Dying for relief | A Times Investigation
Legal drugs, deadly outcomes
By Scott Glover, Lisa Girion. Video and photos by Liz O. Baylen
November 11, 2012
Prescription overdoses kill more people than heroin and cocaine.
An L.A. Times review of coroners’ records finds that drugs prescribed by a
small number of doctors caused or contributed to a disproportionate number of deaths.
Terry Smith collapsed face-down in a pool of his own vomit.
Lynn Blunt snored loudly as her lungs slowly filled with fluid.
Summer Ann Burdette was midway through a pear when she stopped breathing.
Larry Carmichael knocked over a lamp as he fell to the floor.
Jennifer Thurber was curled up in bed, pale and still, when her father found her.
Karl Finnila sat down on a curb to rest and never got up.
These six people died of drug overdoses within a span of 18 months. But according to coroners’ records, that was not all they had in common. Bottles of prescription medications found at the scene of each death bore the name of the same doctor: Van H. Vu.
After Finnila died, coroner’s investigators called Vu to learn about his patient’s medical history and why he had given him prescriptions for powerful medications, including the painkiller hydrocodone.
Investigators left half a dozen messages. Vu never called back, coroner’s records state.
Over the next four years, 10 more of his patients died of overdoses, the records show. In nine of those cases, painkillers Vu had prescribed for them were found at the scene.
Vu, a pain specialist in Huntington Beach, described himself as a conscientious, caring physician. He declined to comment on individual cases, citing confidentiality laws, but he said he treats many “very, very difficult patients” whose chronic pain is sometimes complicated by substance abuse and depression, anxiety or other mental illness.
“Every single day, I try to do the best I can for every single patient,” he said in an interview. “I can’t control what they do once they leave my office.”
Prescription drug overdoses now claim more lives than heroin and cocaine combined, fueling a doubling of drug-related deaths in the United States over the last decade.
Health and law enforcement officials seeking to curb the epidemic have focused on how OxyContin, Vicodin, Xanax and other potent pain and anxiety medications are obtained illegally, such as through pharmacy robberies or when teenagers raid their parents’ medicine cabinets. Authorities have failed to recognize how often people overdose on medications prescribed for them by their doctors.
A Los Angeles Times investigation has found that in nearly half of the accidental deaths from prescription drugs in four Southern California counties, the deceased had a doctor’s prescription for at least one drug that caused or contributed to the death.
Reporters identified a total of 3,733 deaths from prescription drugs from 2006 through 2011 in Los Angeles, Orange, Ventura and San Diego counties.
Dr. Van H. Vu said of his patients: “I can’t control what they do once they leave my office.” (Liz O. Baylen / Los Angeles Times)
An examination of coroners’ records found that:
- In 1,762 of those cases — 47% — drugs for which the deceased had a prescription were the sole cause or a contributing cause of death.
- A small cadre of doctors was associated with a disproportionate number of those fatal overdoses. Seventy-one — 0.1% of all practicing doctors in the four counties — wrote prescriptions for drugs that caused or contributed to 298 deaths. That is 17% of the total linked to doctors’ prescriptions.
- Each of those 71 physicians prescribed drugs to three or more patients who died.
- Four of the doctors — including Vu — had 10 or more patients who fatally overdosed.
- Vu had the highest total: 16.
Experts said the findings challenge the prevailing view of what is driving the surge in overdose deaths and should prompt closer scrutiny of doctors and their prescribing practices.
“The data you have is something that’s going to shock everybody,” said Dr. Jorge F. Carreon, a former member of the Medical Board of California.
Carreon, a South Gate physician whose term on the board ended in July, said he had long suspected that doctors’ prescriptions were contributing to the increase in overdoses. The Times’ analysis, he said, showed that it was “worse than what I thought.”
President Obama’s drug czar, R. Gil Kerlikowske, said of the findings: “Do I think this has the potential to change the game in the way it’s being looked at and being addressed, both at the state and federal level? Yes, I do.”
In its review of prescription drug fatalities, The Times examined cause-of-death findings, toxicology reports and other information in county coroners’ files, including lists of prescription medications found at death scenes. Those lists typically identify the prescribing doctor.
The deaths often stemmed from multiple drugs, sometimes prescribed by more than one physician. In some cases, the deceased mixed alcohol or illicit drugs with prescription medications.
Medical experts say that even one overdose death should prompt a doctor to conduct a thorough review of his or her prescribing.
“Personally, it would be a big, big deal,” said Dr. Peter Przekop, a pain and addiction specialist at the Betty Ford Center in Rancho Mirage and an assistant professor at Loma Linda University School of Medicine. “I would certainly want to stop using those medications until I knew what was going on.”
The 71 doctors with three or more fatal overdoses among their patients are primarily pain specialists, general practitioners and psychiatrists. Almost all work alone, without the peer scrutiny that is standard in hospitals, group practices and HMOs.
Four of them have been convicted of drug offenses in connection with their prescriptions. A fifth is awaiting trial on charges of second-degree murder in the overdose deaths of three patients.
The rest have never faced criminal prosecution over their practice of medicine, and most — including Vu — have spotless records with the Medical Board of California, which licenses and oversees physicians.
Dr. Lynn Webster, president-elect of the American Academy of Pain Medicine, said many physicians lack an appreciation of how easily patients with chronic pain can become addicted to their medications, and how dangerous those drugs can be.
“It leads them down a path that can be very harmful, and that’s what physicians have to watch for,” said Webster, who practices in Salt Lake City.
He said physicians who prescribe pain medications have a duty to screen patients for risk factors for addiction and then watch them closely to prevent abuse.
In interviews, several of the 71 Southern California doctors with multiple patient deaths described themselves as compassionate caregivers who try to ease the suffering of those in pain.
Vu and others said they follow recommended practices to deter drug abuse, including requiring patients to sign “pain management contracts” in which they agree to take their medications as directed and not obtain more from other doctors.
Some of the 71 doctors said overdose victims caused their own deaths by ignoring instructions on the safe use of medications. Some said family members of the deceased bore responsibility too for failing to intervene. Some also faulted health insurers, saying that reduced payments to physicians have made it difficult to spend the time to monitor patients adequately.
These doctors’ 298 patients who died of overdoses ranged in age from 21 to 79. The median age was 48.
Many had histories of mental illness or addiction, including previous overdoses or stints in drug treatment. Others did not start out as high-risk patients. They were middle-aged adults — teachers, nurses and police officers — with bad backs, injured knees and other non-life-threatening conditions.
Lynn Blunt was a 46-year-old mother of four who suffered from degenerative disc disease. Despite the pain, she was careful not to exceed the recommended dosage of her medications, said her husband, Lonnie. She wanted to remain alert enough to care for her two youngest children, girls ages 14 and 11, he said.
The condition eventually crippled Blunt, leaving her dependent on a cane and unable to continue working as a U.S. customs inspector. She saw a series of doctors, eventually ending up at Vu’s California Pain Center.
According to coroner’s records, Vu prescribed skin patches containing fentanyl, a pain reliever 100 times more powerful than morphine.
