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.
She 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.