February 19, 2015

Connecticut Nurse Among Highest Prescribers In U.S.

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A Derby nurse practitioner was among the top 10 prescribers nationally of the most potent controlled substances in Medicare’s drug program in 2012 – an anomaly in a state where Medicare records show nurse practitioners rarely prescribe such drugs, which have a high potential for abuse.

Heather Alfonso, an advanced practice registered nurse (APRN) at the Comprehensive Pain & Headache Treatment Centers, LLC, wrote out 8,705 prescriptions for opioids and other Schedule II drugs in 2012 – the most prolific prescriber among all Connecticut practitioners, including pain specialists and other physicians, according to Medicare data compiled by ProPublica.

pills and RXShe wrote out more prescriptions for the opioid Exalgo than any other Medicare provider in the country, and was the seventh highest prescriber nationally of Oxycontin, writing out more than twice as many prescriptions for that narcotic as the next highest prescriber in Connecticut. She also was the 10th highest prescriber nationally of Avinza, a morphine product.

There is no indication that Alfonso’s unusual prescribing frequency drew scrutiny from state or federal officials. Last July, she received a reprimand and fine from the state for improper prescribing practices related to one patient, but was allowed to continue practicing without restrictions.

Alfonso and Dr. Mark Thimineur, an anesthesiologist who is medical director of the privately run pain center, housed in Griffin Hospital, did not respond to messages seeking comment. Asked about Alfonso’s Medicare prescribing rate in 2012 – the most recent year for which data is available — a spokeswoman at the pain center said only, “We are a very large practice for pain management, and with our patients’ (complex) diagnoses, those are factors.”

Connecticut officials have been working to stem an increase in opioid prescribing and overdoses. In January, the Connecticut Hospital Association joined the state Department of Public Health and two physicians’ groups in endorsing a set of “voluntary guidelines” aimed at reducing opioid prescribing in hospital emergency departments. The guidelines discourage emergency clinicians from providing “replacement prescriptions” for lost or stolen medications, and recommend dispensing small amounts of opioids to patients who have acute injuries, such as fractures.

This month, Gov. Dannel Malloy proposed several initiatives designed to stem substance use and opioid overdose, including one that would require any prescriber supplying more than a 72-hour supply of a controlled substance to first review the patient’s record in a statewide prescription database. All pharmacies would be required to report prescriptions for controlled substances immediately – rather than weekly – through the state’s prescription monitoring program, to help ensure that prescribers have real-time data for treatment decisions. The legislation also would require education on opioid prescribing for medical professionals, as part of the license-renewal process.

Malloy’s proposals stop short of initiatives in some other states which have health agencies and medical boards using prescription data to spot problem prescribing, mandate drug screening for patients on long-term opioid treatment, or impose special regulations on pain management clinics.

William Gerrish, spokesman for the state Department of Public Health, said the DPH and the state medical board do not monitor the prescription database, which is maintained by the Department of Consumer Protection’s drug control division. “We can only access the database when there is a complaint (or) referral,” he said. The consumer protection agency is empowered to notify law enforcement or regulatory agencies of any improper prescribing activity.

In the past several years, a number of Connecticut physicians have been charged with illegal prescribing of controlled substances. Last July, for example, a long-term Drug Enforcement Administration investigation, which included the use of undercover agents, led to the arrest of a Fairfield doctor, Dr. John Katsetos, on charges he wrote prescriptions for large quantities of controlled substances to patients addicted to the drugs, outside the scope of legitimate medical practice.

Gary Mendell, founder and CEO of Shatterproof, a Norwalk-based organization dedicated to combating addiction, applauded the governor’s proposals, but said more work is needed to educate both prescribers and consumers about the risks of opiates and the potential for abuse. He said state regulators should be reviewing the statewide prescription database regularly to identify clinicians with unusually high rates of prescribing.

In addition, Mendell said, prescribers and pharmacies should be better educating consumers about the safe keeping of controlled substances and programs to dispose of excess pills.

“There’s too large a supply of these medications and too little education about them,” he said.

The federal Centers for Medicare & Medicaid Services (CMS) has been slow to police high prescribers. The agency adopted regulations last year that will allow it to remove providers from the program – starting in mid-2015 — if it finds a pattern of prescribing that is “abusive,” or if a state suspends or revokes a provider’s ability to prescribe.

Alfonso was reprimanded last July by the state Board of Examiners for Nursing for providing narcotic pain medications to a non-cancer patient seven times without personally examining the patient, instead “inappropriately” relying on an unlicensed assistant to examine the patient, state records say. She paid a $2,000 fine and took courses in safe prescribing and delegating work duties. She was allowed to continuing practicing without restrictions.

There is no indication in the records that the state DPH or the medical board had reviewed her level of prescribing.

