Thu. Nov 15th, 2018
Rogue doctors exploit loopholes to let a powerful drug ‘devastate a community’

Rogue doctors exploit loopholes to let a powerful drug ‘devastate a community’

Medication-assisted addiction treatment with Suboxone is gaining popularity in Kentucky and across the nation. But Suboxone is an opioid, so it’s possible to abuse it. Close monitoring and responsible prescribing is key.

Laura Ungar/Courier-Journal/USA TODAY Network/Wochit

Dr. Roi Reed couldn’t always make it to his Suboxone clinic in the hills of Eastern Kentucky, but addicts still got their prescriptions — from his receptionist and maintenance man.

The two stood in for the doctor when he wasn’t there, seeing patients and phoning in scripts, providing easy access to an opioid instead of the path to recovery promised by the clinic’s name: Restart Medical.

A new employee complained to police, and Kentucky’s medical board eventually barred Reed from practicing last year. In a recent interview, the 63-year-old Winchester physician, who said he had suffered a head injury, conceded, “You can’t argue with the board.” He let his medical license expire in February.

Reed’s Ashland, Kentucky, practice isn’t unique. A Courier-Journal investigation found rogue Suboxone doctors across Kentucky have allowed the opioid drug to seep onto streets already saturated with illicit prescription drugs and heroin. In the hands of these doctors, the much-touted medicine designed to curb opioid cravings and ease withdrawal is instead fueling the scourge of addiction in one of the nation’s hardest-hit states.

“What we are seeing is a rise of dozens of rogue Suboxone clinics in our state that I believe are the second coming of our pill mills,” Attorney General Andy Beshear said. “More complaints come to us than we can count. These rogue Suboxone clinics devastate a community.”

The Courier-Journal compared a federal list of Kentucky doctors authorized to treat opioid addiction with buprenorphine, the main ingredient in Suboxone, against state medical board records on physician discipline. The CJ also examined regulators’ reports on doctors, reviewed government rules about Suboxone prescribing and interviewed doctors, drug experts, officials and patients.

The investigation found:

►Buprenorphine doctors were more than three times as likely to have current disciplinary orders against them as doctors overall — the majority stemming from inappropriate prescribing of controlled substances. Six percent of the 465 buprenorphine-prescribing doctors were the subject of disciplinary orders for any reason as of mid-May, compared with 1.8 percent of all doctors registered in Kentucky. Officials acknowledge other rogue doctors may be operating under the radar, since they only come to the board’s attention through complaints — a system that limits the state’s ability to crack down on them.

►Suboxone clinics can be lucrative for doctors and owners. Some only take cash for office visits. Some pay doctors by the patient, giving them an incentive to see as many as possible. Former Lexington doctor David Swan, whose license was revoked in February, said the clinic where he worked paid him $130 for each patient he saw, “far more than I ever made in my life.”

►Kentucky’s buprenorphine regulations require regular drug screens, pill counts and other measures to prevent medication abuse, but contain loopholes rogue doctors can exploit. Patients must participate in “behavioral modification” such as counseling or 12-step programs — but the rules don’t say how often, so it can vary from several times a week to less than once a month. And if patients fail drug screens, it’s up to doctors to use “appropriate clinical reasoning” to support changes in treatment such as increased screening or more frequent visits. Rogue doctors sometimes make no changes.

►Doctors can prescribe buprenorphine with very little training — just an eight-hour course required nationally, which can be done online, and another 12 hours of continuing education every three years in Kentucky. Critics say this isn’t enough for well-meaning doctors to learn what they need to know, and makes it too easy for unscrupulous doctors to put up a shingle.

“We’ve got some good doctors prescribing Suboxone,” said Dr. Burns Brady, former medical director of the Kentucky Physicians Health Foundation. “But we’ve got a lot who are charlatans.”

All this is happening amid a surge in the popularity of medication-assisted treatment, which is supported by prominent addiction experts, state and federal officials, even politicians such as Barack Obama. The former president stressed its importance at an opioid addiction conference in Atlanta last year, where he announced that the patient limit for prescribers would go from 100 to 275 to give people more access to the drug. In Kentucky, the amount of Suboxone dispensed statewide rose 28 percent in less than two years.

