Healthcare, enforcement must be equal partners in opioid fight

Yesterday, as my wife walked home from work in our working-class Philadelphia neighborhood, she came across a homeless man slumped beside a parked car, and he appeared to be suffering from the effects of heroin.

This is the second time in a year that she has encountered this type of incident in front of our home in what classifies (in Philadelphia terms) as a relatively quiet neighborhood.

For the people of cities like Philadelphia, Baltimore and Seattle; the problems related to heroin addiction are not a new trend. For generations, law enforcement has tried to counter the constant flow of violent and property crimes committed by those addicted to opioids.  

However, the sheer numbers of addicts on America’s streets have exploded over recent years, and the demographics have shifted away from the residents of neighborhoods known for high-drug trafficking and now include those from rural communities, middle-class and affluent suburbs as well.

This national issue was at center stage at the 2016 conference of the Association of Inspectors General (AIG) last November in Boston. The annual conference of fraud and corruption fighters brings together inspector general agents from the U.S. Department of Health and Human Services as well as those from the various state medicaid inspectors general.

{mosads}However, the conference kicked off with a heartfelt speech from Gov. Charlie Baker (R-Mass.), a former healthcare executive; who spoke in great detail about his efforts to address the opioid crisis.

The following day, attendees discussed “Innovations in Combating Prescription Drug Misuse and Abuse” a conversation which included Maine State Health Officer Dr. Christopher Pezzullo, CeltiCare President and CEO Jay Gonzalez, CeltiCare and, most notably, Dr. Sameer V. Awsare, who is the associate executive director at Kaiser Permanente Medical Group in Oakland, Calif.

The focus of the discussion highlighted the need for healthcare to be an equal part to enforcement, as the unnecessary over-prescription of opioid painkillers like Oxycodone and Oxycontin are addicting patients who are turning to lower-cost heroin when their prescriptions run out. 

Dr. Awsare put even more emphasis on the need for physician oversight, noting that the highly addictive opioids like Oxycodone and Oxycontin have never been proven to be more effective in pain management than their less-addictive alternatives.

Yet, physicians continue to prescribe addictive amounts to patients without sufficient follow-up. Given the audience he was presenting to, this called into question the many gaps in oversight that currently exist in healthcare.

Because physicians are so highly educated, there has traditionally been a high trust factor for them to behave ethically and legally in their practices. Therefore, much of the practice of medicine has been self-regulated. 

In order to practice medicine, you must pass the three-part U.S. Medical Licensing Exams and be licensed by a state medical board. Medical quality is often measured by skill, and nonprofit specialty boards certify physicians on a voluntary basis, usually driven by a physician’s desire to obtain admitting privileges or insurance carrier designations.

However, state medical boards rarely have comprehensive, professionally-certified investigators with the necessary authority to take action in a decisive way and specialty boards that normally focus on the integrity of their assessment no longer have investigators.

On a federal level, the largest healthcare-based law enforcement agency is the Health and Human Services Office of the Inspector General, but they only have roughly 1,600 employees nationwide and are mainly focused on Medicare/Medicaid fraud.

The U.S. Drug Enforcement Administration employs diversion investigators who are responsible for addressing the problem of diversion of controlled pharmaceuticals and regulated chemicals from the legitimate channels in which they are manufactured, distributed, and dispensed. Unlike special agents, diversion investigators are unarmed and have no arrest authority.

While DEA special agents work cases when it’s reported that physicians are illicitly selling or trading prescriptions criminally, the diversion investigators are normally responsible for compliance auditing of the legitimate prescribing or distribution of opioids — where much of the abuse in this crisis stems from.

Diversion investigators only make up a segment of the DEA’s 10,800 employees who also have the insurmountable responsibility of policing the distribution of illegal drugs, like heroin. Some of the states that have been drastically impacted by the opioid crisis have drafted legislation.

In February, Gov. Chris Christie (R-N.J.) signed a bill into law that sets a five-day limit on initial prescriptions for pain-killing opioids and mandates insurance companies to accept addicts into treatment without delay.

Christie declared the law, (S3) the toughest in the country in the fight against heroin and opioid addiction, which in 2015 claimed the lives of 1,600 people in New Jersey alone. While other states are also drafting legislation and attempting to get a handle on the problem, the patchwork of policies do little to address this national crisis.

So, as the current drastic rise in opioid addiction is attributed to over-prescribing of narcotics which lead to illicit drug use; who takes the responsibility for trying to curb this trend in the practice of medicine?

If you legally sell firearms or distribute alcohol in America, the Bureau of Alcohol, Tobacco, Firearms and Explosives is responsible for your regulation, audit and enforcement. 

However, if you practice medicine with a great responsibility to public health and prescribe opioids as a part of your job, you’re regulated by a patchwork of federal, state, and nonprofit organizations who are currently all looking to each other to take the lead in crafting a solution to this issue.

What may be needed is for the President to appoint a new Director of National Drug Control Policy (e.g., the Drug Czar) and direct them to focus on the audit and enforcement of opioid prescription in the medical community as well as their traditional focus on the enforcement and treatment of illicit drugs.

Developing a national approach to this crisis is of vital importance. While the nation awaits the medical community’s response to this crisis, law-abiding citizens of all walks of life continue to cross the line into criminality in pursuit of an addiction created by a medical treatment. Unresponsive bodies continue to be found in neighborhoods like mine on a daily basis.

A. Benjamin Mannes is the former director of the Office of Investigations at the American Board of Internal Medicine. He serves on the academic advisory boards at St. John’s University in New York, Peirce College in Philadelphia and is on the executive board of InfraGard, the FBI-coordinated public-private partnership for infrastructure protection. Follow him on Twitter @PublicSafetySME.

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