they approach you.  That particular informant must have been desperate to get his numbers up.  Ten tablets lol.  Diversion is diversion of course.  However it appears anecdotally it is being taken to an extreme.




 La Flor county is the  other county that seems most aggressive in sending out informants to detect microdiversion.  I can't imagine why any doctor would want to treat pain or addiction there. 


I will have more to post later.


It is later lol.  Here is how the death spiral starts.  You are the new doctor out there.  You know the dosing guidelines and the intent behind them.  Since there are so few buprenorphine prescribers out there you eventually end up with people who feel they are getting ripped off at $200 plus per visit or who have to travel an hour or more to see a buprenorphine doctor.  You will end up with a lot of transfers if you are reasonable in your pricing and in your dosing.  You are probably dealing with a population where 9 out of 10 are sincere.  One out of ten is looking for a new doctor for nefarious purposes.  Many will tell you the previous doctor has forced reductions on them and they are either at risk of relapsing or have already relapsed.  In good faith you give them the dose they say they need.  The first bad actor then goes out and tells his or her buddies.

  Then they all start transfering to you or scheduling with you for an initial appointment. 


This brings up another issue we have learned.  Watch for "clusters," patients from the same area who schedule within a month of each other.  Assume they know each other.  A cluster may be legitimate or may not be.  However any cluster must have more random pill counts than people who come in sporadically from various areas who  have a middle class lifestyle, good insurance, a job, and don't look like the stereotype of an addict.  We have never caught a client with Blue Cross and a good job short on a pill count.


Once you have a group of five or more taking two tablets per day on average and selling one tablet per day on average eventually one of them gets caught.  Law enforcement may give you a break on the first one or two.  Most likely by the third or fourth time one of the counties decides to give the next one they catch an opportunity to become an informant.  This informant usually knows many of the other patients who come to the clinic since this is a small area and most opiate dependent people seem to know  the other ones who live in the same town or county.  The informant then starts approaching your other patients.  If they can finagle a few pills out of them then they go to the next and next.  Pretty soon law enforcement has rolled up most of your patients diverting medications that you didn't catch.  This may spread to another county and then another county as the "problem doctor" is discussed among the various drug task forces.  


Pretty soon they may have caught ten or heaven forbid 20  of your patients selling a few pills here or there.  That actually may be the baseline rate of diversion.  Since no one knows the baseline rate for sure it doesn't really matter though.  Once you are targeted and they exceed their implicit or explicit predetermined threshold you are finished.  At that point they may just inform the DEA about the diversion problem and you will get an inspection order.  It is hard to survive an inspection order but you might.It is possible but rare.  Why do doctors fear a DEA inspection?  Because even if you win you lose.


http://www.tribtown.com/2018/11/24/pain_clinic_doctor_tries_to_move_forward_after_raid/


  However if they have decided that you are a problem they want to eliminate or make an example of to the community then undercover comes through with a wire.  


The undercover agent will note and record everything you do. Don't ever joke with your patients since that will be used against you as it was to a colleague of mine.  If you miss a vague comment that might indicate diversion you are sunk too.   One doctor recently in another state had an undercover agent make several appointments.  On one appointment she said she had to sell a few pills in order to help pay rent.  The doctor probably felt sorry for her, admonished her not to do that, and continued to prescribe for her original condition.  Wrong move.  After he was arrested law enforcement tried to get the medical board to take his license but the medical board refused.  Even medical boards can tell when some things just go too far.


 The amount of time you spend with patients will be noted too.  In general you will be criticised for spending too little time with patients or not conducting "appropriate" exams.  In general, however,  doctors don't do comprehensive physical  exams.  I am not aware of any buprenorphine prescribers who do actual physical exams during clinic visits. Some don't even take blood pressure.  They aren't necessary and we gave them up for a basic mental status exam and assessment of gait and balance and drowsiness.   It is somewhat rare for a doctor to do physical  exams any more in a regular clinical practice or the ER either, since we have more efficient tools if necessary than 100 year old exam techniques.  Brief visits and "superficial" or "no exam"  will be considered evidence the doctor is sloppy and not managing his clinic appropriately As a result the doctor is held responsible for the  diversion.


   There you have the playbook as it is applied to "problem doctors."   The fact that for chronic pain issues or addiction management that comprehensive physical exams do not help in the decision making process and that you are doing what every other doctor in the area does is irrelevant. 


Diversion is going to happen even if you spend an hour on the physical exam and an hour in the interview.  That is why we have tried to develop other techniques to detect diversion.  However it is a balancing act.  The more aggressive you are in diversion minimization and the more quick you are to pull the trigger the more likely you are to discharge legitimate patients who lost a prescription, had no minutes on their phone to get the message for a quick pill count, or other such things.


 


 If your patients are asking for a dose increase because they are saying they are afraid they will relapse then you can generally be confident they are taking the current number of pills prescribed and not selling any.  You will have to err on the side of increased risk of relapse in your patient population in order to protect yourself, unless you are part of a large respectable group.   I am doubtful anyone would go after UAMS for diversion for example.


