The politics of pain
A St. Petersburg Times special report. Second of two parts
When pain medications double as dangerous party drugs, doctors are left to balance the well being of their patients with an accountability to society.
By CHRIS TISCH and ABBIE VANSICKLE, Times staff writers
Published February 24, 2008
Dr. Lynne Columbus, here giving a patient with lower back pain an epidural steroid injection, is judicious in prescribing painkillers, but doesn't hesitate if she deems it appropriate. "If you're running your practice the right way, you don't really need to be in fear of regulatory issues."
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Dr. David VanDercar looks at files on a patient before an exam. "It's very important for a physician to spend a lot of time educating patients about the drugs they are using."
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Dr. VanDercar came out of retirement four years ago, spurred by frustration when his daughter couldn't get pain medication he thought she needed. "It's extraordinarily important that we not ignore pain."
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Dr. Rafael Miguel often works with patients who are already on pain killers, and he tries to lower their doses. "I consider myself a good pain doctor, but I know I have patients who are fooling me."
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Dave Carrington, 52, takes two morphine time-release capsules per day to manage his pain from rheumatoid arthritis, osteoarthritis and back problems. "It's not about making the pain go away. It's about managing the pain so you can live a relatively normal life."
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Law enforcement officials confiscate prescription records seized from the G&H Pharmacy in Pinellas Park during a May 2006 raid that followed arrests at a nearby clinic.
Dr. David VanDercar was retired four years ago when his daughter, Ashley, felt pain in her neck. An equestrian, she had taken several falls that caused a cervical spine injury.
VanDercar, an anesthesiologist, thought prescription painkillers would best treat Ashley, but he says doctors pushed expensive surgeries and injections.
By the time he found a doctor to prescribe painkillers, the frustrated physician decided to come out of retirement.
At his Tampa Pain Clinic on Fletcher Avenue, VanDercar, 65, prescribes opiate painkillers like OxyContin and methadone to all 800 of his patients.
"How could I not be giving my patients opiates?" says VanDercar, whose daughter, now 24, is in law school. "I'm managing chronic pain. If it controls the person's pain and lets them have a life, why not?"
As deaths from prescription drug overdoses have mushroomed to nearly 2,000 a year in Florida and 500 in the Tampa Bay area, law enforcement and medical professionals agree the problem has become a public health crisis.
Doctors find themselves in the middle of a fierce debate about how drugs should be used to treat pain. Some no longer prescribe painkillers or give them only in light amounts. Some push options such as surgery or physical therapy. And some have gone to jail as police have shifted some of their attention to prescription drug abuse.
In 2002, a Florida doctor was the first in the nation convicted of manslaughter in an OxyContin death. He was sentenced to 63 years in prison.
While doctors toe a precarious line, various studies show between 40-million and 80-million Americans suffer chronic pain, and many do not receive enough treatment.
The dilemma has ignited debate between those in pain and those who have lost loved ones to prescription drugs. On Internet blogs and chats, pain patients who can barely walk argue with mothers of children who fatally overdosed.
The ultimate issue: Is it possible to relieve pain without tempting death? Can law enforcement be aggressive and restrained? Can doctors balance mercy with accountability?
Dr. Lynne Columbus often thinks of her children when she writes a painkiller prescription.
"I don't want to see some prescription I wrote end up in the community and in some teen's hands," says Columbus, whose kids are 11 and 14.
Columbus, 43, operates a Palm Harbor pain clinic that treats about 3,000 patients, only half of whom are on long-term painkillers. Columbus is relaxed and charming, but runs a strict and orderly clinic.
She lectures to other doctors about how to prescribe painkillers and avoid being duped by drug abusers and dealers. She says many doctors don't realize the severity of prescription drug abuse.
At a recent lecture, she asked about 500 doctors if they had heard of "pharm parties," where teens gather to abuse prescription drugs.
"I would say maybe 10 physicians raised their hands," Columbus says.
At her clinic, Columbus takes a number of steps to ensure her patients aren't fooling her. These include random drug tests, psychological screenings and signed agreements in which patients promise to take pills only as prescribed.
One patient, Dave Carrington, has rheumatoid arthritis, osteoarthritis and back problems that stem from 35 years managing and working on his feet in restaurants.
For a long time, Carrington's doctors wouldn't provide him with pain pills beyond low-dosage Percocets.
"One of them flat out told me, 'I don't want it on my record that I'm prescribing narcotics,' " says Carrington, 52, who lives in Indian Rocks Beach.
Columbus prescribed him the morphine pain pill Kadian. Carrington takes two a day and sometimes adds a Percocet if his pain flares.
Carrington says he admires the steps Columbus takes to make sure he's legitimate.
