Doc­tors who pre­scribe oft-abused drugs face scru­tiny

High vol­ume can point to other prob­lems; physi­cians cite big caseloads

The Washington Post Sunday - - FRONT PAGE - BY CHRIS­TIAN DAVEN­PORT

Twice, the pa­tient, a man in his mid30s, said he lost his pre­scrip­tions for Val­ium and Per­co­cet. Once, he said he was in a car ac­ci­dent that scat­tered his pills on the road. An­other time, he said the medicine he was first pre­scribed was no good, so he “re­turned the pills.” An­other time, his wife called and said their house had been “searched by au­thor­i­ties” and the medicine had gone missing.

Each time, no mat­ter the story, Peter S. Trent or Hampton J. Jack­son Jr., doc­tors at the same or­tho­pe­dic prac­tice in Oxon Hill, re­filled the pre­scrip­tion, ac­cord­ing to the Mary­land Board of Physi­cians. Over the course of 2 1/2 years, the doc­tors gave the pa­tient 275 pre­scrip­tions, mostly for Per­co­cet, a pow­er­ful, highly ad­dic­tive painkiller.

Some­times they wrote the pa­tient more than one pre­scrip­tion for the drug on the same day. In a sin­gle month, they wrote him 11 pre­scrip­tions for Per­co­cet, to­tal­ing 734 pills.

Jack­son and Trent— who main­tain that they did noth­ing wrong — are among a small group of doc­tors who were the top pre­scribers of tightly reg­u­lated drugs in their state Med­i­caid pro­grams, ac­cord­ing to a Washington Post anal­y­sis of state data.

Last year, Sen. Charles E. Grass­ley (RIowa) asked state reg­u­la­tors to pro­vide lists of the top 10 Med­i­caid pre­scribers of eight drugs — some of which have high street value be­cause of their pop­u­lar­ity among abusers — in an ef­fort to iden­tify doc­tors who might be over­pre­scrib­ing pricey medicines at tax­payer ex­pense.

The data he col­lected — which do not in­clude pre­scrip­tions writ­ten out­side of Med­i­caid — show that some doc­tors pre­scribe far more of the drugs than most of their peers. Grass­ley said the find­ings do not nec­es­sar­ily sug­gest “any il­le­gal or wrong­ful be­hav­ior,” be­cause doc­tors on the lists may have a cer­tain ex­per­tise or pa­tient pop­u­la­tion that jus­ti­fies their pre­scrib­ing pat­terns.

But the find­ings “may also sug­gest overuti­liza­tion or even health-care fraud,” Grass­ley said. In one case, he noted, a Florida doc­tor wrote nearly 97,000 pre­scrip­tions for mental-health drugs over a 21-month pe­riod.

Af­ter re­ceiv­ing Grass­ley’s data, The Post re­quested the same in­for­ma­tion from the District, Mary­land and Vir­ginia for other drugs — such as Per­co­cet, Vi­codin and Ri­talin— that are prone to abuse.

The Post’s anal­y­sis found not only that cer­tain doc­tors rou­tinely pre­scribe some med­i­ca­tions far more than their peers, but also that some of them have a long his­tory of sanc­tions by pro­fes­sional dis­ci­plinary boards for un­eth­i­cal and un­pro­fes­sional be­hav­ior, in­clud­ing over­pre­scrib­ing med­i­ca­tions to pa­tients who may have been us­ing them to get high in­stead of well.

The state boards that over­see med­i­cal mis­con­duct say over­pre­scrib­ing is a huge prob­lem that they take very se­ri­ously.

The top pri­or­ity is to do “what­ever you think is nec­es­sary to pro­tect the pub­lic,” said Wil­liam Harp, ex­ec­u­tive di­rec­tor of the Vir­ginia Board of Medicine. “I want us to be very ob­jec­tive and very fair to these doc­tors and the cit­i­zens they treat.”

Reg­u­la­tors say they are caught be­tween try­ing to keep doc­tors from pre­scrib­ing drugs un­nec­es­sar­ily and sat­is­fy­ing doc­tors who say heavy-handed in­ves­ti­ga­tions dis­cour­age them from pre­scrib­ing med­i­ca­tion that pa­tients need.

“We get heat from both sides,” said C. Irv­ing Pinder Jr., ex­ec­u­tive di­rec­tor of the Mary­land Board of Physi­cians. “Pain-man­age­ment doc­tors say we’re tak­ing them out of busi­ness, but we’re only get­ting those that ob­vi­ously cross the line.”