On Sept. 7, 2006, coroner’s records show, Blunt went to Vu’s clinic to receive an epidural injection of an unspecified medication for her pain. A day later, she was found dead in her family’s apartment in Downey.
Blunt overdosed on multiple drugs prescribed by Vu and two other doctors, coroner’s records show. High levels of fentanyl were found in her system.
Blunt had been looking forward to a planned trip to the East Coast to visit one of her two grown children, her husband said.
“We followed the prescriptions,” he said. “Something didn’t mix well.”
Vu, a native of Vietnam, was 11 when he and his family immigrated to the U.S. as refugees just before the fall of Saigon in 1975. They settled in Seattle.
As a high school student, he volunteered at a clinic for low-income families and was impressed, he said, by the selflessness of physicians serving “people who really needed help.”
He earned undergraduate and medical degrees from the University of Washington and served a residency in anesthesiology at USC. He is board-certified in that field and in pain medicine.
“I pretty much achieved the dream come true that America affords,” said Vu, 49, who lives with his wife and four children on Christiana Bay in Huntington Beach.
I am doing the best I can in this very difficult field …
But we have limits.”— Dr. Van H. Vu
Vu said most of his patients are referred by other doctors, who turn to him as “a last resort” for those who have been battling pain for years. Many patients come to him already dependent on narcotics, he said.
Vu said he conducts routine urine tests to make sure they take their medications as prescribed and do not use illegal drugs. He said he regularly uses a state-run prescription monitoring program to see whether any of his patients are also obtaining drugs from other doctors.
“I am doing the best I can in this very difficult field,” he said. “I consider myself to be one of the best. But we have limits.”
He said any patient death from an overdose was unacceptable, but added that he has treated thousands of patients successfully with the same drugs.
“Are we willing to trade that?” he asked. “Are we willing to withhold pain medications from everyone?”
Vu said he was unaware of many of his patients’ deaths until Times reporters contacted him. He called the information “eye-opening.”
“I’m a physician,” Vu said. “I feel terrible when somebody loses their life. I’m the one who should be prolonging life, so I’m saddened by that.”
Asked whether he could have taken steps to prevent any of the deaths, Vu paused.
“No,” he said, finally. “I don’t think so.”
Larry Carmichael was a problem drinker who got sober through Alcoholics Anonymous. A doting single father, he coached his son’s T-ball team and passed on his love of surfing and fishing.
Carmichael worked as a carpet layer until a car accident left him with debilitating back pain, recalled his son, Dan. He went from one doctor to another in search of relief, and eventually became Vu’s patient.
By 2007, Carmichael “had a high tolerance and was known to take too many pills for his pain,” coroner’s records state. Renee Allen, Carmichael’s girlfriend, said she encouraged him to see if he could live without the medications, and to find another doctor.
“I’m not going to sit around and watch you die,” she recalled telling him.
But Carmichael kept taking pills. In the months before he died, Carmichael twice passed out, his son said.
“He needed real help,” Dan said.
On March 7, 2007, Carmichael filled prescriptions from Vu for half a dozen pain and anxiety medications, including morphine, according to coroner’s records.
After Carmichael failed to return phone calls for two days, Dan went to his father’s apartment in Lake Forest and found him dead. He was 51.
Dan grabbed his father’s prescription bottles and smashed them against a wall, sending pills flying around the room, according to a report by a coroner’s investigator.
The coroner concluded that Carmichael died of an accidental overdose of morphine.
For decades, prescriptions for narcotic painkillers were limited largely to cancer patients and others with terminal illnesses. The prevailing view was that the risk of addiction outweighed any benefit for the great majority of patients whose conditions were not life-threatening.
Today, narcotic painkillers are among the most popular prescription drugs in the U.S.
The seeds of this turnabout were planted in the late 1980s, when influential physicians argued in medical journals that it was inhumane to ignore suffering in non-cancer patients.
This new perspective coincided with efforts by drug makers to win approval for formulations of narcotics intended to ease moderate pain.
Pharmaceutical companies launched sales campaigns that downplayed the risks of addiction and overdoses and promoted the benefits of pain relief.
In 2001, Congress declared the start of the Decade of Pain Control and Research. Medical boards across the country encouraged physicians to assess and treat pain in all patients. In 2007, California lawmakers expanded the scope of pain relief, making it legal for doctors to prescribe narcotics to addicts, so long as the purpose was to treat pain and not simply feed a habit.
The use of painkillers quadrupled between 1999 and 2010. Doctors write about 300 million prescriptions a year for painkillers. That is enough for every adult American to be medicated around the clock for a month, according to the Centers for Disease Control and Prevention.
Hydrocodone became the most commonly prescribed drug in the U.S., eclipsing the leading antibiotics and cholesterol medications.
Older pain drugs — including morphine, codeine and Dilaudid — found new life outside hospital wards, while new ones such as fentanyl and Opana were brought to market. OxyContin, a chemical cousin of heroin, had sales of more than $1 billion within a few years of its introduction.
Narcotic pain relievers now cause or contribute to nearly 3 out of 4 prescription drug overdoses and about 15,500 deaths each year, according to the CDC. For every death, 32 people are treated in emergency rooms for nonfatal overdoses.
Although the death toll has received considerable attention, the medical board and law enforcement agencies in California have not mined coroners’ files, as The Times did, to identify doctors whose patients overdosed on drugs they prescribed.
Nor have officials tried to take advantage of detailed information that pharmacies provide to the state attorney general’s office, listing the kinds and quantities of drugs prescribed, by which doctors and for which patients.
Narcotic pain relievers now cause or contribute to nearly 3 out of 4 prescription drug overdoses and about 15,500 deaths each year
— Centers for Disease Control and Prevention
The Controlled Substances Utilization Review and Evaluation System was designed to help doctors learn whether any of their patients were seeking drugs from other physicians too.
The system could also be used to identify doctors who write large numbers of prescriptions for commonly abused drugs. The CDC has urged state authorities to use such programs to identify not only doctor-shopping patients but the physicians who cater to them. In California, authorities do neither.
Karl Finnila had a long record of drug arrests by the time he became Vu’s patient. He was bipolar, had attempted suicide and had overdosed several times, according to coroner’s records and his sister Sally, a tax accountant in Irvine.
Finnila, the oldest son of a Mattel Inc. executive, had been addicted to prescription drugs since he was a teenager, his sister said. He had been in and out of mental hospitals and was unable to hold a job.
He would lose touch with his family. But every so often, Sally would find him, take him to lunch and buy him a new pair of shoes and socks.
On June 29, 2007, Finnila was discharged from a hospital in Orange County, according to Carol Spetzman, a friend and caregiver. He had been treated there for a drug overdose, his sister said.
That same day, he filled prescriptions from Vu for hydrocodone and carisoprodol, a muscle relaxant, at a pharmacy down the hall from the doctor’s office, coroner’s records show.
Finnila then checked into a sober-living home in Westminster. After dinner, he went for a walk, sat down on a curb and died, coroner’s records state.
The cause was “combined effects” of hydrocodone, carisoprodol and seven other medications prescribed by Vu and other doctors. He was 43.
Jennifer Thurber had been coping with pain for much of her life by the time she came under Vu’s care.