As a solo doctor in jurisdictions where there isn't any tolerance for diversion and no distinction is made between buprenorphine and other more dangerous opiates then you are probably safest doing what the other doctor in my area does.  He might start them out on three tablets per day.  he won't ever go to four.  He also starts tapering them fairly quickly.  In such a practice diversion is minimized but at the cost of higher relapse and treatment dropout rates. 


 If I were ever going to do this again i would ignore the guidelines and start mandatory forced  tapers after a period of time that might be more flexible and slower  for some who appear safe and less flexible and more rapid for others.  


The forced taper is  not the generally recommended treatment and does increase  the risk of relapse.  However it is  the safest approach in some jurisdictions, especially if you fit the profile of an at risk doctor.  In more tolerant and realistic jurisdictions maintenance treatment with generous dosing is probably safe.  Some jurisdictions know that it isn't possible to get a lot of relatively safe buprenorphine out there to combat the opiate epidemic and reduce the overdose rate without some level of diversion.  


In summary if you fit the profile of a high risk practice and you live in a high risk jurisdiction your safest approach is mandatory buprenorphine tapers at some point after stabilization rather than indefinite maintenance treatment.



If you decide to do maintenance treatment then you must understand that you will have some percentage of diversion.  This will be mostly casual diversion where a person takes a portion of their pills and sells or trades a portion.  Diversion is diversion however.  Here are a couple of things we have developed.


1.  Mandatory pill counts on appointment day and drug screens are insufficient.  you will need to have the ability to do random pill counts of a certain percentage of your patients between appointments.  Poor people who lack reliable transportation, reliable phones and lack insurance are at the highest risk of an overdose death.  Unfortunately they are also at the highest risk of casual diversion to make a little extra income.  The lack of reliable transportation  or inability to get away from work during clinic hours for a random pill count can be addressed by internet pill counts.  Ask them to send a clear photo of their pills face up then have them put something in the picture to demonstrate the picture was taken in the right time frame  "write merry xmas" on a piece of paper and stick it in the photo for example.  We have also had people put a spoon in the photo, write their first name and date on a piece of paper, and other such things.  The problem with this method is that the poor people most likely to be tempted to divert a portion of their pills as an income supplement are also the people most likely to have a phone with limited minutes.  Some live in places with limited connectivity.  Some may have changed numbers and not notified the clinic.  Some may have a broken or lost phone.  This can be time consuming and you may end up discharging legitimate patients who actually give a real excuse as to why they did not complete the pill count as requested. 


2.  There are legitimate reasons a patient may have to reschedule.  Some may reschedule so they can  show up with a zero pill count and be considered legitimate.  Everyone who calls to reschedule must have a mandatory internet pill count that day.  They can't pretend they missed the message or their phone wasn't working or they were in a dead zone if you ask for the pill count at the time they call to reschedule.  Your legitimate patients will be understanding.


3. Constantly exhort your patients to be on guard to someone approaching them to buy a few pills and to inform you immediately of their name.  Your legitimate patients will do so.  This is how we detected we had informants attempting to entrap our patients.  Consider this your last line of defense.  However once a pattern is established that you have informants targeting your patients then it may be too late.  The diverters  you didn't catch have likely been caught and turned and at that point LE is just attempting to run up the score.


4.  Try to get in contact with your local drug task force and any drug task forces in areas where you attract patients.  Do this before you write your first prescription.  Explain to them ahead of time your procedures and you would like their assistance in deterring diversion.  Give them your cell phone number.  Obviously any calls about diversion would be the highest priority.   If you can get them to collaborate with you then they will let you know of any diversion or rumors of diversion.  You can simply demand an internet or in person pill count that day and solve the problem quickly before it progresses to the point you have someone in your office with a wire.


5.  In a high risk jurisdiction don't agree to a dose increase for any reason.  It is better to err on the side of  relapse or treatment failure at least in terms of your professional career.


So good luck in your addiction management prescribing or pain management practice.  If you have had several law enforcement complaints or detect informants attempting to entrap your patients then you have been labeled a bad doctor.  It is possible you career might survive its first DEA or medical board enquiry.  However once you have been targeted your career will not survive in that area.  It is only a matter of time before law enforcement finds more diversion or slips undercover into your practice wearing wires.  It won't be just one.  They will keep sending undercover in until they catch you saying or doing something they can use against you.  Once you realize you are on the radar then you simply have to stop prescribing an opioid for any reason.  That may sound drastic but anyone who has been watching the pain management or opiate dependence scene in certain jurisdictions for a decade or more knows that I am speaking the truth.  In my case after the first law enforcement threat was relayed to me I thought I could tighten up and continue to practice.  I was obviously mistaken.  Close up shop after your first board review or DEA review, especially having  had a threat left on your voice mail by law enforcement, or you detect informants.  Eventually after law enforcement  sends enough people through with a wire you will be caught off guard and they have you.  I have seen doctors try to stick it out after they have been targeted.  It never works out

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