Mean­while, il­licit use of pre­scrip­tion medicine has be­come the nation’s “fastest-grow­ing drug prob­lem,” ac­cord­ing to R. Gil Ker­likowske, di­rec­tor of the White House Of­fice of Na­tional Drug Con­trol Pol­icy. Be­tween 1999 and 2005, un­in­ten­tional deaths from pre­scrip­tion drug over­dose more than dou­bled, to more than 22,000, ac­cord­ing to a study funded by the fed­eral Cen­ters for Dis­ease Con­trol and Pre­ven­tion, mak­ing such over­doses the sec­ondlead­ing cause of un­in­ten­tional death, af­ter au­to­mo­bile ac­ci­dents.

Part of the prob­lem, Ker­likowske said, is that peo­ple do not see the drugs as dan­ger­ous, be­cause they are le­gal and have a le­git­i­mate use. Many doc­tors are pre­scrib­ing more of these highly ad­dic­tive drugs with­out fully un­der­stand­ing how hooked peo­ple can be­come, he said.

Doc­tors “don’t get very much, if any, train­ing in de­pen­dence, in ad­dic­tion, in pain man­age­ment,” he said.

The drugs driv­ing the prob­lem are opioid anal­gesics, which among teenagers are more pop­u­lar than mar­i­juana, ac­cord­ing to a fed­eral study from 2006. These drugs have been flow­ing out of re­tail phar­ma­cies at a bur­geon­ing rate. Pre­scrip­tions for two of the most com­mon opi­oids, hy­drocodone and oxy­codone, jumped from 44 mil­lion in 1991 to 179 mil­lion in 2009, ac­cord­ing to the Na­tional In­sti­tute on Drug Abuse.

“I don’t think any­one be­lieves that pain has in­creased that sub­stan­tially in the coun­try,” Ker­likowske said.

The lists of doc­tors who write the most pre­scrip­tions in­clude some who have got­ten in trou­ble be­fore for over­pre­scrib­ing and some who have been sanc­tioned by state med­i­cal boards for other of­fenses, in­clud­ing bor­row­ing large sums of money from a pa­tient, giv­ing nar­cotics to a pa­tient even af­ter be­ing warned that the pa­tient was sell­ing those drugs, and mis­tak­enly pre­scrib­ing a lethal dose of an an­tide­pres­sant to an 11-year-old boy, who col­lapsed on a school trip to an amuse­ment park and died.

Pa­tients in and out

Hampton Jack­son — who also prac­tices in the District — pre­scribed far more OxyCon­tin and Rox­i­codone (two brand names for the nar­cotic painkiller oxy­codone) than did the city’s next most pro­lific Medic aid provider. He wrote 63 pre­scrip­tions in 2008 and 191 in 2009; the run­ner-up on the list wrote 27 in 2008 and 64 in 2009. But Jack­son said his to­tals were rel­a­tively small given the num­ber of pa­tients he treats. He also said he rig­or­ously mon­i­tors pa­tients on heavy drugs for signs of abuse.

On an av­er­age day, he said, he sees 30 to 50 pa­tients. On an ex­tremely busy day, he said, he can see as many as 90 in nine hours. That caseload — 10 pa­tients an hour — is pos­si­ble, he said, be­cause many are rou­tine fol­low-ups and “ be­cause I have a big staff.”

Jack­son said many pa­tients whoare in pain are un­der­med­i­cated. Doc­tors, fear­ing dis­ci­plinary ac­tions from med­i­cal boards, are not pre­scrib­ing the drugs peo­ple need, he said.

Even though he is on pro­ba­tion and his priv­i­leges at Ge­orge Washington Uni­ver­sity Hos­pi­tal have been re­voked since 2004, Jack­son said he will con­tinue to prac­tice medicine as he deems best. If that means treat­ing peo­ple who re­quire strong drugs, so be it.

“A lot of peo­ple say, ‘I’m not get­ting in trou­ble with the board’ and ‘Get them out of my of­fice.’ That’s not true tomy oath and my de­sire to help my pa­tients,” he said. “I have all these pa­tients be­cause doc­tors won’t treat them.”

In 2004, the Mary­land board sanc­tioned Jack­son and Peter Trent, say­ing that they did not heed signs of a pa­tient’s abuse prob­lem and failed to en­sure that he was “not di­vert­ing these med­i­ca­tions for non-ther­a­peu­tic pur­poses or was stock­pil­ing the med­i­ca­tions for per­sonal use.”