Thurber’s childhood was marred by a painful stomach condition that caused severe indigestion. She had corrective surgery when she was 11, but a car accident seven years later brought the problem back.
She was prescribed various medications for the pain and eventually began abusing them, according to her father, Charles, an Orange County sheriff’s deputy.
Thurber obtained drugs through various doctors. On May 21, 2007, she filled prescriptions for morphine and methadone written by Vu.
Two days later, her father climbed the stairs of the family’s Fountain Valley home and pushed open the door of her bedroom to ask her to get ready for dinner.
He found his daughter in bed, pale and motionless. Blood trailed from her nose. He laid her on the floor and attempted CPR.
Thurber died of an overdose of multiple drugs prescribed by Vu and two other doctors, coroner’s records show.
Morphine and methadone were among the drugs. She was 22.
“That was my birthday,” her father recalled, his voice wavering. He said he blames himself for not seeing the signs of drug abuse sooner and for not paying closer attention to her doctors and what they were prescribing.
“At the time,” he said, “we thought they were trying to help her.”
Reckless prescribing, lost lives
The Medical Board of California is often slow to act when investigating doctors suspected of abusing their prescription pads – even when patients are dying.
Dr. Carlos Estiandan was up to no good, and the Medical Board of California was on to him.
By Lisa Girion and Scott Glover. Video and photos by Liz O. Baylen
December 9, 2012
He prescribed powerful painkillers to addicts who had no medical need for them, conducted sham examinations and appeared to be a key supplier for drug dealers, according to court records.
He wrote more prescriptions than the entire staffs of some hospitals and took in more than $1 million a year.
Worse, one of Estiandan’s patients had fatally overdosed on drugs he prescribed, a board investigator learned. The investigator said in her report that she confronted the doctor and told him the death was “the inevitable result” of giving narcotics to an addict.
Unknown to the investigator, two other Estiandan patients had suffered fatal overdoses. More deaths would follow.
By the time the medical board stopped Estiandan from prescribing, more than four years after it began investigating, eight of his patients had died of overdoses or related causes, according to coroners’ records.
It was not an isolated case of futility by California’s medical regulators. The board has repeatedly failed to protect patients from reckless prescribing by doctors, a Los Angeles Times investigation found.
It is board policy to give such cases a high priority. But The Times’ examination of board records and county coroners’ files from 2005 through 2011 found that:
“Material things are nothing now,” said Dr. Carlos Estiandan, who was released from prison in September, after serving roughly half of a five-year sentence. (Liz O. Baylen / Los Angeles Times)
- At least 30 patients in Southern California have died of drug overdoses or related causes while their doctors were under investigation for reckless prescribing. The board ultimately sanctioned all but one of those 12 doctors, and some were criminally charged — too late to prevent the deaths.
- The board seldom tries to suspend the prescribing privileges of doctors under investigation. The agency can petition a judge for an interim suspension order. It has obtained orders only rarely: 12 times in the last five years in cases of excessive prescribing, in a state with more than 100,000 practicing physicians.
- Even when the board sanctions doctors for abusing their prescribing powers, in most cases it allows them to continue practicing and prescribing. In 80% of the 190 cases of improper prescribing filed by the board since 2005, the offending physician was given a reprimand or placed on probation. In most of those cases, the doctor was allowed to continue writing prescriptions with few or no restrictions.
- Eight doctors disciplined for excessive prescribing later had patients die of overdoses or related causes. Prescriptions those doctors wrote caused or contributed to 19 deaths.
At the heart of these shortcomings is the board’s approach to oversight. It investigates when it receives a complaint of abuse or poor treatment of a specific patient or patients. It generally does not look for evidence of wider problems in a physician’s practice.
Bitter Pills
In rehab, Edward Shut fights his addiction to prescription drugs.
For example, in looking into cases of improper prescribing, investigators usually do not search county coroners’ files to determine whether — as in Estiandan’s case — a doctor’s patients are dying of drug overdoses.
Dr. Rick Chavez, a pain management physician in Redondo Beach, serves as an expert for the board in cases of reckless prescribing. He said overprescribing is a pervasive problem, and oversight is inadequate.
“We have doctors out there doing things that no one is monitoring,” he said. “It’s scary.”
The medical board’s president, Sharon Levine, a pediatrician who is an executive at Kaiser Permanente, declined to be interviewed, saying it would be “inappropriate” because disciplinary cases are ultimately decided by the board. Executive Director Linda Whitney declined to comment, and staff members said they are barred by policy from speaking with reporters.
Responding by email to written questions, board officials asserted that their “highest priority and primary mission is consumer protection.”
In response to The Times’ findings, they have asked the Legislature to require county coroners to report all prescription drug deaths to the board.
“If only one physician was found to be overprescribing,” the board said in its request to legislators, “this could save numerous lives.”
Estiandan, a diminutive man with a cheerful demeanor, had a thriving general practice. He sang tenor in his church choir, played golf once a week with his sons and took his wife ballroom dancing. He was a lieutenant colonel in the U.S. Air Force Reserve and led medical relief missions to the Philippines, where he grew up and attended medical school.
In October 2004, one of his employees reached out anonymously to authorities.
The man told Robin Hollis, a medical board investigator, that Estiandan, then 62, was taking in $3,000 in cash a day selling prescriptions. Drug-addicted patients, the employee said, crowded the lobby of the doctor’s clinic west of downtown Los Angeles, one of three he owned.
“Estiandan will give the patients anything they want,” he told Hollis, according to her report.
The U.S. Drug Enforcement Administration and the Los Angeles County Sheriff’s Department were also investigating Estiandan, and the agencies shared information.
Evidence accumulated quickly. Alleged drug dealers were arrested in Los Angeles carrying bottles of medications prescribed by Estiandan, court records show.
A Costco pharmacist reported that groups of men in their 20s and 30s were showing up at his counter with prescriptions from Estiandan for painkillers, tranquilizers and muscle relaxants — the makings of a drug cocktail that is popular with addicts.
The pharmacist, Edward Wong, told authorities he would call Estiandan to make sure the prescriptions were legitimate, and the doctor would instruct him to fill them. Eventually, Wong stopped calling and simply refused to fill the prescriptions.
In Albuquerque, DEA agents stopped a man who was carrying more than 1,800 pills and several bottles of narcotic cough syrup with a street value of up to $500 each. According to court records, the medication labels identified Estiandan as the prescriber.
In the summer of 2005, about 10 months into the investigation, Leo Martinez checked in at Estiandan’s clinic in Reseda. He paid a $120 fee for the office visit and waited a half-hour to see the doctor.
What happened next is detailed in court records.
Estiandan asked Martinez what was wrong.
“Nothing,” Martinez said. He explained that he wanted a refill for painkillers he had been prescribed by another doctor whose clinic had since closed.
Estiandan asked him why he was in pain: Had he fallen or been in an accident?
No, Martinez replied.
He asked Martinez again if he had hurt his back or been in an accident. This time, Estiandan nodded and raised his eyebrows.
Estiandan said the other doctor must have had a reason to prescribe painkillers.
Martinez said it was a long time ago and he couldn’t remember.