"They get a pretty good feel for who is just looking for drugs and who is a legitimate patient," he says.
Columbus knows a few patients may be fooling her.
Take the 80-year-old woman from New Port Richey who came in with a painfully twisted spine. Columbus prescribed her methadone.
Columbus didn't pay much mind to the neighbor who gave her rides to the clinic. He always sat quietly in the waiting room.
About six months after the woman's first visit, a random drug test showed no methadone in her system. Columbus became suspicious.
Around the same time, police began investigating the woman's neighbor for drug dealing. They searched his home and found the woman's pill bottles.
She had been selling pills to him, Columbus says, because her husband's social security wasn't enough to pay for food.
Columbus stopped treating the woman, but worried: Where did those pills wind up?
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Pain, the old saying goes, toughens the soul.
But over the past three decades, health organizations the world over have urged doctors to pay more attention to patients' pain.
In Florida, a 1994 special commission on pain found that doctors often feared prosecution or censure if they prescribed narcotic painkillers, even to terminal patients. Florida joined several states in adopting guidelines that protected doctors who prescribed pain relievers.
In 1995, the American Pain Society recommended doctors treat pain as a fifth vital sign - along with temperature, blood pressure, pulse and respiratory rate, measures that had been in place for nearly a century.
"The pendulum swung," says Dr. Lawrence Gorfine, a Lake Worth anesthesiologist and former president of the Florida Academy of Pain Medicine. "Everyone felt a lot more comfortable that we were able to prescribe drugs, and it more or less opened the floodgates."
But some pharmaceutical companies' downplayed the drugs' side effects and addiction potential.
Doctors untrained in pain medicine started prescribing opiate painkillers and gave out potent drugs such as OxyContin and fentanyl - sometimes for little hurts and aches.
Other doctors, like Gorfine, stopped prescribing pills because they didn't find them to be effective in the long term.
But a handful of physicians cashed in on the growing demand by prescribing to anyone, including doctor shoppers, addicts and drug dealers. Police called them pill mills.
By 2000, news reports revealed an increasing number of prescription drug deaths.
Police responded by closing pill mills in a crackdown that occasionally swept up doctors who thought they were just helping patients in pain.
Shuttering pill mills was one thing. Convicting earnest doctors was another.
"The pendulum swung back again," says Gorfine. "Doctors are scared to death."
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Detective John Barna can tell which doctors are easy targets.
Files in their offices are in disarray. Prescription pads are scattered. No one is paying much attention.
Barna usually pockets a script pad and presents it to the doctor.
"If I can do this, then one of your patients can do this," he tells them.
Barna is powerless to do much else. The doctors usually aren't breaking the law.
"I see a lot of sloppy doctor's offices," says Barna, 55, who has worked in narcotics at the Pinellas sheriff's office for 19 years. "It's a zoo when you walk in."
Police say these offices frequently are home to prescription drug diversion.
Diversion means steering drugs from their intended use. It might involve doctor shopping, pharmacy robberies or street sales.
"Diversion is as bad as any problem we have at this point," says Capt. Michael Platt, commander of the Pinellas sheriff's office narcotics section. "It's screaming."
Platt, 56, says prescription drug tips to his agents increased by 40 percent last year, while investigations rose by nearly 20 percent.
Fighting diversion can require delicate judgments: Is a doctor a criminal if he or she doesn't screen patients or runs a sloppy office?
To make such judgments, investigators must decide if the doctor acted in bad faith. This has prompted criticism that they are invading doctor-patient relationships.
Is the criticism warranted?
Officials with the Drug Enforcement Administration point out that of 750,000 doctors practicing nationwide in 2006, only 412 lost their license to dispense drugs. Only 71 were arrested.
Platt and other narcotics agents say law enforcement actually needs to do more.
"Law enforcement as a whole has been dragging their feet," Platt says.
Only two of the Tampa Police Department's 27 narcotics agents are assigned to prescription drugs. The Hillsborough sheriff's office also has only two.
Platt, who has spent 17 years in narcotics, oversees a division with 60 drug agents. Fewer than a half-dozen investigate prescription drugs.
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Alex Petro was a once-bankrupt chiropractor in 2004 when he opened Doctors Urgent Care Walk-In Clinic in St. Petersburg.
Petro bought newspaper ads that asked: "Need painkillers? Vicodin, Percocet & Xanax prescribed here." He hung a similar banner outside the door.
Before long, lines of patients curled into the parking lot. Patients paid $225 for their first visit and $100 after that. The clinic saw about 60 people a day.
Chiropractors cannot prescribe painkillers, so Petro hired a physician, Dr. Ty Anderson, as clinic medical director. Anderson rarely visited but supplied Petro with hundreds of presigned, blank prescriptions.
