Police, physicians point fingers in painkiller epidemic
Posted July 15, 2013
Fayetteville, N.C. — Six days after her release from the Moore County jail in December, Ann Butler overdosed on prescription pain pills and died.
Investigative records from the Moore County Sheriff’s Office show that Butler had been in jail on charges of prescription fraud. The records say she had visited seven doctors in a span of 14 months, an illegal practice addicts sometimes use to get more drugs.
During his investigation of Butler, Detective Sgt. Jesse Stubbs said, he alerted all seven doctors that Butler had been doctor shopping.
Stubbs, the county’s lead prescription crime investigator, said doctors usually ban such patients. But, Stubbs said, Dr. Aaron Gootman told him he planned to continue treating Butler at his Cape Fear Pain and Laser clinic in Sanford. Stubbs said Gootman advised him that he would try an alternative pain treatment, one that Butler would be less likely to abuse.
Sometime after her release from jail, Butler returned to Gootman’s clinic, where a physician assistant prescribed her Oxycontin, one of the most powerful painkillers on the market.
Sheriff’s records show that 37 pills were missing from a new bottle of Oxycontin on the day deputies arrived at Butler’s home and found her unresponsive.
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The state Medical Examiner’s Office concluded that Butler died from a lethal dose of Oxycontin combined with smaller amounts of Klonopin and Xanax, two anti-anxiety medications that can intensify the heart-stopping potential of painkillers.
Karin Suess, a pharmacist and leader of a local effort to prevent painkiller overdoses, said Butler should not have been given more Oxycontin after getting out of jail.
“That’s not a safe practice or a standard practice,” Suess said. “I would think that the Medical Board would frown upon that.”
Gootman said he does not recall talking to Stubbs about Butler, and he said he did not know that she had died until a reporter told him.
He acknowledged that the pain clinic should not have given Butler Oxycontin, but he said his employees do everything possible to prevent addiction and painkiller abuse.
“The process obviously broke down in this case,” Gootman said.
Gootman and Dr. Robert J. Allen Jr. operate the region’s largest pain management practice, with clinics in Fayetteville, Sanford, Lumberton, Laurinburg, Whiteville and Southern Pines. Their team of physician assistants sees many of the patients and writes prescriptions.
Neither Gootman nor any of his prescribers have faced public sanction or allegations of criminal wrongdoing in Butler’s death.
But some police, drug-abuse counselors and medical providers say they see Gootman’s clinics as evidence of a wider problem: Little or no repercussions for prescribers whose patients exhibit signs of addiction, sell their drugs on the street or overdose from them.
According to the federal Drug Enforcement Administration, more oxycodone is sold in the Fayetteville area than anywhere else in North Carolina. Sales of hydrocodone — a slightly less powerful painkiller — rank third-highest in the state.
The amounts are so high in the Fayetteville area in large part because of the military’s presence. Womack Army Medical Center on Fort Bragg and the Fayetteville Veterans Affairs Medical Center have both seen huge increases in the number of painkiller prescriptions since 9/11 — the years in which so many soldiers have come home injured from war.
“Patients wouldn’t be addicted if the doctors weren’t out there writing these prescriptions,” said Sandra Norfleet, an addiction specialist at the Roxie Avenue Center, a detoxification clinic in Fayetteville. “We’ve got to hold these physicians accountable.”
Detective Sheila Valdez, head of the Fayetteville Police Department’s prescription drug unit, said Gootman’s name shows up time and again as a prescriber when she investigates people accused of crimes involving painkillers.
“When I pull prescription histories on people that I am looking into, I start to notice trends,” Valdez said. “The trends I notice are that almost everyone I am looking into goes to Gootman or went to Gootman.
“When you think about how many doctors and people there are in this town, the small percentage of people I am looking at, and they have all been or are still going to Gootman...”
Stubbs, the Moore County detective, said he often has to travel to Gootman’s clinics in other counties to investigate allegations of doctor shopping. Stubbs said he probably visits Gootman’s clinics more often than all of the doctor’s offices in Moore County combined.
Suess said she has had concerns about Gootman’s clinics based on the large number of prescriptions she has filled from them. She said she has noticed numerous cases of multiple doctors prescribing opiates for Gootman’s patients.
“At some point,” Valdez said, “there needs to be where the doctor is responsible for how the patient uses their meds. The laws are so far behind what’s going on.”
The last time Butler visited his pain clinic, Gootman said, she was told she could not come back.
