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Doctors aren't top opioid prescribers in NH

New Hampshire Union Leader

December 22. 2015 12:23AM

The highest-volume prescribers of opioids in New Hampshire are not doctors, but nurse practitioners and physician assistants who work at specialty pain clinics, according to Medicare and Medicaid data reviewed by the New Hampshire Union Leader.

The data show that the top 25 prescribers of oxycodone HCL and Oxycontin wrote more than 22,500 prescriptions for the two drugs for Medicare and Medicaid patients in 2013.

None of the top five had a doctor’s license. Four of the five worked at specialty pain clinics. And one — physician assistant Christopher Clough — was permanently banned from prescribing narcotics and working in the pain care field by the state Board of Medicine earlier this year.

The data come from two sources. Data from Part D Medicare billings were obtained through ProPublica, a non-profit journalism website that has compiled publicly available data from the Center for Medicare and Medicaid Services. The New Hampshire Union Leader obtained digital Medicaid billing records from the New Hampshire Department of Health and Human Services.

The most recent ProPublica data are for 2013, which is more than a year before the heroin and opioid abuse crisis rose to prominence in the Granite State. Of the top 25 prescribers, nine are physicians, 12 are nurse practitioners, four are physician assistants.

New Hampshire law allows nurse practitioners to work independently and issue prescriptions without physician oversight; physician assistants must be overseen by a doctor.

Kelly Doherty, a nurse practitioner of 15 years, issued more Medicare prescriptions for oxycodone HCL than anyone else in New Hampshire. Doherty, who now heads the palliative care program at Cornerstone VNA, said she was working in 2013 at Interventional Spine Medicine, a specialty pain clinic in Barrington.

She said her job was to manage medications at the practice, a job that involves drug testing, calling patients randomly to count their pill supply, and other efforts to discourage abuse.

She was not surprised at the findings. And she disputed contentions that prescription opioids are responsible for the heroin epidemic.

“Even Tylenol can be addicting. Any pain medicine can cause addiction when used inappropriately,” she said.

“I believe the heroin epidemic is due to the government’s lack of initiative in mental health treatment. It does not start with me prescribing drugs to people who need it.”

NH’s top prescribers, 2013

Medical professionals who submitted the most claims to Medicare and Medicaid for Oxycodone HCL and OxyContin prescriptions and refills in 2013:
Name License* Community Medicare Medicaid Total
Doherty, Kelly NP Dover 1722 264 1986
Murphy, Katherine NP Newington 1422 281 1703
Clough, Christopher PA Somersworth 1129 325 1454
Talon, Kasey NP Somersworth 1004 399 1403
Dion, Joshua NP Bedford 1063 236 1299
Fothergil, John MD Colebrook 648 418 1066
Laurent, Christopher NP Whitefield 606 409 1015
Coolidge, Catherine NP Somersworth 818 173 991
Hevern, Gerard MD Allenstown 671 226 897
Alcorn, Bridget NP Manchester 744 131 875
Strevel, Wesley PA Somersworth 574 226 800
Toscano, Steven PA Somersworth 697 100 797
Kane, John NP Somersworth 640 110 750
Sponseller, Brian MD North Conway 575 170 745
Doane, Peter MD Bristol 498 216 714
Greenspan, Joshua MD Portsmouth 686 686
Berger, Ruth PA Nashua 674 674
Moran, Peter MD Colebrook 424 186 610
Siddiqui, Sohaib MD Berlin 573 573
Defeo, Kelly NP Tamworth 426 143 569
Tung, David MD Somersworth 543 543
Meadows, Jacqueline NP Bedford 505 505
Karcher, Christine NP Barrington 502 502
White, Kathleen NP Manchester 482 482
Caloras, Daniel MD Charlestown 332 332
Licenses: NP= Nurse Practitioner; PA=Physician’s Assistant; MD=Physician
Source: ProPublica; NH Department of Health and Human Services.

Specialty pain clinics

The New Hampshire clinic that employs several high-volume prescribers said that pain-management clinics have the expertise, skills and policies to deal with the complexities of opioid prescribing.

“Family practitioners typically avoid managing their most complex pain patients, because they simply do not have the resources that a pain management clinic has,” said Tom Barnes, administrator for the Somersworth-based PainCare, which bills itself as the leading pain management clinic in New Hampshire with 10 locations.

“Although pain management clinics have been painted as part of the problem, they are actually part of the solution,” he said.

An addiction specialist was also not surprised by the findings.

Doctors at specialty pain clinics usually concentrate on treatments and procedures. Nurse practitioners and physician assistants handle medications and prescriptions, said Dr. Seddon Savage, an addiction specialist at the Dartmouth Medical School and a member of the Governor’s Commission on Alcohol and Drug Abuse Prevention, Treatment and Recovery.

“Prescribing opioids, particularly prescribing them well, is very time-consuming,” Savage said.

No medical professionals, not even physicians, get enough medical training in school about opioids and narcotics, Savage said.

“I think everyone needs more training,” Savage said. Doherty agreed and said most of what she learned about opioid medication came from her job.

“It’s really on-the-job training and conferences. It’s just like everything else, you learn what works when you’re doing it,” Doherty said.

New regulations

At this point in New Hampshire, nurse practitioners actually have more freedom to write prescriptions for narcotics than physicians do. Pressured by Gov. Maggie Hassan, the state Board of Medicine early last month adopted opioid-prescribing regulations that call for documentation, disclosure and risk assessments.

But Hassan did not make a similar overture to the Board of Nursing at the time. The Nursing Board has discussed regulations and has issued recommendations for nurse practitioners, said the chairman, Nora Fortin, a registered nurse and director of child and maternal health at Portsmouth Regional Hospital.

Fortin said the board is working with other medical boards, including the Board of Medicine, and will likely adopt regulations sometime this winter.

“It’s a work in progress,” Fortin said. “It’s a process. It’s not decided in a one-month meeting.”

Fortin said the Nursing Board will “probably adopt” a lot of what the Board of Medicine does. Savage said it’s important that the same rules apply to everyone.

A joint legislative task force is recommending a law that would require all seven boards in the health care fields to adopt rules for prescribing controlled drugs. The boards cover doctors, dentists, nurses, optometrists, podiatrists, naturopaths and veterinarians.

License suspended

In October, the Board of Medicine, which oversees licensing for physician assistants, suspended the license of physician assistant Christopher Clough for 90 days and banned him from prescribing narcotics and the practice of chronic pain management.

The physician who oversaw Clough, PainCare physician John Schermerhorn, was reprimanded for failing to oversee Clough.

According to the ProPublica data, Clough wrote 3,911 total Medicare Part D prescriptions in 2013, billing the federally funded program $1.25 million. Clough billed New Hampshire Medicaid $14,240 in oxycodone and Oxycontin prescriptions in 2013.

The Board of Medicine hired a Dartmouth Medical School instructor to review the case against Clough.

PainCare’s Barnes said the case against Clough was based upon a handful of extremely complex patients, and some of those involved decisions outside the normal standard of patient care, which is acceptable in complex cases.

“Not all of your patients are going to fit the standard presentation. The ability to manage those complex cases who are not standard is what makes pain management specialist so important in these days in which opioid misuse is such an issue,” Barnes wrote in an email.

He also said that Clough’s case did not come about from negative outcomes or patient complaints. He said the complaints originated from a jealous colleague whose goal was to disparage Clough.

Savage said some pain care patients do become addicted to opioids, but thousands of patients don’t. Surveys have found that most heroin users who started with opioid medication obtained the drugs from friends or family who were legally prescribed the drug, she said.

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