PILLS AT WILL Deception, Incompetence and Greed Can Lead to Over-Prescribing For years, Dr. Thomas Michael Barrett wrote prescriptions for large amounts of pain medication, sometimes in potentially lethal doses. But outside his circle of patients, nobody knew just how many pills the San Bernardino County doctor was prescribing. The first time authorities heard of Barrett was in 2002, when an elementary school principal in Big Bear decided a mother was too looped to drive her children home. When police arrived, the woman showed them prescriptions for morphine, Vicodin and other pain pills written by Barrett. A few weeks later, a woman who had taken large doses of numbing pain drugs slammed her car into another car in Apple Valley. She, too, waved a prescription from Barrett. When state authorities began investigating Barrett, they found a pattern of over-prescribing pain medications that federal health officials say is being repeated across the United States by careless, inept or greedy doctors. The officials say the nation is facing a new drug crisis - with more Americans now addicted to prescription drugs than to cocaine, and deaths linked to prescription medication increasing in alarming numbers. The problem is exacerbated by gaps in policing the state's 89,000 practicing doctors by the Medical Board of California, which struggles to keep up with the complaints it receives. Although the board's $35 million annual budget has increased slightly over the past four years, its staff of investigators has dropped to 60 from 79 because of a state hiring freeze. Meanwhile, the number of complaints hit an all-time high of 11,566 last year. The board is so overworked that if Barrett's patients hadn't been involved in such public incidents, he might never have been caught. State Deputy Attorney General Thomas S. Lazar, who works with the Medical B oard to weed out and discipline bad doctors, said physicians over-prescribe for three reasons. They do it for greed. They do it because they are incompetent. They do it because they are easily deceived. "These motives all add up to bad medicine for patients," Lazar said. San Diego County Medical Examiner Dr. Glenn Wagner said doctors often are so rushed that they write prescriptions as a convenient form of treatment. "On the average, the patient spends a short time with their physician - 11 minutes or less," Wagner said. "A patient comes in and says (a drug) has helped in the past, and if the person isn't clearly stoned, they will probably get the prescription again. If a patient is really sophisticated, they can fool their doctor." Medical Board investigator Jim Ball said too many doctors miss the signs of addiction or give patients what they want without explaining the consequences. Busy doctors sometimes issue perfunctory cautions to patients and advise them to read the warnings that accompany the drugs, Ball said. "But often the stuff never gets read," he said. Doctor Shopping All Sal Moceri had to do was fib a little to get the pain pills that fed his addiction, which began in 1986 after he hurt his back in a traffic accident. Moceri went shopping for doctors who would prescribe the drugs he craved. He said he visited about 100 over the years. "Seventy-five of them gave me whatever I wanted without questions," said Moceri, a Mira Mesa resident who says he has been clean since 2002. "Maybe 10 of them gave me any warnings." If any of the doctors gave him a physical exam, it was cursory at best, Moceri said. If there was a warning about the addictive nature of the drugs, it was usually hurried. "When what they prescribed called for taking two every four hours and I was taking 60 a day, well what did that tell them?" Moceri said. "In my eyes, the doctors are just as guilty as I am." Dr. Robert Hertzka, president of the California Medical Association and a San Diego anesthesiologist, vigorously defends the vast majority of doctors against any broad-brush contention that the blame for addictions lies with them. Hertzka said he believes that less than 1 percent of doctors over-prescribe. "I am absolutely convinced that it is anything but a widespread problem," he said. "It is a very serious problem, but it's not an issue that the average patient needs to be concerned with." The Medical Board doesn't track how many doctors it has cited for over-prescribing. Since 2001, at least three San Diego County doctors have been accused of endangering patients by over-prescribing drugs. In an accusation filed in July against Dr. Therese Hunley Yang, investigators said the Santee physician lacked the medical knowledge to diagnose addictions and properly treat chronic pain. Yang noted in her medical records that one of her patients was suffering from "drug dependency," yet Yang continued prescribing oxycodone-based narcotics in doses up to 10 times the amount commonly given, according to the Medical Board's accusation. Yang, who declined to discuss her case, was licensed in California in 1988 and is still practicing medicine while awaiting an administrative law hearing. Last year, La Jolla doctor Douglas Simay surrendered his license after the Medical Board accused him of prescribing painkillers without examining his patients and continuing to write prescriptions for patients he knew were taking twice as many pills as they should. Allied Gardens doctor Katarzyna Rygiel is fighting to get her license back after the board revoked it for excessive prescribing, negligence and dishonesty. In one instance, Rygiel prescribed a month's supply of methadone - 240 tablets - for a patient who then returned 17 days later for another month's supply. The patient kept coming back for more drugs without Rygiel acknowledging the addiction, authorities said. Simay and Rygiel declined to be interviewed. Authorities don't think greed played a motive in any of the San Diego County cases. But they say greed is what motivated an Oxnard doctor, Michael Huff, and a Ventura pharmacist, Richard Ozar, to improperly prescribe and fill OxyContin prescriptions. Huff and Ozar, who are awaiting trial, are accused in a 90-count federal indictment of putting so much OxyContin into the hands of recreational pill-poppers and drug dealers that the indictment said they ushered "a new drug culture into the region." Officials say they made millions of dollars in the process. The case drew so much attention