addressing the opioid crisis: collaboration between a
TRANSCRIPT
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Addressing the Opioid Crisis: Collaboration between a Medical Expert and Law Enforcement / Prosecutor –Case Study
Tim Munzing, M.D.Kaiser Permanente Family MedicineMedical Expert Consultant to DEA, FBI & Medical Board of CaliforniaNADDI – Norfolk, VA. 2018
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Disclosure• Dr. Munzing has no relevant financial interests
to disclose
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Goals & Objectives:Participants will be able to:• Identify Elements of Opioid Prescribing
Cases• Discuss Standards of Care for Controlled
Substance Prescribing• Identify “Red Flags” for Potential Controlled
Substance Abuse / Diversion• Describe How to Optimize the Use of a
Medical Expert
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1. The DEA/FBI/HHS→ U.S. Attorney’s Office
2.Local Law Enforcement→ District Attorney’s Office
3.HQIU/MBC→ CA Office of the Attorney General
Investigation and
Enforcement to Stop Opioid
Epidemic
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• Family members of addicts / patients who overdose or die
• Fellow physicians or ERs who see the inappropriately managed patients
• Pharmacists• Coroners• Medicare arrest or
conviction
How do Physicians come to the Attention of
law enforcement?
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• Cases reviewed - ~150• Prison sentences – 75 years• Loss of medical license - >25• Administrative Probation -
>25• Added training - >50• Many cases pending
The Consequences?Heartache for
Others
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• Dr. Kim Case –ABC News Clip
• 17 Felony Convictions
• Sentence – 3 years
Stranger than
Fiction:High
Profile and Salacious
Case
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Soaring Towards Improved Outcomes and Patient Safety
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• Dr. Edward RidgillCase
• Multiple UC patients• PDMP Review• Red flags everywhere
Example Case:
Illustrates so Many
of the Key Issues
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Ridgill Investigation Origins
Gang Investigation – Local LE Gang Unit
Gang burglariesProfits – to obtain drugs to sellCapper scheme with gang members
DEA Added
SurveillanceUC patients
Medical Expert
UC ReviewPDMP Review
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Medical Record
Reviews
Federal Court Testimony
UC & PDMP
Reviews
Medical Expert Involvement
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Ridgill Case Origins• Investigation of targeted burglaries
– robberies• Victims – wealthier appearing
Asians• East Coast Crips identified• Social media postings of stolen
property
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Ridgill Case• Office surveillance – many gang
members – monthly office visits• Cappers used – gang leader would direct• Front office – gang connection• Burglary “profits” used for medical visits
- to obtain drugs• Drugs results in greater profits – sold on
the streets
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Ridgill Case• Younger patients• Some drove > 100 miles for appointment• Search warrant - >$70,000 cash• Torrance PD gang unit, LAPD, DEA,
HIDTA (High Intensity Drug Trafficking Area)
• 2 Physicians involved – 2nd physician charged – died of cancer
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Ridgill Case• Undercover “patients”• “Pain and anxiety”• Minimal or no history or exams• Capper observed in the office
helping the front office staff
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Ridgill Case• Cash business ($150)• Drugs prescribed as requested• Visits - few minutes• After 4 visits – pick up Rx
without appointment• Red flags ignored by Ridgill
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Prescriptions Obtained• Norco (Hydrocodone) 10 mg• Xanax (Alprazolam) 2 mg• Soma (Carisoprodol) 350 mg• Nearly every prescription and visit
had non-controlled substance medications prescribed (less suspicious)
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Additional Review• PDMP Review – high priority list
developed• Many selected – gang members• Search warrant – medical records –
reviewed• Multiple findings – similar to UC’s• Not medically legitimate• Not used in prosecution
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• Excessive prescription of medications
• Prescribing without an appropriate exam
• Overall prescribing• Falsification of records
Dr. Munzing’sFindings in Ridgill
Case
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Outcome• Federal prosecution – AUSA• 26 Felony counts – illegally
distributing controlled substances• Convicted on all counts (jury – 30
minute deliberation)• 5 year sentence – Federal Prison
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1. Xxx2. Xxx3. Xxx4. Xxx5. Xxx6. Xxx
Illegal -Inappropriate
Rx – Why?
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• Dr. Greed ($$$) / Dr. Sex• Dr. Addict• Dr. Underworld• Dr. Feelgood• Dr. Naïve• Dr. Running Late• Dr. Ill Prepared• Dr. Satisfaction Scores
Illegal -Inappropriate
Rx – Why?
