DEALING WITH GOVERNMENT SCRUTINY
OF PAIN MANAGEMENT BY PRIMARY
CARE PHYSICIANS
How To Anticipate And Avoid Government
Interference With This Crucial Area Of
Medical Care
By Alan I. Kaplan, Attorney at Law
310 420 6961 www.alanikaplan.com
alan@alanikaplan.com

Introduction-Origins of Opiophobia
• Food and Drug Act of 1906
• Harrison Act of 1914
• Webb (1919) Moy (1920), Behrman (1921)
– The Doctor’s Dilemna-purpose of pain meds
• Controlled Substances Act (1972)
• DEA Reassurances
– 2002 Asa Hutchinson speech to American Pain
Society: “We never want to deny deserving patients access to drugs that relieve suffering and improve the quality of life”

• Chronic Intractable Pain
• Other sanctioned treatment has run its course
– E.g. workers compensation system
• Needs pain management to work
• Financial Limitations
• Treating with PCP

DEA REASSURANCES
The Myth of the "Chilling Effect"
Doctors Operating Within Bounds of Accepted Medical
Practice Have Nothing to Fear From DEA
•
Drug Enforcement Administration (DEA) statistics show that the vast majority of practitioners registered with DEA comply with the requirements of the Controlled
Substances Act (CSA) and prescribe controlled substances in a responsible manner in treating their patients' medical needs.
• One of the the missions of the Drug Enforcement Administration (DEA), Diversion
Control Program (DCP), is to prevent, detect and investigate the diversion of legitimately manufactured controlled substances. The Controlled Substances Act
(CSA) requires doctors to become registered with DEA in order to prescribe, dispense or administer controlled drugs to their patients for legitimate medical reasons.
• The DEA may initiate an investigation of a practitioner upon receipt of information of an alleged violation of the provisions of the CSA and may pursue sanctions against the practitioner based upon the facts determined from that investigation.
• Since FY 1999 the DEA registrant population has continually increased reaching almost 1 million doctors (as of June 30, 2003). During this same time, DEA has pursued sanctions on less than one tenth of one percent of the registered doctors.
The pie charts pictured put this in graphic perspective.

• Doctors who, faced with a patient in pain, fearing being targeted by the DEA, modify their treatment in an attempt to avoid regulatory attention.
• Distortion of the doctor-patient relationship
– E.g. selecting less effective, more toxic noncontrolled medications when a trial of opioid analgesics would be in patient’s best interest

• “963,385 total registrants in 2003, only
557 investigations initiated, 441 actions against M.D.s, 34 arrests..<.1% of registered doctors”
• Estimated that only 5000 registrants are engaged in chronic opioid therapy
(Hochman, Nat. Fnd. For Trtmt. Of Pain)
• Over 10% of Chronic Opioid treaters face
DEA investigation

Strategies to Combat the
Undertreatment of Pain
• Identifying the areas of pain management most subject to greatest scrutiny
– Long term opioid use for chronic pain states
– Pain regimens where other family members object
– Operating an office dispensary
– Government databases that tabulate prescribing and purchasing patterns- CURES and ARCOS
– Older Physicians

Strategies to Combat the
Undertreatment of Pain
• Identify Agencies that have the most interest in the area and understand how they target physicians
– DEA, Medical Board, Medicare, MediCal
– Data Mining-CURES/ARCOS
– Reports from other agencies
– “Joint Task Forces”
– Use of undercover operatives

Strategies to Combat the
Undertreatment of Pain
• Risk management strategies to minimize the likelihood of being targeted
– EHR
– Use of CURES data
– Second opinions and the Intractable Pain Relief Act
– Office staff issues
– Urine tests and other methods to expose malingering and drug seeking behavior
– Documenting decision making with patients who have developed a tolerance or who have undergone detox.
– Pain contracts and surveys
• DO NOT SURRENDER YOUR REGISTRATION