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Painkiller addictions often start in the doctor's office, but prescribers are rarely punished

Opioid Tablets (copy)

Opioid painkillers are rare or unavailable in several low-income countries where patients have legitimate pain management needs.

To hear Dr. Charles Bruyere tell it, his problem was he had too much empathy. That’s why he doled out painkillers at such a high rate, why he landed in jail and why he was stripped of his medical license, he said.

The former physician, who operated a cash-only pain management clinic in Greenwood, said he didn’t know he was breaking the law by writing prescriptions for future dates when he would be out of the country. And anyway, he doesn't believe in opioid addiction, or doesn't believe doctors should have to take responsibility. The blame, he said, lies with the American people.

"There are so many people that just lie about their situation," Bruyere, 64, said. "I don't know that the doctor has to accept the blame."

The state didn’t see it his way. In stripping Bruyere of his license two years ago, authorities noted he kept prescribing painkillers to people who had lost medications, were suspected of doctor-shopping or were downing more pills than prescribed. Investigators said he ignored worries from a spouse that one patient was becoming addicted. He gave more painkillers to another after learning the patient was in a methadone clinic, according to a state order.

Criminal cases against doctors like Bruyere remain rare in South Carolina, where experts say most prescription blunders tend to be rooted in physicians' desire to help ease their patients' pain. But overprescribing of highly addictive painkillers remains a persistent problem that endangers lives and contributes to an opioid epidemic Gov. Henry McMaster described as a "silent hurricane" that is only getting worse. 

In 2016, 616 people died of opioid-related overdoses in South Carolina, according to state data. McMaster declared a state of emergency Monday and limited pill amounts for opioid painkillers to five days when used following a hospital stay. While opioid prescription rates in the state have been on the decline, South Carolina remains in the top 10 of states that prescribe the most of these addictive drugs. The Palmetto State comes in ninth, between West Virginia and Michigan.

The top 10 states for opioid prescriptions in 2016, according to the CDC

Each rate represents the number of prescriptions issued for an opioid painkiller for each 100 people living in the state. South Carolina doctors wrote 89 prescriptions for every 100 people in 2016, an improvement over 2014. Source: Centers for Disease Control and Prevention

State 2014 2015 2016
Alabama 135.3 125.1 121
Arkansas 123.2 117.2 114.6
Tennessee 121.4 114.9 107.5
Mississippi 116.3 111 105.6
Louisiana 108.9 100.4 98.1
Oklahoma 111 104.5 97.9
Kentucky 109.9 102.6 97.2
West Virginia 126.4 111.5 96
South Carolina 101.3 95.1 89.4
Michigan 98 90.5 84.9

It may begin with an Oxycontin allowance after having wisdom teeth pulled, or with leftover drugs carelessly kept and taken from a medicine drawer. Either way, most opioid addictions start with pills and shift to heroin and fentanyl, the culprits behind many overdoses.

Even given the gravity of the problem, poor prescribing practices are generally not illegal, or if they are, it's hard to prove. There is nothing necessarily criminal about prescribing an opioid, even in excess. Most doctors and public health experts said a strong public health campaign and better treatment opportunities are needed, not a more forceful law enforcement response.

Dr. John Emmel, medical director at Charleston County's substance abuse clinic, said most doctors are simply acting out of compassion and trying to help their patients feel better.

"There are a few doing it wrong," Emmel said. "But most are just trying to do what they've been taught."

The state's response

An effort to change doctors' practices has spurred a massive public health campaign. Coalitions of state health leaders, including a new one announced by the governor last week, have popped up around the state to combat the crisis. Physicians are now required to check a database before they prescribe a narcotic, which has been shown to cut down on doctor-shopping. Doctors are required to complete courses on prescribing practices.

The state's Bureau of Drug Control investigates criminal allegations against health care practitioners and makes arrests when warranted. But it is rare. The law enforcement agency, an outfit of the Department of Health and Environmental Control, has arrested 179 health care practitioners since 2016. Only 16 had a medical degree. 

Most others were nurses, pharmacists or pharmacy technicians. And most were arrested for crimes like obtaining drugs or poor record-keeping. Four doctors were arrested for distribution of narcotics. 

There is no reliable pattern for pinpointing cases of irresponsible prescribing, and the bureau relies heavily on complaints to identify doctors who may be breaking the law, said Adrianna Bradley, a spokeswoman for the state's Bureau of Drug Control. The bureau investigates as many as 1,000 such complaints every year, according to its website.

There are some tell-tale signs that investigators look for, including high-volume prescribers, Bradley said. They will also be wary of practitioners whose patients are young, travel long distances or complain often of lower back pain, for example.

The state's Board of Medical Examiners also fields complaints. Dr. Jeffrey A. Welsh, chairman of the board, said in a prepared statement the board takes complaints from the Bureau of Drug Control and from the public. Complaints, or any information about them, are shielded from public view by the state's public records laws.

A Post and Courier review of every order the board has issued in the last five years shows many cases of doctors mishandling opioid prescriptions, but given there is scant public information about each case, the trail is murky. 

About 220 physicians have appeared in front of the board in the five years since 2012. Of those, 60 could be identified as cases of mishandling of prescriptions. Most either prescribed to an acquaintance or took the medications themselves, however.

