Ten Connecticut prescribers, including a Derby nurse who is at the center of a federal kickback probe, were responsible for more than 23 percent of the state’s Medicare spending on opioids in 2014, suggesting that the largest share of those prescriptions is concentrated among a small number of clinicians.
Recently released federal Medicare data show that Heather Alfonso, formerly a nurse with the Comprehensive Pain & Headache Treatment Centers, LLC, in Derby, and four other advanced practice registered nurses (APRNs) at the clinic in 2014 dispensed more than $8.4 million in opioids in the Medicare program – accounting for a full 15 percent of all such prescriptions in the state. They were among the top 10 opioid prescribers in 2014, who accounted for $13 million of the $56 million spent on the drugs, the data show.
More than 4,800 Connecticut clinicians, mostly physicians, wrote Medicare prescriptions for oxycodone, fentanyl and other opioids. But the prescribing was not evenly spread out – only two-dozen prescribers wrote out more than $250,000 worth of prescriptions. On average, the 4,830 providers billed Medicare for about $11,000 in opioids.
Alfonso has pleaded guilty to accepting kickbacks from Arizona-based Insys Therapeutics in exchange for prescribing Subsys, a powerful fentanyl pain medication intended for patients with cancer. A previous C-HIT story reported that she and three other nurses at the Derby clinic were responsible for nearly all of the state’s 2014 Medicare spending on Subsys – 279 claims, at a cost of $2.3 million.
None of the other three nurses has been implicated in a federal probe of Insys’ marketing of Subsys that resulted in criminal charges against Alfonso. The Derby clinic, located in Griffin Hospital, and a Meriden affiliate remain in operation.
Dr. Mark Thimineur, who runs the treatment clinic, also has not been implicated. He did not return messages seeking comment on the clinic’s opioid prescribing.
Alfonso topped the list of opioid prescribers, with $3.5 million in prescriptions (6,240 claims). Second on the list was Monika Chaves, a former APRN at the clinic, with $1.85 million (3,664 claims).
Dr. Michael Brennan, a Fairfield pain specialist, was the third highest prescriber, with $1.84 million (4,596 claims). Brennan declined comment, but previously told C-HIT that he specialized in patients with chronic pain and was selective in accepting patients and diligent in monitoring prescriptions.
The three other APRNs who worked at the clinic were: Jean Vulte, with $1.7 million in opioid charges; Ashley Dizney, with $773,000; and Karlene Jean-Pierre, with $594,700.
The other prescribers in the top 10 were: Dr. Vincent Carlesi, medical director of Pain Management Associates of Connecticut, in Stamford, with $817,000; Dr. Mohan Vodapally, of Connecticut Regional Pain Specialists, LLC, in New Haven, with $692,360; Jon Lum, a physician assistant in New Haven, with $639,000; and Dr. Christopher Mastino of Fairfield, with $524,400.
None of them returned messages, but managers at several of their offices noted that the practices specialize in pain management and said prescribing is carefully monitored.
Drug overdose deaths in Connecticut have climbed in recent years, with fentanyl partly to blame. In 2015, 729 people died of accidental overdoses, 188 of them involving fentanyl. Dr. James Gill, the chief state medical examiner, said in a September report that he expects the total for 2016 could reach nearly 900.
The rise in overdose deaths has strained Gill’s office, which was told in October that it will lose its national accreditation and be placed on probation by the National Association of Medical Examiners.
The state has adopted a number of legislative changes to regulate prescribing of opioids and improve reporting. In July, the state shifted from weekly to “real-time” reporting of prescriptions for opioids and other controlled substances. Pharmacies are now required to report controlled substance (Schedule II to V) prescriptions “immediately,” or at least within 24 hours after they are dispensed, into a central database, known as the Connecticut Prescription Monitoring and Reporting System (CPMRS).
The CPMRS, maintained by the Department of Consumer Protection, can be accessed by doctors and pharmacists to give them a complete picture of a patient’s medication use, and also can be used by law enforcement officials to investigate physician prescribing. However, Connecticut’s program is one of only two in the country housed in the consumer protection department, according to the National Alliance for Model State Drug Laws; most are overseen by state health departments, which license and discipline doctors. And unlike other states, Connecticut does not have specific laws regulating pain clinics or pain management.
In addition to the change in the reporting requirement, reforms effective in July included a provision that limits initial prescriptions for opioids to a seven-day supply in most cases.
Alfonso also was the highest prescriber of Schedule II controlled substances in 2013, Medicare data show, accounting for $2.7 million in prescriptions. She is now cooperating with federal investigators in the ongoing probe of Subsys.
C-HIT data analyst Matt Wynn contributed to this story.