Al­though the word­ing of the sanc­tion sounded tough, it re­ally was lit­tle more than “a slap on the wrist,” Jack­son said in an in­ter­view. The pun­ish­ment did not pro­hibit him from see­ing pa­tients or pre­scrib­ing medicine.

In fact, records show that in 2009, while Jack­son’s li­cense was un­der pro­ba­tion, he was among Mary­land’s top pre­scribers of Rox­i­codone and of Vi­codin, a painkiller that com­bines hy­drocodone and ac­etaminophen. In ad­di­tion, Jack­son and Trent were first and sec­ond in the District, re­spec­tively, in the num­ber of Per­co­cet pre­scrip­tions writ­ten in the 12 months that ended Sept. 30, 2010. Dur­ing that pe­riod, Jack­son wrote 684 Per­co­cet pre­scrip­tions and Trent wrote 223.

Both Jack­son and Trent, who is no longer on pro­ba­tion, said in in­ter­views that they did noth­ing wrong and were vic­tims of an overly ag­gres­sive board.

“They were head hunt­ing,” Jack­son said. “ They were look­ing to show the pub­lic they were crack­ing down on drugs.”

Asked to com­ment on his ap­pear­ance on the District’s most-pre­scribed list, Trent said, “ They ought to give me an award.” He said the num­ber is not high given that he sees 100 pa­tients a week.

Both doc­tors said that they use many tech­niques to treat pa­tients but that medicine is of­ten a key com­po­nent. “If there’s no other rea­son­able way to con­trol the symp­toms, then we are forced to use med­i­ca­tions like OxyCon­tin,” Jack­son said.

As for the pa­tient for whom they wrote 275 pre­scrip­tions, both doc­tors said that they were work­ing in dif­fer­ent lo­ca­tions at the time and that nei­ther knew the other was pre­scrib­ing the same med­i­ca­tion.

The pa­tient “would come to me, then the next day he would go to the of­fice in Sil­ver Spring, and we wouldn’t have the records in Sil­ver Spring, so nei­ther one of us knew he was get­ting med­i­ca­tion from us si­mul­ta­ne­ously,” Jack­son said.

That case has led to a change in the doc­tors’ prac­tice. “We’ve tight­ened up,” Trent said. “ The an­swer now is no if they say they lost their pre­scrip­tion.”

‘Egre­gious’ vi­o­la­tions

Mont­gomery County po­lice in 2000 found a woman fad­ing in and out of con­scious­ness in a house so squalid it would soon be con­demned as un­fit for hu­man habi­ta­tion. At the hos­pi­tal, the pa­tient, who had at­tempted sui­cide be­fore, was found to be full of booze and the same type of med­i­ca­tions that had been pre­scribed by Joel Co­hen, who, as it turned out, was her fi­ance.

For more than a year, Co­hen, then a psy­chi­a­trist in Bethesda, had been pre­scrib­ing the woman med­i­ca­tions such as hy­drocodone and the anti-anx­i­ety drug di­azepam but failed to keep records, ac­cord­ing to the Mary­land Board of Physi­cians, which placed him on pro­ba­tion in 2001.

In Fe­bru­ary 2006, that pro­ba­tion was lifted. Five months later, Co­hen was sanc­tioned again af­ter what the board called a “dan­ger­ous fail­ure to meet the stan­dard of care” with a sec­ond pa­tient, for whom he pre­scribed “ large amounts of med­i­ca­tions” de­spite her his­tory of al­co­hol and pre­scrip­tion drug abuse. Co­hen did this, ac­cord­ing to the board, even while he “was aware that the pa­tient was abus­ing pre­scrip­tion med­i­ca­tions,” in­clud­ing the stim­u­lant Ri­talin.

In 2008, ac­cord­ing to the D.C. Board of Medicine, Co­hen was the District’s top pre­scriber un­der Med­i­caid of three an­tipsy­chotic med­i­ca­tions: Sero­quel, Abil­ify and Geodon.

In the 2006 sanc­tion, the Mary­land board said Co­hen had com­mit­ted “egre­gious bound­ary vi­o­la­tions” with the pa­tient, a vic­tim of spousal abuse who had de­vel­oped bor­der­line per­son­al­ity dis­or­der. He gave gifts to her chil­dren, al­lowed her to take his chil­dren on vacation and gave her real es­tate ad­vice. He also let the pa­tient, whom he had been treat­ing for 21 years, shower at his of­fice and pre­scribed Ri­talin for her son with­out eval­u­at­ing him.

