By Oklahoma Watch/The Oklahoman
OKLAHOMA CITY —
On Jan. 27, 2010, Dena Kay Brasfield died in her sleep.
Two days earlier, the 40-year-old clothing store worker had gone to see Oklahoma City doctor Cecil Allen Moore, complaining of migraines, anxiety and panic attacks. He prescribed her unusually large doses of alprazolam, an addictive anti-anxiety drug, and oxycodone, a potent opiate painkiller.
The medical examiner ruled it an accidental overdose. Nobody reported the death to the Oklahoma Board of Osteopathic Examiners.
It wasn’t until late 2011, after receiving complaints about Moore from pharmacists, other patients and relatives, that the board launched an investigation of his prescribing practices. They soon made a gruesome discovery: Eight of Moore’s patients had died of overdoses in 2010 and 2011. Not one had been reported to the board.
By the time the board revoked Moore’s license in mid-2012 for prescribing violations, more than two years had passed since Brasfield swallowed her fatal cocktail of prescription drugs.
The eight deaths on Moore’s watch, and others like them, expose troubling gaps in the state’s system for combating an epidemic that has seen Oklahoma surge to near the top of national rankings for prescription drug abuse and overdose deaths.
In 2012, unintentional prescription drug overdoses claimed the lives of 534 Oklahomans. State health authorities say about half of them had taken drugs prescribed by their own doctors.
While much of Oklahoma’s enforcement efforts are aimed at drug-seekers, far less effort is dedicated to identifying, investigating and pursuing the problem providers — the doctors who supply the sometimes deadly dosages.
Despite the fact almost one out of every two overdose deaths involves a drug the person was prescribed legally, state investigators don’t check regularly to see whether the prescriber might be linked to other overdose deaths.
In some instances, that allowed problem prescribers to escape detection by regulators and to continue to overprescribe, in some cases for years, leading to additional deaths and injuries, an investigation by The Oklahoman and Oklahoma Watch has found.
Doctors such as Joshua Livingston, who saw 60 to 100 patients a day at his South Pointe Pain Clinic in Tulsa. Four of his patients died of overdoses. After the first death in August 2011, 18 months went by before Livingston was placed on probation and his prescribing practices were restricted.
Or Dr. Joseph Knight, a Tulsa infectious disease specialist who had nine patients die of overdoses from 2009 to 2011. It wasn’t until March of this year the medical board heard his case, more than five years after his first patient died.
Or Dr. Amar Bhandary, an Oklahoma City psychiatrist, who, during 2008 and 2009, wrote prescriptions that resulted in the overdose deaths of five people. It wasn’t until 2013 that the state medical board and prosecutors moved against him.
Or Dr. R. Wayne Mosier of Talihina, who, in 2007 and 2008, had four patients die from lethal overdoses shortly after he prescribed them controlled substances. It wasn’t until 2009 that the narcotics bureau pulled his prescribing license.
Had it not been for complaints from the public, their prescribing practices might never have been discovered.
“We need a process to speed this up. We need it desperately,” said Deborah Bruce, executive director of the Oklahoma Board of Osteopathic Examiners. “If we’re really going to save lives and reduce the number of deaths, we need a process … that speeds up the attention.”
Some defend the doctors, saying it’s wrong to blame prescribers for the bad behavior of some patients or make them assume primary responsibility for preventing overdoses from occurring.
“To say that the responsibility for deaths rests solely on the shoulders of physicians is grossly unfair,” Bruce said. “But to say that physicians share in the responsibility for solving this problem ... is imminently fair.”
The investigation also found:
•The medical examiner’s office typically takes two to three months — and even sometimes a year or more — to complete its death investigation reports and turn them over to the state narcotics bureau for review. By the time the drug agency finds out about a fatality, more overprescribing and overdoses have occurred.
•The state’s primary tool for tracking narcotic sales — the Prescription Monitoring Program — is underused by enforcement authorities and many prescribers. The narcotics bureau does not mine the program data routinely to target over-prescribers, instead relying on tips and complaints to initiate almost all cases. Many physicians do not regularly check the program to prevent “doctor-shoppers” from obtaining multiple prescriptions for dangerous drugs.
•State agencies and licensing boards do not regularly share with each other information about overprescribing and patient deaths. The medical examiner typically does not record the names of prescribing physicians when it collects evidence in overdose cases. Neither the medical examiner nor the narcotics agency routinely notify the medical boards of overdose cases they might want to review. And the state’s Medicaid agency does not notify the medical boards if the agency pulls a doctor’s Medicaid license for any reason.