Medicare records from 2012 show that 94 percent of Alfonso’s patients received at least one prescription for a potent Schedule II medication. Other nurse practitioners in Connecticut wrote such prescriptions rarely or not at all, according to the federal data compiled by ProPublica. Alfonso issued an average of 18 prescriptions per patient – double the average for nurse practitioners – the data show.

Until 2014, APRNs in Connecticut could only practice and prescribe in collaboration with a licensed physician. A change in law now allows them to work independently after a three-year collaboration with a physician.

Comprehensive Pain & Headache Treatment Centers advertises itself as using “state of the art procedures” to help control patients’ pain. “Today there are many options other than oral narcotics to give a chronic pain sufferer back the quality of life that they are craving,” its website says.

Thimineur had fewer Medicare prescriptions for controlled substances than Alfonso; he was the third-highest prescriber among pain medicine specialists in the state in 2012, data show. Like Alfonso, most of his prescriptions were for Schedule II drugs, defined as those with a high potential for addiction and abuse.

Thimineur was cited in a 2009 workers’ compensation case brought by the wife of state corrections officer Anthony Sapko, who died in 2006 of “multiple drug toxicity” due to excessive doses of oxycodone (20 times higher than the therapeutic dosage) and Seroquel (more than five times higher). Thimineur treated Sapko for back pain, prescribing at least eight drugs, including oxycodone, records say. The Comprehensive Pain & Headache Center “counseled the decedent on the proper use of the drugs prescribed for pain control and required the decedent to participate in a ‘controlled substances agreement,’” according to records of the compensation review board. The center’s treatment was not questioned in the case.

In 2014, Connecticut emergency departments had nearly 1,900 visits related to opioid overdose – a 50 percent increase over 2011. Close to 500 state residents died from accidental drug overdoses in 2013, a 38 percent increase from 2012, a state report shows. While 257 of those deaths were from heroin overdoses, the rest were from oxycodone, morphine and other prescription drugs.

 

9 thoughts on “Connecticut Nurse Among Highest Prescribers In U.S.

  1. The Epidemic Discrimination of the
    Disabled by the State and Peoples of Connecticut

    Let me tell you a tale, a tale of discrimination; discrimination
    and the outright contempt toward the disabled and the handicapped. Who might
    you ask is performing in such an atrocity? The answer unfortunately is simple,
    the State of Connecticut, its leaders, its citizenry, and yes, very likely you.
    This discrimination has reached epidemic proportion here in the State of Connecticut,
    fueled by lies, propaganda, and ignorance. This article and many like it are
    the vector through which this discrimination is propagated and is feeding a lie
    which is destroying far more lives than this article falsely alleges are negatively
    impacted or cut short within its contents. But before I get into the details of
    these lies and falsifications let me tell you a little about myself and many
    like me; the victims of this discrimination, this contempt, this outright
    hatred of our very existence.

    I am sharing my tale in the hopes that some of you might see
    the truth, open your eyes, and maybe see through the lies that you are being
    fed by our extremely liberal government. I pray that you will see and understand
    the tremendous damage that is being caused by the draconian policies, so
    adamantly applauded by the ignorant, that are being instituted to eradicate a fictitious
    problem, fabricated to bolster political careers by creating a false perception
    that something is being done to stem the tide of illegal drugs and of drug
    addiction.

    You see I am disabled and a sufferer of SEVERE CHRONIC PAIN.
    I have TRIED EVERYTHING that every doctor that has treated me has asked of me,
    including 11 knee surgeries, one being a patellar femoral replacement. All that
    that has accomplished is to make matters worse. Worse than I could have ever
    imagined. The pain is so severe that even with the very medications attacked by
    this article, and its proponents, I can barely live even a semblance of a life;
    having to choose between shaving and showering or going to work, not being able
    to take my children to a carnival, not being able to stand long enough to cook them
    dinner, or even to go shopping to feed them without suffering from excruciating
    pain. However, despite the pain I still work to support my family, I still want
    to work, but the actions of this government, its supporters, and the attacks on
    honest doctors and nurses who are seeking to help people such as myself put my
    very existence, my very life in danger. Unless you suffer from severe chronic
    pain, you cannot understand it, most cannot even truly emphasize with it as
    they equate it to a tooth ache, labor pains, or migraine headaches. It IS NOT
    like an abscessed tooth, child labor, or a migraine headache, which all come to
    an end over time. It is all consuming, ever present, and when not properly
    treated is 100% fatal, as its suffers will either seek to self-medicate or they
    will commit suicide to end their suffering, in the hopes that their families
    will be able to survive off of their life insurance benefits, because living
    with the constant severe pain is just not an option. How many tales have you
    heard of the tortured begging for the mercy of death? Severe chronic pain is a constant,
    never ending torture, far worse than any tortures inflicted by the tools of the
    inquisition. Imagine serrated knives constantly cutting away at the cartilage of
    your patellar (knee cap) with every step, imagine a broken bone that never
    heals or reduces in pain levels; imagine the pain of thumb screws that can
    never be removed.

