|Sunday, September 07, 2003
Roanoke pain specialist's trial likely to focus on scope of legitimate medical practices
|Depending on one's perspective, Dr. Cecil Knox's practice was either a haven for patients no one else would treat or an efficient drug-distribution operation.
By JEN McCAFFERY
THE ROANOKE TIMES
A Vietnam veteran who overdosed on methadone. A longtime community leader who died with OxyContin in her system. A baby girl born suffering from drug withdrawal.
These are just a handful of the people federal prosecutors will claim were victims of Roanoke pain specialist Dr. Cecil Byron Knox and his office manager, Beverly Gale Boone. Knox and Boone are scheduled to be tried, along with two of their colleagues and the medical practice itself, starting Monday in federal court in Roanoke.
Depending on one's perspective, Knox's practice, Southwest Virginia Physical Medicine and Rehabilitation, was either a haven for patients no one else would treat or an efficient drug-distribution operation.
Selected jurors will spend much of at least the next six weeks hearing evidence from both sides on that question. It could mean the difference between life in prison or freedom for Knox and Boone.
Since federal authorities went public with their investigation of Knox's office in June 2001, the path to trial has been marked by questions of whether federal prosecutors were controlling the case and whether Knox would be able to stand trial at all. After Knox was diagnosed with lymphoma, Chief U.S. District Judge Samuel Wilson postponed the first trial date.
But Knox, 54, is now in remission and able to help with his own defense. Much of the trial will likely center on the question of pain management and whether Knox went outside the scope of legitimate medical practices with his prescriptions of powerful painkillers such as OxyContin and methadone.
Federal prosecutors Rusty Fitzgerald and Pat Hogeboom have characterized Knox's practice as a criminal enterprise, a place where fraud was prevalent and prescriptions were doled out freely, even through a side door. They argue that, in at least 10 cases, those prescriptions led to death or serious injury of Knox's patients.
Defense attorneys in the case are expected to present evidence from experts who will testify that Knox's prescriptions did not violate medical standards. Most of his patients suffered from "serious, life-altering, often debilitating pain," according to the opinion of one of the defense expert witnesses, Dr. Richard Bonfiglio of Pittsburgh. He also found that Knox had established procedures to monitor his patients' prescriptions.
Bonfiglio also expressed the opinion that there was a limit to Knox's responsibility for his patients' actions.
"Despite any doctor's best efforts, there is nothing that will absolutely prevent or detect a patient's lying, attempting forgery, or misdirecting medications," Bonfiglio said, according to court documents.
Michael Troyer, president of the National Chronic Pain Outreach Association, an advocacy group in Millboro, Va., for people who suffer chronic pain, said he had been watching developments in the Knox case closely.
"The last thing we need to be doing is persecuting physicians who are willing to take these risks for those that the entire rest of the medical community has shunned," Troyer said. He estimated that about four to five million Americans suffer from "intractable pain," and added that the medical community has only in recent years tried to start addressing chronic pain management.
According to court documents, the medical histories of Knox's patients that are likely to be examined at trial show that collectively their lives have been a painful litany of car accidents, workplace injuries, multiple surgeries and addictions.
Those patients will likely include Michael Lee March of Moneta, according to court documents. An Army veteran who won a Silver Star in Vietnam, March was 53 and had a wife and eight children when he died on Jan. 8, 2001, according to his obituary. His widow, Kristi March, filed a lawsuit against Knox in 2002, alleging that her husband overdosed on methadone prescribed by Knox.
The story of Lin Edlich will also likely be part of the trial, according to court documents. Edlich, who in 1976 co-founded VA CARES , a program to help prisoners adjust to life after incarceration, was also a patient of Knox's, according to court documents.
Edlich, 54, was found dead in her Smith Mountain Lake home in July 2001. Her ex-husband, TAP president Ted Edlich, told The Roanoke Times later that year that a toxicology report said her death was caused by an overdose of OxyContin.
The effects of Knox's prescriptions may have also reached a generation beyond his immediate patients, according to court documents. A baby girl born to one of Knox's patients tested positive for opiate drugs and suffered life-threatening withdrawal symptoms, according to a summary of testimony from Roanoke neonatologist Robert Wilson Allen Jr. that was part of court documents.
The newborn had to stay in the hospital for three weeks and needed morphine to control her withdrawal symptoms, according to the summary.
Knox's former medical assistant, Tiffany Durham, 29, did not dispute that she told Knox she was concerned that some of his patients were abusing or reselling some of the narcotics he prescribed for them. Durham was also charged in the case and is the only defendant so far to have pleaded guilty to federal charges . Her attorney, Jeff Dorsey, has said he expected Durham would be called to testify against her former boss.
The case has also been characterized by intermittent concern about the number of charges against the defendants. After federal prosecutors returned to a grand jury in October 2002 and came back with 250 more charges in the case, Judge Wilson questioned whether the adversaries in the case were "on a level playing field" or whether the prosecution was "driving the ship."
Under a plea agreement with the prosecution, Durham pleaded guilty Aug. 21 to two felony counts of knowledge that a felony was going on and not letting law enforcement authorities know about it.
Before her plea, Durham, who operated the prescription refill hotline at the practice, also faced dozens of charges that she assisted in the distribution of narcotics outside the scope of medical practice that in at least 10 cases resulted in death or serious injury. If Durham had been convicted of any of those counts, she would have faced a mandatory sentence of 20 years in prison.
Federal prosecutors have also leveled racketeering and a variety of fraud charges against Knox, Boone and the three other defendants in the case - Willard Newbill James, Kathleen O'Gee and the practice, Southwest Virginia Physical Medicine and Rehabilitation. James and O'Gee were not employees at Knox's clinic, but they worked out of the same building.
James, 58, is a licensed counselor and O'Gee, 54, practiced a treatment called craniosacral therapy. Prosecutors argue that the method is not recognized by the medical establishment and thus not eligible for health care reimbursement claims.
Essentially, federal prosecutors say Knox, Boone, James and O'Gee cheated the health care programs Medicaid, Medicare, Trigon and TRICARE, a program for veterans. They argue that the office submitted claims for reimbursement for services that were more expensive than the ones that were actually performed, which is known as "upcoding."
The defendants hid that they were billing for O'Gee's alternative therapy, craniosacral therapy, federal prosecutors say, because the claims were submitted under Knox's name. And they also charge that James and O'Gee paid Knox and Boone kickbacks for patient referrals.
David Damico, who is representing James, said Knox's office handled the billing for his client.
"I think the evidence is going to show that there were some technical errors in a very complicated area," Damico said. "But the evidence is going to be clear that he [James] didn't do anything wrong and made no effort to misrepresent what he was doing."
Randy Cargill, who is representing O'Gee, also said that his client was not involved with the billing to the health care programs. Cargill did say that when O'Gee testified before the grand jury, federal prosecutors told her that what the practice was doing in terms of health care billing was wrong.
But O'Gee went back to Southwest Physical Medicine and Rehabilitation and continued to work. Soon after, she was indicted on federal charges.
"She suffered a grave consequence for not following their advice," Cargill said. "Advice, by the way, that I'm not even sure is correct."