When used correctly, proponents say the medicine offers the best hope for some addicts, particularly in a state short on treatment.

Consider Justin Stalnaker of Lexington, who began abusing OxyContin and hydrocodone after two shoulder surgeries. Seeking to get well, he eventually made his way to Dr. Molly Rutherford, a Crestwood addiction specialist and president of the Kentucky Society of Addiction Medicine. Rutherford keeps a close eye on her Suboxone patients, requiring them to have “behavioral health contracts,” which, among other things, mandate counseling as often as twice a week.

Suboxone, under Rutherford’s guidance, “saved my life,” said Stalnaker, 36. “It’s been a miracle.”

But Ashley Blanford of Bardstown, 28, said Suboxone simply worsened her addiction. After getting hooked on pain pills, she sought help at the cash-only Center for Behavioral Health in Elizabethtown. But when she saw other addicts selling Suboxone in the parking lot, she said she couldn’t resist joining them — which got her kicked out of care. Clinic system owner Brant Massman said his staff monitors parking lots closely, but can’t prevent every sale. And while patients can be dismissed for selling Suboxone, he said they’re referred to other clinics.

Blanford said she doesn’t remember a referral. And with no idea where to go, she turned to the street to ease her cravings.

“In the end, it would lead to heroin,” said Blanford, who got help, without medicine, at The Healing Place in Louisville. Suboxone “is just trading one drug for another.”

Disciplined doctors

Whether patients get well on Suboxone or plunge deeper into addiction depends a lot on the care they get.

Sometimes they wind up with a doctor like Swan, one of 27 recently disciplined.

(Deeper dive: Scroll to the bottom of this article for details on the 27 disciplined doctors.)

Swan came to the medical board’s attention after a report from the Kentucky Cabinet for Health and Family Services Office of Inspector General listed 15 patients whose prescriptions raised concerns. These included getting doses greater than 24 milligrams a day, getting other controlled substances in combination with Suboxone, traveling long distances to see Swan and getting their medicine from several pharmacies, a practice known as “pharmacy shopping.”

Medical board documents say several patients were prescribed doses as high as 36 milligrams. Rutherford, a consultant for the medical board on the case, said all of the brain’s opioid receptors are occupied at 24 milligrams, and patients don’t need more. She said Swan also prescribed the anti-anxiety medicine benzodiazepine with Suboxone — a potentially dangerous combination — even though several patients showed signs of benzo abuse.

Swan disagreed with the board’s findings, saying he never broke any laws and the 24 milligrams Suboxone limit is arbitrary. Before Kentucky adopted rules about buprenorphine prescribing two years ago, he said he followed national standards on dosing. The medical board disputed this.

“My philosophy is each patient deserves appropriate medicine to control their disease,” he said in an interview. “If it takes 24 milligrams or 28 milligrams or 38 milligrams, what it takes to treat the patients is what they should get.”

Swan said he never started patients on benzos and Suboxone but realized some may have been getting benzos elsewhere.

As for cracking down on selling or sharing medications, Swan said, “I’m not a policeman. I’m a therapist.”

“I’m not going to withdraw patients for diversion unless I have proof,” he said. “Patients appreciated the care I gave them. I gave them careful care.”

Swan, a 79-year-old former obstetrician/gynecologist, acknowledged the prospect of making good money was one reason he joined the clinic. “I didn’t look a gift horse in the mouth,” he said. “I’m not one of these wealthy doctors. I have a family farm.”

Money is often a factor in these cases. Another disciplined Suboxone doctor, Curtis Edens, was recently indicted by a Lawrence County, Kentucky, grand jury on charges including two counts of Medicaid fraud at the now-closed Suboxone clinic he ran in Louisa. Edens, who was ordered to surrender his Kentucky license late last year, allegedly charged Medicaid patients cash for services already covered by the program.

Reed, the doctor whose employees sometimes saw his patients, didn’t discuss his finances. But medical board documents say patients and their insurance companies were billed for physician visits even when workers with no medical expertise handled them.