At the clinic, physician's assistants wrote out prescriptions by the dozens.
Petro became a rich man. He bought a $1.9-million, 12th floor penthouse in the planned Trump Tower Tampa. He invested in a strip club. He drove a bright yellow Acura NSX sports car with the license plate: BAKPAIN.
Cops had heard his clinic was a pill mill. They sent in undercover agents with no injuries or medical records. The staff wrote prescriptions without conducting physical exams. Consultations usually lasted less than 10 minutes.
In 2006, Pinellas sheriff's detectives shut the clinic and arrested Petro and several associates on drug trafficking charges. Deputies found 132 blank prescriptions that had been presigned by Anderson in Petro's desk. Petro lost his license.
At least three patients had died of prescription drug overdoses, including a chiropractor who had worked at the clinic.
Anderson's license was suspended. He later reached a settlement with the Board of Osteopathic Medicine. He was placed on probation, which requires supervision by another physician.
He continues to practice in Pinellas County, though he must inform the state Department of Health if he writes prescriptions.
Anderson said he didn't know Petro had hired unqualified people to fill out his prescriptions without exams. He said presigning the prescriptions for Petro was an "administrative error."
A year after his arrest, Petro cut a deal with prosecutors reducing the trafficking charges to drug possession. He pleaded guilty and a judge sentenced him to 10 years of probation.
Three members of Petro's medical staff also received probation.
No one at the clinic spent a day in prison.
Petro, 43, declined an interview through his attorney, Jay Hebert. Petro now lives in St. Petersburg and works in real estate and land development, Hebert said.
As part of the investigation, detectives also seized records from the G&H Pharmacy, which is where the clinic recommended patients to fill their prescriptions. No one at the pharmacy was arrested.
The pharmacy on 66th Street sits just four blocks from the main offices of Operation PAR, Pinellas County's largest drug treatment center.
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In recent years Largo defense attorney Roger Futerman has seen a new type of client: no arrest record, steady job, good family.
Looking at 25 years in prison.
Florida drug laws presume that possessing a certain amount of drugs is trafficking. For cocaine, it's 28 grams.
For prescription drugs like opiate painkillers, 28 grams, which can be a single bottle of pills, calls for a minimum mandatory sentence of 25 years in prison.
Why should a pain patient with a bottle of pills get 25 years while a dealer trafficking 10,000 pounds of marijuana gets 15?
"It's so Draconian," says Futerman, 37. "I don't think there should be minimum mandatory sentences for personal use."
No person better illustrated the issue than Richard Paey, the chronic pain patient arrested in 1997 for forging prescriptions. Paey, 49, who requires a wheelchair, turned down a plea deal and went to trial.
The Pasco County man was convicted and sentenced to 25 years in prison for drug trafficking. His story triggered outrage, coverage by the national media and a story on 60 Minutes.
Gov. Charlie Crist pardoned Paey last year - after he spent three years in prison.
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Dr. Rafael Miguel squints at an X-ray of a woman's warped spine, clear evidence of painful days and sleepless nights.
Miguel asks the woman to stand up and turn around. He lightly touches her back. She winces and bucks.
Miguel, 52, is a University of South Florida professor in anesthesiology and pain medicine who treats patients in Tampa and Sarasota.
When new patients come to see him, they often are on high doses of narcotics that cause them to slur their words and appear dazed.
Miguel gradually decreases their doses and pursues treatment options such as steroid injections, burning nerves or physical therapy. He and his staff usually spend about 45 minutes talking with new patients about their options.
Only about 60 percent of his nearly 1,000 patients are on long-term opioid painkillers.
Larry Schisel, who went to Miguel for chronic back pain, appreciates the doctor's approach.
Schisel's pain began when he was a teenager and worsened during a 25-year career as a clothing store manager, where he spent 12-hour days standing on concrete floors.
At 55, Schisel's medical history includes seven chiropractors, two back surgeries, a half-dozen pain management doctors and countless painkillers.
One prescription made him so lethargic he couldn't drive or leave the house.
Miguel installed a pump about the size of a hamburger patty into Schisel's abdomen. The pump sends time-released morphine and other medications to pain receptors in his spine. It must be refilled about every seven weeks
Schisel still walks with a cane and can't drive from his Clearwater home to Miguel's office in Tampa without stopping to stretch. But he says the merits of the treatment far outweigh any inconvenience.
"The pain is more manageable now," Schisel says.
Miguel cites another benefit:
"It takes the patient out of the pill-popping mode."
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Wearing black Crocs and blue scrubs, Dr. David VanDercar, a slight man with gray hair and a beard, moves through his Tampa pain clinic to meet with patients.
Some limp, some lean on walkers.