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Universal Precautions for Opioid Prescribing• Evaluate the need• Assess risk• Select the specific treatment - opioid not first choice• Discuss – informed consent – risk / benefit – written
agreement• Monitor closely• Trust but verify• Document thoroughly
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CDC Prescribing Guidelines (2016)- Published JAMA – March 15, 2016
• Avoid benzodiazepines with opioids [increases risk of overdose death ten-fold versus only opioid use]
• Periodic benefit / risk evaluation, including PDMP and Urine Drug Screen
• Non-pharmacologic and non-opioid tx – first line
• Chronic pain – avoid opioids – risk outweighs benefits for most
2016 CDC Guidelines
for Controlled Substances
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• Discuss risk / benefits with patients and document
• Establish realistic goals – prior to opioid starts
• Start immediate release – avoid Methadone as first line – higher risk
• Additional precautions if dose exceeds 50 MME mg /day
2016 CDC Guidelines
for Controlled Substances
Con’t
CDC Prescribing Guidelines (2016)- Published JAMA – March 15, 2016
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• “Generally avoid increasing the dosage >= 90 MME mg/day
• Should only give 3 days max for acute pain for most non-traumatic, non-surgical pain
• Avoid combinations – short and long acting opioids
• Concerns – may limit opioids for some for whom they may benefit
2016 CDC Guidelines
for Controlled Substances
Con’t
CDC Prescribing Guidelines (2016)- Published JAMA – March 15, 2016
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29
PeriodicReview –
Monitoring
InformedConsent
Treatment Plan & Objectives
Medical History
Physical Exam
STANDARD OF CAREGuidelines
Controlled Substance Prescribing
Adapted from the Medical Board of California; American Academy of Pain Medicine; American Pain Society
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STANDARD OF CAREGuidelines
Medical
Prescribing to Addicts
Compliancewith Laws & Regulations
RecordsConsulta-tion
Controlled Substance Prescribing
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• Analgesia: rating of average pain, worst pain, and pain relief
• Activity: progress in patient’s functional goals
• Adverse Effects: nausea, dizziness, drowsiness, other forms of impairment, etc.
• Affect: impacts to mood, anxiety, depression, ability to be happy, etc.
• Aberrant behaviors: taking meds as prescribed, illicit drug use
The 5 A’s Plus
(Monitoring Pearls)
• Reference: 1. Executive Committee of the Federation of State Medical Boards of the United States, Inc. Model policy on the use of opioid analgesics in the treatment of chronic pain. July 2013. (Sourced 25/2/14) www.fsmb.org/pdf/pain_policy_july2013
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• Prescription Drug Monitoring Program (PDMP)
• Urine Drug Screening (UDS)• Updated History, Exam, and
Assessment• Taper medications when possible• Include the Morphine Equiv Dosing
– Every visit
The 5 A’s Plus
(Monitoring Pearls)
• Reference: 1. Executive Committee of the Federation of State Medical Boards of the United States, Inc. Model policy on the use of opioid analgesics in the treatment of chronic pain. July 2013. (Sourced 25/2/14) www.fsmb.org/pdf/pain_policy_july2013
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Phases of a Case with a Medical Expert
Phase – Pre Med Expert• Initial Investigation• Surveillance• Undercover visits (when
possible)• Additional materials as available
and pertinent
Phase 1• Review Undercover (if any)• CURES / PDMP Review (to
identify red flags, select ~10 – 20 patients with potentially suspicious prescribing profiles)
• Initial Report – List of Patients Files to Get at Search Warrant
Phase 2• Review Search Warrant
Materials• Opinion and Detailed Report
Generation
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Phase 3• ISO – Suspension Order (if
needed) – Washington, D.C. DEA
• Phase 4Grand Jury vs Preliminary Hearing - Testify (as needed)
Phase 5Criminal Prosecution –AUSA vs Deputy DA -Plea bargain vs trial –
Testify (as needed)
Phases of a Case with a Medical Expert Continued
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Morphine Equivalent Dosing (mg/day)
Drug Brand Relative Strength
100 mg/d MED Equiv
Morphine 1 100
Hydrocodone Norco, Vicodin 1 100
Oxycodone OxyCodoneRoxycodone
1.5 66
Hydromorphone Dilaudid 4 25
Oxymorphone Opana 5 20
Methadone 10 + 10
Fentanyl Duragesic 100 42
Adapted from Opioid Calculator - Available at http://agencymeddirectors.wa.gov/mobile.html
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Physician Drug Monitoring Program (PDMP) –[Example]
Date Med Strength Amount PhysicianPharmacy
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A. Opioid MED > 250 mg/day
B. Early refills of medsC. Using multiple doctors\D. Driving a long distance
to be seenE. All of the aboveF. None of the above
Question-Red Flag(s) that confirm
abuse / diversion
include???:
37October 7, 2018
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1. Xxx2. Xxx3. Xxx4. Xxx5. Xxx
List Red Flags for Abuse /
Diversion
38October 7, 2018
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Identify Potential Red Flags in PDMP• Early Refills• MED > 100 mg / day• Multiple concurrent prescribers• Multiple pharmacies• Combinations (i.e. Opioid,
Benzodiazepine (e.g. Alprazolam (Xanax)), Carisoprodol (Soma))
• Prescriptions at maximum strength
Dr. Tim Munzing SCPMG
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Additional Potential Red Flags • Inconsistent UDT results• Patients driving a long distance for
care• Multiple family members – identical
or similar meds• Drug overdoses• Buy/ give / sell meds• Use of THC – even with Marijuana
Card
Dr. Tim Munzing SCPMG
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How does Administrative action differ from a Criminal trial?
