In Ohio, 'room for improvement' on both sides of the pain pill equation
May 27, 2016 12:00 AM
Toby Talbot/Associated Press
In November, U.S. Attorney David J. Hickton discussed at Passavant Hospital Foundation Conference Center the DEA’s 360 Strategy to combat opiate abuse.
By J. Brady McCollough / Pittsburgh Post-Gazette
Peggy Ferguson knew exactly what a pill mill looked like. There was the parking lot full of patients waiting for their drugs, the small room inside the doctor’s office with the big folders of pre-signed prescriptions in lieu of an actual physician, the dollar-per-milligram deals already being brokered outside, all under the guise of “pain management.”
Mrs. Ferguson, 55, visited two such facilities in rural southern Ohio as she sought relief for her chronic pain, born of bouts with cervical and skin cancer, a vascular disease and nerve damage, among other ailments. Her doctor, the one who got her out of her wheelchair and walking again with seven 80-milligram OxyContin and eight 30-milligram Roxycodone per day, had moved to Iowa. She could have gotten the pills she needed at one of these clinics, but Mrs. Ferguson wasn’t simply shopping for pills. She needed a doctor, a face she could count on.
She found Frank Demint, who treated pain in Kingston, Ohio. Dr. Demint would see her during her visits and talk to her about what she was experiencing. He initially decreased her dosage, but then she struggled to walk. He gradually increased it to the former level. Mrs. Ferguson noticed that she rarely saw more than a couple patients at a time at Dr. Demint’s office.
“If he was one of those pill mills,” she said, “you would see hundreds of people out in his parking lot.”
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That didn’t stop the State of Ohio Medical Board from disciplining Dr. Demint for his treatment of 14 patients with intractable pain. Dr. Demint would plead with the board that he watched for diversion of the drugs he prescribed, that he discharged half of those patients because they were showing addictive behavior, but the board suspended his license for 180 days in April 2013. Today, nearly three years later, he is not practicing.
Since then, Mrs. Ferguson has been on her own. She tells a familiar story for displaced chronic pain patients: Nobody will take her on because her last doctor was disciplined for prescribing opioids, and nobody wants the medical board investigators following that physician’s patients to their doorstep.
Mrs. Ferguson has decided she isn’t going to spend her days in pill-mill parking lots or turn to cheap street drugs like heroin, so, her days are hard.
“I have to sit here every day in pain,” she said, “because I’m not going to do something like that. I have children and I have grandchildren. There isn’t anything I can do. I’m 55 years old … I still hope to have a life. I guess I’m just a very strong-minded person. Trust me, I’ve considered ending it.”
This is the other side of the doctor discipline that Ohio Gov. John Kasich and Attorney General Mike DeWine demanded when they took their oaths of office in 2011. The state had a serious pill mill problem, evidenced by the 2,493 “doctor shoppers” — individuals receiving a prescription from five or more physicians in a month — that showed up in the Ohio Automated Rx Reporting System database in 2010.
In 2015, that number was down to 720, according to Cameron McNamee, director of policy and communications for the State of Ohio Board of Pharmacy — a clear indication that the improved measures of monitoring doctors’ prescribing behavior is working to prevent diversion by those hoping to manipulate the system.
But, to Mr. DeWine, the bigger challenge has been sniffing out the doctors who don’t stick out from the crowd.
“Most of the doctors who are overprescribing don’t fit into the criminal area, nor do they fit into taking their license away,” Mr. DeWine said. “Some of this is incremental. It’s hitting that right spot. … It’s easier to get the low-hanging fruit, the doctors who are just over the top, crazy, nothing more than drug dealers. It takes longer as you try to change the culture. We just have to keep hammering at it.”
But what about displaced patients like Mrs. Ferguson, those caught off guard by the purge?
Some who can’t get pills through legal means will turn to heroin use out of desperation.
“Every time the government puts a restriction on narcotics, the problems get worse,” said Narinder Khosla, a Sandusky, Ohio, doctor who was given a citation by the Ohio board in October 2015 for prescribing opioids to 99 percent of his patients and in December permanently surrendered his license instead of going through the legal process. “Very few physicians are prescribing narcotics, and there are more heroin addicts than ever before, because they cannot get narcotics from physicians. Ultimately, patients end up dead.”
Several Ohio doctors interviewed by the Pittsburgh Post-Gazette, including Dr. Khosla, said they made this plea to the medical board during their disciplinary hearing. It wasn’t heard, they said.
“We’re trying to get this back to a happy medium,” Mr. DeWine said, “where people with long-term intractable pain, for example who have cancer, we certainly want them to not have pain. We want them to reduce the pain. But on the other hand, there’s really no need for a 20-year-old who has their wisdom teeth taken out to get 30, 40 or 50 pills. We still have a ways to go.”
A political problem
As Mr. DeWine and his wife, Fran, campaigned around the state in 2010, they repeatedly heard the same complaint from sheriffs, police chiefs and coroners: Too many Ohioans were addicted to prescription painkillers.
“Bluntly, before that, I wasn’t aware of the problem,” said Mr. DeWine, a former U.S. senator. “We understood when we went in, we had to do something about this.”
