|Sunday, September 28, 2003
|Law enforcement officials nationwide are targeting doctors they say are running 'pill mills'
Charges against doctors rise across U.S.
|Roanoke pain specialist Cecil Knox is on trial in connection with prescriptions for opiate drugs.
By JEN McCAFFERY
THE ROANOKE TIMES
Dr. Frank Fisher lost his health clinic in rural northern California.
He misses the children who used to fill his waiting room. He has his license back, but can't get a job. He's still facing three wrongful death lawsuits.
Still, Fisher was lucky. State authorities dropped murder charges in 1999 that alleged Fisher killed three of his patients, for lack of evidence.
But the tide has changed, and the prosecutions of doctors are more successful now, Fisher said.
"Doctors generally lose, and their best shot is an appeal," Fisher said.
Fisher is one of an increasing number of doctors across the United States who have been investigated and in some cases prosecuted for what law enforcement officials say is running "pill mills." In some cases, doctors have also faced charges that they killed or contributed to causing the deaths of some of their patients.
One of those doctors is Roanoke pain specialist Cecil Byron Knox. Knox, 54, and his office manager, Beverly Gale Boone, 44, are on trial in federal court in connection with the prescriptions of opiate painkillers such as OxyContin and methadone. Federal prosecutors argue that Knox's prescriptions led in eight cases to patient deaths. In nine other cases, prosecutors say, the prescriptions led to serious patient injury.
Knox's and Boone's futures are also at stake. They each face maximum sentence of life in prison if they are convicted of prescribing narcotics outside the scope of legitimate medical practice that led to a patient's death.
A precedent was set in 2002 when Dr. James Graves of Florida became the first doctor in the United States to be convicted of manslaughter in connection with the OxyContin death of a patient. He was convicted in the deaths of four of his patients who died from overdoses.
If the federal jury in Roanoke convicts Knox, it will likely be the first conviction of that kind on federal charges.
The prosecutions of doctors in connection with what prosecutors say is the prescription of opiates outside the scope of legitimate medical practice have pitted some law enforcement officials against some members of the medical community.
"If a prosecutor thinks that he has a federal case, then he's going to go after it," said Charlie Cichon, president of the National Association of Drug Diversion Investigators and the head of the investigative unit for the Maryland Medical Board.
A spokesman for the Drug Enforcement Agency, Ed Childress, did not return a call for comment on how many doctors are being investigated around the United States.
The DEA has identified the abuse and diversion of OxyContin as a serious problem in certain parts of the United States, particularly in the East, according to its Web site. And the DEA identifies doctors and pharmacists as being the primary route through which pharmaceuticals get illegally diverted to the black market, according to its Web site. Several doctors in far Southwest Virginia have been convicted of writing illegal prescriptions.
From 1996 to 1999, the last year figures were available, deaths from drug abuse that were reported in connection with the use of oxycodone quadrupled, from 51 deaths in 1996 to 268 deaths in 1999, according to the Web site.
Meanwhile, Dr. Jane Orient, executive director of the Arizona-based Association of American Physicians and Surgeons, characterized the investigations and prosecutions of doctors as a "witch hunt."
"Being a bad doctor is not a crime," Orient argued. "Without an intention to harm the patient, and without an intention to participate in drug dealing, how can you say it's a crime?"
The American Medical Association has also weighed in on the prosecution of doctors.
In a statement issued in July, the association said it planned to tell President Bush, Department of Health and Human Services Secretary Tommy Thompson, and Attorney General John Ashcroft that the association opposes the use of federal law to go after doctors who prescribe opiate painkillers.
Caught in the middle of the debate are patients with chronic pain. The American Pain Foundation estimates that 50 million Americans live with pain.
Fisher said his concern was not only for himself when he got charged.
"When this happens, a guy's life gets destroyed," Fisher said. "And his patients' along with him."
Fisher's case never made it to trial. The preliminary hearing in the case lasted 21 days.
The hearing ended with a cross-examination of a state law enforcement officer by Fisher's attorney, Patrick Hallinan of San Francisco.
The officer admitted that he went undercover into Fisher's office several times and asked the doctor to prescribe him narcotics for no medical reason.
Fisher refused each time. The charges were dismissed against him soon after.
Since then, Fisher has closely observed the prosecutions of other doctors .
Prosecutors typically target doctors with large practices, and practices in which Medicaid or Medicare covers the care of a lot of patients. Cichon said that doctors who divert drugs are often eventually charged with health care fraud.
Fisher said prosecutors are going after doctors the same way throughout the country.
Sometimes, law enforcement officials try to catch the doctor with a sting operation, as they did in his case, Fisher said. If that doesn't work, "they accuse the guy of drug dealing and murder."
"Then they bring in an expert from a university hospital center to read the chart," Fisher said. "And he testifies that he thinks this doctor's care fell below the standard of care. The government has been using that [argument] of evidence of manslaughter, drug dealing and murder. They're using testimony about what would be malpractice as evidence of criminality."
Prosecutors around the United States have also used a series of "red flags" they say show the doctor is prescribing indiscriminately.
Those red flags include the argument that the doctor prescribed more than one opiate at a time to a patient. Fisher argued that the question of whether that can help a patient is still unresolved in pain management circles.
Fisher thinks people are afraid of opiates , even though he said medical research shows most users with chronic pain do not get addicted to them.
"The big picture is that it's become a drug war issue where superstition is colliding with medical science," Fisher added. "The government's winning because everyone's in a panic about opioids That's why we have an enormous problem with the treatment of pain in this country."
Cichon said he does not oppose the use of opiate medications.
"All these drugs are good drugs, when prescribed for legitimate purposes," Cichon said.
Fisher, Orient and Cichon agree that diversion of prescription drugs was a problem long before OxyContin came along.
But Orient said she thinks law enforcement is focusing its resources in the wrong area when it comes to preventing the diversion of prescription drugs.
"They seem to care more about putting doctors in prison and preventing patients from getting the drugs they need instead of stopping the street diversion," Orient said.
But Cichon said he thinks "99.999 percent of doctors are good doctors."
"Unfortunately, when you have that bad doctor, it's going to draw the bad patients," he added.
Fisher and Orient also argued that law enforcement officials should not be prosecuting doctors on the question of whether their care falls within medical standards because they are not doctors, and don't know about the latest research in pain management.
Cichon said that a lot of doctors he's worked with don't know a lot about the nascent field, either. And he said the National Association of Drug Diversion Investigators gets pain management doctors to train law enforcement members.
Of course, as the trials of doctors around the country have demonstrated, experts have a range of opinions on what constitutes effective pain management.
Fisher worries that while prosecutors and some doctors wrangle over that question, it's the patients who suffer.
"Pain is a festering sore on society and the profession," he said.