FAMILIES' COMPLAINTS LED TO RAID ON CLINIC

State Agencies Track Prescription Data But Can't Detect Problems

If not for the complaints of grieving family members, investigators might
have never known about the prescriptions written from a South Dallas
medical office, as detailed this week in an affidavit. Officials with
several state agencies said Thursday that they track facets of doctors'
practices and drug-prescribing habits ­ but some don't analyze the
information, and others say problems aren't readily identified. Acting on
family members' complaints, investigators on Tuesday raided the South
Dallas clinic of Dr. Daniel Maynard after Dallas police linked his
prescription practices with the deaths of 11 patients.

The state has since stopped his Medicaid reimbursements.

Dr. Maynard has not been charged with a crime, and his lawyer insists that
he has done nothing wrong. District Attorney Bill Hill said Thursday that
publicity from the raid has generated several calls to his office from
people complaining that their family members became dependent on
painkillers prescribed by Dr. Maynard. Officials with Texas Department of
Public Safety said that they track physicians who prescribe certain
narcotic, stimulant and depressant drugs, but they generally don't analyze
the information. The DPS started its tracking program ­ called the
Triplicate Prescription Program ­ in 1982 to help stop medically useful
controlled substances from traveling from legal to illegal channels.

The program tracks what are known as Schedule II drugs, which can cause
severe dependence, including morphine and oxycodone. DPS spokeswoman Tela
Mange said doctors' licensing agencies use the drug information that her
agency gathers.

She said the prescription tracking program was intended as a tool to help
the licensing agencies determine whether there is a problem. "We share that
[information] with the licensing boards," Ms. Mange said. "We don't make
that judgment about whether they are prescribing too much of something.
That's something the licensing board should do. We're not doctors." Dr.
Donald Patrick, executive director of the Texas State Board of Medical
Examiners, said he could not comment on any action that board investigators
might or might not have taken regarding Dr. Maynard. But he said that, in
general, a physician who was prescribing large numbers of Schedule III
drugs ­ including certain anti-anxiety drugs, tranquilizers, sedatives and
stimulants, such as hydrocodone and Tylenol with codeine ­ would not
necessarily come to the attention of the board. Even information on
Schedule II prescriptions that the DPS collects might not prompt an
investigation, Dr. Patrick said. "There's no mandate to analyze that data,"
he said. Dr. Patrick said he hopes to put into place a board operation for
such analysis in conjunction with DPS. According to a search warrant
affidavit, Dr. Maynard was the leading prescriber of diazepam in Texas in
2002 and the second highest prescriber of Tylenol with codeine that same
year. Diazepam, also known as Valium, is a Schedule IV drug. Ms. Mange said
DPS officials were trying to determine where authorities would have gotten
that information about Dr. Maynard since DPS does not track those drugs.
"If he was writing all of these through Medicare and Medicaid, I would
assume that they would keep track of that," she said. Robert Evans, Dallas
DEA spokesman, said there is no federal prescription monitoring program.

There is a tracking system at the wholesale-distribution level of Schedule
I and II drugs, and controlled substances in Schedule III. Some pharmacists
buy from the wholesale-distributor level, he said. "If a doctor or someone
was prescribing something that was below what DEA looks at, at a federal
level, there would be no way we would know it unless someone brought it to
our attention," he said. "Then, of course, we would look at it." Meanwhile,
the Medicaid vendor drug program at the Texas Health and Human Services
Commission monitors physicians who prescribe drugs for reimbursement. But
problems aren't always caught. "We should catch it," said Aurora LeBrun,
associate commissioner for investigations and enforcement. "Sometimes you
do, sometimes you don't. ... Sometimes they know enough to stay below a
pattern of utilizing that will bring them to the attention of
investigators." The Texas Health and Human Services Commission monitors
Medicaid use, doctors' prescribing patterns and the recipients of Medicaid
benefits.

For about the last two years, the vendor drug program has used a new system
in which a computer analyzes patients' diagnoses and prescriptions against
normal standards and hunts for irregularities. Even then, problems might
not be flagged because the socioeconomic status of a doctor's practice and
the number of his patients are taken into account. "The system is built to
pay the claim and pay it on time," Ms. LeBrun said. "So, in the system,
yes, there's a large volume, but when you analyze it ­ there are things
that come into play. What type of population is he serving? Is his
clientele sicker than the average?

A lot of work has to be done before you come to conclusion that because he
is prescribing in a high pattern it is fraud or abuse." Another hurdle is
the fact that Texas has no way to compare records of patients who, for
example, pay for their doctor visit with federal Medicare but then pay for
their prescription with state Medicaid, she said. "Texas is one of two
states working with the federal government to start a data match project"
to compare Medicare and Medicaid information, she said.

Drug Risks

Controlled drugs are rated in the order of their abuse risk and placed in
schedules by the federal Drug Enforcement Administration. The drugs with
the highest abuse potential are in Schedule I, and those with the lowest
abuse potential are in Schedule V. Here is a look at the drugs in each
schedule: Schedule I ­ Drugs with a high abuse risk. These drugs have no
safe, accepted medical use and include heroin, marijuana, LSD, PCP and
crack cocaine. Schedule II ­ Drugs with a high abuse risk, but they also
have safe and accepted medical uses in the United States. These drugs can
cause severe psychological or physical dependence. They include certain
narcotic, stimulant and depressant drugs such as morphine, cocaine and
oxycodone. Schedule III, IV and V Drugs with an abuse risk less than
Schedule II. These drugs also have safe and accepted medical uses in the
United States. Schedule III, IV or V drugs include those containing smaller
amounts of certain narcotic and non-narcotic drugs, anti-anxiety drugs,
tranquilizers, sedatives, stimulants and non-narcotic analgesics. Some
examples are acetaminophen with codeine, paregoric, hydrocodone with
acetaminophen, diazepam and alprazolam.