that U.S. Attorney General John Ashcroft used it to emphasize that federal authorities will "pursue vigorously" those who turn "a legitimate painkiller to a vehicle of addiction and death." In a more recent case, a New Mexico physician was charged with murder after seven people overdosed on pills he prescribed. According to court records, Jesse B. Henry Jr. spent six minutes or less evaluating his patients and was known as "Doctor Feelgood." Earlier this month Henry, 69, pleaded guilty to reduced charges of seven counts of involuntary manslaughter and surrendered his medical license. Battling Pain Medical schools across the country are just beginning to recognize the importance of educating doctors about pain management, said Dr. Deborah Danoff, associate vice president of the division of medical education for the Association of American Medical Colleges. The Bush administration is so concerned about the education gap that it has called for meetings with medical groups across the country to advise doctors of the growing problem. "There has been an increase in the use of synthetic analgesics and opioids that provide an enormous help to people in pain, but there has not been a corresponding effort at educating physicians," said John Walters, director of the White House Office of Drug Control Policy. Among the early advocates for such training was Dr. Mark Wallace, associate clinical professor of anesthesiology and a program director for the UCSD School of Medicine's Center for Pain and Palliative Medicine. "Until the last 10 years, medical schools taught doctors to diagnose and treat problems," Wallace said. "Then we started to realize that patient suffering also required the attention of doctors." Although most medical schools don't require pain-management courses, they are popular electives. The one Wallace teaches is in such demand that a lottery determines which students get into the course. Since 2002, California has required that doctors obtain training in pain management. By 2006, all doctors in the state must prove they have taken a continuing education course in pain management before their licenses can be renewed. A Doctor's Wife It's not known what warnings Dr. James Grisolia's 52-year-old wife, Linda, got regarding the powerful drugs prescribed by her husband and other doctors. Linda Grisolia, a Chula Vista resident who had epilepsy and suffered from chronic pain after a fall several years ago, died in October of an accidental overdose of prescription drugs, including some prescribed by her husband, according to a report on file at the Medical Examiner's Office. James Grisolia, who is chair of medicine at Scripps Mercy Hospital, disputes the report, saying he believes his wife died of an epileptic seizure. "There is a substantial disagreement between me and the medical examiner," Grisolia said. "I think it was a missed call on their part." Linda Grisolia had over-medicated accidentally at least once in the past, and in the days before her death she was using so much morphine that she was hallucinating, the report said. The autopsy report attributes Linda Grisolia's death "to the combined effects of the multiple sedating prescription medications." The autopsy showed seven prescription drugs in Linda Grisolia's system, including elevated levels of the pain-killers morphine and hydrocodone. Suspended By the time San Bernardino law enforcement and state medical authorities opened an investigation into Dr. Thomas Michael Barrett's practice, documents filed in administrative law court allege the 57-year-old doctor had: Prescribed thousands of pills for a man he knew had been illegally reselling the drugs for nearly a year. Scheduled appointments so close together that he once booked 15 patients in 30 minutes. Prescribed adult doses of morphine for a 6-year-old boy healing from a dog bite when ordinary Tylenol would have worked. Prescribed 550 tablets of morphine in a seven-day period for a woman already taking five other pain medications. At one point during the investigation, an undercover deputy sheriff posed as a patient, claiming he felt intense pain in his left shoulder. Barrett listened to the deputy's chest with a stethoscope and pressed on his right shoulder but not his left, according to the accusation. "Following an examination that lasted 56 seconds and involved no questions about pain," the accusation stated Barrett wrote the deputy a prescription for 150 tablets of OxyContin and 90 tablets of morphine. Barrett, who has been licensed in California since 1975, did not respond to requests for an interview. Last year, he was suspended from practicing medicine for a year, placed on 10 years' probation and ordered to take refresher courses on prescribing, record keeping, ethics and clinical training. Shared Responsibility Dr. Bob Wailes, an Encinitas pain-management specialist, said doctors are in a tight spot when it comes to prescribing addictive drugs. They have to treat the pain, but they also have to prevent addiction. "The competing forces are to balance good care with compassion and caution," Wailes said. Wailes thinks most doctors are adept at spotting abuse problems in their patients, though some miss the warning signs. Tiffany Aylesworth thinks her mother, Monique Adams, was one of those whose addiction slipped past her doctors. Adams, who lived in Vista, became addicted to painkillers after a car accident and took nearly a dozen types of drugs each day. "I tried for years and years to get her doctors and the pharmacists to see what was happening," Aylesworth said in a brief interview. "I couldn't get anybody to listen." On May 9, 2002, Adams, 47, went to bed about 8 p.m. complaining of moderate back pain and tooth pain. She was found dead on the floor of her bedroom the next day, still in her nightshirt and with the television humming. Aylesworth said doctors and pharmacists seemed to think her mother couldn't possibly be addicted. "Well she was," Aylesworth said. "And they didn't care." The duty of making sure prescription drugs don't dominate patients' lives or destroy them has to be shared, said Dr. Mark Chenven, with friends," Chenven said. "Doctors have a responsibility to maintain an awareness of the possibility their patients may be using their medication inappropriately. But it is up to the patient to use the medications in the fashion they are prescribed."