In contrast with the conversation Stubbs remembers, Gootman called the ban “an obvious move” because of the prescription fraud charges.
But giving Butler a prescription for Oxycontin along with her walking papers was the wrong decision, Gootman said, and he would not have approved it had he known.
For two years, Gootman said, his clinics have had a policy of not giving patients prescriptions on the day they’re told not to come back — an order usually given when patients are suspected of misusing prescription drugs.
Before that, he said, there were rare instances when patients might receive a few days’ supply of painkillers to curb withdrawal symptoms.
Gootman said he is improving the clinic’s written policies so a case such as Butler’s won’t happen again.
“I cannot guarantee that error will not occur, but I can work to make everyone more knowledgeable regarding policy, as well as more forthcoming about adverse events so that, as in this case, improvements can be made to the practice,” Gootman said. “We should not need a reporter to shame us into these improvements.”
Gootman’s practice has come under scrutiny in the past. Last year, he admitted during a state Medical Board investigation that he was guilty of “unprofessional conduct” for violating rules for prescribing painkillers.
According to a consent order signed by Gootman after the Medical Board’s investigation, Gootman’s office relies on a team of physician assistants and nurse practitioners to see patients and write them prescriptions. One of them, Cynthia Helen Wrenn, was not licensed to prescribe painkillers because she had been caught improperly writing them for a boyfriend and a co-worker’s parents in 2008, according to the consent order.
Computers in Gootman’s office printed prescriptions for Wrenn’s patients using one of the other prescriber’s names. The other prescribers would sign the prescriptions without personally examining Wrenn’s patients, the documents say.
Gootman, the documents say, “knew of this practice and allowed it to happen and continue.”
Gootman’s punishment amounted to a stern warning, with no restrictions placed on his ability to prescribe.
Gootman said he was not aware Wrenn’s prescribing was against the rules. He said Medical Board officials who were investigating Wrenn visited his office monthly to check up on her and never alerted him to the issue.
“I accept the criticism. I have corrected the problem, and it will never happen again,” Gootman said, adding that he believes all of Wrenn’s recommended prescriptions were appropriate and the violation was a technicality.
“I am confident that no patient harm was ever intended or occurred,” he said.
The Medical Board used much stronger language in its seven-page consent order reprimanding Gootman, calling the violation serious enough to “annul, suspend (or) revoke” his license.
Gootman said the blame cast his way is part of the price of being successful. He said he has gone from five patients in his first week after opening in 2006 to 200 patients a day now.
A small percentage of every clinic’s patients misuse their painkillers, he said. With so many patients coming through his doors, even a low percentage of people misusing can result in high overall numbers, Gootman said.
He said he and his team work hard to keep painkillers out of the hands of people who misuse them.
He said he would welcome calls from anyone in law enforcement or drug counseling letting him know if one of his patients should no longer receive painkillers.
His office manager said the Drug Enforcement Administration has inspected Gootman’s books looking for signs of illegal prescriptions and called the books “immaculate.” Gootman said he uses urinalysis machines that can detect within 12 minutes what drugs someone is taking.
But pain is a notoriously hard problem to treat, Gootman said, and he knows that some of his patients are hooked on legal drugs.
“You can’t really assess a person’s character based on a 20-minute office visit. Sometimes, the shades of gray are so close to white you can’t see them,” Gootman said. “I would rather have a patient fool me and get medicine illicitly than to deny medicine to a patient that is suffering in pain.”
During an interview with the Observer, Gootman vowed to do what it takes to help his practice curb painkiller abuse.
He said he planned to stop prescribing two types of narcotic painkillers — methadone and a skin-patch known as fentanyl — in almost all situations because of the risk for abuse. Patients are being switched to medications that have safety mechanisms that make them more difficult to abuse, he said.
Taking certain types of medications out of the practice is more practical than explaining to each patient why he or she should not receive a certain drug, Gootman said.
Gootman in a later interview said most patients had adapted to the new medications without a problem, but some have walked out cursing without their drug of choice, something he described as “a huge red flag” that those patients may have been abusing or selling the drugs.
It’s not the first time patients have become aggressive there, he said. Gootman and his workers have been assaulted in prior cases involving aggressive patients, and one patient threatened to shoot him in the face, Gootman said.
Gootman is far from alone in being reprimanded by the state Medical Board.
One out of every three prescribers — or 24 of 73 — publicly disciplined by the Medical Board in the 10-county Cape Fear region between 2007 and 2012 was involved with improper prescriptions or abusing painkillers, according to an Observer analysis. That’s roughly the same as the state average.
