Last week, 51˶ reported on the California state medical board's investigations of physicians, nurse practitioners, and physician assistants who prescribed opioids for individuals who later overdosed. Here we take a closer look at the physicians who, as of Sept. 23, have been formally accused of wrongdoing.
If one had to identify a physician to symbolize its "Death Certificate Project," an aggressive effort by the Medical Board of California to nab doctors who overprescribe opioids, a likely candidate would be Harold S. Budhram, MD, of Shasta Lake. (All cities named in this article are in California.)
Triggered by deaths of two of his patients attributed to opioid overdoses, the board investigated his practice and, in April, filed a .
Those two deaths were summarized as follows: "Patient A, a 22-year-old male, died of an apparent accidental morphine overdose, complicated by a known seizure disorder, which developed after the patient was taking opioids," and "Patient B, a 52-year-old female, died of an apparent methadone overdose, which were prescribed by respondent."
A third referenced death, a suicide, was said to occur after Budhram prescribed "a cocktail of Norco, methadone, Seroquel, Trazodone, and two different benzodiazepines" which "increased her risk of death or severe injury even without her ultimate suicide."
Other phrases scattered through the complaint include "did not choose the lowest doses," "never attempted to wean the patient off the medications," "failed to conduct an assessment of the patient's addiction risk," and "continued prescribing opioid pain medication despite this red flag." Budhram's care of one patient was "grossly negligent," according to the document.
Adding insult to injury, the complaint also dinged Budhram for "poor penmanship."
The complaints against Budhram and eight other physicians are the result of the medical board's review of death certificates of patients who lethally overdosed in 2012 and 2013. The board matched those names in the state's prescription drug database to identify providers who prescribed opioids to those patients within 3 years of their death. Nearly 450 allopathic physicians, 12 osteopaths, and 60 nurse practitioners and physician assistants were targeted by expert reviewers for investigation and possible action. About half of the cases have been closed without further action; but in addition to the nine who have been formally accused of wrongdoing, dozens of others still face potential sanction.
The California effort is said to be the only one like it in the country with such a broad, 3-year lookback. (A has tighter restrictions on what it can review. For example, it limits scrutiny to those doctors with two or more patient deaths in 1 year and who prescribed opioids within 60 days of that patient's death while the California program goes back 3 years.)
'Incredibly high' doses
Many of the accusations repeat these phrases: "gross negligence," "furnishing dangerous drugs without examination," "unprofessional conduct," and "inadequate record keeping." Several physicians were said to have failed to check the state's prescription database, (the California Controlled Substance Utilization Review and Evaluation System), which could have told them their patient had received opioids from other prescribers.
of Escondido faces nine causes of discipline. "Patient E," the accusation said, "was found dead in his home as a result of the combined effects of multiple substances including alcohol, methadone, hydrocodone, alprazolam, and bupropion." And for "Patient A," Chesler was said to have written 56 prescriptions for opioids and other medications, including products containing "an average of 5000 mg. of acetaminophen per day." (The FDA-approved label for products containing acetaminophen says daily doses should not exceed 4,000 mg, even under a professional's supervision.)
of San Diego faces six causes of discipline in an accusation that references two patient opioid deaths. For one, Smith "prescribed patient B escalating doses of opioids in combination with other controlled drugs, including, but not limited to benzodiazepines, antidepressants, muscle relaxants, and testosterone.
"In fact, [Smith] prescribed excessive amounts of opioids including, but not limited to, on or about Oct. 1, 2013, issuing a prescription for Roxicodone (30mg) (#140) amounting to approximately ten (10) tablets daily. Significantly, this prescription alone equaled an incredibly high four hundred fifty (450) MME" (morphine milligram equivalents).
The board's accusation against of Atwater details two long lists of drugs he prescribed to a patient in 2011 and 2012, including methadone, zolpidem, diazepam, alprazolam, temazepam, hydrocodone bitartrate, and clonazepam. Though Yaqub noted his patient was non-compliant, he provided refills. The medical board's formal complaint said "documentation of the assessment and plan at each visit was cursory at best."
Methadone and other opiates don't mix
At this writing, the most recent accusation stemming from the project was filed Aug. 24 against alleging four causes of discipline. The Bakersfield doctor is said to have committed an "extreme departure from the standard of care" and prescribed "Patient A" carisoprodol, alprazolam, and methadone (at her previously established dosage). Patient A died on April 25, 2012 of methadone toxicity (overdose). The accusation adds that when a patient is taking methadone, no other opiates should be prescribed.
Asked for comment, Dozier said he was unaware of the project but said the accusation references care he provided as far back as 2011. He said he's meeting with his attorney to decide how to respond.
The accusation against , of Lakeport, references his care of three patients including three who died: one listing polypharmacy as the probable cause of death, the second from cardiorespiratory arrest after possibly being overmedicated, and a third from metastatic cancer, for which tests were not ordered to diagnose. He is accused of "prescribing excessively and/or inappropriately" to five patients.
of Susanville, faces 10 causes of discipline, many related to his "extreme departure from the standard of care" involving several patients, one of whom died in 2013 of an oxycodone overdose one day after he prescribed 240 pills of that drug, which he had prescribed to her since 2010 monthly or every other month. He also prescribed many other controlled substances during this period.
of San Francisco has had a determination of his case following accusations against him stemming from the Death Certificate Project. He was issued a public reprimand and ordered to enroll in courses on record keeping and prescribing. He was alleged to have repeated documentation for multiple patient visits in chart notes, not discussing a patient's addiction risk before prescribing fentanyl, oxycodone, and Norco (acetaminophen-oxycodone), and not documenting discussions about non-opioid alternatives.
of Santa Rosa, faces two causes for discipline in his alleged care of a patient at heightened risk of suicide, for whom he prescribed diazepam for anxiety and did not consider options for treating the patient's headache besides butalbital and codeine, "medications with a known side effect of causing headaches."
Requests for comment were placed to all physicians but Dozier was the only one to respond as of publication.
An accusation against , MD, of San Francisco was filed Aug. 31, making him the 10th California physician to face charges in what the state Attorney General said includes nine causes for discipline.He was said to have prescribed Norco, Soma and Alprazolam to one patient constituting “a high level of a morphine-equivalent daily dose,” and the patient, who 10 days later was found dead at his apartment. A necropsy showed “a potentially toxic level of hydrocodone.”
, MD, of La Mesa, wrote 16 prescriptions for controlled substances, including seven for morphine sulfate and five for APAP/hydrocodone, for one patient over a six month period, according to an accusation filed Sept. 6. The patient was taken to a hospital emergency room for “slurred speech” due to a “possible medication effect.” True was said to have failed to regularly assess the patient or have an established treatment plan and other “repeated negligent acts.”
, MD, of Cardiff-by-the-Sea, prescribed oxycodone and Oxycontin on a long-term basis to a patient, “despite (the patient’s) active alcoholism” and “prescribed diazepam, concurrently with oxycodone and Oxycontin without proper tapering of these medications,” according to the acusaiton filed Sept. 13. Schulman also failed to timely refer the patient for a pain management consultation. One day after Schulman advised the patient, who continued to complain of severe pain, to go to the emergency room for relief, the patient “passed away.”
The board's executive director, Kimberly Kirchmeyer, said the board intends to proceed with reviews of death certificates in subsequent years. Additional staff have been assigned to the project. A board spokesman said all nine accusations involve patients who died of opioids, although not all the documents made public to date reference a patient death.
She noted that for most of the cases so far, a hearing has not yet been held so the physician has not been found guilty.