Estiandan told Martinez he couldn’t prescribe the drugs unless there was an indication Martinez was in pain.
Then he asked Martinez again if he had hurt his back or been in an accident. This time, Estiandan nodded and raised his eyebrows.
Reading the cue, Martinez said he hurt his back lifting weights.
Estiandan pulled out his prescription pad.
Martinez was an undercover sheriff’s narcotics investigator who had been secretly recording the conversation. He left Estiandan’s office with prescriptions for the painkiller Vicodin, the muscle relaxant Soma, the anti-anxiety drug Valium and a 16-ounce bottle of narcotic cough syrup.
The medical board and law enforcement agencies were not the only ones interested in Estiandan.
Medi-Cal agents suspected him of fraudulent billing and put him under surveillance. They followed him as he drove home to Northridge in a Lincoln Navigator or Lexus sedan, sometimes stopping at a hospital or to pick up takeout at a Filipino restaurant.
But amid this intense scrutiny of Estiandan’s life and medical practice, one thing appears to have escaped attention: what was happening to his patients.
One of them, Pamela Stone, suffered chronic pain from herniated disks. She also struggled with anxiety and had trouble sleeping.
Stone’s mother grew concerned when she didn’t hear from her daughter for a couple of days and asked the manager of the Reseda apartment building where Stone lived to check on her.
On Nov. 20, 2006, the manager opened the door to the apartment and found Stone’s lifeless body on her bed. There was a trace of dried white foam around her nose and mouth.
The coroner determined that Stone died of an accidental overdose of multiple drugs, including an anti-anxiety medication prescribed by Estiandan. She was 54.
Hollis continued with her investigation, unaware of the death.
Hollis is one of about 130 medical board investigators on the front lines of patient protection in California. They look into allegations of physician misconduct ranging from botched surgeries to sexual abuse of patients.
Their ranks have dwindled, even as the number of licensed physicians in the state has risen over the last decade, to 102,000.
There are about 30 fewer investigators today than in 2001. The board opened 1,577 investigations last year, a 40% decline from a decade ago, and investigations now take longer to complete: an average of 347 days, compared with 256 in 2001.
The agency is overseen by a 15-member board appointed by the governor and legislative leaders. By law, eight members must be doctors. The board is funded by physician licensing fees, a revenue stream that was supposed to be immune to California’s boom-and-bust budget cycles.
Members of the Medical Board of California meet in Torrance in May. (Liz O. Baylen / Los Angeles Times)
But Govs. Arnold Schwarzenegger and Jerry Brown used the board as a piggy bank, taking $15 million in licensing fees — the equivalent of a quarter of one year’s budget — to help fill holes in the state general fund.
Schwarzenegger ordered state employees to take three unpaid furlough days per month, hobbling the board’s enforcement efforts. Brown imposed hiring freezes. At one point, 1 in 4 investigator positions were vacant.
The board’s staff has warned for years that the cuts were crippling its ability to protect the public. Julianne D’Angelo Fellmeth, a public interest lawyer who has monitored the board for the state Legislature, said the situation is urgent.
“The medical board is regulating the most important profession in terms of irreparable harm,” Fellmeth said. “It should not be neutered.”
The board’s challenges go beyond the financial. Unlike medical regulators in other states, it cannot suspend a doctor’s license or prescribing privileges on its own, even to prevent imminent harm.
Instead, the board must petition a state administrative law judge for an interim suspension order. If it obtains an order, the board must file a complaint against the doctor within 15 days — a legal provision for which physician groups lobbied, Fellmeth said.
The 15-day rule means that “an investigation must be nearly complete” before the agency can seek a suspension, board spokeswoman Jennifer Simoes wrote in an email.
If a doctor has been criminally charged, the board can ask a Superior Court judge for a suspension. It has done so a handful of times in recent years in cases of excessive prescribing.
Board officials said they sometimes hold off on seeking suspensions until that point to avoid jeopardizing a criminal investigation.
Steve Opferman, a Los Angeles County sheriff’s deputy who runs a task force on healthcare fraud and took part in the Estiandan investigation, questioned that rationale. He said the board should move swiftly to shut down a doctor’s prescribing whenever lives are at stake — even if it could affect a criminal prosecution.
The danger in waiting, he said, is that “people are going to die.”
Andrew Corless began abusing drugs at the age of 15 and spent at least eight stints in drug treatment. On Aug. 11, 2006, he had a moment of resolve.
He called Estiandan’s office at 11:45 a.m. that day and left a message.
He was about to undergo drug detoxification, according to a handwritten note by a receptionist, and he asked that the doctor “please not see him anymore.”
Three hours later, Corless called back with a message “to disregard” the earlier call.
Leslie Greenberg lies in the grass at a park after leaving flowers at the nearby grave of her boyfriend Andrew Corless, who died in 2006 of prescription drug and alcohol intoxication. (Liz O. Baylen / Los Angeles Times)
Corless was in Estiandan’s office 10 days later, pleading for drugs, court records show. He was back again in December, this time after leaving rehab early.
On Dec. 13, 2006, Corless, 46, was found on the street in front of his house in Northridge, dead of an overdose. Two of the drugs found in his system — hydrocodone and alprazolam — had been prescribed for him by Estiandan.
A month later, authorities searched Estiandan’s offices and home. They found hundreds of partially completed prescription forms, some of them already signed, along with $12,300 in cash, court records show.
Looking at patients’ records, investigators saw that groups of people from as far as Bakersfield, the Antelope Valley, Victorville and San Bernardino would show up at Estiandan’s clinic near downtown Los Angeles on the same day, describe the same symptoms and leave with prescriptions for the same drugs.
Shortly after the raid, Estiandan was back at work — and writing prescriptions at a furious pace.
DEA agents consulted a database on prescriptions for controlled substances, written for patients paying in cash, to see where Estiandan stood. For March 2007, he ranked first in Southern California, Nevada and Hawaii, and fifth in the United States, according to court records.
For Joyce Saldivar, 55, he prescribed hydrocodone.
Saldivar had chronic back pain and was known to abuse her medications, according to coroner’s records. She died June 29, 2007. The cause was an overdose of multiple drugs, including hydrocodone.
Estiandan acknowledged that Corless was an alcoholic and an addict and had “begged” him for drugs, according to Hollis’ report.
By then, Hollis had learned about Corless’ death from his girlfriend, who complained to the medical board about Estiandan, court records show.
Hollis got Corless’ medical records and the autopsy report, and summoned Estiandan to an interview at a board office in Glendale on Sept. 12, 2007.
Estiandan acknowledged that Corless was an alcoholic and an addict and had “begged” him for drugs, according to Hollis’ report.
Hollis told Estiandan that she couldn’t understand how he could “continue to give pain medication to a person who is addicted,” according to her report. “I explained that now there was a patient death…. This was the inevitable result. It was just a matter of time.”
Hollis later obtained a report from an expert physician stating that Estiandan’s treatment of Corless included “extreme departures” from accepted standards and contributed to his death.
Another patient, Wilma Jones, 47, was found dead in an unfurnished one-room apartment in South Los Angeles on Feb. 14, 2008. She had contracted pneumonia, and various drugs had suppressed her breathing to the point of death, coroner’s records show.
