Demystifying the DEA's Role in Medication-Assisted Treatment
Featured Guest: Dennis Wichern
How can healthcare professionals join forces with law enforcement to bring medication-assisted treatment to more people who could benefit from it?
I’m David Condos and we’ll tackle this with former special agent in charge of the DEA's Chicago office Dennis Wichern on this episode of Recovery Unscripted.
David: Hi, everyone. I’m here with Dennis Wichern. Thank you so much for being with us.
Dennis Wichern: Thank you, David.
David: Absolutely. Let’s start by having you tell us some of your story, how you got into working with the DEA and what’s your background?
Dennis: You bet, I look forward to it. I joined DEA back in 1987, and I recently retired about 14 months ago. I had the pleasure to work for DEA about 30 years, and I retired out of Chicago, Illinois as the agent in-charge where I oversaw five and a half states and about 580 people.
David: Chicago, that’s a huge district, I imagine, within the DEA.
Dennis: It was. Great cases up there to investigate and things like that, but where I got where I am today where I’m happy to speak to the foundation and these podcasters. Before I went to Chicago, I worked in Indiana and we went through the opioid crisis there, where a lot of it was driven by a few bad pill mill pain prescribers. From that, I learned there was a need and a lot of questions by very good and legitimate medical providers like, “Hey, what’s the rule on this, why is DEA doing this, what’s the view on this?” From that, I actually transferred into the MAT arena, medication-assisted treatment, where I found out the same questions existed.
Where I am today and I’m sitting with you today is my goal is to try and extend what I used to do by training, teaching and giving tips of the trade from a law enforcement side to providers to helping people with OUD.
David: Just for people who just are not familiar at all, DEA is Drug Enforcement Agency?
David: Drug Enforcement Administration. What’s an overview of what they do? You said you’re working on investigations, I’m sure there’s a wide breadth of stuff.
Dennis: You got it. The agency is about 95, 100 people. Half of them are special agents like myself and the primary focus is going after the Mexican cartels and gang members, fentanyl traffickers and things like that. Only a small portion of DEA regulatory side oversees pharmaceutical controlled substances. DEA’s only authority is drugs, whereas if you were speaking to an FBI agent, they could do this crime, this crime or that crime, the Secret Service protects the president, the ATF does gun crimes, DEA’s sole enforcement authority pursuant to a Congress-made is the investigation of illegal drugs.
David: Like you said, your more recent role in Chicago was investigating, but then previously, in Indiana, you were dealing with the regulatory side. Talk about how that works and how that involves you in the addiction treatment world.
Dennis: In the regulatory world, DEA oversees all of the pharmaceutical controlled substances. For example, any benzodiazepine or any opioid drug like oxycodone or hydrocodone and they call it you operate within a closed system where in theory, every drug from manufacturer until the patient or the prescription to the patient, you can track it from beginning to the end. Congress made these laws and they empower DEA regulatory side to enforce them and oversee them.
It was in Indiana where as I often say we were in Ohio or West Virginia or Kentucky in the heyday of the opioid crisis we were pretty bad. Then that’s when I recognized, “Hey, we need to do a better job working with the providers, and the hospitals and let them know what the rules were and things like that. At the same time, we were looking into bad doctors too that were prescribing illegitimately.
David: About what years were you doing that in Indiana?
Dennis: 2005 all the way up to 2014.
David: You really saw the swell, the rise of the opioid crisis become a national story, for sure. You’re giving a presentation here at the conference, Innovations Recovery on DEA and MAT Regulations demystifying that role. Let’s start by having you tell us what are the regulations currently, where does that stand?
Dennis: If you’re a prescriber or a provider that uses MAT and it’s primarily the buprenorphine side, the buprenorphine drugs, the Schedule Three, the most common ones are going to be Subutex, Suboxone and there’s some newer ones coming out. If you maintain an inventory of those at your office, you’re required, pursuant to federal law, to keep inventory records. I think the same records of your check-in account where your money goes, where it comes in from the same thing on the records are controlled.
