By Christian Davenport
Washington Post Staff Writer
Saturday, January 1, 2011; 9:41 PM
Twice, the patient, a man in his mid-30s, said he lost his prescriptions for Valium and Percocet. Once, he said he was in a car accident that scattered his pills on the road. Another time, he said the medicine he was first prescribed was no good, so he "returned the pills." Another time, his wife called and said their house had been "searched by authorities" and the medicine had gone missing.
Each time, no matter the story, Peter S. Trent or Hampton J. Jackson Jr., doctors at the same orthopedic practice in Oxon Hill, refilled the prescription, according to the Maryland Board of Physicians. Over the course of 21/2 years, the doctors gave the patient 275 prescriptions, mostly for Percocet, a powerful, highly addictive painkiller.
Sometimes they wrote the patient more than one prescription for the drug on the same day. In a single month, they wrote him 11 prescriptions for Percocet, totaling 734 pills.
Jackson and Trent - who maintain that they did nothing wrong - are among a small group of doctors who were the top prescribers of tightly regulated drugs in their state Medicaid programs, according to a Washington Post analysis of state data.
Last year, Sen. Charles E. Grassley (R-Iowa) asked state regulators to provide lists of the top 10 Medicaid prescribers of eight drugs - some of which have high street value because of their popularity among abusers - in an effort to identify doctors who might be overprescribing pricey medicines at taxpayer expense.
The data he collected - which do not include prescriptions written outside of Medicaid - show that some doctors prescribe far more of the drugs than most of their peers. Grassley said the findings do not necessarily suggest "any illegal or wrongful behavior," because doctors on the lists may have a certain expertise or patient population that justifies their prescribing patterns.
But the findings "may also suggest overutilization or even health-care fraud," Grassley said. In one case, he noted, a Florida doctor wrote nearly 97,000 prescriptions for mental-health drugs over a 21-month period.
After receiving Grassley's data, The Post requested the same information from the District, Maryland and Virginia for other drugs - such as Percocet, Vicodin and Ritalin - that are prone to abuse.
The Post's analysis found not only that certain doctors routinely prescribe some medications far more than their peers, but also that some of them have a long history of sanctions by professional disciplinary boards for unethical and unprofessional behavior, including overprescribing medications to patients who may have been using them to get high instead of well.
The state boards that oversee medical misconduct say overprescribing is a huge problem that they take very seriously.
The top priority is to do "whatever you think is necessary to protect the public," said William Harp, executive director of the Virginia Board of Medicine. "I want us to be very objective and very fair to these doctors and the citizens they treat."
Regulators say they are caught between trying to keep doctors from prescribing drugs unnecessarily and satisfying doctors who say heavy-handed investigations discourage them from prescribing medication that patients need.
"We get heat from both sides," said C. Irving Pinder Jr., executive director of the Maryland Board of Physicians. "Pain-management doctors say we're taking them out of business, but we're only getting those that obviously cross the line."
Meanwhile, illicit use of prescription medicine has become the nation's "fastest-growing drug problem," according to R. Gil Kerlikowske, director of the White House Office of National Drug Control Policy. Between 1999 and 2005, unintentional deaths from prescription drug overdose more than doubled, to more than 22,000, according to a study funded by the federal Centers for Disease Control and Prevention, making such overdoses the second-leading cause of unintentional death, after automobile accidents.
Part of the problem, Kerlikowske said, is that people do not see the drugs as dangerous, because they are legal and have a legitimate use. Many doctors are prescribing more of these highly addictive drugs without fully understanding how hooked people can become, he said.
Doctors "don't get very much, if any, training in dependence, in addiction, in pain management," he said.
The drugs driving the problem are opioid analgesics, which among teenagers are more popular than marijuana, according to a federal study from 2006. These drugs have been flowing out of retail pharmacies at a burgeoning rate. Prescriptions for two of the most common opioids, hydrocodone and oxycodone, jumped from 44 million in 1991 to 179 million in 2009, according to the National Institute on Drug Abuse.
"I don't think anyone believes that pain has increased that substantially in the country," Kerlikowske said.
The lists of doctors who write the most prescriptions include some who have gotten in trouble before for overprescribing and some who have been sanctioned by state medical boards for other offenses, including borrowing large sums of money from a patient, giving narcotics to a patient even after being warned that the patient was selling those drugs, and mistakenly prescribing a lethal dose of an antidepressant to an 11-year-old boy, who collapsed on a school trip to an amusement park and died.Patients in and out
Hampton Jackson - who also practices in the District - prescribed far more OxyContin and Roxicodone (two brand names for the narcotic painkiller oxycodone) than did the city's next most prolific Medicaid provider. He wrote 63 prescriptions in 2008 and 191 in 2009; the runner-up on the list wrote 27 in 2008 and 64 in 2009. But Jackson said his totals were relatively small given the number of patients he treats. He also said he rigorously monitors patients on heavy drugs for signs of abuse.
