The Current State of Opioid Prescribing and Drug Enforcement Agency (DEA) Action Against Physicians: An Analysis of DEA Database 2004-2017.

BACKGROUND: Prescribing opioids has become a challenge. The US Drug Enforcement Agency (DEA) and Centers for Disease Control and Prevention (CDC) have become more involved, culminating in the March 2016 release of the CDC's "Guidelines for Prescribing Opioids for Chronic Pain." OBJECTIVES: Given the new guidelines, we wanted to see if there have been any changes in the numbers, demographics, physician risk factors, charges, and sanctions involving the DEA against physicians who prescribe opioids, when compared to a previous DEA database review from 1998 to 2006. STUDY DESIGN: This study involved an analysis of the DEA database from 2004 to 2017. SETTING: The review was conducted at the Henry Ford Health System Division of Pain Medicine. METHOD: After institutional review board approval at Henry Ford Health System, an analysis of the DEA database of criminal prosecutions of physician registrants from 2004-2017 was performed. The database was reviewed for demographic information such as age, gender, type of degree (doctor of medicine [MD] or doctor of osteopathic medicine [DO]), years of practice, state, charges, and outcome of prosecution (probation, sentencing, and length of sentencing). An internet-based search was performed on each registrant to obtain demographic data on specialty, years of practice, type of medical school (US vs foreign), board certification, and type of employment (private vs employed). RESULTS: Between 2004 and 2017, Pain Medicine (PM) had the highest percentage of in-specialty action at 0.11% (n = 5). There was an average of 18 prosecutions per year vs 14 in the previous review. Demographic risk factors for prosecution demonstrated the significance of the type of degree (MD vs. DO), gender, type of employment (private vs. employed), and board certification status for rates of prosecution. Having a DO degree and being male were associated with significantly higher risk as well as being in private practice and not having board certification (P < .001). In terms of type of criminal charges as a percent of cases, possession with intent to distribute (n = 90) was most prevalent, representing 52.3% of charges, with new charges being prescribing without medical purpose outside the usual course of practice (n = 71) representing 41.3% of charges. Comparison of US graduates (MD/DO) vs. foreign graduates showed higher rates of DEA action for foreign graduates but this was of borderline significance (P = .072). LIMITATIONS: State-by-state comparisons could not be made. Specialty type was sometimes self-reported, and information on all opioid prosecutions could not be obtained. The previous study by Goldenbaum et al included data beyond DEA prosecution, so direct comparisons may be limited. CONCLUSION: The overall risk of DEA action as a percentage of total physicians is small but not insignificant. The overall rates of DEA prosecution have increased. New risk factors include type of degree (DO vs. MD) and being in private practice with a subtle trend toward foreign graduates at higher risk. With the trend toward less prescribing by previously high-risk specialties such as Family Medicine, there has been an increase in the relative risk of DEA action for specialties treating patients with pain such as PM, Physical Medicine and Rehabilitation, neurology, and neurosurgery bearing the brunt of prosecutions. New, more subtle charges have been added involving interpretation of the medical purpose of opioids and standard of care for their use. KEY WORDS: Certification, CDC, criminal, DEA, opioid, prescribing, prosecution, sanctions.

Characterization of exposures to workers covered under the U.S. Energy Employees Compensation Act.

Since the mid-1940s, hundreds of thousands of workers have been engaged in nuclear weapons-related activities for the U.S. Department of Energy (DOE) and its predecessor agencies. In 2000, Congress promulgated the Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA), which provides monetary compensation and medical benefits to certain energy employees who have developed cancer. Under Part B of EEOICPA, the National Institute for Occupational Safety and Health (NIOSH) is required to estimate radiation doses for those workers who have filed a claim, or whose survivors have filed a claim, under Part B of the Act. To date, over 39,000 dose reconstructions have been completed for workers from more than 200 facilities. These reconstructions have included assessment of both internal and external exposure at all major DOE facilities, as well as at a large number of private companies [known as Atomic Weapons Employer (AWE) facilities in the Act] that engaged in contract work for the DOE and its predecessor agencies. To complete these dose reconstructions, NIOSH has captured and reviewed thousands of historical documents related to site operations and worker/workplace monitoring practices at these facilities. Using the data collected and reviewed pursuant to NIOSH's role under EEOICPA, this presentation will characterize historical internal and external exposures received by workers at DOE and AWE facilities. To the extent possible, use will be made of facility specific coworker models to highlight changes in exposure patterns over time. In addition, the effects that these exposures have on compensation rates for workers are discussed.Introduction of Characterization of Exposures to Workers (Video 1:59, http://links.lww.com/HP/A3).

[Domestic violence: any progress?]. / Violences conjugales : a-t-on progressé ?

