Thursday, October 28, 2010

Who's the Doctor?

In my post Independent Treatment: The Whole Truth I believe I made it clear that I like the idea of independent providers for treatment of psychiatric disorders, a psychiatrist to prescribe medication, rTMS, ECT or whatever, and a non-physician psychotherapist to provide psychotherapy. I believe we can overcome the challenges posed, one of which arises when the psychotherapist advises the patient about medication.

I admit to irritation when my patient tells me her psychotherapist told her she should ask me about lamotrigine, or her chemical dependency counselor told her the acamprosate I prescribed for alcoholism really misses the mark for her particular drinking pattern. But I also must admit to considerably greater irritation when I have never worked with the psychotherapist before. If I know the psychotherapist and am familiar with his work, it just doesn't bother me as much.

Several key facts impact these situations. Psychotherapists may not be qualified to recommend or prescribe medications, but every now and then one of them has an idea that works, and I cannot claim to be perfect in my knowledge of psycho-pharmacology. Bottom line, if the patient gets better I'm glad for the help. Psychotherapists often express surprise that I, a physician, bother to contact them to coordinate treatment. This model does not require weekly or even monthly email or phone contact between psychiatrist and psychotherapist, but, especially when the two professionals do not know each other, either should initiate contact with the other on learning of the other's involvement in the case, and each should always respond promptly to attempts to contact the other. Without such open communication you cannot provide the best care to your patient.

Still, I wonder how a patient feels when his psychotherapist suggest, "Ask Moviedoc about clonazepam." I imagine my patient must wonder what's wrong with me if I didn't think of that, or what's wrong with the psychotherapist when I tell the patient what a horrible choice that would be and why. I believe we would all do better if the psychotherapist contacted me directly with the suggestion or question. I would also like to think I might not be too proud to give the psychotherapist credit for the idea if I endorse it and bring it up with the patient.

Usually such discussions between myself and the psychotherapist extend beyond a simple suggestion of a drug and thus likely lead to better treatment overall. Sometimes what's behind the suggestion of a drug is a symptom of which I was not aware, either because the patient didn't tell me, or because I didn't ask.

The independent practitioner model works, but we must do it right by working as a team. If you're a psychiatrist, always respond promptly when the psychotherapist tries to reach you about a patient. If you're a non-physician psychotherapist, consider contacting the physician directly about your idea of that medication you think might help the patient before you mention it to the patient. And if you don't get a response, consider suggesting the patient find another psychiatrist.

Wednesday, October 20, 2010

The Audit

The big audit. At last.

In my last post I told you I expected DEA agents to return, "Administrative Warrant" in hand, to conduct the obligatory audit of my buprenorphine practice. The entourage did arrive on October 14, conducted the audit, and I'm still a free man. Nobody got hurt.

Let me recap: When I applied for the special DEA number that allows me to treat opiate addiction with buprenorphine it was clear that I might have to submit to audit of my prescribing records. However, only about a year ago I discovered DEA had embarked on a project of auditing all such physicians. I only objected to a few aspects of the plan. DEA law enforcement agents, the sort that might carry badges and guns, would conduct the audits. This I could accept, but what really galled me was DEA's refusal to schedule the audits. I guess they thought they might catch me red-handed doing something illegal. I expected this to disrupt my practice unnecessarily, and I began to protest. Professional associations such as the American Psychiatric Association, the American Association of Addiction Psychiatry, and the American Society of Addiction Medicine, to my disappointment, focused their efforts on assisting physicians in complying rather than assisting us in assuring that our rights and those of our patients would not be violated. We all learned early on to expect agents to present physicians with Form 82 on arrival. This form permits agents to enter the office and conduct the audit. We were warned that if we refused to sign Form 82 agents would return with an "Administrative Warrant." (Yikes!)

Warrants, even the administrative kind, sound pretty bad, like something to be avoided at all costs, something that will brand you a criminal for the rest of your life. But it seemed possible there might exist some advantage in going this route, and that has turned out to be true. I asked DEA to provide me with a copy of such a warrant and detailed description of how they conduct such an audit. The description proved vacuous and useless, and DEA refused to send me a copy. I figured I would have to get it the hard way.

