Prince’s state, Minnesota, went easy on doctors for overprescribing narcotics
The 57-year-old performer was found dead on April 21 at his Minneapolis-area estate.
June 2, 2016 3:51 PM
Prince performs in 2007 during the halftime show at the Super Bowl XLI at Dolphin Stadium in Miami.
Liu Heung Shing/Associated Press
Prince performs in 1985 at the Forum in Inglewood, Calif.
By Rich Lord and Maia Silber / Pittsburgh Post-Gazette
Musician Prince’s struggle with painkillers, and his April 21 death from a fentanyl overdose, occurred in a state that has disciplined few physicians for prescribing too many narcotics and where regulators only recently shifted their emphasis from reducing pain to averting addiction.
On Thursday, the Midwest Medical Examiner’s Office in Ramsey, Minn., released a one-page report revealing that the musician died from fentanyl — 50 times more potent than heroin — that he administered to himself. The report did not indicate whether Prince had a prescription for the drug. At least one Minnesota doctor’s office has been the subject of a search in the investigation of Prince’s death.
States hard hit by painkiller addiction, especially in Appalachia, have in recent years stepped up efforts to identify, discipline and in some cases prosecute physicians who have prescribed narcotics to excess.
But in Minnesota, physicians have until recently faced little discipline in relation to their painkiller practices.
From 2011 through 2015, the Minnesota Board of Medical Practice disciplined just 25 doctors in relation to their narcotics prescribing practices. That represents just 1.5 out of every 1,000 doctors active in the state.
A six-month Post-Gazette study of prescribing and physician discipline in seven states found that just one — Pennsylvania — disciplined doctors for prescribing at a lower rate than did Minnesota. The other six all had rates more than double that of Minnesota.
“Our policy in Minnesota is pretty vanilla as compared to the rest of the country,” said Minnesota state Rep. Dave Baker, who lost a son to an overdose five years ago. “We need to get the medical community to the table and to take ownership of what I think is one of the greatest medical mistakes in our history — to allow time-delayed heroin to be used as pain medication.”
In 2004, the Minnesota boards regulating doctors, nurses and pharmacies issued a joint statement declaring that: “The effects of unmanaged pain are serious and wide-ranging, and yet, pain is widely under-treated.” The statement’s first suggestion to Minnesota’s doctors: ”Consistently and thoroughly assess all patients for pain."
“We were encouraging adequate treatment of pain,” said Ruth Martinez, executive director of the Minnesota Board of Medical Practice. “I think the response by some physicians was certainly to turn to narcotics as a tool.”
Only last year did the boards substantially revise the statement, acknowledging that there “is a critical balance between preventing opioid misuse and managing pain." “It reflects recognition of some of what we’re facing in this opioid crisis,” said Ms. Martinez.
While some states’ medical regulators have responded to rising overdoses by suspending or revoking the licenses of doctors who prescribe too many narcotics, Minnesota has focused on re-educating those who have strayed. Of the 25 Minnesota physicians disciplined in relation to their prescribing practices over the past five years, 18 are still active, according to online license status information. Of those, 11 are practicing under board-imposed restrictions or conditions, while seven have unrestricted licenses.
James R. Eelkema, who practiced in the Minneapolis suburbs, prescribed narcotics to a patient with back pain and a history of substance abuse, and at one point “met [the patient] at a location outside of [his] office and engaged in sexual conduct,” according to a Board of Medicine order that he signed in 2011. “On the same day, [the doctor] authorized a prescription for narcotics for the patient,” according to the board order.
For that, he received a reprimand, plus required coursework, meetings and a $5,577.80 penalty. The board lifted all restrictions on his license a year later.
In 2013, though, the board found that he “inappropriately prescribed narcotics” even after the initial reprimand. The board made him take more courses and “write and submit a paper … discussing what he has learned.”
“I think the board was fair with education, not punishment,” Dr. Eelkema said Thursday. Asked about the accusations, he said, “The case is closed. My memory has sort of faded.”
Dr. Eelkema now runs the nonprofit Heroin Project Ltd., which promotes medication-assisted treatment for addicts. The group, founded in October, appeals to clinics, legislators, police departments, prosecutors, and advocacy groups, urging more distribution of Suboxone, a medicine which staves off withdrawal.
Shock and storm
Mr. Baker said his son “was a healthy kid,” prior to an injury. “He couldn’t get off of the pain pills once we got his back fixed surgically.”
When the son’s physicians stopped prescribing pills, said Mr. Baker, “he had to reach out to heroin.”
Mr. Baker owned a small business then. Now he’s a first-term legislator, and the House’s clearest voice for a new approach to pain medicine. “We have lagged here,” he said.
Some states have sought to force changes in prescribing culture through data and education. Kentucky, for instance, demands that its doctors check their patients’ drug histories in a database before prescribing narcotics, respect guidelines on when and how to employ opioids, and take 4.5 hours of refresher courses on the subject every two years.
Minnesota has taken a much less forceful approach.
Doctors there must register with the state’s prescribing database — thanks to a new law spearheaded by Mr. Baker — but aren’t required to check their patients’ histories before recommending narcotics. The licensing boards haven’t endorsed prescribing guidelines. And nobody is required to take a refresher course.
“I don’t see that it’s really helpful to micromanage the providers,” said Ms. Martinez.
“We need to rely on prescribers to do what they do, and not set up a situation where we’re second-guessing their decisions.”
Minnesota saw the second-smallest decline in per capita opioid prescribing of the states the Post-Gazette studied — a 3.23 percent drop from 2012 to 2014. Only Pennsylvania saw a more modest dip in opioid prescribing. (Minnesota’s opioid consumption rate has remained lower than that seen in the other states studied, which also included Kentucky, Maryland, Ohio, Tennessee, Virginia and West Virginia.)
Minnesota has, however, seen the number of fatal overdoses rise by 30 percent from 2010 to 2014 — a rate of increase that is in the middle of the pack among the states studied.
"For kind of a rural state that has a great work ethic, [where] people are not used to seeing these kinds of problems, it's taking small communities by shock and storm,” said Daniel Hall-Flavin, an addiction psychiatrist at the Mayo Clinic, in Rochester, Minn.
Minnesota’s approach has been “very rational, not draconian,” said Dr. Hall-Flavin. “Prescriptions [for opioids] are going down, but then we need to see this other illicit use, or access, going down.”
The Prince effect
Carver County, where Prince lived and died, has seen few cases of prescription opioid abuse. Carver does have a heroin problem, according to Mark Metz, the county prosecutor. In some cases, he said, heroin dealers have been charged with third-degree murder for their clients’ overdoses.
The report of the medical examiner’s office does not specify the source of the fentanyl. The investigation into his death continues.
On April 27, detectives searched the Robbinsdale, Minn., office of a physician who treated the musician. The search warrant application indicated that the doctor saw Prince on April 7 and April 20, prescribed unspecified medications and conducted tests.
The doctor named in the search warrant has not been charged, and according to the state board website, he has not been subject to disciplinary action.
Prince’s death, Mr. Baker said, “tells everyone, ‘See, this is what it does.’ Prince was a healthy person. … He was a clean-living man. And he was in pain from his stage performances, and he tried to fix that, and it got out of control with him.”
Rich Lord: firstname.lastname@example.org. Maia R. Silber: email@example.com.
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