Co­hen ad­mit­ted to the board that he had “mis­han­dled the pa­tient’s case in many ways and had un­der­es­ti­mated his own dif­fi­cul­ties,” ac­cord­ing to the board’s fi­nal or­der in the case.

In that sec­ond sanc­tion, the board said Co­hen’s ac­tions “were not a one-time, short-term lapse of judg­ment with one pa­tient, but rather a long­stand­ing, doc­u­mented pat­tern of un­eth­i­cal be­hav­ior dat­ing back to 1977.”

Co­hen’s li­cense in Mary­land has ex­pired, but he con­tin­ues to prac­tice at Com­mu­nity Con­nec­tions, a clinic on Capi­tol Hill.

In a brief in­ter­view, he said he sees as many as 16 pa­tients a day, many of whom are home­less and do not have in­surance.

“I work with se­verely men­tally ill peo­ple,” he said. “I re­ally don’t want to go into all of this. This is a very tough place to work here. We have very sick peo­ple. I think that’s enough said.”

Clear signs of mis­use

One pa­tient’s fi­ancee asked the doc­tor to please stop pre­scrib­ing so many med­i­ca­tions. The pa­tient was an al­co­holic with a his­tory of abus­ing nar­cotics and seda­tives. Once, he over­dosed, and now he was in a detox clinic. Still, the doc­tor did not stop pre­scrib­ing, ac­cord­ing to Mary­land’s Board of Physi­cians.

In fact, over the course of a decade, Daniel M. How­ell, a fam­ily-care doc­tor in Wal­dorf, pre­scribed more drugs, in in­creas­ing doses, even when there were clear signs that the pa­tient was abus­ing his medicine, the board found.

In 2008, How­ell was among Mary­land’s top pre­scribers un­der Med­i­caid of OxyCon­tin, Xanax and Per­co­cet.

In an in­ter­view, How­ell said he “fol­lowed na­tional pain-man­age­ment guide­lines in the sense that we did ran­dom urine test­ing on any­one that we had any sus­pi­cion about.” In one year, he said, his prac­tice dropped 50 to 100 pa­tients for abus­ing pre­scrip­tions.

How­ell started see­ing the al­co­holic pa­tient for “pos­si­ble bro­ken ribs” in 1994. By the next year, a CVS phar­ma­cist called How­ell to re­port that the pa­tient had been get­ting mul­ti­ple re­fills for sev­eral nar­cotics from dif­fer­ent doc­tors in the area. But when the pa­tient com­plained of kid­ney stones soon there­after, How­ell pre­scribed Per­co­cet.

Ini­tially, he pre­scribed 20 to 30 pills at a time, the board found. By 1997, it was 40, then 60. By 2000, he was pre­scrib­ing the pa­tient 100 pills ev­ery two weeks. Then How­ell dou­bled the strength of the pills from 5 mil­ligrams to 10. Once, he pre­scribed Per­co­cet be­cause the pa­tient had a “ headache — frontal.” At one point, How­ell pre­scribed 300 pills within 10 days, along with 90 tablets of OxyCon­tin, to the same pa­tient, an amount the board called “well above the safe limit.” By 2003, the pa­tient was tak­ing eight to 14 Per­co­cets a day.

In 2008, the board placed How­ell on pro­ba­tion, re­quir­ing him to take a course on pre­scrib­ing con­trolled sub­stances. But he was al­lowed to con­tinue see­ing pa­tients and writ­ing pre­scrip­tions. A year later, he was charged again. This time, the phar­ma­cies— and other doc­tors— were com­plain­ing.

“ Three concerned area phar­ma­cists,” as they called them­selves in a let­ter to the board, said How­ell was pre­scrib­ing ex­ces­sive nar­cotics to pa­tients who “ap­pear to have ques­tion­able and/or doc­u­mented his­tory of overuse of pain med­i­ca­tion.”

A few months later, an emer­gency room doc­tor at St. Mary’s Hos­pi­tal in South­ern Mary­land com­plained that How­ell’s over­pre­scrib­ing was caus­ing over­doses. One pa­tient had ended up in the ER but then re­turned to How­ell’s of­fice, where he “re­ceived an­other very large pre­scrip­tion for Per­co­cet and Xanax,” the board said. The pa­tient was found un­re­spon­sive again and was taken to the ER a sec­ond time.