After agents Sanchez and Carter left my office on October 8 I wondered how long I would have to wait for them to return with the dreaded administrative warrant I had the audacity to demand from them, but I decided to use the time to prepare. I would not have wanted to do the audit on the 8th anyway. Although my office manager was there to help, it had been a busy morning, and I was running behind. The buprenorphine prescription logs I wanted to show the auditors still needed hours of work to remove patient names, so that night I copied all buprenorphine prescription records of patients I deemed active going back the requisite 90 days to a single spread sheet on Google docs. Then it was just a matter of keeping it up-to-date.

When I walked back into my waiting room October 14 after lunch and a haircut, a casually dressed man introduced himself, handed me my warrant (the moment I had been waiting for -- I wonder how long he had been waiting.), and told me to read it over and get settled while he summoned the rest of the troops. He staked out the waiting room for the rest of the audit. Agent Carter took charge. A big guy with a couple suitcases turned out to be their computer "expert" (his description). There was an African-American woman who didn't do much. And remember the attractive woman I mentioned from my own unannounced visit to the DEA field office? She's their secret weapon. I call her Ms. Waterboard. She can interrogate me any day. Anytime she wants to. I'll confess to anything. Making obvious assumptions about everyone's sexual orientation and marital status, if you're 10-20 years younger than me, and have not already found the woman of your dreams (like I have), and practice in the area covered by the Seattle field office, do whatever it takes to get interrogated by Ms. Waterboard. And she loves dogs, so arrange to have one in your office for the audit.

Just to speculate on DEA strategy: Have enough agents to keep the doc so busy that he won't really notice when they do something they probably shouldn't or that he might say something he might have preferred to avoid saying. I let down my guard with the interrogation. I can only blame Ms. Waterboard so far. I did confront the agents with the fact that there was no mention on the warrant of any interrogation. However, it seems fair to me that they should be able to ask me questions directly related to my buprenorphine records.

I do believe DEA exceeded the appropriate boundaries in interrogating me. Agent Carter asked me my observations about the relative numbers of heroin addicts versus pharmaceutical opiate addicts presenting for treatment. I had no idea. I was also asked how many active patients I was currently treating. When I asked for a definition of "active" none was forthcoming. When I made a wise crack about my experience testifying in court where a definition would be damanded, the African-American woman reminded me that she knew all about my background. So I hedged and estimated between 30 and 40 patients without a real definition. Ms. Waterboard asked me about my office hours. Rather than getting into a discussion of the fact that I don't really have set office hours, I evaded the question by reporting the days and times when my office manager is usually present. No one seemed to notice that I didn't really answer the question. (This often works in court, too, by the way.)

The auditors presented me with a single page printout of prescriptions from a local pharmacy, citing it as evidence that I stocked buprenorphine in my office, which I never have. When I explained that these were simply prescriptions picked up by patients before coming to the office to have their induction the auditors made a few phone calls and dropped the issue.

The real fun was with my log. The DEA computer "expert" seemed befuddled by the notion that my log resided on a server somewhere in cyberspace. The warrant simply did not contain any language to allow for seizure of such an abstract entity. I offered to print a copy, but I think he really wanted to snoop around in my hard drive. It appeared as though he had never seen a tablet PC before. He opened a case containing an impressive array of hard drives, and connected one to a USB port, but ultimately was unable to figure out how to download the elusive file. I offered to help. He accepted, and thus began the most time-consuming part of the audit. We are dealing with computers here after all. Unfortunately, I had not yet installed Adobe Acrobat Reader on my tablet since installing Windows 7. After 15 or 20 minutes I was able to download a copy of the file to the hard drive so he could make a copy, and I was also able to print a copy on paper.

Of course the whole notion of "seizing" evidence, whether on a computer or elsewhere, implies that the evidence will be incriminating. In this situation, however, the only evidence would likely exonerate me.

Early in the audit one of the agents confronted me that this all could have been so much easier had I just cooperated by signing Form 82 the week before. Although I will never be sure, I suspect they meant to imply that they subjected me to a more intimidating or disruptive audit to punish me for forcing them to get a warrant. In fact, though, because I had time to prepare, I believe things went more smoothly, and the timing disrupted my practice much less. Only one patient appeared in the waiting room while they were doing their dirty work, and he complimented me on my handling of the situation. (One of the agents seemed to be holding the door to the waiting room open during most of the audit.)

