Licensed to pill: Little scrutiny of doctors who overprescribe addictive opioids

Herald-Tribune - 4/23/2018

Editor's note: This is the first of a three-part series on ways doctors, regulators and drug companies contribute to the nation's opioid addiction epidemic.

LEWISBURG, Tennessee ? Shortly after Dr. Mark Murphy, a top opioid prescriber in the U.S., started practicing in Lewisburg, Tennessee, three days a week last year, the clinic owners asked a police detective to meet for dinner.

Lewisburg Police Lt. Tom Miller thought the request seemed like a pre-emptive strike to keep the cops away from the Specialty Associates clinic.

"They ? wanted to stress with me they weren't doing anything wrong," said Miller, who served as Tennessee's drug task force commander for 18 years before joining the Lewisburg force.

But Miller's suspicions of the doctor were already amplified. He knew Murphy had been the No. 1 opioid prescriber in the federal Medicare program for years; that he closed his practices in Alabama when that state's medical board accused him of writing excessive opioid prescriptions.

He also knew that many of Murphy's patients were driving far distances to see him: Alabama, Florida, Georgia, Louisiana and Mississippi.

That led Miller and Lewisburg Police Chief David Henley to conclude Murphy's practice had all tell-tale signs of a pill mill.

Murphy declined repeated requests for an interview. A woman on his staff shooed a reporter out of the clinic parking lot, stating: "We don't need any TV (expletive) going on."

Weak oversight

Despite law enforcement crackdowns and new federal guidelines and state laws to limit the amount of opioids given to patients, some of the highest prescribers have avoided scrutiny, a Raycom Media national investigation found.

The top 1,000 highest prescribers in the Medicare Part D program, which provides drug benefits to the elderly and disabled, collectively wrote 14.6 million prescriptions between 2013 and 2015, public records show.

Some wrote prescriptions for so many opioids that the patients' daily supply of the pain-killing medication exceeded, on average, the number of days in a year.

Murphy gave 1,100 of his Medicare patients opioids that, if taken as prescribed, would have lasted each of them 432 days in 2015.

Medicare covers one out of every four prescriptions written in the U.S.

But some medical and law enforcement experts say being a top prescriber in the Medicare program should raise red flags. Murphy wrote more prescriptions between 2013 and 2015 than anyone else in the U.S., the Medicare data shows.

"The doctors who top the list ? one has to question whether they are drug dealers in white coats," said Andrew Kolodny, co-director of the Opioid Policy Research Collaborative at Brandeis University. "If you're prescribing that aggressively, you are killing patients."

As opioid drug makers and distributors have found themselves in the crosshairs of cities and states ravished by the opioid epidemic, doctors and other prescribers largely avoid scrutiny by state and federal regulators, Raycom's investigation found.

A deep dive into the backgrounds of Medicare's top 1,000 opioid prescribers found few have faced discipline for prescribing drugs that the Centers for Disease Control and Prevention says should be restricted to cancer patients, those who had surgery or were involved in a serious accident and some with chronic pain.

Only 95 prescribers on the list have been sanctioned for inappropriately prescribing medicine; 21 are facing criminal charges or have been convicted.

But 53 of the prescribers with checkered pasts ? including Murphy ? remain on the job.

Opioid hot spots

The data also shows the highest volume prescribers are practicing in the south ? and not in the states typically associated with the opioid crisis such as Kentucky, Ohio and West Virginia.

Among Medicare's top 1,000 opioid prescribers, Alabama had twice as many health-care providers on the list than Ohio, a state with nearly three times as many residents.

Mississippi, a state with only 3 million residents, has 23 prescribers on the list. Pennsylvania, with a population of nearly 14 million, had just 24.

In Mississippi, there were enough opioid prescriptions filled last year to give everyone in the state a bottle of 70 pills, said John Dowdy, director of the Mississippi Bureau of Narcotics and a former assistant U.S. Attorney General.

"We have an addicted state because of over prescribing," Dowdy said. "I knew that with us having that kind of prescribing rates, we were going down the same paths as Ohio, Kentucky and West Virginia."

Nearly 12 percent of everyone in the U.S. recorded as having died of prescription opioid overdoses between 2013 and 2015 came from those three states.

The highest opioid-prescribing rates has shifted into southeastern states in recent years.