One of the things I passed on to the participants today is if you can prescribe, that’s the smart way and it gets you away from all that record-keeping. A lot of people have gone to that and that’s risk mitigation tip number one.
David: What’s the difference between that and what other people would be doing?
Dennis: When the buprenorphine was first approved by SAMHSA for an office-based opioid treatment drug, most of the docs would have to buy quantity of it, keep it in their office and when that person suffering from OUD came in, they would induct them and the doctor would watch them and they’d try and get the right level of the drug in their system before they left their office.
That, most of the docs were not taught, how to keep the appropriate records. Then when the DEA did go in, A, it scared the blank out of them and then B, they weren’t keeping the records pursuant to the way Congress told them to, so they usually got a little slap on the hand like, “Hey, you got to pick your records up via a simple little memorandum or worse.
David: In this industry, people who are working in treatment centers in that field, what are some misconceptions about the DEA’s role specifically dealing with MAT?
Dennis: Great question on that one. As I talk to the providers, many of the providers think when DEA does come in and it’s relatively hardly gaining anymore, David, you know what I mean? Because with the fentanyl crisis and the opioid, there’s really not an issue anymore, but many of the providers feel DEA is looking over their shoulder, second-guessing their medical decisions. DEA doesn’t have that authority.
The authority on the practice of medicine and how one performs it is delegated to the state universities and the state medical boards, but the perception is out there, “DEA is coming and checking my patient files and they second-guess whether I gave the patient this or that or I should have did this.” DEA is not doing that. In fact, DEA has zero doctors on staff. DEA, when we’re talking about our regulatory side, I teach people, “You’ve got to think being counters. Like bank auditors, they’re just checking the records on the drugs. That’s all they’re checking, but there’s a big misconception about that.
David: The reality is that it’s more of you’re accounting, basically and instead of money, it’s drugs?
Dennis: You got it. When DEA was formed in ’73 and they made the law that governs all this, I’m almost certain, David, just like you said, they copied the US banking system because it’s almost the same. You’ve got to have a record where every dollar went, same that you’ve got to have a record where every drug went. It’s that simple.
David: Some of the other national organizations in the space like SAMHSA, FDA, DEA, how are those roles different? How do they all make up this ecosystem of federal involvement?
Dennis: You’re a knowledgeable man young man and understand all that in the sea of federal acronyms. DEA’s authority is really only the enforcement side and it only pertains to controlled substances. HHS, Health and Human Services, is the big player across the country and it’s a federal agency but below them is SAMHSA, Substance Abuse Mental Health Services Agency. They oversee and dictate, it’s the only audity to some extent, the practice of treatment medicine. Where if me and you were talking about pain or like cancer, that’s a state oversight the board, but SAMHSA drives the train over the treatment of addiction.
What happens is, if you’re a provider, you first have to take a SAMSHA class and do that class before you can treat people with OUD. They notify DEA and DEA gives that provider a special registration or license to do it. It doesn’t cost them anything. Again, in essence, you have the FDA approves all the medicines, they approve buprenorphine products and things like that, the HHS dictates the practice of treatment medicine and then DEA only oversees how those controlled substances if the records are there. DEA can also criminally charge somebody or look at them if there’s a violation but then that has to be second-guessed by a prosecutor. It’s simple, but at times, it’s confusing too.
David: You said SAMHSA and DEA work together, like they’re sharing information kind of thing?
Dennis: You got it. Yes sir. They each have their part, but when the treatment arena SAMHSA is the big player, DEA has got that little portion.
David: Like you mentioned, MAT, medication-assisted treatment, used to be something that was less common, more fringe, but now it’s being accepted more and more even among people who had been more strictly 12-step programs and that kind of thing. What are the latest stats telling us about MAT that’s being overwhelmingly accepted now more and more?