How would I handle the audit differently if I could do it again? First, I would not have volunteered access to my computer. As far as I can tell the warrant does not require me to allow DEA to commandeer my computer for its own purposes. Instead, I would have printed out a fresh copy of the log every day so I could simply present it to the auditors. I might also refuse to answer questions unrelated to my buprenorphine practice. I would really like to know whether DEA would revoke my license just because I refuse to confabulate office hours that do not exist.

What else did the auditors do wrong? When I did resist answering questions, citing absence of reference to interrogation in the warrant, I seem to recall at least a veiled threat of admonishment or revocation of my DEA number. When I sarcastically suggested that that might not be such a bad thing, agent Carter, a little too eagerly, offered to relieve me of the burden of the audit if I would surrender my special number. This same interaction has played out before around these audits elsewhere in the US, and I have seen at least one letter from a DEA field office claiming to deny any effort to discourage physicians from treating addicts with buprenorphine. Agent Carter's offer would seem to betray DEA's real position: By treating opiate addicts we threaten DEA job security. I believe the agancy would be very happy to have us abandon our efforts.

DEA also needs to get up to speed with computers and the Internet. I had provided agent Carter with access to my log at Google docs months ago. Let's compare the costs of two or more agents showing up only to be told they need to return with the warrant and five agents showing up the next week unnecessarily versus the cost of going online and peeking at my log at your leisure while sitting in your office downtown. Think about this next time you pay federal income tax. Maybe the auditors thought they would find a meth lab in my office. If so, they did not conduct a very thorough search. The whole exercise was a waste.

If you prescribe buprenorphine to treat drug addiction, I strongly suggest you place your prescribing log online. If DEA has not yet audited your practice, plan to refuse to sign Form 82 when agents arrive unless you are completely prepared, and they have arrived at a convenient time for your office. If we all   force them to obtain warrants, maybe they will back down and start scheduling.

I cannot speak from experience since I have never wanted to stock any controlled substance in my office. When the opportunity presented itself for me to stock buprenorphine, I declined. I suspect those of you who do stock that drug or others will find the audit considerably more difficult regardless of whether you sign Form 82.

I initiated a moratorium on accepting new buprenorphine patients almost a year ago with the idea that I would end the moratorium after my audit was completed. I do plan to accept a few new patients for buprenorphine induction and maintenance, but before I will want to accept significant numbers of new patients (like anywhere near my limit of 100) I would like the United States government to deal with its ambivalence. All the agencies need to get together and decide whether they want us to treat addicts or not. If not, I certainly have better things to do with my time than subject myself to this kind of harassment.

DEA can chalk up another victory in the war on drug treatment.

The saga continues.

Saturday, October 9, 2010

DEA Suboxone Audit: The Wait is Finally Over. Or Is It?

This story started for me almost a year ago: DEA On-Site Investigation of Suboxone Prescribing Physicians

Sometime late last year I wrote a letter to the Seattle field office asking to schedule my audit as soon as possible. I asked DEA to provide a detailed description of how they carry out the audit after serving an "administrative warrant" on a physician who refuses to sign Form 82, giving permission for the audit. After several months without a response it occurred to me to give the DEA a taste of their (it's?) own medicine. I had to be in the city early for an orchestra rehearsal anyway, so I made my own unannounced visit to the Seattle field office last spring.

When I entered the office I explained to the polite guard that I wanted to hand deliver a letter and that I wanted to dispose of some unused samples of modafinil I brought with me. He asked me whether I was carrying any explosive devices. Fortunately that day I had left my C-4, dynamite, and IED's at home. He asked whether I had an appointment. The answer of course was no. He asked whether the agents might know who I was. The answer of course was yes. Sitting in the waiting room I was struck by a wall covered by portraits of DEA agents who lost their lives in the line of duty. I trust none of the deaths occurred while auditing physicians trying to treat patients suffering from addictive diseases.

After a short wait a very attractive young woman entered the waiting room and asked me whether I might wait for agent Carter since chief agent Thomas was on vacation. When I asked agent Carter to please proceed with my audit, she explained this would not be possible and told me how to dispose of my drug samples.

Once more there was no response to my letter.