One of the drugs was hydrocodone, which Estiandan had prescribed for her, records show.
Within a six-week span that summer, three more people died after taking medications prescribed by Estiandan. In all, seven of his patients had died since the medical board began investigating nearly four years earlier.
Estiandan, an early riser, was on the computer, tending to his stock portfolio on the morning of July 23, 2008, when a throng of DEA agents and sheriff’s deputies appeared at his doorstep.
The doctor was polite and cooperative as an officer handcuffed him and led him to a police car. He was charged with 13 felony counts of illegally prescribing controlled substances. He was not charged with any of his patients’ deaths.
Clint McKinney, center, hugs his mother and wife after scattering the ashes of his father, Bill, who died of cancer, and brother, Byron, who died of prescription drug-related causes. (Liz O. Baylen / Los Angeles Times)
Three weeks later, the medical board asked a Superior Court judge to suspend Estiandan’s license, saying it was “the surest way to protect the public” from a doctor who “supplied patients with drugs, not medical care.”
While the board waited for a ruling, Estiandan was free on bail and seeing patients.
Byron McKinney, a former pro wrestler, had been seeing Estiandan for eight years and had gotten hooked on the muscle relaxant carisoprodol, the anti-anxiety drug Xanax and a narcotic cough syrup, according to his brother, Clint.
McKinney, 33, died Nov. 18, 2008, of heart disease. The coroner said carisoprodol and hydrocodone were contributing factors. An empty bottle of hydrocodone cough syrup prescribed by Estiandan was found on a coffee table near McKinney’s body.
Clint McKinney told a coroner’s investigator that he and his brother “were able to regularly obtain prescription painkillers at free will via an unethical doctor who would write them five prescriptions for $120,” records show.
In February 2009, six months after the board went to court, a judge barred Estiandan from prescribing painkillers and other addictive drugs. He surrendered his medical license that September. The next year, he was tried and convicted on the criminal charges and sentenced to five years in prison.
He was released in September after serving about half his term. A few days later, he spoke with Times reporters in the spacious home where he now lives on a ridge of the Verdugo Mountains in Burbank.
He referred to his time in state prison as “my vacation” and described how he practiced guitar, tutored inmates, volunteered in the chapel and read the Bible.
By turns defensive and contrite, Estiandan complained of being unfairly targeted by prosecutors for simply doing his job.
He said he warned patients of the dangers of becoming addicted to prescription drugs, telling them: “Eventually you will lose control of yourself.”
He recalled that his wife, Gloria, a nurse, had warned that he was headed for trouble. She saw the disheveled people in his waiting room, Estiandan said, and told him: “Just let them go.”
Estiandan, now 70, said he was not motivated by greed and never intentionally harmed patients. But he said he realizes he used poor judgment in prescribing drugs.
“Instead of helping them, I might have harmed them,” he said of his patients. “I made a mistake.”
Rogue pharmacists feed addiction
Some provide massive amounts of painkillers and anti-anxiety drugs to addicts and dealers, according to state records, regulators and law enforcement officials.
BY SCOTT GLOVER, LISA GIRION AND HAILEY BRANSON-POTTS, LOS ANGELES TIMES
DEC. 19, 2012 6:19 PM PT
Joey Rovero’s quest for pills ended at Pacifica Pharmacy.
It was the same for Naythan Kenney,
Matt Stavron and Joseph Gomez.
All four were patients of a Rowland Heights
physician who was a prolific prescriber of narcotic
painkillers and other addictive drugs. To get their fix,
they needed more than a piece of paper.
They needed a pharmacist willing to dispense the drugs,
and at Pacifica they found one.
By Scott Glover, Lisa Girion and Hailey Branson-Potts
Video and photos by Liz O. Baylen
December 20, 2012
All four died of drug overdoses after filling prescriptions at the tiny pharmacy in Huntington Beach, court and coroners’ records show.
Pacifica’s owner, Thang Q. “Frank” Tran, sold pain medications in large quantities. Particularly popular with his customers were high-dose, 80-milligram tablets of OxyContin. Tran filled nearly twice as many of those prescriptions as did nearby Walgreens, CVS and Sav-On pharmacies combined, according to state records.
Many of his customers traveled long distances and paid cash. Rovero drove more than 350 miles from Arizona State University in Tempe to get his prescriptions in Rowland Heights and then 33 more miles to the pharmacy.
“I thought to myself, ‘Why in the world would these kids go that much farther out of their way?’ ” said April Rovero, whose son was 21 when he died. “Someone must have told them to go there.”
Pharmacists are supposed to be a last line of defense against misuse of prescription medications. By law, they are required to scrutinize prescriptions, size up customers and refuse to dispense a drug when they suspect the patient has no medical need for it.
Thang Q. Tran is appealing the revocation of his license. The state Board of Pharmacy found in April that he had improperly dispensed narcotics at Pacifica Pharmacy in Huntington Beach. (Liz O. Baylen / Los Angeles Times)
Voices
Bitter Pills
In rehab, Edward Shut fights his addiction to prescription drugs.
Some, however, provide massive amounts of painkillers and anti-anxiety drugs to addicts and dealers with no questions asked, according to state records, regulators and law enforcement officials.
Rogue pharmacists are key enablers of drug abuse and an important source of supply for the illegal market.
State officials who license and oversee pharmacies are overmatched by the scale of the problem.
Prescription drug abuse has increased sharply over the last decade, fueling a doubling of drug fatalities nationwide.
California’s 42,000 pharmacists filled 318 million prescriptions last year.
Those for OxyContin, Dilaudid and other potent painkillers have increased 52% over the last five years, according to a review of prescription data collected by the state. The total dosage dispensed by pharmacies has also grown: by nearly 50%, the data show.
The task of identifying careless or corrupt pharmacists and initiating disciplinary action falls to 37 investigators for the California Board of Pharmacy.
“We are struggling to keep up because there are more pharmacies, more licensees, more places to go,” said Virginia Herold, the agency’s executive director. “We work really hard. But there’s a limit to what we can do.”
The board has added investigators in recent years. Even so, “we do have some pharmacies that seem to be able to help deliver unconscionable quantities of drugs to patients,” Herold said.
It doesn’t help that illegal dispensing is a low priority for law enforcement agencies. Criminal prosecutions are rare and penalties typically light.
Rogue pharmacists have a symbiotic relationship with physicians who prescribe drugs for addicts. Neither can flourish without the other.
Their cooperation is usually unplanned. Through trial and error, addicts whose doctor writes prescriptions for narcotics will discover a pharmacist willing to dispense the drugs without the appropriate scrutiny. Then word gets around.
Both pharmacist and doctor can reap a windfall by writing and filling large numbers of prescriptions for cash.
High-volume dispensing of addictive drugs was par for the course at Burbank Medical Pharmacy, according to board records.
In a single day — Dec. 3, 2007 — the pharmacy filled 85 prescriptions for pain medications, according to a board accusation. None of the doctors who wrote the prescriptions were from the Burbank area, nor were any of the patients, the complaint states. Both are signs that a pharmacy is catering to addicts, according to regulators and law enforcement officials.
