Legally, doctor is under no limits

By Marshall Allen

Tuesday, Oct. 21, 2008 | 2 a.m.

Despite the deaths of three patients and numerous examples of alleged prescription drug malpractice, Dr. Kevin Buckwalter is still allowed to see patients in Nevada.

Investigations of Buckwalter are continuing, but the Nevada State Medical Examiners Board has not suspended his license or taken any steps to force him to curtail his prescribing of large quantities of narcotic painkillers. The lack of action is coupled with regulations that prevent pharmacists from refusing to fill suspicious prescriptions.

The situation reveals major flaws in the state system of overseeing doctors, said Assemblywoman Sheila Leslie, D-Reno, chairwoman of the Legislative Health Care Committee.

Nevada’s “medical regulatory system has to be entirely reformed,” Leslie said.

Pharmacists should have complained about Buckwalter to the Medical Examiners Board long ago, Leslie said. And the medical board’s failure to take action shows a clear “disconnect between the medical board and what’s happening on the streets,” she said. The board has the authority to summarily suspend the license of a doctor who is putting patients in imminent harm.

“They can’t seem to intervene to stop the bad doctors from literally killing people,” Leslie said of the medical board.

Dr. Andrea Trescot, a Florida pain specialist who reviewed the cases of four Buckwalter patients at the request of the Las Vegas Sun, said the medical board has already waited too long.

“The guy’s license needs to be pulled now,” Trescot said. “He needs to have an emergency revocation of his license.”

The Sun reported last week that four medical doctors said Buckwalter’s prescriptions apparently contributed to the deaths of three patients whose records they reviewed. Buckwalter said in a sworn deposition that he performed no physical examination of one of the patients who overdosed and died, and gave her large quantities of drugs because she asked for them.

The Sun reported a month ago that Buckwalter prescribed thousands of narcotic painkillers to a self-admitted drug addict with no questions asked and no examinations performed, even after the man’s overdose on the pills.

The Sun has confirmed that the medical board is investigating Buckwalter.

Louis Ling, the board’s executive director, said state regulations preclude him from commenting on ongoing investigations, but he said the silence should not be interpreted as a lack of action.

Generally speaking, the threshold for the medical board to determine the incompetence of a physician is much higher than it is for the Sun to publish stories, he said. And doctors are well known for suing to maintain their licenses, he said.

“The medical board can take away their license, ruin their ability to make a living,” Ling said. “If that is appropriate, we want to make sure it is done in a legally supportive way.”

The Drug Enforcement Administration is also investigating Buckwalter, the Sun has confirmed. The agency will not comment on the case.

Buckwalter did not respond to requests to comment for this story.

Health care regulators primarily depend on patients or health care professionals to complain when they think something is wrong. In Buckwalter’s case, only one known complaint existed before the Sun’s investigation. In recent weeks, a half-dozen more have been lodged with various agencies.

In some instances, such as the case of Michael Hammond, it seems pharmacists should have known better than to fill prescriptions for large quantities of pills for Buckwalter patients.

Hammond, a businessman and self-described drug addict, told the Sun in September that Buckwalter prescribed him narcotics with no questions asked and no examinations required. In just more than two years, Hammond filled prescriptions for 13,760 narcotic pain pills at Evergreen Drugs & More in Henderson — an average of 510 a month.

In May, June and July 2007, records show, pharmacists at Evergreen Drugs filled narcotics prescriptions for Hammond of 1,020, 1,020 and 1,170 pills.

The pharmacist at Evergreen Drugs, an independent store near St. Rose Dominican Hospital—Sienna, refused to give his name when the Sun reached him on the phone. The pharmacist was asked why he continued filling Buckwalter’s prescriptions, and said there is no way for him to know the medical condition of a patient who presents him with prescriptions. Then he hung up.

Nevada State Pharmacy Board officials said state regulations sometimes put pharmacists in a difficult position, even when they’re asked to fill prescriptions for unjustifiably large quantities of potentially dangerous drugs.

In some legitimate cases, patients need extremely large quantities of painkillers on a monthly basis, the pharmacists said. Pharmacists do not have a patient’s medical records and do not conduct physical examinations, so it’s difficult to refuse prescriptions that appear to be legitimate.

Leo Basch, a pharmacist who sits on Nevada’s pharmacy board, said he’s heard from at least a half-dozen pharmacists who have questioned the quantities of controlled substances prescribed by Buckwalter. But pharmacists are allowed to deny a prescription only if they think it’s fraudulent, if they think it’s going to hurt the patient or if there’s no legitimate medical purpose for the drugs, the regulations state.

Some suspicious pharmacists did call Buckwalter to verify the prescriptions, regulators said, but the doctor said they were valid and should be filled. And without knowing the patient’s medical history, it was difficult to say there’s no medical need for the drugs, the regulators said.

Nevada’s controlled substances database — which tracks the details of every narcotics prescription in the state — is also of limited use in monitoring doctors. The database’s purpose is to identify drug addicts who shop for drugs by visiting multiple doctors. Larry Pinson, a pharmacist and executive director of the Nevada pharmacy board, pointed out the regulations that say the database must not infringe on the legal use of controlled substances to treat pain, which could be the case if regulators used the data to police those who prescribe narcotics.

The regulations also say the pharmacy board “shall report any activity it reasonably suspects may be fraudulent or illegal” to the appropriate authorities. This never happened in Buckwalter’s case, Pinson said, because the prescriptions were legitimate and it’s hard to reasonably suspect they were illegal. The use of the drugs may have constituted malpractice, Pinson said, but that would be for the medical board to investigate.

The pharmacists did take the only action they could to monitor Buckwalter, regulators said.

Ling, the medical board’s executive director, may have the most behind-the-scenes knowledge of the situation. Before August, he was the pharmacy board’s general counsel.

Ling said pharmacists started complaining about Buckwalter — and other doctors — after the Sun published an analysis of DEA drug consumption data in July. The Sun found that Nevada has a prescription narcotics crisis. Nevadans rank No. 1 nationally in per capita consumption of hydrocodone, commonly known as Lortab or Vicodin, and fourth for consumption of methadone, morphine and oxycodone, the primary ingredient in the often-abused drug OxyContin.

“After those stories ran, people were seeing in a macro view what many knew to be true in their personal views — there are an awful lot of controlled substances being misused in Las Vegas,” Ling said.

Pharmacists started calling the pharmacy board saying: “I’m getting all these crazy scripts for Dr. Buckwalter,” Ling said.

Pinson said Buckwalter’s license to prescribe controlled substances is issued by the pharmacy board, but it’s contingent on his license to practice medicine, which is granted by the medical board. Therefore, the medical board has jurisdiction, he said.

After the pharmacists complained, the pharmacy board sent a complaint to the medical board, which already had an open investigation on the doctor, Ling said.

Sun reporter Alex Richards contributed to this story.