I was pleasantly surprised when, on September 29, agent Sanchez left a message on my voicemail asking me to call him back on his cell phone. I in turn left a message on his voicemail suggesting when he might reach a person by dialing my office number, but I did not hear from him until Friday, October 8. I was standing at the reception window talking to my office manager and agents Sanchez and Carter entered the waiting room, introduced themselves, and told us they were ready to perform my audit. I asked them whether they had a warrant. They said no. (If only I could have obtained a photograph of the look on their faces.) I explained to them that I wanted to know what would happen during an audit performed under administrative warrant. They asked me if I had not received a letter from the diversion office in Springfield. I explained that the letter I had received was woefully inadequate. I asked if they wanted to schedule an audit later, but they repeated the mantra that that doesn't fit with their policy. I pointed out that I had shared my buprenorphine prescribing log, which resides in Google Docs, with Agent Carter. They told me they are not allowed to access the Internet.  They left. I completely forgot to ask whether they were carrying explosives.

So I'm back to waiting and wondering what will happen next. It would have been so much easier for everyone concerned if they had only honored my request for a detailed explanation of how an audit is conducted under administrative warrant. But I hope without too much further delay to be able to provide a first-hand description.

As a taxpayer I'm really OK with DEA agents having access to the Internet. Maybe we could arrange for the FBI to monitor their use. Or maybe we could establish another agency. We could subject them to unannounced visits to audit their browser histories.

Next: The Audit

Wednesday, October 6, 2010


Psychology vs. Psychiatry: What's the Difference, and Which Is Better?

Starts out, "Psychologists and psychiatrists tend to hate each other."

Metaphor or joke? Did this guy talk to even one representative of either profession? Is this just a wild extrapolation from his gross misinterpretation of the new APsychiatricA Guideline? Regardless, it's an opportunity for me and others to set the record straight.

Psychologists and psychiatrists not only should not, but do not, hate each other. In fact as fewer psychiatrists do psychotherapy we tend to refer our patients to psychologists for psychotherapy more than ever. Which reminds me of the biggest insult in this article, namely that the author seems to completely ignore the most numerous categories of psychotherapists and counselors, those who are neither psychologist nor psychiatrist, and who are, in my experience, often equally respected for their skills.

There is no "idea of psychiatry." Psychiatry is a profession, a medical subspecialty.  Psychology is a science. Clinical psychology is another profession. The first "chemical" treatment used on psychiatric patients was probably a group of drugs called mercurials which effectively treated neurosyphilis, leaving mostly patients with bipolar disorder and schizophrenia in the asylums. Morphine and barbiturates may have been the only chemicals available to help them at that time, and those drugs simply sedated them.

Contrary to what the author would have us believe, after Sigmund Freud (a neurologist) developed his very psychological theory of neurosis, psychiatry began to embrace talk therapy in the form of psychoanalysis, and circa the 1970's I believe psychologists had to sue to gain acceptance to psychoanalytic institutes that only admitted physicians. (I wonder whether the author realizes that the picture that accompanies the article portrays a "psychiatrist" -- not a psychologist -- psychoanalyzing a patient on a couch.)

So he thinks the Guideline "denigrates" CBT. Perhaps this best illustrates that such guidelines are just that, and are intended for trained professionals, not amateurs hoping to conjure up conflict where none exists. The real problem is that too many psychiatrists cling to psychoanalytic/psycho-dynamic methods. Those of us who restrict our practices to prescribing chemicals, however, regularly refer to psychologists, usually the real CBT experts.

The author accuses our leaders of acting like children for not relinquishing the acronyms APA, one organization to the other. Surely this must lead to confusion from time to time, but I have been blissfully unaware that anyone on either side ever wanted the other to change it's name. I wonder if the author would think the same of two SCCA's, the Seattle Cancer Care Alliance and the Sports Car Club of America.

I do agree with one statement: Combining medication with the right type of psychotherapy often works better than either alone. But "national guidelines that will shape the treatment of millions?" Most psychiatrists will not even read them, and those who do will probably keep practicing as they always have.

Which is better? Neither. Apples and oranges. They are just different.

I only have one (more) comment. Almost any psychologist or other psychotherapist could probably help John Cloud get in touch with reality and let go of his hatred for psychiatry.