Since the publication of the French national survey of violence against women in 2000, the fight against domestic violence has made steady progress. Knowledge of the phenomenon has significantly improved. A nationwide study of murders and manslaughters perpetrated by one partner of a couple against the other has been published annually since 2006. In 2012, domestic violence resulted in the deaths of 314 persons: 166 women, 31 men, 25 children, 9 collateral victims, 14 rivals, and two former spouses killed by their ex-fathers in law. In addition, 67 perpetrators committed suicide (51 men and3 women). The number of victims fluctuates from year to year but has remained fairly stable since 2006 (n=168). Legislation has improved significantly: eight new laws have been passed since 2004, all designed to protect women and to ensure that violent men are restrained and treated. New measures to inform and protect women have been implemented and others have been improved, such as the anonymous helpline (phone no 3919, "domestic violence information"). An inter-ministerial committee on the protection of women from violence and the prevention of human trafficking (MIPROF) was created on 3 January 2013. A website entitled "Stop violence against women " (Stop violences faites aux femmes) is now available. The "Imminent Danger" mobile phone system, designed to alert police if a suspected or known perpetrator breaches restraint conditions, will be extended to the entire country from January 2014. Referees charged with coordinating comprehensive long-tern care of women victims have been deployed at the county level. Information centers on the rights of women and families (CIDFF) now form a local nationwide network. Routine interviews with a midwife during the fourth month of pregnancy, focusing on the woman's emotional, economic and social conditions, have been implemented in 21 % of maternity units and should gradually be generalized. The authorities who have enforced the law have modified their behavior, as have the victims, although for a lesser extent. Perpetrators are increasingly subject to restraining orders, with an obligation to undergo treatment and to attend awareness sessions. Victims are also more likely to go to the police. Social workers, self-help groups and, since 2006, psychologists are now available for victim support in police stations. Management of perpetrators has improved. Finally, despite the continuing reluctance of many physicians, an encouraging trend is emerging among younger members of the profession. A recent survey of 1472 French medical students showed that, while 90 % of them said they had received no training in this area, 93 % considered that doctors should play a role and 95 % said they felt highly concerned. Specific university diplomas have been created and domestic violence is now included in the midwifery curriculum. The delicate question of prevention remains to be resolved; a program is currently being tested.

La última reforma del sistema general de seguridad social en salud Colombiano / The latest reform of the Colombian healthcare-related social security system

Objetivo El propósito de este ensayo es explorar y analizar los cambios y oportunidades generados con la reforma del sistema de salud colombiano, a partir de la ley 1438 del 2011. Métodos Para lograrlo se revisan documentalmente algunos temas pendientes desde la reforma introducida por la ley 100 de 1993 y los compara con la norma del 2011; también se contrastan con algunas estrategias de la salud pública inoperantes en la etapa de la reforma, bajo condiciones del modelo de mercado. Resultados Se discute esta segunda fase de la reforma en relación con el alcance del derecho a la salud, el acceso y la equidad global. Se reconoce el avance en temas importantes, como la igualación de los paquetes de beneficios, la atención primaria en salud, las redes integradas de servicios de salud, pero se discute su inoperancia para modificar aspectos medulares del sistema, como la sostenibilidad financiera y la lógica económica que se imponen sobre las estrategias mencionadas las cuales ven cercenada su capacidad de respuesta, en aras de mantener incólume el modelo de la ley 100 de 1993. Conclusión Finalmente, se esbozan los puntos cruciales necesarios a una gran reforma estructural del sistema de salud colombiano que se base en el derecho a la salud y en la equidad.

Objective This essay was aimed at exploring and analysing the challenges and opportunities arising from reforming Colombian law 1438/2011 dealing with the healthcare-related social security system. Methods Some outstanding issues from the reform introduced by Law 100/1993 were reviewed and then compared to the 2011 regulations; they were also contrasted (in market model conditions) with some public health strategies which were inoperative during the reform stage. Results This second reform phase was discussed in relation to the scope of the right to health, access and overall equity. Progress regarding important issues such as benefit package equalisation, primary healthcare attention, integrated healthcare service networks was recognised; however, its failure to change core aspects of the system was discussed, i.e. financial sustainability and the economic rationale imposed on the aforementioned strategies which curtailed its responsiveness to keep the model introduced by law 100/1993 intact. Conclusion The crucial points necessary for major structural reform of the Colombian healthcare system based on the right to health and equity were then outlined.

Evaluation of Brazil's public health surveillance system within the context of the International Health Regulations (2005).