Dennis: I think like anything it’s almost medicine is changing and treatment is changing, but I was talking with somebody at the conference, there’s SAMHSA and the states have ramped up and are allowing more NTPs, Narcotic Treatment Programs, in my age methadone clinics. There’s more of those coming out in each state. They’ve ramped it up in response to the opioid, fentanyl crisis. In the same regard, Congress passed the Cure Act in 2016, which allowed nurse practitioners and physicians assistants to also treat OUD with MAT. Prior to 2016 and at law, it could only be a medical doctor that could do it.
David: They’re opening up kind of the licensure and there’s just more availability.
Dennis: Well said, and then as I talked to David about 60,000 medical providers have the special license to treat OUD. That sounds very good, but there’s just a little bit less than one million MDs and DOs practicing in the United States, and there’s another 330,000 NPs and PAs. The bottom line is out of all the medical providers out there, it’s still a relatively few that have the license to do what hovers maybe around 3% to 4% generally, but it is on the rise, David.
David: You say OUD.
Dennis: Opioid use disorder.
David: I’m used to hearing substance use disorder but that’s kind of a specific opioid version of that. Cool. Even with the statistics that say MAT can be helpful and the licensure like you said is opening up. Is it still a barrier where treatment programs are afraid to use it because they have these misconceptions about the DEA, is that still a barrier?
Dennis: That still there, and that one goes back from the DEA inspections. DEA hasn’t on a regular basis inspected any doctors since 2016, but, previous to that, DEA did do these visits. Although they are well-intentioned, the unintentional consequence was it possibly scared some providers.
David: They say like, “It’s not worth it. I just don’t want anything to do with it.”
Dennis: I’ve heard that. I was at the ASAM Conference a couple of weeks ago, and I was amazed how much I heard that. I think too, the other one is the newer and younger providers are more open to it, where somebody in their 50s or 60s might have a preconceived idea, the classic argument, “We’re only replacing one opioid with another.” The last one is you’re going to know from your expertise is treating SUD or OUD, whatever you want to call it, is time-consuming, difficult and [unintelligible 00:12:52].
A number of people relapse and some people just don’t want to practice that type of medicine. It’s a lot cleaner to be the family practice doc, giving out kid shots or looking toward things like that. I see big inroads, but I see some people not saying, “That isn’t the type of medicine I want to practice.”
David: It’s just like anything else. You could be a counselor in a family setting or you could be a counselor at a residential treatment program. It has extra challenges but you got to want to be there. You got to want to fight that mission.
Dennis: I couldn’t say it any better than that. It’s just there’s not enough people. It’s still bad out there and people have different views.
David: What’s your view of MAT in general? Pro-MAT, you wish more people would use it? Is that your opinion?
Dennis: I’m a believer of the MAT. I know how the methadone clinics work, MAT’s a great tool too. For my previous life, I’ve seen it used inappropriately at times, but it should be a tool and a treatment provider’s toolbox. It’s a powerful tool. At times, I’m hearing now that many people are using buprenorphine more as a harm reduction drug, than actually trying to treat the person.
I understand that argument, but it’s outside my wheelhouse. It’s the practice of medicine if that’s where they’re going. It should be a tool. I believe in it, but it’s a powerful tool that should be used appropriately too.
David: If we want more treatment programs to have that tool in their toolbox, what are some tips for those in behavioral health care to help them feel a little bit better about using it and maybe preparing for if they are audited because that could still happen?
Dennis: It could, but the likelihood is about one out of a hundred. I mean, it’s really minimal, but I can’t take back history. I find some people use it as an excuse so they don’t have to do it.
A tip, go take a class. Once you get your SAMHSA class, which is an eight-hour class, partner up with somebody that has experience and learn from them, just like residency program. Don’t fear the DA and slowly practice your craft. People need you and then follow a guideline, I often preach about that. SAMHSA guidelines, ASAM has guidelines. There’s a number of general practice guidelines, go find the one you like and follow it to some degree.
You don’t have to be perfect at it and then practice medicine and then don’t fear the law enforcement coming in, but recognize that every now and then there’s a high value for those drugs when they’re diverted on the street. There’s ways to minimize that risk but go practice medicine.
