Vermont officials are encouraging private physicians to treat addicts in an all-hands-on-deck battle against opioid abuse. But state sanctions against some of them illustrate the potential pitfalls of putting office docs on the front lines.
Take Dr. Robert Penney. The Vermont Medical Practice Board found that the Burlington-based doctor prescribed the recovery drug buprenorphine even after a urine test showed one of his opioid-addicted patients was not taking it.
Penney also failed to halt buprenorphine prescriptions after urine screens showed patients were taking other prescriptions or illicit street drugs that can pose safety risks when combined with "bupe," according to the board's official sanction.
The Medical Practice Board fined Penney $2,000 in 2015 for failure to practice competently with six patients who were either opioid addicts or classified as suffering from chronic pain. It ordered him to attend medical education courses, and Penney complied. He did not respond to a message seeking comment.
Penney is not the only doctor whom the state has faulted for problems with addiction care, according to records obtained by Seven Days. Over the past five years, the board has sanctioned at least four other Vermont physicians for improperly prescribing buprenorphine or methadone.
In 2011, the Medical Practice Board found that psychiatrist Dr. Louis Frank of St. Johnsbury was treating opiate-addicted patients with methadone for "chronic pain." He wrote more than 130 false prescriptions, according to the board, which revoked Frank's license for seven years.
His punishment was more severe than most. In 2014, Brattleboro physician Loren Anthony Landis had to pay a $3,000 fine and agree to treat no more than 30 patients at a time with buprenorphine. That was for not keeping proper records, failing to create treatment agreements with patients, and, in one case, prescribing "extremely high doses" of opioids to a patient with chronic pain, serious mental illness and addiction.
In 2013, the board determined that Dr. Michael Schorsch of Lebanon, N.H., failed to meet the standard of appropriate care for Vermont patients receiving buprenorphine prescriptions. He refilled one eight times for a patient who claimed it had been lost, stolen or destroyed. The year before, the board found that Dr. Donald Weinberg of Berlin failed to properly care for three patients with opioid addictions. He continued to prescribe buprenorphine to one despite evidence of cocaine and Ritalin abuse. Another got meds without having face-to-face contact with the doc for almost two years.
Stand-alone clinics offer the most intensive services for addicts, many of whom have lost jobs, children and housing, and, in some cases, have been in and out of jail, by the time they agree to treatment. But some of those facilities have waitlists, or they aren't conveniently located for rural patients who have to make the treatment trek every day. Office-based care expands the options for far-flung addicts as well as those no longer in need of daily monitoring.
State regulations and federal law governing office-based treatment are intended to reduce the risks of anti-addiction drugs, which can cause overdoses if misused, said David Herlihy, executive director of the Medical Practice Board. At least 27 people in Vermont have fatally overdosed on buprenorphine or methadone since 2010, including five last year, according to the Vermont Health Department. The figure is higher for deaths involving those drugs combined with others.
Under federal law, it's illegal for office-based physicians to prescribe methadone for opioid treatment. That's because the drug, which eases cravings for heroin and painkillers such as OxyContin, poses an overdose risk. For this reason, methadone is supposed to be prescribed only for opioid recovery in a clinical setting, where doses are typically taken on-site under close supervision.
However, office doctors are allowed to prescribe methadone for chronic pain, and, in some cases, Vermont doctors have been sanctioned for using that diagnosis improperly, as a guise for opioid addiction treatment.
"We get complaints from neighbors, loved ones: 'I think this doctor is turning my neighbor into a zombie,'" Herlihy said. For the Medical Practice Board, failure to follow the guidelines can amount to a violation of state law to provide proper care.
Nonetheless, Herlihy agrees with Vermont Health Commissioner Harry Chen that office-based care can benefit patients and reduce the tragic toll of addiction. The number of Vermont physicians who are federally certified to prescribe buprenorphine for opioid addiction increased from 169 to 269 between 2013 and August 2016, according to the health department.