As the attorney general, Mr. DeWine served as the top lawyer for the medical board. Upon taking office, he and Mr. Kasich pressured the board to start being more aggressive with doctors. They pushed through House Bill 93, which gave the pharmacy board and the medical board more freedomto discipline pill mills or pain management clinics.
They were also on the lookout for a target, one of those “low-hanging fruit” doctors who could set an example.
Their research pointed them to James Lundeen, who operated about 12 pain management clinics throughout the state. The numbers showed that Dr. Lundeen was prescribing 61 percent of Scioto County’s opioids among the Ohio Bureau of Workers Compensation’s chronic pain patients. He had about 800 patients at any given time, many of whom, he said, were permanently disabled because of their pain.
Dr. Lundeen began prescribing opioids consistently in the 1990s, once pain became accepted as the fifth vital sign and insurance companies stopped approving physical therapy and other pain treatments as often, he said. Dr. Lundeen, who also has degrees in electrical engineering and chemistry, considered himself smart with his dosages.
But after the 2010 election cycle was complete, he could feel the political pendulum swinging in the other direction. In February 2011, Mr. Kasich publicly promised that he was going to clear “the devil” out of Scioto County.
On the morning of March 16, 2011, in Portsmouth, Ohio, Mr. DeWine and a multi-agency task force staked out Dr. Lundeen’s office, located on the fourth floor of a Masonic Temple. Mr. DeWine noted that in just a few hours, 43 patients had come and gone. Armed with a search warrant, Mr. DeWine entered the temple around lunch time.
Investigators spent about five hours inside questioning Dr. Lundeen as TV camera crews who had been tipped off about the raid waited outside.
“I look around,” Mr. DeWine recalled, “I see a doctor with no nurse, no receptionist, not much there other than a prescription pad. And so it just kind of brought home to me how bad the situation is.”
Dr. Lundeen remembers that the investigators told him that if he signed away his medical license, they would drop everything else and leave him alone. He said he wadded up the proposed agreement and threw it in the trash. Around 4:30, when investigators left without an immediate victory, Dr. Lundeen opened his doors and began seeing patients again.
The next month, the governor urged the medical board to wield its power against Dr. Lundeen.
“This guy’s still practicing medicine,” Mr. Kasich said then. “Suspend the guy for probable cause. … Either we’re serious about this, or we’re not.”
On May 11, 2011, Dr. Lundeen received a phone call telling him the board had suspended his license. He is one of 123 Ohio medical doctors and osteopaths who were disciplined for improper prescribing practices during 2011-15, according to the Post-Gazette’s review of medical board documents.
Dr. Lundeen has not practiced since having his license suspended. He has a pretty good idea of what happened to most of his chronic pain patients.
“It was always a concern of accepting patients from a doctor whose license was pulled,” Dr. Lundeen, 62, said. “Whenever a doctor’s license was pulled, you’d get a flurry of phone calls, and all the patients would want to come to you. We’d try to discourage it.”
Dr. Lundeen is in the process of trying to be licensed again in Kentucky and Indiana. He also expects that one day he will practice again in Ohio. Until then, he plans to continue working as an electrician and plumber in Cleveland Heights.
The letter of the law
In June 2013, Dr. Demint penned a letter to the governor. He wrote about how the medical field got to this crazy place. He wrote about how cracking down on pain doctors will lead to more suicides for patients with chronic pain. He even got in a line about his view that small government was a cornerstone of the Republican Party. Dr. Demint never received a response.
“All of a sudden, we stopped all these pills, but did we think people were going to all of a sudden stop using? No, they’re addicted,” Dr. Demint said in a recent interview. “They’re going to go out and find it on the street. Heroin is a whole lot cheaper.
“I know this may sound strange, but we were better off with the pills. At least when they got a 30-milligram OxyContin, they knew how much they were taking. When you get heroin, you have no idea how pure it is, what it’s cut with.”
Dr. Khosla has been out of practice for six months now. In that time, he said, he has run into former patients who have admitted they are now using street drugs.
“Physicians got so scared, they stopped prescribing narcotics for pain management,” Dr. Khosla said. “Those people who are in chronic severe pain, they’re being treated worse than animals. Animals will get relief of pain, but not humans. That is the tragedy.”
Paul Wilson, a Toledo doctor, was cited and given notice of a pre-hearing suspension in May 2015 for his care of 14 patients and prescribing controlled substances for intractable pain. He also had many Suboxone clients, and by the time 2015 came around, only had a few pain patients. The board permanently revoked his license in April 2016. If he could go back in time, he never would have experimented with treating pain.
“I would have nothing to do with pain patients,” Dr. Wilson said. “Once you let them in, they’re like a demon. They don’t ever go away. I guess I could have been real strict, and said, ‘Get out. Don’t come back.’ I just wasn't that type. I just tend to be too soft on people.”
Dr. Lundeen, one of the original targets of the Ohio politicians, doesn’t tell his story with bitterness. He has tried to see the situation clearly.
“It’s going to take training physicians how to appropriately prescribe,” Dr. Lundeen said, “and it’s going to take educating the lawmakers not to practice medicine. There’s a lot of room for improvement on both sides of the equation.”
J. Brady McCollough: email@example.com and Twitter @BradyMcCollough.
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