One day last March, a health cabinet investigator came to Reed’s practice when he wasn’t there. According to her report, obtained through an open-records request, an employee explained that Reed occasionally didn’t show up if it was snowy or rainy, saying a motorcycle accident made it tough for him to see well enough to drive safely in bad weather.

The employee told the investigator how it worked when Reed wasn’t there: She’d look at urine screens and ask patients if they were having side effects. If all was well, she’d call in a prescription refill. If there was a problem, she’d call Reed.

That day, she told the investigator, she handled six patients. She never called the doctor.

Off the recovery track

Suboxone Q and A with Chase Adams, a recovering addict using Suboxone, with Molly Rutherford MD, a Bluegrass Family physician who has been prescribing Suboxone for years.

While Reed is no longer practicing, 17 of the other recently disciplined doctors are still listed as active. Beshear said an uncounted number of rogue doctors — including some who have never been disciplined — are still out there as Suboxone “is being actively abused by thousands of Kentuckians.”

An ongoing study by the University of Kentucky’s Center on Drug and Alcohol Research, which looks at past experiences with buprenorphine among addicts at The Healing Place, suggests that diverting and abusing the medicine are common.

Of 1,674 addicts interviewed, 985 reported taking Suboxone at some point. Six percent said they got it only by legitimate prescription, 62 percent by illegal means and 32 percent both ways. Nearly eight in 10 who got it both ways admitted selling, trading or giving away what they were prescribed. More than three-quarters admitted mixing Suboxone with other drugs or alcohol to get high.

Dr. Quintin Chipley, a counseling coordinator at the University of Louisville involved with the research, said Suboxone is used as currency in Kentucky prisons, particularly in the form of strips that go under the tongue. “You could hide the strip under the stamp on a letter,” he said.

One way Suboxone makes it into the illegal market, some doctors and patients say, is when prescribers — including well-meaning ones — don’t do enough to keep recovering addicts on track. That’s what Jon Newsome said happened when he was treated by Dr. David Easley of Louisville.

Newsome — a pill addict from Pike County, Kentucky, recovering at The Healing Place — said he saw Easley in his Bardstown Road office in 2015 and 2016. Medicaid paid for the Suboxone, he said, but he paid $300 or $400 a month out of his own pocket for the visits. Newsome said Easley did urine tests and worked with a counselor who he’d see for 15 minutes.

But none of this stopped him from drinking and using benzos while taking Suboxone — or melting down his medication and shooting it up.

Easley said he does all he can to prevent diversion and abuse. For one thing, he said, he gives patients as low a dose as necessary so they don’t have extra to abuse or sell. Also, he prescribes Suboxone – which includes naloxone to deter abuse – instead of the pure buprenorphine medicine Subutex. (Kentucky regulations generally require doctors to choose Suboxone unless someone is allergic to naloxone or pregnant.) And each urine sample a patient gives, he said, “is witnessed, and then it’s tested for 10 different substances.”

But Easley said if patients misuse their meds, he doesn’t stop Suboxone treatment since addiction “is a lifelong disease.”

Easley also said he doesn’t always require patients to see counselors. “Some patients (such as those with consistently clean urine samples) simply get their prescription,” he said. “Some are seen as often as twice a week.”

Easley said he takes cash for office visits — adjusting charges to the patient — because insurance reimbursement is so poor.

Although he hasn’t been in trouble with the medical board in recent years, Easley did agree to an order in 1998 over his management of two pain patients. Among other things, the three-year order, obtained through an open-records request, said he couldn’t treat those patients and had to attend a mini-residency on prescribing controlled substances. That’s over now, and Easley said he’s conscientious about his Suboxone prescribing.

“(Opioid abuse) is a big problem in our community and I can help people,” said Easley, adding that he believes medication-assisted treatment is much better than abstinence-based programs for opioid addicts. “I sleep well at night.”

Like Easley, Massman, owner of the Center for Behavioral Health chain, said his staff is “absolutely” doing enough to prevent Suboxone abuse and diversion. He said they start patients on low doses, require them to come to the clinic daily until they are stable, require counseling and randomly call in patients with take-home Suboxone to count their medicine and test their urine.