OBJECTIVE: To evaluate Brazil's public health surveillance system (HSS), identifying its core capacities, shortcomings, and limitations in dealing with public health emergencies, within the context of the International Health Regulations (IHR 2005). METHODS: In 2008-2009 an evaluative cross-sectional study was conducted using semistructured questionnaires administered to key informants (municipal, state, and national government officials) to assess Brazilian HSS structure (legal framework and resources) and surveillance and response procedures vis-à-vis compliance with the IHR (2005) requirements for management of public health emergencies of national and international concern. Evaluation criteria included the capacity to detect, assess, notify, investigate, intervene, and communicate. Responses were analyzed separately by level of government (municipal health departments, state health departments, and national Ministry of Health). RESULTS: Overall, at all three levels of government, Brazil's HSS has a well-established legal framework (including the essential technical regulations) and the infrastructure, supplies, materials, and mechanisms required for liaison and coordination. However, there are still some weaknesses at the state level, especially in land border areas and small towns. Professionals in the field need to be more familiar with the IHR 2005 Annex 2 decision tool (designed to increase sensitivity and consistency in the notification process). At the state and municipal level, the capacity to detect, assess, and notify is better than the capacity to investigate, intervene, and communicate. Surveillance activities are conducted 24 hours a day, 7 days a week in 40.7% of states and 35.5% of municipalities. There are shortcomings in organizational activities and methods, and in the process of hiring and training personnel. CONCLUSIONS: In general, the core capacities of Brazil's HSS are well established and fulfill most of the requisites listed in the IHR 2005 with respect to both structure and surveillance and response procedures, particularly at the national and state levels.

Evaluation of Brazil's public health surveillance system within the context of the International Health Regulations (2005) / Evaluación del sistema de vigilancia de salud pública del Brasil dentro del contexto del Reglamento Sanitario Internacional (2005)

OBJECTIVE: To evaluate Brazil's public health surveillance system (HSS), identifying its core capacities, shortcomings, and limitations in dealing with public health emergencies, within the context of the International Health Regulations (IHR 2005). METHODS: In 2008-2009 an evaluative cross-sectional study was conducted using semistructured questionnaires administered to key informants (municipal, state, and national government officials) to assess Brazilian HSS structure (legal framework and resources) and surveillance and response procedures vis-à-vis compliance with the IHR (2005) requirements for management of public health emergencies of national and international concern. Evaluation criteria included the capacity to detect, assess, notify, investigate, intervene, and communicate. Responses were analyzed separately by level of government (municipal health departments, state health departments, and national Ministry of Health). RESULTS: Overall, at all three levels of government, Brazil's HSS has a well-established legal framework (including the essential technical regulations) and the infrastructure, supplies, materials, and mechanisms required for liaison and coordination. However, there are still some weaknesses at the state level, especially in land border areas and small towns. Professionals in the field need to be more familiar with the IHR 2005 Annex 2 decision tool (designed to increase sensitivity and consistency in the notification process). At the state and municipal level, the capacity to detect, assess, and notify is better than the capacity to investigate, intervene, and communicate. Surveillance activities are conducted 24 hours a day, 7 days a week in 40.7% of states and 35.5% of municipalities. There are shortcomings in organizational activities and methods, and in the process of hiring and training personnel. CONCLUSIONS: In general, the core capacities of Brazil's HSS are well established and fulfill most of the requisites listed in the IHR 2005 with respect to both structure and surveillance and response procedures, particularly at the national and state levels.

OBJETIVO: Evaluar el sistema de vigilancia de salud pública del Brasil, identificando sus capacidades básicas, deficiencias y limitaciones para manejar emergencias de salud pública, dentro del contexto del Reglamento Sanitario Internacional (RSI 2005). MÉTODOS: En el período 2008-2009 se llevó a cabo un estudio transversal de evaluación utilizando cuestionarios semiestructurados administrados a informantes clave (funcionarios del gobierno municipal, estatal y nacional) a fin de evaluar la estructura del sistema de vigilancia de salud pública del Brasil (marco jurídico y recursos), y la vigilancia y los procedimientos de respuesta, con relación al cumplimiento de los requisitos del RSI 2005 para el manejo de emergencias de salud pública de importancia nacional e internacional. Los criterios de evaluación incluyeron la capacidad de detectar, evaluar, notificar, investigar, intervenir y comunicar. Las respuestas se analizaron por separado según el nivel gubernamental (departamentos de salud municipales y estatales y ministerio de salud nacional). RESULTADOS: En general, en los tres niveles del gobierno, el sistema de vigilancia de salud pública del Brasil tiene un marco jurídico bien establecido (incluidas las reglamentaciones técnicas esenciales) y la infraestructura, los suministros los materiales y los mecanismos requeridos para el enlace y la coordinación. Sin embargo, todavía hay algunos puntos débiles a nivel estatal, especialmente en las zonas fronterizas y los pueblos pequeños. Los profesionales de campo deben conocer más la herramienta de decisión del anexo 2 del RSI 2005 (diseñada para aumentar la sensibilidad y la consistencia del proceso de notificación). En el nivel estatal y municipal, la capacidad para detectar, evaluar y notificar es mejor que la capacidad para investigar, intervenir y comunicar. Las actividades de vigilancia se llevan a cabo 24 horas al día, 7 días a la semana, en 40,7% de los estados y 35,5% de los municipios. Existen deficiencias en las actividades de organización y los métodos, y en el proceso de contratación y capacitación del personal. CONCLUSIONES: En general, las capacidades básicas del sistema de vigilancia de salud pública del Brasil están bien establecidas y cumplen la mayoría de los requisitos enumerados en el RSI 2005, tanto con respecto a la estructura como a la vigilancia y los procedimientos de respuesta, en particular en los niveles nacional y estatal.