• Administrative Law Judge• No jury• Rules of evidence are relaxed (somewhat)• Decision is written by ALJ and issued some
time after the hearing—not like jury trial where result is announced immediately at end of deliberations
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Frequently Identified Issues: A Medical Expert’s Findings• Minimal/missing documentation• Minimal or no history – no past medical history• No verification of a patient’s history of pain /
controlled substance medications• No inquiry of mental health and potential addiction
issues• Exam – missing, minimal, or too much - unbelievable• No customization of treatment
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Frequently Identified Issues: A Medical Expert’s Findings
• Appropriate monitoring missing• Lack of consultation, re-evaluation • High dose (MED > 100 mg/d) without intensive
management• Same Rx for all patients• Lots of young patients• All cash business
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Frequently Identified Issues: A Medical Expert’s Findings
• Multiple family members with similar medications• Patients drive long distances for care• Minimal to too much lab testing (?fraud involved)• Long gaps in care or appointments• Deaths• Patient doctor or pharmacy shopping
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Pertinent State and Federal Regulation/Potential Charges• Business and Professions Code 725 – Excess treatment or over-prescribing• Business and Professions Code 2242 – Prescribing without medical indication• Business and Professions Code 2234 – Unprofessional conduct• Business and Professions Code 2234 (b) – Gross negligence• Business and Professions Code 2234 (d) – Incompetence• Business and Professions Code 2241 – Prescribing to or treating an addict• Business and Professions Code 11153 (a) – Illegal Prescriptions• DEA Regulation 21 C.F.R. 1306.04 – Purpose of issue of prescription
- medically legitimate, usual course of professional practice• Business and Professions Code Section 2242 (a): Furnishing dangerous drugs
without an examination: Prescribing, dispensing, or furnishing dangerous drugs as defines in Section 4022 without an appropriate prior examination and a medical indication, constitutes unprofessional conduct
• FRAUD involved???• [The decision as to which of these or other charges apply
specifically in this case is under the knowledge and decision of law enforcement and/or legal prosecutors.]
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Improving Patient Safety and Outcomes
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References• Medical Board of California Guidelines for Prescribing Controlled Substances for Pain – 1994,
2003, 2007, and 2014
• “Physician Guide to Appropriate Opioid Prescribing for Noncancer Pain”; Permanente Journal, Timothy Munzing; 2017
• DEA Regulation 21 C.F.R. 1306.04 – Purpose of issue of prescription
• “Opioid Prescriptions for Chronic Pain and Overdose: A Cohort Study”; Annals of Internal Medicine, Kate Dunn, PhD, et al; January 19, 2010 [MED dosing information / risks]
• “Use of Opioids for the Treatment of Chronic Pain” – American Academy of Pain Medicine, http://www.painmed.org/files/use-of-opioids-for-the-treatment-of-chronic-pain.pdf
• Washington State Agency Medical Directors’ Group – in conjunction with the Interagency Guideline on Opioid Dosing for Non-cancer Pain
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References
• Drug Enforcement Administration• Centers for Disease Control - Overdose and Overdose death statistics• “Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic
Noncancer Pain”, American Pain Society – American Academy of Pain Medicine Opioids Guideline Panel – February 2009 – Journal of Pain -http://www.jpain.org/article/S1526-5900(08)00831-6/fulltext
• National Forensic Laboratory Information System (NFLIS) data – found at: http://www.deadiversion.usdoj.gov/mtgs/pharm_awareness/conf_2012/sept_2012/houston/drug_trends_1002.pdf
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• Dreamland: The True Talk of America’s Opiate Epidemic; Author: Sam Quinones
• American Pain: How a Young Felon and His Ring of Doctors Unleashed America’s Deadliest Epidemic; Author: John Temple
• Drug Dealer, MD: How Doctors were Duped, Patients Got Hooked, and Why It’s So Hard to Stop; Author: Anna Lembke
Books
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50
Physician Guide to Appropriate Opioid Prescribing for Noncancer Pain (Dr. Tim Munzing SCPMG) May 1, 2017
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Opioid Prescribing Review
• “Physician Guide to Appropriate Opioid Prescribing for Noncancer Pain”, The Permanente Journal
• Author – Timothy Munzing, MD• https://doi.org/10.7812/TPP/16-169
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• [email protected]• Kaiser Permanente
• 1900 E. 4th Street• Santa Ana, CA. 92705
• Medical Expert Reviewer• Medical Board of California• DEA, FBI• Multiple other law enforcement
agencies
Tim Munzing,
M.D.