David: It’s interesting to say, “Don’t fear the DEA.” I imagine part of this is also just kind of that mindset thinking of DEA or law enforcement as some other separate thing that’s like possibly against you instead of thinking, “That’s someone that you could work with.” That could be a great opportunity. I guess what do you say would be some ways that behavioral health treatment people could work better with law enforcement.
Dennis: They ought to just call them and break bread with them, that’s what I learned in Indiana. I saw this void and it’s like, “Would you come teach us or tell us how you see things.” I just sit down and it’s, “Here’s what the law says, are you guys aware of it?” Many times they aren’t aware of the regulations or the law and used to say, “Hey, we’re humans like you guys. We want to see people get help.” At times I met other people, they’ve asked me, “Why is DEA anti-MAT.” It’s like, “DEA is an anti-anything.” They oversee drug records. That’s what they do, but they don’t do a good message of getting that out.
It’s easy to follow that trap; law enforcement is anti-MAT. I guarantee you, so many cops I worked within Chicago, in Indi, you get tired of seeing the pain and misery of somebody from suffering from SUD, what it does to the family. The family members if there’s any way to get those guys help and get them better, that’s what all cops want to see, truly [unintelligible 00:17:12].
David: Just like reaching out.
Dennis: Pretty much, yes.
David: You mentioned earlier the risk mitigation strategies and I know in your presentation you get into what’s called zero risk program. Could you unpack that for us?
Dennis: You bet. Sometimes I laugh at myself on that one, but it goes back. If you want zero risk in MAT, prescribe it only and when you induct them, when that first visit, when that patient comes in seeking help from you, give them the prescription, follow ASAM or SAMHSA guidelines via prescription maybe for three days, let them go fill it, they’ll come back with the drugs and then you work with them to get them on the right dose.
Then follow the other guidelines, you should be doing urine drug testing, hopefully, be pushing that guy, referring him or her to counseling. Because as I’ve learned by the great treatment providers most of the people addicted they have an underlying mental health issue that needs to be addressed first. It’s like find a plan and work a plan and then stay on and you’re going to have relapses but stay with that person and then practice medicine. That’s really it. It’s that simple.
David: That’s a good point. I’ve head by someone else on the podcast they said, “MAT can’t just be M.” You need to follow it up. It should be some part of a larger plan, and so that’s a good point. You’re saying to help them get to that next step.
Dennis: I’m only smiling when you say that because that’s actually what the guidelines say, the best practices. I left the conference a couple of weeks ago and these MATs evolved and where there’s a big consensus now. The medications is all they need. I worry that we’re repeating what we did in the mid-2000s, here we are again in America and one pill is going to fix every underlying issue me and you have. I’ve seen that one before, David.
David: That’s the mindset that got us here, in a lot of ways, sure. Looking at maybe a bigger picture, what are one or two things you wish more people in behavioral health care in addiction treatment field understood about the DEA and MAT and all these?
Dennis: The one thing is DEA doesn’t have a view on what type of medicine or anything like that. All the employees recognize the issue America is facing right now. DEAs, all their authority is grounded in laws that Congress made almost 50 years ago. I always think of DEA [unintelligible 00:19:53]. If you’re going to keep this stuff, just keep good records, you’re going to be fine.
Secondly, as far as MAT or the opioid, DEA is focused on going after the fentanyl and the heroin traffickers. That is priority number one, has been for the last eight years because of the deaths. All the DEA’s efforts is focused there and they will continue to focus. They don’t want to ever have to get in the way of a MAT provider or a legitimate provider at all, but it is a part of their responsibility.
David: Do you have a great story that you like to share from your Chicago investigation days of busting something like fentanyl or anything like that?