Burbank Medical also dispensed painkillers in volume to a drug dealer who claimed to be picking them up for patients too sick to do so, according to the board accusation and court files. The dealer was convicted in a prescription drug fraud scheme that prosecutors said generated millions of dollars.
Pharmacist Nancy Cha and the pharmacy are accused by the board of failing to ensure that the drugs they dispensed were for patients with legitimate need. They have not been implicated in the drug dealer’s fraud scheme.
The pharmacy also failed to account for 12,610 OxyContin tablets with a street value of more than $1 million, the board said.
Cha’s attorney, Richard Moss, said she was a well-meaning pharmacist who naively believed she was helping people in need.
“This was a real wake-up call,” Moss said of the board accusation. At a recent hearing on the case, Moss presented a defense that he said was largely “explanation and mitigation.”
The 13-member board will decide whether to revoke Cha’s license or take other disciplinary action.
In recent years, the board has taken disciplinary action only infrequently against pharmacists for filling customers’ prescriptions without ensuring that they were for legitimate medical needs.
Since 2006, five pharmacists have had their licenses revoked on those grounds, according to board records. Twelve others surrendered their licenses, and 22 were placed on probation. Over the same period, 23 California pharmacies have been sanctioned for similar offenses.
Derrick Jones, an agent for the U.S. Drug Enforcement Administration who oversees a prescription drug task force, said corrupt or inattentive pharmacists are a boon to addicts and dealers.
“If you’ve got a 22-year-old kid coming in with a prescription for enough Oxy to put a horse down, that’s got to raise some red flags with a good pharmacist,” Jones said.
“When those questions don’t get asked, that’s when the floodgates open. You’ll have people coming from L.A. all the way down to Orange County because they know they can get that prescription filled without any questions.”
Andrew Snay was adrift. The 22-year-old bounced from job to job. He worked at Home Depot, as a Kirby vacuum cleaner salesman and as a telemarketer.
The one constant in his life, his mother said, was his addiction to pills.
At one point, he used a shoulder injury as a pretext to obtain pain medications, his mother said. “He was just getting high,” she said.
If you’ve got a 22-year-old kid coming in with a prescription for enough Oxy to put a horse down, that’s got to raise some red flags with a good pharmacist.”
— Derrick Jones,
U.S. Drug Enforcement Administration
He went to great lengths to get pills — literally.
He would travel 40 miles from his home in Thousand Oaks to the office of Dr. Bernard Bass, a general practitioner in North Hollywood who treated people for chronic pain. Prescription in hand, he would go five more miles to Jay Scott Drugs in Burbank.
Bass would prescribe — and Jay Scott Drugs would dispense — the painkiller Norco, the anti-anxiety drug Xanax and a muscle relaxant called Soma, according to pharmacy board records. Together, they form a drug cocktail popular with addicts.
In a 14-month period, Snay filled 89 prescriptions at Jay Scott Drugs, according to a board accusation. Snay filled two of them — for hydrocodone and Xanax — two days before he died of an overdose on March 20, 2008, records show.
An empty bottle of painkillers with the pharmacy’s label was at his bedside.
Shortly after his death, Snay’s mother, Kim, confronted Albert Daher, the supervising pharmacist and owner of Jay Scott Drugs, according to her testimony at a pharmacy board hearing. She asked for a record of the drugs her son had purchased. Daher gave her a printout, then asked for it back moments later, she said.
She said she refused and walked out.
Scanning the document, Snay saw that her son was able to obtain 400 pills in one four-day period in 2007, the year before he died.
“I almost fainted,” she said.
Snay and three other people from Ventura County, ages 21, 25 and 31, died of overdoses in the span of a month in 2008 after filling prescriptions at Jay Scott Drugs, according to the board accusation.
Binders of evidence fill the prosecutors’ table at a hearing on Jay Scott Drugs (Liz O. Baylen / Los Angeles Times)
All four were patients of Bass, who pleaded guilty in May 2009 to illegally prescribing painkillers and other addictive drugs. Bass, 62, died of a heart attack a month later.
Over a 19-month period, Jay Scott Drugs filled an average of 68 prescriptions a day written by Bass for painkillers and other commonly abused drugs, the board said.
On a single day — Sept. 7, 2007 — 93 out of 132 prescriptions for controlled substances filled at the pharmacy were for patients of Bass.
In July of the same year, Jay Scott’s wholesaler alerted the pharmacy board that the drugstore was ordering more than 100,000 hydrocodone pills a month, records show. A board expert said at the hearing that 100,000 pills was a “huge amount” for a pharmacy of that size.
In all, the pharmacy dispensed $1.7 million worth of drugs prescribed by Bass, according to a board investigator’s report.
Jay Scott Drugs also catered to patients of Dr. Masoud Bamdad when others would not fill his prescriptions, according to board records and testimony.
Bamdad’s patients routinely drove from his office in San Fernando to Jay Scott Drugs, 11 miles away. The pharmacy filled 1,357 prescriptions for Bamdad’s patients over 18 months. Nearly three-fourths were for painkillers and other controlled substances.
Bamdad is serving a 25-year sentence in federal prison for selling prescriptions to addicts, one of whom died of an overdose at age 23 after filling a prescription for Xanax at Jay Scott Drugs.
The pharmacy board is seeking to revoke or suspend the licenses of Daher and two colleagues and the pharmacy’s operating permit.
In an interview, Daher denied any wrongdoing and said he and his colleagues are “extremely vigilant” in dispensing narcotics. He said he looked forward to mounting a defense against the board accusation when hearings in the case resume next summer.
Albert Daher, right, talks with attorney Daniel R. Friedenthal at his hearing before the state Board of Pharmacy in November. Daher, owner of Jay Scott Drugs, denies any wrongdoing. (Liz O. Baylen / Los Angeles Times)
“I want to clear my name,” he said.
Daher said he spoke to Bass after his patients began showing up at the pharmacy with prescriptions for narcotics. He said Bass seemed knowledgeable and compassionate and told him his patients, including the younger ones, suffered from pain and needed the medications.
Daher said that an investigator with the Medical Board of California, which licenses and oversees doctors, visited the pharmacy in July 2007 to obtain records on two of Bass’ patients. Daher said he asked whether he should stop filling Bass’ prescriptions. Daher said he asked the same question of pharmacy board officials when they visited for a routine inspection.
In neither case did the regulators inform him of the allegations against Bass or tell him to stop filling the doctor’s prescriptions, Daher said.
“They should have been more forthcoming,” he said.
The pharmacy board said it could not comment on a pending case. The medical board also declined to comment.
Daher said that as soon as he learned of overdose deaths among Bass’ patients, he stopped dispensing drugs to patients with chronic pain.
Regarding Bamdad, Daher said that by all indications the doctor was a responsible prescriber, and that he felt betrayed when he learned otherwise.
Brian Spahr, a financial planner in Huntington Beach, would occasionally look out the window of his office at the parking lot he shared with Pacifica Pharmacy. Young men would congregate there after walking out of the pharmacy. Some would leap into the air and exchange high-fives.
