U.S. Attorney's Offices ("USAOs") across the country are issuing warning letters to physicians and other prescribers (collectively, “Prescribers") cautioning them about their opioid prescribing practices (the "Warning Letters"). In just the last week, the USAO for the Eastern District of Wisconsin sent warning letters to over 180 prescribers identified by Drug Enforcement Administration ("DEA") data as prescribing opioids at relatively high levels. The Food and Drug Administration and the Federal Trade Commission have also been issuing their own warning letters to opioid marketers and distributors over the past several months, evidencing a concerted effort to combat the opioid epidemic on a number of fronts through various federal enforcement and regulatory efforts.
The Warning Letters appear to be based entirely on review and analysis of DEA's data with no other investigation into the patients who received opioid prescriptions or their medical conditions. Importantly, each of these USAOs has recognized explicitly that the prescribers have not necessarily broken any laws and that the prescriptions may all be medically appropriate. Nevertheless, any warning from an office wielding criminal enforcement authority should never be taken lightly, particularly when related to an issue – opioid overprescribing – that remains a top Department of Justice and U.S. government enforcement priority. While the Warning Letters themselves are issued without meaningful investigation, they may often signal that additional investigatory or enforcement action is forthcoming. In some cases, for instance, prescribers may be visited unannounced and in-person by DEA diversion investigators, special agents, or other law enforcement officers.
Prescribers who have already received a Warning Letter should contact legal counsel to assist in taking measures to assess their degree of risk and preparing for potential further government inquiry. Contacting legal counsel early and preserving privilege could be key to prevent an informal inquiry from becoming a protracted criminal investigation. Experienced counsel can help focus the government's inquiry, provide the information in a manner that is responsive to the government's request while also providing relevant context, and limit disruption to the provider's practice. In collaboration with their counsel, contacted Prescribers should consider:
- An audit of medical records related to patients who have received opioid prescriptions to confirm their propriety in light of medical documentation;
- Correction and supplementation of any deficient records, consistent with government requirements for medical documentation to support such prescriptions; and
- Implementing any required process improvements to mitigate future risk.
Prescribers who prescribe opioids as part of their practices but who have not received a Warning Letter should consider taking prophylactic measures in response to this increased government scrutiny, as should their employers and partners. For instance, Prescribers – and those who employ or contract with prescribers – should consider:
- Reviewing prescribing patterns against local and national benchmarks;
- Reviewing a sample of documentation related to opioid prescription decisions to ensure that it sufficiently supports medical necessity and provides additional training on documentation practices as needed;
- Reviewing and implementing the most current standards of care related to opioid prescribing and patient monitoring, including recommendations issued by the Centers for Disease Control and Prevention's Guideline for Prescribing Opioids for Chronic Pain; and
- In larger practices, implementing or updating, as necessary, policies and procedures related to opioid prescribing.
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