Dennis: After a while, you get bored. I’ll tell you, Chicago is a great city, but it’s like it’s the stronghold of the Sinaloa Cartel. The former leader was Chapo Guzman. It was before my time, but the people I was fortunate enough to manage had a big part in that case, they’re very proud of it. Since Chicago is in the middle of America and it’s a melting pot, the cases, David, they always go to Mexico or across the world and it’s just cool being a part of that compared to when I worked in Indianapolis. St. Louis, they were smaller scale.
What I’m saying is you play on a big arena and it isn’t uncommon, if we’re fortunate, to find $5 million in currency in a house or 100 kilograms of heroin and fentanyl. You’re playing in the big leagues, as I call it, and that was so impressive.
David: Yes, making a big impact. Now, I don’t know if you’ve read Sam Quinones’ book, Dreamland.
Dennis: Yes, sir. I have.
David: Yes, that. It makes me think of that because he does such a great job of laying out that story and all the different cells. I don’t know if he mentioned Chicago specifically, I don’t know how big of a part it was for the Jalisco Boys, but, yes, it’s just really cool. There might have been some DEA presences in some of those stories, but it was just really cool to see. Lots of times, it would be one agent or one person on the law enforcement side who just– Their sense perked up when they saw, “Hey, something doesn’t seem right here.” Then they just kept following that trail and following that trail and then they uncovered– There was a guy in Portland, the guy in Virginia, all this stuff and, eventually, they all realized, “Hey, we’re all working on the same thing.” This is all the same thing. It’s crazy.
Dennis: Now, it’s a fun job and you mentioned that and you rolled that arrow good on Jalisco. It took me a while too, The New Generation and Guerrero and the Los Temples and then the Gulf Cartel and all these bigger organizations.
DEA, you have good employees and you have mediocre ones, but I will say if you put 10 DEA agents together, one or two are going to be outstanding. I used to call them hunting dogs. They get it faster, they get it better, they understand it. I used to say, “You let the dogs run.” Let them know that there’s a fence line way out there. They can’t go past that fence line without talking to the boss.
What you use to describe, and Quinones’ book was too so-well-done. It primarily centered on Ohio and the problem they’ve had, but sometimes it just takes one good person with a great attitude, who refuses to give up a lucky break. Hopefully, he’ll see something that me and you would, but on any given day, me and you might miss it and he might see it and it steamrolls from there.
David: Yes, cool. All right. Anything else you want to cover that we haven’t covered yet?
Dennis: The only other one, somebody asked me, it’s like, “Hey, what do you see in the future?” It’s like, “CBD oil.” That is the new miracle drug. I have to admit, it seems to be benign. It was approved for a couple of special epilepsy in young children by the FDA.
David: The epileptic? Okay.
Dennis: Epileptic seizures. A couple of Houston kids. Man, I see that one, David. People are using it for insomnia, anxiety. I don’t know the science behind it, but it seems fairly benign, but that’s the hot drug. Now, I will say, Kratom. Are you familiar with Kratom?
David: Yes, a little bit.
Dennis: The FDA just came out again saying there’s multiple deaths behind it. DEA tried to emergency schedule it and outlaw it a couple years ago, but we got our butt kicked by the industry and some congressmen. People continue to try and self-treat themselves with Kratom. You really don’t know what you’re buying. At least with some other [unintelligible 00:24:38] products or Vivitrol, or whatever brand you want to use, you know what you’re putting in your body. I understand it, but I really do think kids and people trying to self-treat with Kratom are playing somewhat of a Russian Roulette with that drug.
David: Because it’s less regulated.
Dennis: There’s no regulation. You don’t know what you’re putting in your body.
David: All right, well, we’ll wrap up with this final question then. Everyone who serves in this field has their own reasons for wanting to fight this fight and to cause a recovery. Men like you, you’re retired. You could be doing anything you want, but you’re here, helping to educate people and, you know, help move this cause along. Could you end by summing up why this mission matters to you? Why it’s so important to you?
Dennis: To save lives. Everybody needs a purpose in life and what better purpose than to save mankind and save a life? It’s as simple as that.
David: Yes, love it. All right. Well, Dennis, thank you so much for being with us.
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