[The latest reform of the Colombian healthcare-related social security system]. / La última reforma del sistema general de seguridad social en salud Colombiano.

OBJECTIVE: This essay was aimed at exploring and analysing the challenges and opportunities arising from reforming Colombian law 1438/2011 dealing with the healthcare-related social security system. METHODS: Some outstanding issues from the reform introduced by Law 100/1993 were reviewed and then compared to the 2011 regulations; they were also contrasted (in market model conditions) with some public health strategies which were inoperative during the reform stage. RESULTS: This second reform phase was discussed in relation to the scope of the right to health, access and overall equity. Progress regarding important issues such as benefit package equalisation, primary healthcare attention, integrated healthcare service networks was recognised; however, its failure to change core aspects of the system was discussed, i.e. financial sustainability and the economic rationale imposed on the aforementioned strategies which curtailed its responsiveness to keep the model introduced by law 100/1993 intact. CONCLUSION: The crucial points necessary for major structural reform of the Colombian healthcare system based on the right to health and equity were then outlined.

The trans fatty acid story in Denmark.

The Danish story started with the publication of Willett's Lancet paper in 1993, and ended when industrially produced trans fatty acids (IP-TFA) were reduced at the Danish market following a ban in 2003. The Danish Nutrition Council, established in 1992, was the driving force behind a campaign that convinced Danish politicians that IP-TFA could be removed from foods without any effect on taste, price or availability of foods. The Nutrition Council argued that as no positive health effect of IP-TFA had ever been reported, then just the suspicion that a high intake exerts harmful effects on health could justify a ban. The Danish success story might be interesting for other countries where this unnecessary health hazard could be eliminated from their foods.

[Complementary to notification required by the national Protection against Infection Act. State-specific mandatory infectious disease notification in Saxony-Anhalt]. / Bundeslandspezifische Meldepflicht als Ergänzung zur Meldepflicht des IfSG. Landesspezifische Meldepflicht in Sachsen-Anhalt.

In May 1991 a decree supplementing the federal Epidemic Law concerning the mandatory notification of communicable diseases was implemented by the Ministry of Health in Saxony-Anhalt. This was updated and newly implemented in 1997. With implementation of the national Protection against Infection Act in 2001 further amendment of the state regulation (published in April 2005) be came necessary. The following diseases or laboratory evidence of the underlying pathogens, respectively, will now be notifiable with inclusion of the affected individual's name: aseptic meningitis, mumps, rubella, varicella, epidemickera to conjunctivitis, pertussis, and pneumococcal meningitis. The possibility of preventing further spread of the pathogen to others though immediate implementation of preventive measures by the public health service justifies notification of the individual's name. Furthermore, the epidemiological situation is to be monitored and evaluated. This also applies to Lyme disease, which will be anonymously notifiable. Particular emphasis is placed on vaccine-preventable diseases in the state regulation for mandatory notification in Saxony-Anhalt, since priority is placed on attaining the health goal "age-appropriate vaccination status in over 90% of the population". The state-specific notification regulation of Saxony-Anhalt has worked well in preventing and controlling communicable diseases. It is a source of reliable data, which may be helpful in the discussion regarding the amendment of the Protection against Infection Act. Non-anonymous notification should be enforced nationally at least for all vaccine-preventable diseases for which a post-exposure vaccination is recommended by the Standing Committee on Vaccination (STIKO).

The future of public health preparedness.

This redacted version of a speech by former United States Senator Sam Nunn, Chairman of the Nuclear Threat Initiative, points out that although there are concerns about global issues involving security and weapons of mass destruction and bioterrorism, it was not until September 11, 2001, that these issues (and new, unforeseen ones) were getting the funding and attention they deserved. In the event of a biological attack, millions of lives may depend on how quickly we diagnose the effects, report the findings, disseminate information to the healthcare communities and to state and local governments, and bring forth a fast and an effective response at the local, state, and federal levels. Public health must become an indispensable pillar of our national security framework. As we develop a national strategy to respond to these challenges, we must think in the broader context of causes as well as symptoms. To provide context for the next 25 years, Senator Nunn provided an overview of the "Seven Revolutions" for change identified by the Center for Strategic and International Studies (CSIS) with which he is also associated. Finally, he discusses major security challenges facing the United States.