Published on December 16th 2014 By Janet Loehrke and Peter Eisler, USA TODAY Prescription drug abuse has become a growing focus for law enforcement in recent years, but the number of prescriptions for narcotics and other controlled substances is still on the rise, new data show. That has prompted a closer look at why there are doctors and nurse practitioners who write many more prescriptions than others. However, there are reasons that can skew the numbers, local doctors say, and it can be a tricky, thorny issue when it comes to determining what prescription practices are legitimate and what are not. For example, some of the doctors on the high-prescription list from North Carolina say their numbers are higher because of the type of patients they see dealing with serious pain issues. Meanwhile, the close scrutiny associated with the practice has prompted many doctors to leave the pain-prescription field altogether, sending their patients to others. USA Today and ProPublica teamed to study analysis of Medicare data and shed light on how prescription drug abuse remains a national problem, and the study reveals that many of the doctors who abuse the system have faced disciplinary actions in their states. There were 269 providers nationwide who wrote at least 3,000 prescriptions for Schedule II drugs in the Medicare Part D plan in 2012, according to an analysis by ProPublica, an independent, nonprofit newsroom that produces watchdog journalism. Medicare Part D covers more than 38 million seniors and disabled people in the U.S. and accounts for more than one of every four prescriptions dispensed, the analysis shows. And Schedule II drugs, which include narcotics like oxycodone, fentanyl and morphine and stimulants like Ritalin and Adderall, have “a high potential for abuse which may lead to severe psychological or physical dependence,” according to the U.S. Drug Enforcement Administration. The three states with the most active prescribers were Florida with 52, Tennessee with 25, and North Carolina with 15, the analysis shows. Six of the 10 states with highest prescribers were in the South, including Georgia with 14, Alabama with 12 and Kentucky with 11, the data show. Of the top 10 prescribers in North Carolina, none is in Buncombe or Henderson counties. But of the top five in Buncombe County, four are in Asheville and one is in Arden, and of the top five in Henderson County, all are in Hendersonville. Among the top prescribers in Buncombe County, the analysis showed that 92 percent of one physician’s 135 patients filled at least one prescription for a Schedule II drug compared to an average of 34 percent. And 77 percent of one nurse practitioner’s 254 patients had gotten at least one of these drugs compared to an average of 10 percent. Among the top prescribers in Henderson County, 43 percent of one orthopedic surgeon’s 301 patients got these drugs compared to an average of 24 percent. And 89 percent of one nurse practitioner’s 131 patients got these prescriptions compared to an average of 10 percent.
Nexus to drugs
Walt Wilkins, 13th Circuit Solicitor for Greenville and Pickens counties in South Carolina, told the Asheville-Citizen Times that eight out of 10 cases he prosecutes have a nexus to drugs. Some involve doctors charged with violating distribution laws by prescribing drugs without medical justification or a bona fide practitioner-patient relationship, such as the Travelers Rest, South Carolina, physician arrested recently and accused of unlawfully issuing prescriptions for oxycodone, according to Wilkins and arrest warrants. The doctor wrote prescriptions in August and September for a man who was incarcerated at the time and also gave prescriptions to a woman without a genuine doctor-patient relationship, according to the warrants. Criminal charges against the doctor are pending. But having a high number of prescriptions doesn’t always translate into inappropriate prescribing patterns or criminal behavior, experts say. Many of the providers are in specialties most likely to prescribe these drugs, such as physical medicine rehabilitation or pain management. There are other reasons as well. For instance, at the Carolina Center for Advanced Management of Pain in Greenville, Dr. John R. Satterthwaite, an interventional pain specialist, said he must prescribe for the patients of at least three nurse practitioners as well as his own because NPs can’t write prescriptions for Schedule II drugs in South Carolina. “Tomorrow, my NPs and I will see 80 patients,” he said. “That’s a lot of prescriptions.” Some 45 percent of Satterthwaite’s 784 patients fill at least one prescription for these drugs compared to an average of 39 percent, according to Prescriber