A board spokeswoman called opiate painkiller prescription problems “one of the most serious issues facing the board today.”
Dr. Scott Kirby, the board’s director, said the board aims to educate doctors instead of stripping their credentials in all but the most egregious cases of improper prescriptions.
But critics say the board and the law are too lenient on health care professionals whose actions have helped foster the epidemic of painkiller dependence and addiction.
The state Board of Nursing has seen a similar trend with painkillers. Prescription drugs are part of the reason for punishment for nearly two of every three nurses in the region who were either sanctioned or required to get treatment for drug abuse.
An Observer analysis of 113 Cape Fear region nurses who received public discipline since 2008 shows that one out of five involved misusing or misprescribing opiates.
Punishment records often do not say what drug a nurse was abusing. But Board of Nursing statistics show that opiates were the drug of choice for between 55percent and 72 percent of all nurses in the substance abuse program from 2009 to 2012 — more than alcohol and illegal drugs combined.
Records show nurses have been caught stealing pills from patients in emergency rooms and nursing homes.
Doctors in the region were caught in some cases prescribing the drugs to themselves, to patients they never examined and to people who were never their patients.
Doctors are supposed to be the first gateway to the powerful painkillers, making sure they end up only in the hands of those who need them.
Drug addiction specialists in Fayetteville say that is not happening because the doctors and nurses who do get caught often face little punishment.
Of the 24 prescribers disciplined in the region, 13 — including Gootman — still have active medical licenses in North Carolina.
The vast majority of medical health professionals properly prescribe opiate painkillers, and only a small fraction of their patients become addicted. But research shows that addiction is directly tied to the ease in getting the drugs.
Valdez, the Fayetteville police detective, said she has caught people driving to Fayetteville from Raleigh and other cities because they have heard some doctors prescribe liberally here, in high doses and high quantities.
And although Gootman says he bans patients who try to visit his clinics from distant cities, Fayetteville police and drug abuse specialists say he is not catching them all.
Norfleet, the addiction specialist at the Roxie Avenue Center, said people who show up at Roxie often say they got their pain pills from Gootman’s practice.
A third of the patients Norfleet sees during drug detoxification are prescription painkiller addicts. Double that if she counts heroin addicts, almost all of whom began their opiate drug use with painkillers.
Addiction is not confined to the traditional population of young drug-seekers. Norfleet said she sees stay-at-home moms, teenagers, veterans and professionals. They are young and old, rich and poor.
And in most cases, she said, they began taking painkillers to treat pain after an accident and never stopped.
Recovering addict Robert Landers said he thought he had hit the painkiller jackpot when he got referred to Gootman’s Fayetteville clinic last year.
Landers said he had been lying to doctors for years by then, exaggerating his lower back pain or faking kidney stones to get prescription painkillers. He said he had been to the emergency room at Cape Fear Valley Medical Center more times than he could count, usually telling doctors he was allergic to hydrocodone so he would receive more powerful oxycodone.
But at Gootman’s office in the Bordeaux Shopping Center, Landers said, the acting was almost unnecessary.
“They didn’t check my back or nothing,” Landers said. “I told them what I used to take and basically what I wanted and got it.”
Landers said he walked out of Gootman’s clinic once a month for about five months with a prescription for 90 Percocet pills and 90 methadone, a narcotic used to treat pain or to wean people off other opiates.
Landers would keep the Percocet, sell the methadone for $5 each, then use the $450 to cover his doctor’s bill and buy more painkillers off the street.
Landers, 51, died last month when a sport utility vehicle ran into his riding lawnmower. He was going through rehabilitation before the accident. During interviews with the Observer, he said he wished a doctor had noticed the signs of his addiction earlier and stopped giving him pain pills.
Once, he said, he failed a drug test at Gootman’s clinic because he had been taking Xanax he bought off the street. Landers said he thought for sure he would be kicked out of the clinic. Instead, he said, he received a prescription for Oxycontin, the same drug Butler took when she overdosed.
Gootman declined to discuss specific patients but said he sometimes switches patients to Oxycontin because it has tamper-resistant features that make it harder to abuse.
Doctors who prescribe addictive medicine ought to be held more accountable for monitoring their patients and helping them find treatment, Landers said.
“You know, the thing about it is, somebody has to take responsibility somewhere. Doctors get away with it, but we’re the ones that suffer and lose in the long run,” he said. “Nobody made you take them, but if they didn’t write them so they’re out there like M&Ms... .”