    I feel for the nurse in this article, as she was simply
    trying to help those like me, as the “State of the art procedures,”
    these procedures cited as “many options other than oral narcotics to give
    a chronic pain sufferer back the quality of life that they are craving” DO
    NOT EXIST and simply just DO NOT WORK! While we as a culture have advanced in
    amazing ways, both medically and technologically since the 1800’s, we are no
    more advanced in the treatment of chronic pain now than we were in the opium
    dens of the 1800’s. Those of us who are suffers of chronic pain and the HONEST
    doctors who treat us will all tell you the same. While there is research into
    how nerves perceive and register pain, until they solve the mystery of pain,
    medications such as those listed here are our only option, our only hope.

    While this article proclaims that this nurse prescribed an
    average of 18 pain prescriptions per patient, that is common accepted standard
    of care, but they don’t tell you that. Many chronic pain sufferers are
    prescribed 2 pain medications, a weaker long lasting medications and a fast
    acting short term medication for breakthrough pain. So there is nothing unusual
    or odd about her practice. Anyone who thinks otherwise needs to do their
    research. As to why she was prescribing for so many patients, there are a lot
    of us who suffer immensely each day and regular doctors refer us to pain
    treatment clinics, such as the Derby pain clinic. That is why her numbers were
    so high, she simply had a lot of patients and was performing to the normal
    standard of care. I know many people who go to the Derby pain clinic and none
    experienced or saw anything out of the norm for that environment under those
    circumstances.

    Yet, while clinically it has been proven that Opiate
    Rotation is a safe and effective protocol to help in the management of Opiate
    tolerance (http://en.wikipedia.org/wiki/Opioid-induced_hyperalgesia), thus
    affording chronic pain sufferers a means by which they can better manage their
    suffering, the State of Connecticut’s “honorable” [sic] Attorney
    General George Japsen and 28 other state AG’s have chosen to declare war on us disabled
    and handicapped, fighting not only to take our medications away from us, but to
    also fight new options that which may be used to better manage our suffering.
    Worse, many ignorant citizens and leaders have also engaged in discriminatory
    onslaught, fighting to prevent this new medication from clinical use. They
    label this medication as a killer despite the facts that this medication is
    safer for the patient and lowers the risks of kidney and liver damage. For an
    example of this outright discriminatory and sadistic contempt for the disabled and
    handicapped read this blatantly incorrect article
    (http://www.salem-news.com/articles/december132013/killer-drug-ms.php). Why do
    so many wish for me and others like me to suffer in agony each day? What have I
    done to any of you to deserve your contempt?
    Why should we be denied some measure of relief from our suffering
    because a small number of people may abuse said medication?

    Now look at the numbers cited in this article. They are
    intentionally misleading you, including illegal street drugs with legally
    prescribed drugs for both Emergency Room visits and for deaths. They cite 500 drug
    related deaths, yet admit over half of them are illegal street narcotics, what
    they do not tell you is that the other 247 deaths include ALL prescription
    medications, birth control, NSAID pain medication, experimental drugs, blood
    thinners, Benzodiazepines, biologics, such as Methotrexate, Humira & Embrel
    and every other prescription drug you can think of.

    Another fact they don’t tell you is that there is an epidemic
    of auto-immune diseases inflicting people in their mid 30’s and above. So while
    the number of chronic pain sufferers increases, we as a society reject them,
    torture them, and just want them to die?
    Just last week a friend had back surgery, she had 2 metal pins put in
    her spine due to a work related injury. Her surgeon prescribed less pain
    medication than what oral surgeons used to prescribe for a simple tooth extraction.
    But the State of Connecticut has an answer, Medical Marijuana. While you
    develop a tolerance to opiate pain medication and it no longer “makes you high”,
    they would prefer that we load up on Marijuana and then go about our daily
    activities higher than a kite. How does make sense in modern society? What
    sadists have we become?

  2. Now because of heathers problem so many patients have been kicked out if the practice,people who are there for the right reasons.Now I can’t find another Dr.When someone has been treated there for 15 yrs for real problems it’s not fair.I’m filling a lawsuit against all involved for discrimination and pain and suffering

    • Dear Steven and Adrienne, I stand firmly in your corner. I do fear that this Nurse Practitioner is being unfairly ” scapegoated” and pain clinics are being targeted for helping an ever growing population of patients experiencing REAL pain. JCAHO mandates that we treat pain, including chronic pain effectively , and created the fifth vital sign , which is our pain scale. Now we have the DEA and politicians tying our hands behind are backs to alleviate pain. I would like to see journalists, politicians, and police mind their own business and allow medical professionals to care for their patients safely and effectively as they deem appropriate. There is no therapeutic range for opioids, because of tolerance. This whole thing smells like somebody’s witch hunt to me. They can’t do anything to control illegal drug cartels …which are selling to people looking to get high; So they are picking on a local nurse practitioner, who is trying to improve patients’ quality of life. Shame on them !!!