“I want you to note that none of the pa­tients I was ac­cused of mis­treat­ing in this fashion died,” How­ell told The Post. “The ER takes care of the moment. But what hap­pens the next day, when they’re shak­ing and sweat­ing and some­times hav­ing hal­lu­ci­na­tions? And there isn’t any acute with­drawal cen­ter in South­ern Mary­land. Do you let them go into acute with­drawal, which could lead them to street meds, which are less safe than a con­trolled com­mer­cial prod­uct?”

In Oc­to­ber 2009, the board sus­pended How­ell’s li­cense but im­me­di­ately knocked the sus­pen­sion down to pro­ba­tion on the con­di­tion that he not treat pa­tients for chronic pain. The board also limited the amount of drugs How­ell could pre­scribe and re­quired that an­other doc­tor su­per­vise him.

How­ell said he has been fired from the prac­tice where he worked be­cause many top in­surance com­pa­nies dropped him af­ter the sanc­tions. He said he hoped to re­turn to prac­tic­ing medicine soon.

“I just want to get back to serv­ing peo­ple,” he said.

Hoard­ing med­i­ca­tions

The Vir­ginia Board of Medicine came down hard on Verna M. Lewis, a phys­i­cal-medicine and rehabilitation doc­tor in Roanoke. Her li­cense was sus­pended af­ter she was con­victed in 1999 of fil­ing false tax re­turns and in­flu­enc­ing a grand jury wit­ness.

In 2002, the board found that she was tak­ing un­used medicine from the hos­pi­tal where she worked and us­ing it in her pri­vate prac­tice. She also told pa­tients to re­turn un­used pre­scrip­tions to her and then had her staff take pa­tients’ names off those bot­tles so she could reis­sue the med­i­ca­tions to other pa­tients, even though, as the board said, she had no author­ity to do so.

State po­lice and health in­ves­ti­ga­tors searched her of­fice and found hun­dreds of doses of drugs, in­clud­ing OxyCon­tin, with no pa­tient or phar­macy names on the la­bels. The board also said she re­moved from her of­fice two pa­tients’ files that had been sub­poe­naed.

Lewis ap­plied to have her li­cense re­in­stated twice, and both times she was de­nied. Then, in 2004, af­ter she com­pleted 108 hours of con­tin­u­ing med­i­cal ed­u­ca­tion, her li­cense was re­stored with sev­eral con­di­tions, in­clud­ing hav­ing to pass an exam given by the na­tional Fed­er­a­tion of State Med­i­cal Boards.

Af­ter she took the test, ac­cord­ing to the Vir­ginia med­i­cal board, Lewis faxed the of­fi­cials a doc­u­ment pur­port­ing to prove that she had scored the min­i­mum pass­ing grade of 75. But when the fed­er­a­tion faxed in her of­fi­cial score the next day, it showed that she had failed with a score of 74.

Lewis did not re­turn calls seek­ing com­ment. She told the board that it had not found any “ac­tual pa­tient harm” and that she ex­ten­sively stud­ied pain man­age­ment and had never been sued for mal­prac­tice.

Harp, the med­i­cal board’s di­rec­tor, re­fused to ad­dress spe­cific cases but said, “We take pre­scrib­ing com­plaints very se­ri­ously.”

In 2006, the board re­in­stated Lewis’s li­cense but or­dered an unan­nounced in­spec­tion of her prac­tice and records and re­quired her to log the con­trolled sub­stances she pre­scribed.

The year af­ter that, she was granted a “full and un­re­stricted li­cense.” The let­ter re­in­stat­ing her ends, “ The board wishes you well in your fu­ture en­deav­ors.”

The year af­ter that, in 2008, Lewis was among Vir­ginia’s top pre­scribers of Oxy Con­tin and Rox­i­codone un­der Med­i­caid.

ASTRID RIECKEN FOR THE WASHINGTON POST

Hampton J. Jack­son Jr. pre­scribed more of the nar­cotic painkillers OxyCon­tin and Rox­i­codone than the next most pro­lificMed­i­caid provider in D.C., writ­ing 63 pre­scrip­tions in 2008 and 191 in 2009. “A lot of peo­ple say, ‘I’m not get­ting in trou­ble with the board,’ ” he said. “ . . . I have all these pa­tients be­cause doc­tors won’t treat them.”

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