Once, Spahr saw Pacifica customers spread cash across the dashboard of a car. On another occasion, he saw “money and prescriptions changing hands,” he said.
Law enforcement officers escort Dr. Hsiu-Ying “Lisa” Tseng out of her Rowland Heights clinic in March 2012 (Liz O. Baylen / Los Angeles Times)
Spahr complained first to Huntington Beach police, then to the pharmacy board.
A board investigator ran Pacifica’s name through a state database and found that the pharmacy was filling an unusually high number of prescriptions for OxyContin and other potent drugs written by a Rowland Heights physician identified as “Dr. T,” according to an accusation filed by the board.
“Dr. T” is Lisa Tseng, who has since been charged with second-degree murder in the overdose deaths of three of her patients.
The investigator studied files on 18 of Tseng’s patients who filled prescriptions for 80-milligram doses of OxyContin at Pacifica Pharmacy. He found that 15 lived 35 miles or more from Tseng’s office in Rowland Heights, and 15 lived at least 20 miles from the pharmacy.
Brandon Barnes, of Laguna Niguel, described in court how he went to Tseng’s office with some friends in 2009 to get prescriptions for narcotics. Barnes, then 19, said he told Tseng his hand hurt from a skateboarding injury. But his real motive was to get high.
Testifying at Tseng’s preliminary hearing, Barnes said the doctor gave him prescriptions for Xanax, Soma and the narcotic painkiller Opana. He said one of his friends told him they would have to go to “a special kind of hole-in-the wall pharmacy” to get the prescriptions filled.
The pharmacy was Pacifica, and he and his friends paid for the drugs with $800 in cash, Barnes testified.
Lisa Gomez questioned how Pacifica could have filled Tseng’s prescription for her son, Joseph. He went on painkillers after surgery to remove a cyst from his tailbone, and he became addicted, she said. Once an avid snowboarder and rugby player, he became red-eyed and listless under the influence of pills.
“I’m sure when he got these prescriptions filled, he wasn’t looking good,” Gomez said in an interview. “It’s a pretty distinct look.”
Joseph Gomez went to Pacifica on Aug. 26, 2009, to fill a prescription for Xanax and Soma, coroner records show. He fatally overdosed two days later on a combination of drugs, including the active ingredient in Xanax, the records show. He was 26.
At a board hearing earlier this year, pharmacist Thang Tran repeatedly invoked his 5th Amendment right against self-incrimination.
The board found “clear and convincing evidence” that Tran had dispensed narcotics improperly and revoked his license and Pacifica’s permit in April. He has filed an appeal in Superior Court.
A sign on the door of Pacifica’s shuttered storefront on Beach Boulevard directs customers to a pharmacy called TLC Xpress in neighboring Fountain Valley.
When reporters visited the pharmacy last week, Tran was behind the counter. When they asked to speak to him, he ducked into a back room and refused to come out.
KAMALA HARRIS HASA POWERFUL TOOLFOR IDENTIFYING RECKLESS DOCTORS,BUT SHE DOESN’T USE IT.
As California’s attorney general, Harris controls a database
that tracks prescriptions for painkillers and other commonly abused drugs
from doctors’ offices to pharmacy counters
and into patients’ hands.
The system, known as CURES, was created so physicians and pharmacists could check to see whether patients were obtaining drugs from multiple providers.
Law enforcement officials and medical regulators could mine the data for a different purpose: To draw a bead on rogue doctors.
But they don’t, and that has allowed corrupt or negligent physicians to prescribe narcotics recklessly for years before authorities learned about their conduct through other means, a Times investigation found.
Prescription drug overdoses have increased sharply over the last decade, fueling a doubling of drug fatalities in the U.S. To help stem the loss of life, the federal Centers for Disease Control and Prevention recommends that states use prescription data to spot signs of irresponsible prescribing, and at least six states do.
California is not one of them.
By monitoring the flow of prescriptions, authorities can get an early jump on illegal or dangerous conduct by a doctor. Among the telltale signs: writing an inordinate number of prescriptions for addictive medications or for combinations of drugs popular among addicts.
Harris’ office keeps CURES off-limits to the public and the news media. But information from a commercial database containing the same kind of data illustrates how valuable CURES could be as an investigative tool.
Pills collected at death scenes await destruction in a coroner’s property room. Prescription overdoses have fueled a doubling of U.S. drug fatalities in the last decade. (Liz O. Baylen / Los Angeles Times)
Private firms purchase prescription data from pharmacies and sell it to drug companies for use in marketing their products. The Times obtained a list from such a database ranking the most prolific prescribers of narcotic painkillers in the Los Angeles area for June 2008.
Of the top 10 doctors on the list, six were eventually convicted of drug dealing or similar crimes or were sanctioned by medical regulators. One of them was a cocaine addict. Some had been prescribing narcotics in high volume for years before authorities caught up with them.
At least 20 of their patients died of overdoses or related causes after taking drugs they prescribed, according to coroners’ records.
Had officials been tracking the doctors’ prescriptions in CURES, some of those deaths might have been prevented.
Harris, a career prosecutor who was elected attorney general in 2010, declined repeated requests to be interviewed for this article.
Nathan Barankin, her chief of staff, said Harris wants to improve CURES so more doctors can use it to identify drug-seeking patients, and to help prosecutors pursue dealers and other drug offenders.
She has not proposed using CURES to detect signs of excessive prescribing.
Barankin said financial constraints limit the attorney general’s options. CURES is “on life support” because of state budget cuts and is barely able to fulfill its primary mission of helping doctors and pharmacists track patients’ use of medications, he said.
Even so, the database, as is, could be used to look for signs of improper prescribing. “It certainly has that capacity, as I understand it,” Barankin said.
He added, however, that if Harris did begin using CURES to monitor doctors, the state Department of Justice lacks the resources to follow up on leads.
“We don’t have the horses or the ability to do that kind of work,” he said.
The Medical Board of California, which licenses and oversees physicians, has appealed to the public to report instances of excessive prescribing, a step it took in response to recent Times articles on overdose deaths.
But the board does not use CURES to identify doctors whose prescribing poses a danger to patients.
“We don’t have the resources,” said executive director Linda K. Whitney.
Dr. Tyron Reece was one physician who would have tripped an alarm early on, if officials had been watching his prescriptions in CURES.
The Inglewood family practitioner ranked fourth among prescribers of oxycodone and hydrocodone in the Los Angeles area in June 2008, according to the commercial database. Reece’s customers paid for nearly all those prescriptions in cash, the data show.
The pharmacies that filled Reece’s prescriptions were required by law to report them to CURES.
But Reece was not stopped until 2011, and then only because federal authorities investigating a drug smuggling ring stumbled upon evidence that implicated him. Dozens of prescription vials bearing the doctor’s name had been found in the trash at a suspect’s home.
Confronted by investigators, Reece admitted that he regularly sold prescriptions for cash to patients he had never examined. He pleaded guilty to drug dealing and is awaiting sentencing.
Nathan Kuemmerle, a West Hollywood psychiatrist, was busted in 2010 after narcotics detectives arrested a suspect for selling prescription pills on Craigslist. The suspect identified Kuemmerle as the source of the drugs, court records show.