On an average day, he said, he sees 30 to 50 patients. On an extremely busy day, he said, he can see as many as 90 in nine hours. That caseload - 10 patients an hour - is possible, he said, because many are routine follow-ups and "because I have a big staff."
Jackson said many patients who are in pain are undermedicated. Doctors, fearing disciplinary actions from medical boards, are not prescribing the drugs people need, he said.
Even though he is on probation and his privileges at George Washington University Hospital have been revoked since 2004, Jackson said he will continue to practice medicine as he deems best. If that means treating people who require strong drugs, so be it.
"A lot of people say, 'I'm not getting in trouble with the board' and 'Get them out of my office.' That's not true to my oath and my desire to help my patients," he said. "I have all these patients because doctors won't treat them."
In 2004, the Maryland board sanctioned Jackson and Peter Trent, saying that they did not heed signs of a patient's abuse problem and failed to ensure that he was "not diverting these medications for non-therapeutic purposes or was stockpiling the medications for personal use."
Although the wording of the sanction sounded tough, it really was little more than "a slap on the wrist," Jackson said in an interview. The punishment did not prohibit him from seeing patients or prescribing medicine.
In fact, records show that in 2009, while Jackson's license was under probation, he was among Maryland's top prescribers of Roxicodone and of Vicodin, a painkiller that combines hydrocodone and acetaminophen. In addition, Jackson and Trent were first and second in the District, respectively, in the number of Percocet prescriptions written in the 12 months that ended Sept. 30, 2010. During that period, Jackson wrote 684 Percocet prescriptions and Trent wrote 223.
Both Jackson and Trent, who is no longer on probation, said in interviews that they did nothing wrong and were victims of an overly aggressive board.
"They were headhunting," Jackson said. "They were looking to show the public they were cracking down on drugs."
Asked to comment on his appearance on the District's most-prescribed list, Trent said, "They ought to give me an award." He said the number is not high given that he sees 100 patients a week.
Both doctors said that they use many techniques to treat patients but that medicine is often a key component. "If there's no other reasonable way to control the symptoms, then we are forced to use medications like OxyContin," Jackson said.
As for the patient for whom they wrote 275 prescriptions, both doctors said that they were working in different locations at the time and that neither knew the other was prescribing the same medication.
The patient "would come to me, then the next day he would go to the office in Silver Spring, and we wouldn't have the records in Silver Spring, so neither one of us knew he was getting medication from us simultaneously," Jackson said.
That case has led to a change in the doctors' practice. "We've tightened up," Trent said. "The answer now is no if they say they lost their prescription."'Egregious' violations
Montgomery County police in 2000 found a woman fading in and out of consciousness in a house so squalid it would soon be condemned as unfit for human habitation. At the hospital, the patient, who had attempted suicide before, was found to be full of booze and the same type of medications that had been prescribed by Joel Cohen, who, as it turned out, was her fiance.
For more than a year, Cohen, then a psychiatrist in Bethesda, had been prescribing the woman medications such as hydrocodone and the anti-anxiety drug diazepam but failed to keep records, according to the Maryland Board of Physicians, which placed him on probation in 2001.
In February 2006, that probation was lifted. Five months later, Cohen was sanctioned again after what the board called a "dangerous failure to meet the standard of care" with a second patient, for whom he prescribed "large amounts of medications" despite her history of alcohol and prescription drug abuse. Cohen did this, according to the board, even while he "was aware that the patient was abusing prescription medications," including the stimulant Ritalin.
In 2008, according to the D.C. Board of Medicine, Cohen was the District's top prescriber under Medicaid of three antipsychotic medications: Seroquel, Abilify and Geodon.
In the 2006 sanction, the Maryland board said Cohen had committed "egregious boundary violations" with the patient, a victim of spousal abuse who had developed borderline personality disorder. He gave gifts to her children, allowed her to take his children on vacation and gave her real estate advice. He also let the patient, whom he had been treating for 21 years, shower at his office and prescribed Ritalin for her son without evaluating him.
Cohen admitted to the board that he had "mishandled the patient's case in many ways and had underestimated his own difficulties," according to the board's final order in the case.
In that second sanction, the board said Cohen's actions "were not a one-time, short-term lapse of judgment with one patient, but rather a longstanding, documented pattern of unethical behavior dating back to 1977."
Cohen's license in Maryland has expired, but he continues to practice at Community Connections, a clinic on Capitol Hill.
In a brief interview, he said he sees as many as 16 patients a day, many of whom are homeless and do not have insurance.
