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.

Conversion of Intrathecal Opioids to Fentanyl in Chronic Pain Patients With Implantable Pain Pumps: A Retrospective Study.

OBJECTIVES: Conversion between routes such as intravenous (IV), epidural (EP), and intrathecal (IT) routes for morphine is well established. Conversion ratios for IV:EP:IT fentanyl and conversion from IT morphine/hydromorphone to IT fentanyl have been challenging given the lipophilic nature of fentanyl. Our study reviews the outcomes and conversion ratios reached after converting IT opioids from morphine/hydromorphone to fentanyl in patients with IT pumps. METHODS: After Institutional Review Board approval at Henry Ford Health System, a chart review was performed on all patients who had Synchromed II IT pumps implanted 2009-2016 and were converted from morphine/hydromorphone to fentanyl. The chart review included the initial fentanyl dose and fentanyl IV:IT conversion ratio, eventual IT fentanyl dose, and IV:IT conversion ratio reached to give superior VAS from previous IT opioid. Wilcoxon non-paired signed rank test was used to examine the change in fentanyl dosage and IV:IT conversion ratio. RESULTS: The mean IT morphine equivalent dose at initial conversion was 15.8 mg/day, and the mean fentanyl IT starting dose was 0.73 mg/day (SD = 1.37 mg). The mean fentanyl dose at the end of titration was 0.94 mg/day (SD = 2.05 mg) which represented a significant 25.1% mean dose increase (P = 0.004). The initial mean IV:IT fentanyl conversion ratio was 38.7:1 (SD = 33.01), but the mean IV:IT fentanyl conversion ratio at end of titration with better analgesia was significantly lower at 32.9:1 (SD = 27.1) (P = 0.016). CONCLUSIONS: Given the pharmacokinetics of lipophilic fentanyl compared to hydrophilic morphine/hydromorphone, the current conversion ratio of IV fentanyl to IT fentanyl and IV morphine to IT fentanyl appears to be conservative.

Prolongation of greater occipital neural blockade with 10% lidocaine neurolysis: a case series of a new technique.

INTRODUCTION: Greater occipital nerve blocks (GONB) have been used for headache but their benefit may be short. Ready et al performed intrathecal injections on rabbits and reported neurologic/histologic changes that required concentrations of at least 8%. Our study tests the hypothesis that the neurolytic effects of GONB with 10% lidocaine can prolong relief. METHODS: After an approval from Henry Ford Hospital Institutional Review Board, a chart review was performed for patients who had GONB with 10% lidocaine. Patients received 10% lidocaine after short response (<1 month / >50% relief) to GONB with 1 cc of a solution containing 9 mL 0.5 % bupivacaine and 40 mg methylprednisolone. They received a block with 10% lidocaine with volume given at <80% of the maximum dose of 4 mg/kg. Injections were performed under fluoroscopic guidance after injection of 0.1 cc of contrast (isovue or magnevist). All patients had intravenous access and were given fentanyl and midazolam. The visual analog scale (VAS) scores were recorded on follow-up, and the duration of response was noted. VAS changes with 10% lidocaine and comparison of duration with methylprednisolone were performed using paired t-test. RESULTS: Thirteen patients were reviewed; 12 were female and the mean age was 47. Ten were diagnosed with migraine, and three with occipital neuralgia; 12 had bilateral symptoms. Baseline VAS prior to 10% lidocaine averaged 86.92 mm. The mean volume injected per nerve was 1.096 mL. There was significant decrease in mean% VAS with 10% lidocaine at 60.4% (mean: -52.69 mm) (P=0.001). The mean duration of relief was significantly higher with 10% lidocaine at 148.05 days ([standard deviation]=98.87) versus methylprednisolone at 6.33 days (standard deviation=5.01) (P=0.001). No complications or side effects were reported. CONCLUSION: Ten percent lidocaine may be a useful neurolytic agent in prolonging the duration of GONB.