During their investigation, detectives requested a CURES report on Kuemmerle in 2009 and found that he was the No. 2 prescriber of narcotic painkillers in California and the No. 1 prescriber of the highest-dose form of the stimulant Adderall, according to court records.
Kuemmerle prescribed nearly four times as many of the Adderall pills as the next doctor on the list, the CURES report showed. A medical expert said Kuemmerle wrote an average of 15 prescriptions per day for controlled substances over a four-year period, a “remarkably high” figure, court records show.
Kuemmerle pleaded guilty in 2011 to drug dealing and was sentenced to three years’ probation.
Investigators expressed amazement that Kuemmerle was able to get away with such high-volume prescribing while his prescriptions were being reported to CURES. The failure to use the database to look for signs of improper prescribing closes off a valuable source of leads, they say.
“If a doctor is prescribing in a way that could be considered unreasonable, there is nothing from CURES to say, ‘This might be a problem,'” said Redondo Beach Police Det. Robert Carlborg, who worked on the case. “If there had been, Kuemmerle would have been caught way sooner.”
On a warm October afternoon in 2003, Carmen Pack was taking her children to buy Slurpees in the Bay Area suburb of Danville.
Troy, 10, was on his scooter. Alana, 7, was riding her bike.
Heading toward them in a gold Mercedes was Jimena Barreto, a nanny for wealthy families in the area. She had been drinking and popping pills.
The Mercedes careened across two lanes of traffic. Alana was killed instantly. Troy died a few hours later.
Evidence emerged that Barreto was a “doctor shopper” who had obtained prescriptions for painkillers from half a dozen physicians at the same hospital. When the doctors testified at Barreto’s trial, each said they didn’t know about the others’ prescriptions.
That exposed a problem that Bob Pack, the children’s father, set out to remedy.
Pack, a technology entrepreneur, learned that California pharmacists were required to submit detailed data to the state on the controlled substances they dispensed. The information includes the name of the patient and the prescribing physician, as well as the drug and dosage.
The information is stored in the Controlled Substance Utilization Review and Evaluation System — CURES. The system has been in operation in various forms since 1939.
When Pack began studying CURES, doctors or pharmacists who suspected a patient of abusing drugs could call or fax requests to review the patient’s history of filling prescriptions for narcotics. But it could take weeks before they received the desired information.
Pack devised a plan for real-time access to the database. He and some Silicon Valley friends helped design an Internet portal that would allow medical professionals to review a patient’s history of medication use while considering whether to prescribe or dispense new drugs.
State officials embraced the idea.
Pack also pitched a separate component that would automatically alert state officials to doctors with suspicious prescribing patterns. In a recent interview, he called it a “built-in red flag system” that would deliver reports weekly or monthly.
Pack said he discussed the idea with then-Atty. Gen. Jerry Brown in 2007 and met regularly with state officials about the project for a couple of years.
At one meeting, in a demonstration of the database’s potential, staff members presented Brown with a list of the 10 most prolific prescribers of narcotics in the state.
“Jerry Brown and his team were really into that,” Pack recalled.
Brown announced the start of real-time access to CURES at a news conference in September 2009. Pack was at Brown’s side as he touted the “high-tech monitoring system” that would “enable doctors and law enforcement to identify and stop prescription-drug seekers from doctor-shopping and abusing prescription drugs.”
A federal agent removes a computer as evidence from a physician’s office. Data the state already collects could help authorities move sooner to stop reckless prescribers. (Liz O. Baylen / Los Angeles Times)
But the idea of using CURES to scrutinize doctors’ prescribing was no longer part of the program. Pack attributed its disappearance to “a combination of apathy and a lack of funding.”
Brown did not respond to requests for comment.
Pack, in an email, said “the idea was always there and still is, but the AG’s office just needs to set it as a priority.”
After Brown became governor in 2011, he eliminated the Bureau of Narcotics Enforcement, the unit that operated CURES, as part of his response to the state’s financial crisis.
CURES is now run by a single full-time employee in the attorney general’s office. A private company under contract with the state collects electronic reports on prescriptions from pharmacies and enters them into the database.
The effort is funded with about $400,000 in fees collected annually from the medical board and other professional licensing agencies.
Of more than 212,000 physicians, pharmacists and other professionals eligible for online access to CURES, fewer than 10% have signed up. The attorney general’s office says the database could not handle the demand if every eligible prescriber signed up for online access.
Earlier this month, when one Los Angeles doctor sent an email to the attorney general’s office seeking help accessing CURES to monitor his patients’ drug use, he received an automated response:
“Unfortunately, due to budget restrictions, there is no staff to accept or respond to your communication.”
Medical experts say improving such databases should be a priority because they can play a crucial role in reducing prescription drug deaths.
“This is life and death … if you can do it for a $100 credit card purchase, why can’t you do it for prescriptions?”
— Dr. Allen Frances
Duke University School of Medicine
Prescription monitoring systems are most effective when they focus on doctors rather than on patients, said Len Paulozzi, a public health physician at the Centers for Disease Control and Prevention who specializes in prescription drug abuse.
Paulozzi said CURES could be used for more than generating lists of top prescribers. Officials could, for example, search for instances of patients driving long distances to see a particular doctor, he said. They could also look for physicians who prescribe high dosages of commonly abused drugs.
“Whether you are talking about firemen, policemen or doctors, somebody needs to be looking at what they are doing,” he said in an interview. “I don’t see anything wrong with that.”
Dr. Allen Frances, a professor emeritus of psychiatry at the Duke University School of Medicine and an authority on misuse of prescription drugs, said credit card companies monitor customers’ purchases more closely than most states monitor prescribing of addictive medications.
“This is life and death,” Frances said. “If you can do it for a $100 credit card purchase, why can’t you do it for prescriptions?”
In New York, Massachusetts, Ohio, Kentucky, New Jersey and Wyoming, information from prescription databases that suggests improper prescribing is sent to law enforcement agencies, medical licensing boards or both. West Virginia is developing a program to analyze prescription data to flag problem doctors. South Dakota plans to create a similar program.
Paul Phinney, president of the California Medical Assn., an advocacy and lobbying group for doctors, expressed reservations about this approach, saying that CURES should not become a “big brother” that could make “physicians think twice about prescribing appropriate pain medication.”
\
But Ronald Wender, former president of the state medical board, said physicians who are prescribing appropriately would have nothing to fear from such scrutiny.
“If you are an oncologist and you are taking care of people in cancer pain, that’s one thing,” said Wender, an anesthesiologist who oversees a large pain-management practice in Los Angeles. “But if you are a general practitioner and writing loads of opioid prescriptions, then something is wrong.”
State officials said it would cost about $2.8 million to make CURES more accessible and easier to use, and $1.6 million more per year to keep it running.
State Sen. Mark DeSaulnier (D-Concord), a longtime supporter of CURES whose father struggled with substance abuse, said he would propose legislation in January to finance such an upgrade, and would like to see the system used to track doctors as well as patients.
“People are suffering and dying from overprescribing right now,” DeSaulnier said. “If there are outliers, people need to investigate that and ask questions.”
Times staff writer Hailey Branson-Potts contributed to this report.