But former patient Blanford said the clinic didn’t do enough to keep her on track. She met with a doctor just once, she said, and other times checked in with different staff to get her Suboxone. After a week, she said, she got a prescription for a 30-day supply to take home. That’s when she started selling.

Suboxone “hurts people more than it helps them,” she said. “Technically, you’re still using opioids.”

Seeking solutions

Stalnaker said that may be true, but he’s been on Suboxone for a little more than four years and has never abused it, sold it or gotten high from it. It simply kept opioid cravings and withdrawal at bay.

“When I was using drugs, I’d wake up and the first thing I’d think of was: How am I going to get my fix today?” he said. On Suboxone, he got his GED, went to community college and repaired a frayed relationship with his mom.

Chase Adams of Louisville, 39, called Suboxone “a great stabilizing factor” that “helped me regain control of my life” after years of OxyContin addiction. Adams, who’s been taking Suboxone for more than two years, said he’s now able to channel energy toward family and friends instead of drugs. He admits slipping a few times and misusing Suboxone but said his doctor, Rutherford, drug-tested him more often, required more visits and counseling and kept him on an even tighter leash than usual. “It’s really helped having a caring doctor like Molly,” he said.

Rogue doctors unfairly give the medication a bad name and “make the rest of us suffer,” Rutherford said. “When you take the medication correctly, it can be very effective. I’ve seen people who do very well. They say it saved their lives, that they got jobs.”

Addiction experts say monitoring and counseling are key when caring for addicts, who can be challenging patients. Dr. James Patrick Murphy, a pain and addiction specialist, put it bluntly: “The disease makes them more likely to screw up with the medication.”

With this in mind, The Morton Center in Louisville has a structured treatment program, making Suboxone available only to patients who agree to go to therapy sessions four days a week and undergo several types of drug screens. Even then, patients can only get short-term prescriptions. Centerstone of Kentucky similarly takes pains to prevent patients from abusing or selling Suboxone, even checking lot numbers on their medicine.

“We use addiction medicine as part of a comprehensive approach,” said Scott Hesseltine, vice president of addiction services at Centerstone. “It’s not a magic bullet; it’s simply one part.”

Dr. Allen Brenzel, medical/clinical director at the state Department for Behavioral Health, Developmental and Intellectual Disabilities, said the two-year-old state regulations on buprenorphine prescribing were “a big step” toward reducing abuse and diversion. He said he’d also support “bundling” Medicaid payments for Suboxone doctors and counselors located in the same place to encourage good, coordinated care.

“We need more prescribers who do this right, and figure out a way to find those who aren’t doing it right,” Brenzel said. “It’s a balance.”

A bill in Kentucky’s most recent legislative session aimed to crack down on rogue prescribers, calling for licensing of medication-assisted treatment programs, more state oversight and inspections. State Rep. Rocky Adkins, D-Sandy Hook, filed it on the request of Beshear’s office.

The bill, which failed, sought “to protect those clinics that are going about medically assisted treatment correctly — and there are such clinics — while shutting down those that are not,” Adkins said. “After Kentucky’s experience with OxyContin, we must make sure that these such clinics are providing real services, while not simply accepting cash in exchange for drugs…”

Steve Towler, judge-executive in Boyd County, where Reed used to practice, supports this idea. “The word ‘Suboxone’ strikes concern among many people,” he said.

But Murphy said Kentucky already has ways to crack down on rogue doctors, and giving the medical board more resources would be a better idea than creating new regulations. While licensing and inspecting clinics would likely reduce the number of bad ones, he said, it would probably also discourage good ones from opening — meaning less access to treatment for addicts struggling with a deadly disease.

Whatever solution the state embraces, one thing is clear, Beshear said: Kentucky can’t afford to let the problem fester.

“If we don’t do something about this, shame on us,” he said. “We should’ve learned our lesson with the pill mills.”

Reporter Laura Ungar, who also reports for USA TODAY, can be reached at (502)582-7190 or lungar@courier-journal.com.