  3. I agree, people do not understand how much pain people are in, I know they tried many different options plus they did mris CST scans and injections, right now I’m doing the trial for the nerve stimulator, I have to say Dr theminuer is one of the best Dr.s who listen to you and try different things before just putting you on any kind of high pill treatment, he finds the one that fits you, I just don’t know why he’s getting a bad rap for a APRN who was probably doing it behind his back, I wish one person can walk in our shoes and see how long they would last, I bet ya they couldn’t make 5 minutes. Dr. Thimnuer is a great doctor.

  4. I agree with every one of these people that suffer every day. I have been a patient of pain management for over 15 years. After EIGHT failed shoulder surgeries I have been left in constant pain and know what it is like to take a shower and try and get up for work or stay in bed and not go to work because you can’t stand the pain. I was a patient of Heather for five years during that time she made it so I got up and went to work every day. Before Heather I would miss three days a week. Since she is no longer at Comprehensive Pain my prescriptions have been cut in half and once again I am missing work. You see the DEA goes in an tells Doctors what they can prescribe of corse these un educated nerds know more than the doctors do they have treated thousands of people for pain. They tell doctors we can’t take the amount of medication we do so we must be selling it. Even though there are pill counts, drug testing to see if we are taking are melds every month, DNA testing to see if the mesds are working properly. But then again the DEA knows more about our body’s than we and our Doctors do. Thank God for people like Heather and Dr Thimeniur because if it wasn’t for them I would have killed myself by now. So don’t stop the Herion, Coke, PCP, and the Meth labs. Let the DEA harass the Doctors and APRN’s that are professionals helping people but let the illegal drugs flow because if I wanted to I could get drugs for pain off the street if I wanted to go that low, because with the DEA bothering the Doctors the illegal pushers are under less pressure than the professionals. Also the reason they write so many prescriptions is because all of the family practitioners will not write prescriptions for narcotics and refur their patients to the pain doctors and then they become overloaded and it looks like all they do is write large amounts of narcotic prescriptions.

  5. Heather was my APRN and she was never less than professional and pleasant as she cared for and treated my pain management needs. I now have someone else who is just as professional. I know that the medication that I’m given for my chronic pain is being closely monitored as they check my blood levels often, order annual ekg’s, and do a questionnaire with each visit that when entered into their program can determine how I am physically AND mentally handling my pain and the medication I take for it. It even lets them know if my medication is or isn’t working anymore or if I’m falsifying information and just looking for another medication. How much better can they get than that? As was said by someone before me, I also get two prescriptions. One for long lasting and the other for breakthrough pain. They count my medication to make sure I’m taking them as prescribed and they do urine testing almost every visit. I’m not special, all patients are treated equally and go through the same routine. Before I had Comprehensive Pain and Headache Treatment Center to go to (I go to the Meriden office)
    My day consisted of me lying on my bed in a fetal position rocking myself back and forth from severe abdominal pain that felt like someone was cutting my insides out without anesthesia. That is at least how I imagined that kind of pain could be.
    I couldn’t eat because it made it worse and I lost 118 pounds. It took 4 years of this dreadful pain but it was finally diagnosed as Crohn’s Disease. So don’t ever take away my pain medication because I can’t live through that again. For anybody who even attempts to stick their nose with strict regulations so tight that it scares these doctors from prescribing this medication at the doses that safely get us through our days, I hope that they get the chance to feel this pain for just one week and I guarantee you that they’d change their minds about signing any changes!! You make it hard for people who are trying to get relief from chronic pain legally and you’re just going to make your troubles worse because people will be forced to get their drugs off the street where there’s no doctor to guide them and protect them from overdoses and the er’s will be flooded again. So what did you gain?

  6. I do go to pain management, 55 yrs old, I am in constant pain and I have a wonderful Doctor, who is cutting me back on my pain medication due to fear of loosing his license. Very sad for I am so worried going in for another knee replacement, Crohn’s, RA, Lupus, on and on..Like this is not enough for me to get my pain managed..If these medications where so bad for us now, Why did the Pharmaceutical Companies push so hard to get them to the Patient? Maybe a class action lawsuit would solve this problem, because I don’t want my future to be buying these shit on the street..I am so afraid of this…

  7. Chronic pain here. It is amazing how self care or lack of influences levels of pain. Chronic use of opiates has severe limits and the pain rebound becomes cyclic. This nurse needs to be removed asap

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