There could be many more cases — in another 78 instances, the board did not specify why the physician appeared.

Welsh said the board released pain management recommendations this year. In cases where a doctor has acted in bad faith, Welsh said the board can restrict a license, require training or ultimately revoke the license.

"While prescribing a narcotic is not a crime, prescribers are required to uphold the appropriate standard of care for prescribing," he said. "The Board utilizes its collective wisdom ... in determining whether a licensee is prescribing outside the standard of care when presented with a specific set of circumstances."

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'Too much to too many people'

Bruyere saw about 100 patients each week at Color-Me-Well Family Medicine, the clinic he owned in Greenwood. Authorities said he missed multiple red flags in his treatment of patients, prescribing "overlapping opioids in high doses with high abuse potential." 

The self-described "fixture of the community" was arrested at a YMCA while working out during a lunch break in July 2010. He served 10 days in jail, pleading guilty to 20 counts of violating the state's drug distribution laws. The state's board of medicine revoked his license in 2015.

Bruyere told The Post and Courier he did not tolerate abuse of the opioids he was prescribing. He said he let about 180 patients go over the years. He also told the medical board he had been instructed there was no upper limit to prescribing opioids, and indicated he was within the guidelines of the Food and Drug Administration. The board did not accuse him otherwise.

"It's almost impossible to tell who's doing right and who's not doing right," he said.

Eighth Circuit Solicitor David Stumbo, who oversees criminal prosecutions in Greenwood County, said he hasn't seen many of these kinds of cases come through his office. But he acknowledged that "overprescribing" cases can be difficult to prove because prosecutors must show that criminal intent exists in providing patients with narcotics, he said.

"They may be doing that in excess, but that might not be a crime," he said. "It's starting out as a legitimate medical issue."

It takes time for investigators to build cases, Stumbo explained, and that is particularly true for medical professionals, who often do not have a criminal history. "You don't want a half-baked investigation that might ruin someone's career," he said.

The state's Bureau of Drug Control took longer to arrest doctors of medicine and dentistry following a complaint, compared to nurses and other technicians. The bureau took 130 days on average for practitioners with a medical degree, compared to 50 days for other health professionals.

Among the cases, state investigators determined:

  • A Charleston doctor prescribed more than 4,000 Oxycodone pills to one patient in 10 months, including a prescription for 735 of the pills at one time. His wife, when contacted, said he suffers from dementia. He surrendered his medical license.
  • A rural doctor near Florence was caught at the Charlotte airport with 23 different drugs including 111 Oxycodone pills, 13 prescriptions on a pad and an ammunition magazine without a gun. He told the medical board he comes from an underserved community and was trying to be "too much to too many people." The board reinstated his license but gave little other information about his motivations. 
  • Another doctor sold Oxycontin to undercover officers in Marion County. He pleaded guilty to unlawful distribution and was sentenced to five years in prison. He told a "customer" he could provide "anything" they wanted and bragged about the amount of Oxycontin he had access to, a Drug Enforcement Administration agent wrote in an affidavit.
  • A doctor in Conway irresponsibly prescribed opioids for pain. The board accused the doctor, who is still in practice, of ignoring his patients' drug-seeking behavior.

Eight people were charged with the same offense as Bruyere in 2016, according to court records, but details about those cases were not immediately available. Two were convicted of the crime. 

Prescriptions on the decline, but not enough

Emmel pointed out rates of opioid prescriptions have been declining for years. From his perspective at the Charleston Center, his patients' fixations have shifted to the more powerful — and cheaper — street drugs. But he said cutting down the volume of prescriptions even more would likely prevent more new addictions.

South Carolina no longer prescribes more opioids than there are people in the state, according to the most recent data from the Centers for Disease Control and Prevention. In 2016, the rate was about 89 prescriptions for every 100 people in the state, representing a drop of about 12 percent since 2014.

Christina Andrews, an addiction researcher at the University of South Carolina, said the rate of decline is just not enough. Compared with other countries, she said, American doctors still prescribe an unreasonable amount of opioids.

"This is the birthplace of a lot of these issues," she said. "Now we know how harmful they are, but we haven't seen very dramatic reductions in these pills." 

Kathleen Brady, vice president for research at the Medical University of South Carolina, said it wasn't uncommon in the past for patients to leave a surgeon's office or a hospital with a month's supply of opioids. But Brady, one of MUSC's most esteemed researchers and an expert in substance abuse, was optimistic about the governor's decision. She said limiting the volume of prescriptions could indeed cut back on overdoses.

That practice is fueling much of the addiction seen today, Emmel said. At the Charleston Center, he said most new patients have already been struggling with addiction for years. 

Brady said patients have to accept responsibility, too, when they neglect to get rid of pills they don't use.

"I think people feel like they paid for that drug," Brady said. "People generally tend to hang on to medications."

To only talk about law enforcement and cracking down on fraud is grandstanding, Andrews said. As concerns circulate that the state is barreling toward a heroin and fentanyl problem to the order of West Virginia or Ohio's, Andrews said the focus may be misplaced. Making treatment more available, she said, is the only good solution.

Reach Mary Katherine Wildeman at 843-937-5594. Follow her on Twitter @mkwildeman.

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