•State licensing boards rarely discipline doctors involved in over-prescription deaths. Since 2007, only 11 doctors linked to overdose deaths have been subject to disciplinary actions by their licensing boards.
•State enforcers say local prosecutors are reluctant to pursue criminal over-prescription cases against doctors, saying they are expensive, time-consuming, difficult to litigate and, in some cases, unpopular with the community where the doctor practices. In the past two years, prosecutors have filed criminal charges against just one doctor investigated by the narcotics agency for drug diversion.
•Existing state laws hamstring the ability of the narcotics bureau and medical licensing boards from collaborating effectively to detect and deter overprescribing. At the insistence of the medical lobby, all Prescription Monitoring Program data is deemed confidential and its dissemination restricted, making it more difficult for the licensing boards to identify problem prescribers.
After an overdose death, authorities gather a wealth of information, including the person’s medical history and, when available, a list of any prescription drugs the person may have been taking.
Unlike their counterparts in some states, Oklahoma medical examiners don’t routinely collect the names of the doctors who prescribed the drugs, saying it’s not their responsibility. Nor does the Medical Examiner’s Office alert the prescribing doctors or their medical licensing boards that a patient has died.
“We stay away from quality-of-care issues,” Medical Examiner’s Office spokeswoman Amy Elliott explained.
Eventually, the medical examiner forwards a death investigation report to the state narcotics bureau. But because of a massive backlog in completing the investigations, it generally takes months before the report is submitted.
An analysis of more than 2,000 overdose deaths by Oklahoma Watch and The Oklahoman shows that, on average, 105 days elapsed between an overdose death and the completion of the report. In 30 cases, it took more than a year to finish the report. The longest time lag was 653 days.
Neither the narcotics bureau, the medical examiner’s office nor local law enforcement authorities routinely report the names of doctors connected to overdose deaths to the licensing boards to review for potential overprescribing.
That’s led to cases where regulators failed to stop a problem prescriber in a timely manner, allowing them to continue to write prescriptions that led to more deaths and injuries.
“At this juncture, we will not know that until somebody is dead and their family member has reported it, and that’s a little late in the game,” Bruce said.
The bureau also doesn’t forward its reports on high-volume prescribers and patients to the state’s medical licensing boards so they can intervene quickly with the physicians they oversee.
For the past eight years, most Oklahoma pharmacists have been logging every narcotic prescription they fill into an online database called the Prescription Monitoring Program.
All in-state medical providers licensed to prescribe controlled dangerous substances in Oklahoma have access to the program’s data. It only takes a minute or two to check a patient’s prescribing history to make sure he or she isn’t getting simultaneous prescriptions from several physicians.
But it only works well if people bother to use it. And many doctors don’t.
Last year, Oklahoma pharmacies filled 9.7 million prescriptions for controlled dangerous substances. The biggest seller by far was hydrocodone — enough doses of the potent painkiller to give every man, woman and child in the state 50 pills apiece.
Yet Oklahoma medical doctors, physician assistants and other licensed prescribers logged into the Prescription Monitoring Program only 1.2 million times last year.
Under existing law, Oklahoma doctors are not required to check the PMP when they write narcotics prescriptions. When attempts have been made to make PMP use mandatory, their professional associations have lobbied successfully to keep that from happening. Most doctors know their patients, the associations argued, and mandatory checks would take too much time.
A review of disciplinary records shows that the state’s two largest licensing boards rarely discipline doctors as a result of overdose deaths.
Despite at least 300 people now dying each year from drugs their doctors prescribed them, the state’s two physician licensing boards have sanctioned just 11 doctors since 2007 for over-prescribing that led to deaths.
The discipline in most cases amounted to the doctor’s license being surrendered, revoked or suspended, in some cases for a year or less. Others were put on probation, sometimes with restricted prescribing ability. Among the 11 doctors with patient deaths, four are still practicing in Oklahoma.
Criminal cases against over-prescribers are even rarer.
In the last two years, only one case that was forwarded by the bureau to a district attorney resulted in criminal charges being filed. Other cases have been submitted, but no action has been taken by prosecutors, she said.
And the deaths continue, at a rate of nearly two Oklahomans per day.
This project resulted from a joint investigation by Oklahoma Watch and The Oklahoman. Oklahoma Watch is a nonprofit journalism organization that produces in-depth and investigative reporting on a wide range of public-policy issues in the state. For more Oklahoma Watch content, go to www.oklahomawatch.org.