When regulators close a 'pill mill,' patients sometimes turn to heroin
May 25, 2016 12:00 AM
Toby Talbot/Associated Press
By Rich Lord / Pittsburgh Post-Gazette
When it came to heroin, Baltimore was an early adopter. “We've had heroin since the mid-1990s, when a lot of areas didn't,” said Christopher Welsh, an addiction psychiatrist at the University of Maryland School of Medicine.
It took doctors, though, to spread the narcotic habit from Ocean City to Hagerstown.
Maryland doctors prescribed opioid painkillers or benzodiazepine tranquilizers to teenagers for menstrual cramps, to pregnant women with histories of heroin use, to sufferers from sunburn or even “gas,” and online to people they hadn’t even seen, according to the state’s Board of Physicians disciplinary documents.
Some accepted any story when patients claimed they needed more drugs ahead of schedule — even the old “her dog had eaten a prescription for Demerol" excuse. One doctor failed to reverse course even when his patient’s OxyContin fell into the hands of a young child.
When the legislature and board started tracking prescriptions, mandating doctor education and disciplining rogue prescribers, it triggered backlash and unintended consequences.
When Maryland authorities would close a pill mill, it would leave “1,500 patients all of a sudden stranded with no prescriber,” Dr. Welsh said. Some turned to cheap Mexican heroin, sometimes mixed with fentanyl.
Drug overdose deaths climbed 65 percent, to 1,070 in 2014, from 650 in 2010. That’s the second-steepest jump among the seven states studied by the Pittsburgh Post-Gazette.
Said Davinder Singh, whose term as chairman of the board ended April 6: “There’s growing awareness [of] frankly the central role that doctors can play in an epidemic, both good and bad.”
Crossroads of an epidemic
Patients came by interstate to Owings Mills, near Baltimore, from Maryland, New York, New Jersey, Kentucky, Ohio, West Virginia, Connecticut, Tennessee and Florida, just to see William James Crittenden III. Once inside Healthy Life Medical Group, they paid $250 to $300, in cash, to get prescriptions for oxycodone and alprazolam, according to plea agreements in the federal case against the clinic’s owners. A jury in February found Mr. Crittenden guilty of nine counts related to narcotics distribution, and the former doctor awaits sentencing.
Patients left trails of destruction from Thomas B. Fioretti’s Ocean City Family Practice, according to a board consent order signed by the former physician. A man in his late 20s, who claimed a snowboarding accident but showed no objective injury, got prescriptions there for OxyContin, Percocet and Xanax, according to the order. The doctor continued to prescribe even after learning that the man “struck another vehicle that had pulled out in front of him traveling at 60 mph,” until less than a year later, when the patient “struck and killed a pedestrian while driving.” The board also noted two other patients’ car accidents in its order revoking Mr. Fioretti’s license in 2013.
Patients took the road of addiction to MWGMD Medical Services, in Hagerstown, where Martin W. Gallagher Jr., a former Jesuit priest, treated them, sometimes for free. He prescribed “large amounts” of oxycodone to a patient in her early 30s with a history of narcotics abuse, according to a license suspension order signed by the board’s executive director. The woman tried the anti-withdrawal drug buprenorphine, but when she reverted to injecting heroin, the doctor put her back on oxycodone, the director wrote.
Mr. Gallagher surrendered his license in 2015. Like Mr. Crittenden and Mr. Fioretti, he could not be reached for comment.
“Occasionally it does surprise me how gullible some physicians are,” Dr. Singh said. “They come to the board and they honestly say, ‘I thought that this was proper.’ And they are so far off the reservation.”
Physicians fear ‘over-policing’
Dr. Singh, the chief of plastic surgery at Anne Arundel Medical Center, said the board he led became aware of the painkiller problem “just a couple of years ago.
“It was the result of a dramatic increase of heroin and opioid-related overdoses in our state,” he said.
The state’s response has been halting.
In late 2013, Maryland launched its prescription drug monitoring program, allowing — but not requiring — doctors to access a database to see the drug histories of their patients. Nearly every state has such a system, designed to thwart people who seek drugs from multiple doctors. Some state medical boards use the data to flag physicians whose prescribing goes out of bounds.
Maryland’s board, though, can’t tap into the data “without going through major legal hoops,” Dr. Singh said. Physician groups, he said, have opposed efforts to ease access, because they fear “over-policing.”
Maryland has not adopted official opioid prescribing guidelines, as some states have.
Maryland’s board tried, however, to follow other states’ regulators by mandating that all doctors get an hour of training on opioid prescribing every two years.
In April, though, the state’s General Assembly nixed that, by passing a bill sponsored by House of Delegates Deputy Majority Leader Dan Morhaim, who is also an emergency medicine physician. “The board should stick with licensing and regulation,” he told the Post-Gazette. “I prefer to do [continuing education] in the things I think I need in my practice of emergency medicine.”
Dr. Morhaim said he disagrees with placing mandates on all physicians. “The general consensus,” he said, “is that it’s a small group of people doing the wrong thing.”
Despite limited tools, Maryland’s board from 2011 through 2015 disciplined 80 doctors in relation to their prescribing of narcotics. At roughly three in every 1,000 doctors, that rate of painkiller-related discipline is lower than that of nearby Kentucky, Virginia, West Virginia, Tennessee or Ohio — but higher than Pennsylvania.
Joan McLean, a Salisbury, Md., physician, said the board overreacted when it restricted her practice following complaints about her prescribing of buprenorphine.
“Why don't they just tell us what we're doing wrong, show us how we can do it, and then let us go back to practicing correctly — instead of taking us out of practice indefinitely?” she asked rhetorically, in an interview.
Rather than practice under probation, she quit medicine to focus on teaching preventive health.
She said that these days no one in her town is prescribing opioids, leaving those with severe pain, or with addictions to painkillers, without legal options.
“Now there's a huge street business of pain medicine,” Dr. McLean said. “And the [street] prices [for opioids] have gone up,” while “heroin has gotten a lot more affordable.”
Rich Lord: email@example.com or 412-263-1542. Twitter @richelord.
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