"You have legal drugs coming from doctors," said Dowdy. "The vast majority of our medical doctors are good doctors. I wish there was an easier way for us to identify the bad doctors."

State medical board records show some states are ramping up scrutiny of doctors who are top prescribers. Michigan, for example, in 2016 and 2017 suspended or revoked the licenses of four doctors who were top prescribers there.

Basing conclusions on prescription data can be dangerous because it overlooks the histories of chronic-pain sufferers who truly need the drugs, said Dr. Stefan Kertesz, a professor of medicine at the University of Alabama at Birmingham School of Medicine and specialist in addiction and opioid safety.

Even so, he said, doctors bear a great deal of responsibility for the opioid crisis.

How addiction happens

Terah Holley's family called the U.S. Drug and Enforcement Agency after her death in 2014 with one request: put Dr. Howard Diamond out of business.

Holley, a 39-year-old mother of three from northern Texas, had died of an overdose after ingesting a lethal amount of morphine that Diamond prescribed for her 10 days earlier.

The family's call triggered a lengthy investigation that ended with Diamond's arrest last summer, nearly three years to the day since Holley died.

During that time, Diamond continued to practice medicine at his two clinics in small towns in northern Texas and prescribed so many opioids that he was among the top 25 Medicare prescribers in the country.

At least 19 of his patients died as investigators built their criminal case.

But there were missed opportunities to sideline Diamond, state and federal records show.

Health insurance companies sent some 100 letters to Diamond expressing concerns he was prescribing excessive doses and toxic combinations of opioids. But those companies did not alert the Texas Medical Board.

In 2015, a pharmacist complained to the board about the prescriptions Diamond was writing. The medical board ordered him to take an eight-hour class on medical record keeping, state records show.

Diamond kept on practicing.

Investigating a doctor is difficult and can take a long time because they have the medical expertise that investigators lack, said Miller, the former Tennessee drug task force commander.

"They know they can do the bare minimum ? touch your wrist, ask you a few questions and make their assumption on how to treat you," he said. "It's hard to challenge a doctor."

As far as her family was concerned, Terah Holley died long before she ingested a deadly amount of morphine on July 24, 2014.

"She didn't function at all. She was a living zombie," her daughter, Allyson, said.

Holley was involved in a car crash in 2001 that left her with nerve damage. She lived with constant pain for more than a decade, holding down three physically demanding jobs as a waitress, maid and cosmetologist.

After a sleep study in 2012, a doctor referred her to Diamond, who immediately prescribed opioids. Over the three years that Diamond treated Holley, she received prescriptions for hydrocodone, oxycodone, Xanax, Lortab and morphine, Allyson said.

The woman who had been a free spirit willing to try or do anything, suddenly was falling asleep in her food at dinner, her family said. She also lost her jobs.

"I feel like the doctor took her life away," Allyson said.

Crossing state lines

Before he left Alabama for Lewisburg, Tennessee, Dr. Mark Murphy's ability to practice medicine was in jeopardy. The Alabama Board of Medical Examiners had levied an eight-count complaint against him in August 2016, for acting unprofessionally, endangering patients, prescribing for non-legitimate medical purposes, performing unnecessary tests and lacking basic knowledge and competency.

The 33-page complaint detailed Murphy's questionable care of 15 patients. One was a 58-year-old man who overdosed on dangerous combination of opioids and other drugs prescribed by Murphy. Several other patients said they received opioids even though they had documented substance abuse issues. In some cases, Murphy increased the doses.

The committee that investigated Murphy had "grave concerns" about him and recommended that the board revoke his medical license.

But that didn't happen.

Instead, the board allowed his license to practice in Alabama expire at the end of 2016 and dismissed the case two months later. That left Murphy's reputation unscathed by formal disciplinary actions.

Procedures and databases exist to prevent disciplined doctors from quietly slipping from state to state. But in the case of Murphy the tepid action of the Tennessee medical board did not prevent the doctor from moving elsewhere.

Murphy had long held a license to practice medicine in Tennessee, where he lives.The state medical board hasn't filed an administrative complaint against him, the only public way to know if a doctor is under investigation.

But the Tennessee Bureau of Investigations knows of Murphy.

Lewisburg police Lt. Tom Miller made sure of it.

Investigative producer Thomas Wright and news content specialist Erin Snodgrass contributed to this report.