PHYSICIANS ADD TO DRUG-ABUSE PROBLEMS IN MORE WAYS THAN ONE

Debby had kicked her heroin habit, regained custody of her two children and
was rebuilding her life when she went into the hospital for surgery. The
Demerol prescribed for post-operation pain triggered cravings she thought
she had conquered.

When the painkillers ran out, she satisfied the hunger the only way she knew
how: She went back to heroin.

Counselors at the Stanley Street Treatment and Resource Center in Fall River
where Debby eventually went to "detox" hear stories like this all the time.
So do workers at area methadone clinics. It's a variation on a theme
involving health-care providers, prescriptions and substance abusers.

Some physicians violate state and federal laws by writing prescriptions for
pain killers they know their patients don't need. Others are conned by
addicts faking pain. Still others treat patients for one problem without
being aware of another, such as a tendency to abuse drugs or alcohol.

The issue of physicians knowingly breaking the law made headlines last week
when Fall River psychiatrist Dr. Kennard Kobrin was arraigned on 82 counts
of Medicaid fraud, writing illegal prescriptions and accepting kickbacks.

Kobrin, who pled innocent to the charges, argued he was unfairly targeted
because of the nature of his practice. He said he uses prescription drugs to
treat such problems as mood swings, and depression. The state Attorney
General's Medicaid Fraud Control Unit alleges he knowingly wrote
prescriptions for Valium-like drugs for patients who did not need them.

The fraud unit prosecutes physicians who write excessive numbers of
prescriptions for excessive numbers of patients. According to a paper
Assistant Attorney General Peter Clark wrote for a national conference last
fall, treating Medicaid-eligible substances abusers allows physicians to get
paid for their visits and the patients to fill prescriptions at no cost to
themselves, wrote Mr. Clark.

The state's fraud unit has prosecuted a handful of cases in recent years, he
said.

In addition to the state's efforts, the federal Drug Enforcement
Administration is forming a special Boston-based task force to investigate
health-care professionals and others who illegally distribute prescription
drugs.

"We will be looking for pharmacists and doctors and other people illegally
diverting drugs, from major script forgers to people burglarizing
pharmacies," said Louis Fisher, manager of the DEA's New England Diversion
Program.

The new task force will include three to four DEA agents and six state
troopers, he said.

A decade ago, physicians and pharmacists were the most common offenders, Mr.
Fisher said. But authorities have noticed a trend involving support staff,
including nurses, office workers and clerks. The DEA handles a handful of
such cases in the region every year, he said.

The state Board of Registration in Medicine, which licenses physicians in
Massachusetts, also regulates such practices.

"The board does not view these cases lightly," said the board's executive
director Alexander S. Fleming.

But few physicians knowingly break the law, said Carl Alves, executive
director of the New Bedford Prevention Partnership. More common are the
cases where doctors are duped.

"Some addicts will get prescriptions from two different doctors," he said.
"Maybe both doctors are being prudent in their prescription but the addict
now has some extra drugs to sell or do whatever."

The board of medicine deals with these negligence cases, as well, said Mr.
Fleming. Punishment can range from the loss of a physician's medical license
to revocation of prescription-writing privileges.

Drug addicts can be very persuasive and persistent when dealing with
physicians, noted Sharon Morello, R.N., nurse manager at the Centers for
Health and Human Service's New Bedford methadone clinic.

"Sometimes they just wear them down," she said.

Mr. Alves, Ms. Morello and others involved in treating drug abuse have held
workshops with area physicians and hospital personnel.

"We can't sit around pointing fingers. We need to work together, to have a
multifaceted approach so physician's offices can get the support they need,"
said Mr. Alves.

In Fall River, staff at St. Anne Hospital's Lifeline methadone clinic say
they sometimes know when a new doctor has moved to the community because his
or her name may show up more frequently on client forms.

"We let them know. 'We're seeing a lot of prescriptions from your office and
you might want to ask more questions about why they needs this," said
Lifeline Director Lisa Garcia.

The prescription drugs most commonly seen on the street include Valium-like
pharmaceuticals such as Xanax or Klonopin, law enforcement officials say.
These drugs lower a person's heart rate and slow respiratory functions.

A sedative like Xanax sells for about 25 cents over the counter, but goes
for as much as $4 a pill on the street, according to the Drug Enforcement
Administration.

While such drugs can help a patient suffering from anxiety or depression,
they can easily be abused, said Nancy Paull, executive director of the
Stanley Street Treatment and Resource Center.

"They have a numbing effect. The bottom line is they can stop respiration,"
she said. "These are drugs that the physicians at our health center would
not prescribe unless there was dire necessity.

In addition, highly addictive drugs like Xanax and Valium are extremely
difficult habits to kick. The withdrawal process can lead to seizures and
even death, health professionals say.

A big issue for drug counselors has been coordinating medical care for
recovering addicts. Physicians need to be more alert to signs of addiction
and to understand that current or recovering addicts sometime need different
treatment plans, counselors say.

"People who have been in recovery, who have major surgery then take pain
medication as part of their regular medical protocol -- oftentimes that will
set off them into a relapse," said Mr. Alves. "And a lot of times folks
aren't up front with their doctors about addiction issues. It would be good
for doctors to understand addiction more."

Heroin addicts use heroin because heroin is the best pain reliever known to
man, he explained.

"You manage the pain and the next logical step to a recovering addict is
going back to heroin when the pain management stops."

Ms. Paull argued physicians need more training in how to confront people
with substance abuse addictions.

"People don't like to confront other people about touchy subjects and
physicians are no different. Addicts have a defense mechanism that makes it
difficult," she said.

Staff at the Center for Health and Human Service's methadone clinic in New
Bedford try to join the dialogue between patients and their doctors, said
Ms. Morello.

Patients are asked to sign agreements allowing the center to contact their
physicians. If the staff suspects a patient may be abusing a prescription
drug and that patient refuses to sign such a release, he or she may be cut
from the methadone program, Ms. Morello said.

"That has happened very rarely," she noted. "I tell patients we can't work
with one part of your health without talking to your other physicians."

Recently, the staff at the clinic held a workshop with emergency room staff
at St. Luke's Hospitals in New Bedford to explain methadone and likely ruses
patients might use to obtain prescription drugs.

The Southcoast Hospital group also works with the DEA to educate physicians
about the danger of prescribing drugs and signs and symptoms to look for in
drug abuser, said hospital spokeswoman Amy Blustein.

Lifeline in Fall River follows a protocol similar to the Center for Health
and Human Services.

"If we find someone is coming in with slurred speech and we feel they are
abusing their prescription medications, we automatically have them sign a
release form and we contact their physicians and say we are concerned," said
Ms. Garcia.

At the opposite end of the spectrum, notes Ms. Morello, are patients with
substance-abuse problems who are under-medicated for legitimate pain.

"We over prescribe to the abusing group who are looking to self-medicate.
And we under medicate those who really need it," she said.

"If a patient has a broken leg, just because he's on methadone doesn't mean
he doesn't feel pain."