His patients come from across Florida and the nation. He has about 50 from other states, including Alaska. He requires they visit his office every other month.
VanDercar says they can't find doctors at home who will prescribe them pain pills. Almost all have tried other types of pain management with no success, he says. Only the pills work.
"If legitimate pain patients could get their pain medications from their doctors, it wouldn't be out there on the street," says Emily Hogin, VanDercar's medical assistant.
VanDercar knows the dangers of these drugs. He has lost four or five patients to fatal prescription overdoses, something he tells his new patients to caution them. He also has dismissed nearly 200 of his own patients for abusing drugs.
He's not that alarmed by the 2,000 prescription drug deaths each year in Florida. He says the pills help far more people than they harm.
"You're going to have people who overdose and die," says VanDercar, whose wife is a Pasco County judge. "That's just going to happen.
"There are over 300-million people in this country and that sounds like a lot of fatalities. If you start looking at it, 2,000 is not really a large number."
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They show up at emergency rooms on weekends and after hours, when their doctors are hard to reach.
They might punch themselves or drop a rock on their foot to feign an injury.
Dr. Michael Hillman has seen an increasing number of them in his 12 years in the emergency room at Bayfront Medical Center.
He now carries a device that the state Agency for Health Care Administration has provided to 3,000 of Florida's 58,000 doctors and physicians. If a patient is on Medicaid, Hillman can punch in the name and see if the patient has received painkillers from other doctors.
If a patient is paying cash, however, Hillman is virtually driving blind.
For several years, Florida lawmakers have turned back attempts to adopt a monitoring system that would help doctors determine if all patients, not just those on Medicaid, have been doctor shopping.
While 35 states have approved such systems, Florida lawmakers have resisted because of concerns about cost and privacy. Law enforcement, doctors, medical associations and even drug companies have urged legislators to reconsider.
In 2002, Purdue Pharma, maker of OxyContin, offered the state $2-million to fund such a program. That offer ended a state investigation of the company's marketing tactics.
But lawmakers wouldn't pass the law, and Purdue's money was pulled off the table in 2004. The federal government also has offered states millions of dollars to start monitoring programs, but Florida hasn't bought in.
Some lawmakers say the programs are too expensive and worry about placing private patient information in the hands of the government.
Lawmakers passed a watered-down version of the bill last year that many doctors say is virtually useless because it doesn't allow communication between pharmacies.
"It doesn't get us where we need to be," says Sen. Burt Saunders, R-Naples, who has proposed a full-fledged monitoring system again this year.
University of Florida Pharmacy Professor David Brushwood said he doesn't think a monitoring program would work here anyway. He says it will make it harder for pain patients to get drugs.
Though other states have reported some success, he says the system is easily undermined by people who use false names or Social Security numbers.
Said Brushwood: "I think the drug diverters are just laughing at this."
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A Kentucky monitoring system adopted in 1999 stands out as a model. Project manager Dave Hopkins says he has seen signs that it is working.
Use of the database has increased tenfold in the past seven years to more than 360,000 users a year.
Hopkins said 93 percent of the program's users are doctors. About 40 percent of Kentucky's doctors use it. The other users are pharmacists, police, judges and licensing boards.
As for privacy, Hopkins said no one ever has hacked the system. Police cannot access the system without a case number indicating they are amid an investigation, which prevents abuse.
In Florida, Saunders says his prescription monitoring program bill has even more privacy protections than the Kentucky system.
Supporters of a full-fledged monitoring system include Pinellas sheriff's Capt. Michael Platt, the veteran narcotics agent; and people like Dave Carrington, the longtime pain patient who needs prescription drugs to live.
Platt says the monitoring system will help doctors and police officers determine who is abusing the system. Carrington says it will help doctors identify legitimate pain patients.
Other supporters of a monitoring program include Dr. VanDercar, who gives painkillers to all his patients; and Dr. Miguel, who tries to get his patients off painkillers.
Both believe the system would keep painkillers away from abusers and help get the pills to those who need them.
Says Miguel: "Nothing we could do would save more lives."
About these stories
Times reporters Chris Tisch and Abbie VanSickle spent nearly a year investigating the increasing prescription drug overdose deaths in the Tampa Bay area. Their research included reading and analyzing the autopsies, toxicology results and investigative reports of more than 700 deaths. The reporters also interviewed nearly 200 people for this series. Times researchers Angie Drobnic Holan, Carolyn Edds and John Martin contributed to the report. Jim Webster copy-edited the stories and Paul Alexander was the designer. Chris Tisch can be reached at 727 892-2359 or firstname.lastname@example.org Abbie VanSickle can be reached at (813) 226-3373 or email@example.com
[Last modified February 22, 2008, 17:57:06]
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