Doctors who prescribe oft-abused drugs face scrutiny

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http://www.washingtonpost.com/wp-dyn/content/article/2011/01/01/AR2011010102801.html

Doctors who prescribe oft-abused drugs face scrutiny

By Christian Davenport

Washington Post Staff Writer

Saturday, January 1, 2011; 9:41 PM

Twice, the patient, a man in his mid-30s, 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, S. Trent or Hampton J.

Jr., doctors at the same orthopedic practice in Oxon Hill,

refilled the prescription, according to the land Board of

Physicians. Over the course of 21/2 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.

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. E. Grassley (R-Iowa) 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, land 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 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 land 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

second-leading 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 - 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 Medicaid 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 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."

said many patients who are 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

Washington University Hospital have been revoked since 2004,

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 to my oath and my

desire to help my patients," he said. "I have all these patients

because doctors won't treat them."

In 2004, the land board sanctioned and 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," said in an

interview. The punishment did not prohibit him from seeing

patients or prescribing medicine.

In fact, records show that in 2009, while 's license was

under probation, he was among land's top prescribers of

Roxicodone and of Vicodin, a painkiller that combines hydrocodone

and acetaminophen. In addition, 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, wrote 684 Percocet prescriptions and

Trent wrote 223.

Both 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 headhunting," 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," 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," 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

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 land 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 land 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 land 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 land's Board of Physicians.

In fact, over the course of a decade, 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 land'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. 's

Hospital in Southern land 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 land.

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. ,

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.

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,

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.

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 '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, was among Virginia's top

prescribers of OxyContin and Roxicodone under Medicaid.

Staff researchers Magda Jean-Louis and Tate contributed

to this report.