That's good, Chen suggested in an interview. "We have a great model," he said. "That doesn't mean that sometimes you aren't going to have things that slip through the cracks." The state doesn't have the resources to police doctors who treat addicts in their offices, and it must rely on doctors to follow best practices, he added.
It's true that recovery drugs have caused fatal overdoses in Vermont, Chen acknowledged. A few have involved patients at state-funded clinics that specialize in opioid addiction treatment. Those fatalities are unusual, Chen said, adding that he has personally reviewed some of the cases.
The benefits of recovery medicines outweigh the risks, Chen said.
Buprenorphine, which acts to quell withdrawal symptoms, is considered to have less of an overdose risk than methadone and can be legally prescribed in an office setting. Often sold under the brand name Suboxone, buprenorphine can be a stabilizing force that helps people stay out of jail, earn a paycheck and recover custody of their children, said Dr. Patricia Fisher, medical director for case management at the University of Vermont Medical Center.
"I think it saves people's lives," Fisher said.
Fisher supports expansion of office-based opioid addiction treatment but warns that it can be "tricky." In some cases, doctors who see 20 or 30 patients daily don't make time to check urine screens as advised by the state guidelines for medically assisted treatment of heroin or OxyContin addiction. Other doctors are reluctant to confront patients who appear to be misusing their prescriptions.
"If it's not in their urine, they are making a living off of selling it; that's what they are doing," Fisher said. "Addicts ... can be charming and conniving, and they can be pretty good at just telling you what you want to hear."
Fisher said she had a patient who admitted to putting a vial of her daughter's urine inside her own vagina and releasing it into a specimen cup during a supervised urine screening.
Good doctors know that they might have to refuse prescriptions to addicts who aren't following the rules and look for other options — including sending patients back to an addiction clinic setting for more closely monitored treatment, she added.
"You feel like you have to be a little bit of a hard-ass," Fisher said.
Federal regulators, meanwhile, are expanding the range of people who can provide office-based treatment. Earlier this month, the U.S. Department of Health and Human Services announced that, starting in 2017, it would allow nurse practitioners and physician's assistants in private practices to prescribe buprenorphine. Currently, only doctors can.
Gov. Peter Shumlin welcomed that as "great news."
"By allowing more medical professionals to prescribe these treatments, we will hopefully further reduce waitlists and get more Vermonters and Americans into recovery," Shumlin said in a statement.
The state-funded Chittenden Clinic, which operates in South Burlington and Burlington, provides opioid addiction treatment in a closely supervised setting, with many patients visiting daily to take their meds while nurses or doctors observe. It was treating 923 people earlier this month but had 243 on a waiting list. Around the state, some 3,000 people are in medically assisted opioid treatment at clinics and about 2,700 are receiving treatment in doctors' offices.
So far the big investments in treatment have not stopped the death toll. Accidental deaths involving opioids in Vermont increased from 50 to 76 per year between 2012 and 2015, according to the Vermont Health Department. As of the end of June, this year has seen 47 fatalities.
State leaders insist more would have died of overdoses without the investment in medically assisted treatment.
At the time he was sanctioned, Penney was a family medicine practitioner at Burlington Primary Care on Pine Street. Today he works at the Community Health Centers of Burlington, which purchased his former practice. Medical director Audrey Wen and Dr. Heather Stein, who treats patients for opioid addiction, said they could not discuss Penney's sanction and emphasized that it happened before they hired him.
The health centers have about 250 patients with opioid addictions who are taking buprenorphine, Wen and Stein said. The center also has patients with chronic pain diagnoses who are being treated with methadone.
Wen and Stein said that opioid addicts getting care at the health centers must come in at least every three months, sign an agreement to quit illegal drugs and undergo random urine drug screening. Even with these rules, it's difficult to prevent patients from selling their meds, they said.
"I wish that we could find a way to completely eliminate it, but the tools are just not good," said Stein.
Both Wen and Stein said they believe it's important to see opioid addiction without stigma, as a chronic illness that requires long-term treatment — at a regular doctor's office.
"A chronic illness is something that we all treat just like we would diabetes or high blood pressure," Wen said. "For many people this is a lifelong struggle."