"I work with severely mentally ill people," he said. "I really don't want to go into all of this. This is a very tough place to work here. We have very sick people. I think that's enough said."Clear signs of misuse
One patient's fiancee asked the doctor to please stop prescribing so many medications. The patient was an alcoholic with a history of abusing narcotics and sedatives. Once, he overdosed, and now he was in a detox clinic. Still, the doctor did not stop prescribing, according to Maryland's Board of Physicians.
In fact, over the course of a decade, Daniel M. Howell, a family-care doctor in Waldorf, prescribed more drugs, in increasing doses, even when there were clear signs that the patient was abusing his medicine, the board found.
In 2008, Howell was among Maryland's top prescribers under Medicaid of OxyContin, Xanax and Percocet.
In an interview, Howell said he "followed national pain-management guidelines in the sense that we did random urine testing on anyone that we had any suspicion about." In one year, he said, his practice dropped 50 to 100 patients for abusing prescriptions.
Howell started seeing the alcoholic patient for "possible broken ribs" in 1994. By the next year, a CVS pharmacist called Howell to report that the patient had been getting multiple refills for several narcotics from different doctors in the area. But when the patient complained of kidney stones soon thereafter, Howell prescribed Percocet.
Initially, he prescribed 20 to 30 pills at a time, the board found. By 1997, it was 40, then 60. By 2000, he was prescribing the patient 100 pills every two weeks. Then Howell doubled the strength of the pills from 5 milligrams to 10. Once, he prescribed Percocet because the patient had a "headache - frontal." At one point, Howell prescribed 300 pills within 10 days, along with 90 tablets of OxyContin, to the same patient, an amount the board called "well above the safe limit." By 2003, the patient was taking eight to 14 Percocets a day.
In 2008, the board placed Howell on probation, requiring him to take a course on prescribing controlled substances. But he was allowed to continue seeing patients and writing prescriptions. A year later, he was charged again. This time, the pharmacies - and other doctors - were complaining.
"Three concerned area pharmacists," as they called themselves in a letter to the board, said Howell was prescribing excessive narcotics to patients who "appear to have questionable and/or documented history of overuse of pain medication."
A few months later, an emergency room doctor at St. Mary's Hospital in Southern Maryland complained that Howell's overprescribing was causing overdoses. One patient had ended up in the ER but then returned to Howell's office, where he "received another very large prescription for Percocet and Xanax," the board said. The patient was found unresponsive again and was taken to the ER a second time.
"I want you to note that none of the patients I was accused of mistreating in this fashion died," Howell told The Post. "The ER takes care of the moment. But what happens the next day, when they're shaking and sweating and sometimes having hallucinations? And there isn't any acute-withdrawal center in Southern Maryland. Do you let them go into acute withdrawal, which could lead them to street meds, which are less safe than a controlled commercial product?"
In October 2009, the board suspended Howell's license but immediately knocked the suspension down to probation on the condition that he not treat patients for chronic pain. The board also limited the amount of drugs Howell could prescribe and required that another doctor supervise him.
Howell said he has been fired from the practice where he worked because many top insurance companies dropped him after the sanctions. He said he hoped to return to practicing medicine soon.
"I just want to get back to serving people," he said.Hoarding medications
The Virginia Board of Medicine came down hard on Verna M. Lewis, a physical-medicine and rehabilitation doctor in Roanoke. Her license was suspended after she was convicted in 1999 of filing false tax returns and influencing a grand jury witness.
In 2002, the board found that she was taking unused medicine from the hospital where she worked and using it in her private practice. She also told patients to return unused prescriptions to her and then had her staff take patients' names off those bottles so she could reissue the medications to other patients, even though, as the board said, she had no authority to do so.
State police and health investigators searched her office and found hundreds of doses of drugs, including OxyContin, with no patient or pharmacy names on the labels. The board also said she removed from her office two patients' files that had been subpoenaed.
Lewis applied to have her license reinstated twice, and both times she was denied. Then, in 2004, after she completed 108 hours of continuing medical education, her license was restored with several conditions, including having to pass an exam given by the national Federation of State Medical Boards.
After she took the test, according to the Virginia medical board, Lewis faxed the officials a document purporting to prove that she had scored the minimum passing grade of 75. But when the federation faxed in her official score the next day, it showed that she had failed with a score of 74.
Lewis did not return calls seeking comment. She told the board that it had not found any "actual patient harm" and that she extensively studied pain management and had never been sued for malpractice.
Harp, the medical board's director, refused to address specific cases but said, "We take prescribing complaints very seriously."
In 2006, the board reinstated Lewis's license but ordered an unannounced inspection of her practice and records and required her to log the controlled substances she prescribed.
The year after that, she was granted a "full and unrestricted license." The letter reinstating her ends, "The board wishes you well in your future endeavors."
The year after that, in 2008, Lewis was among Virginia's top prescribers of OxyContin and Roxicodone under Medicaid.
Staff researchers Magda Jean-Louis and Julie Tate contributed to this report.