Checkup. Among his patients are people suffering terrible pain from failed back surgeries, nerve damage, diabetic neuropathies, severe arthritis, osteoporisis, compression fractures and other conditions that produce chronic, unyielding pain that that doesn’t respond to most treatments, he said. “Narcotics are not our first option. But if that’s all they’ve got left, what can you do?” he asked. “There are no alternatives. If there was, we’d try them.” There are other reasons his numbers are higher as well, he said. For instance, many doctors will no longer prescribe these drugs because they’re afraid of losing their licenses or even going to jail for failing to document them properly, he said. So they go to Satterthwaite. “We’re getting referrals from family doctors and internists who’ve been writing prescriptions for hydrocodone for years. But now that it’s a Schedule II drug, they don’t want to write it any more,” he said. “They’re afraid of the medical board and the DEA.” In addition, he said, some pain physicians will only perform steroid injections and other procedures that are more lucrative than a doctor visit for a prescription. One of the top prescribers in Henderson County is physician assistant James Lee, of Park Ridge Health, according to the analysis. Lee wasn’t available for comment. Jason Wells, vice president of physician services, said the hospital takes prescribing controlled drugs very seriously but wants its patients to have the treatments they need to find healing and quality of life under the guidance of a provider. At Park Ridge, patients taking prescribed narcotics also are subject to random drug tests and sign a contract as a safeguard to prevent accidental or intentional misuse of the medication, Wells said. Providers also regularly monitor the North Carolina Controlled Substances Reporting System to identify patients who misuse or abuse controlled drugs, he said, adding that Park Ridge is a founding member of HopeRX, a coalition formed in 2013 to curb the abuse of prescription drugs that includes law enforcement, health care organizations, faith groups, educators, and civic and community leaders. None of the South Carolina doctors had disciplinary actions against their licenses, according to the state Department of Labor, Licensing and Regulation. Of the North Carolina doctors, four had actions, two involving inappropriate prescribing, but all were several years old and all the licenses were current, according to the state Medical Board.
Quality of life
“Although we tend to focus on the national problems of addiction, abuse and overprescribing, there remains a group of patients that live with chronic, and quite real, pain,” said Dr. George A. Helmrich, chief medical officer at Baptist Easley Hospital in South Carolina. Helmrich said all patients seen in the Baptist Easley primary care offices are co-managed with Pain Management Associates, an independent group of physicians. At the same time, he said, the medical community has worked to reduce prescribing of narcotic painkillers and move toward other therapies when possible. Dr. Bert Blackwell, medical director of Pain Management Associates in Easley, where three of the top five Pickens County prescribers work, said he wasn’t surprised by the findings. First, he said, there are few other pain management providers in the county. Also, the doctors in the practice are not like their peers. Dr. Jay Patel is in physical medicine and rehabilitation, a specialty that can cover a broad range of conditions, like traumatic brain injury, sports medicine and pain management, or can be very limited, for example, to pediatric rehabilitation, he said. Because Patel sees a broad variety of patients, Blackwell said it’s natural for him to have a higher number of prescriptions. Dr. David Rogers is a neurologist who doesn’t have a routine neurology practice but specializes in headache and chronic pain, he said. “It’s rare to find neurologists who do pain management,” he said. And though Dr. Dwight Jacobus is licensed as an orthopedic surgeon, he no longer does surgery, Blackwell said. Instead, he sees patients with painful orthopedic conditions.
‘All we have left’
“There are a lot of patients who are elderly who need knee or hip replacements, but are not candidates for surgery,” he said. “Medication is all we have left for them.” Patients are closely monitored and screened for abuse, he added. Blackwell also agreed that many providers don’t want to prescribe Schedule II drugs any longer and funnel the patients to pain management practices like theirs. “There was a time years ago, when I cringed to say I was in pain management because everybody assumed it was a pill mill,” he said. “But times are changing.”
