One reason behind Nevada’s problem with narcotic painkillers

By Marshall Allen

Tuesday, Sept. 16, 2008 | 2 a.m.

A Las Vegas man says his Henderson physician turned him into a drug addict and caused him to overdose by prescribing him as many as 1,170 narcotic painkillers in a single month.

The prescriptions by Dr. Kevin Buckwalter were so extreme, and the documentation so bad, that four pain management experts who examined the patient’s medical records at the Sun’s request say the overprescribing could constitute malpractice and violations of law.

Buckwalter’s prescribing habits have been the subject of at least one previous investigation by the Nevada Medical Examiners Board, according to medical board correspondence sent to the family of a different patient who filed a complaint against him. And he’s the subject of a current investigation by the board, according to correspondence by investigators.

The patient, Michael Hammond, a Las Vegas business executive, is not the only person to complain about Buckwalter.

The Sun has spoken with the families of two people, in addition to Hammond, who have overdosed while under Buckwalter’s care. Their claims are supported by medical records and death certificates.

The pain management doctors who analyzed Buckwalter’s care said there was no documented evidence to justify the amount of narcotic medicines Buckwalter prescribed to Hammond, based on their review of all of the patient’s records involving Buckwalter.

They all agreed that Buckwalter should be investigated.

“I’m not sure this guy belongs practicing medicine — and certainly not pain management — if this is representative of his care,” said Dr. David Kloth, a Connecticut specialist who is a past president of the American Society of Intervention Pain Physicians.

Kloth said the amount of painkillers prescribed for the patient might be appropriate if the patient were dying of cancer. But Hammond did not have cancer.

Hammond contacted the Sun after the paper published a series of stories highlighting Nevada’s high per capita rate of narcotics use.

The growing consumption is blamed in part on drug addicts who “doctor shop” — visit multiple physicians with complaints of pain to score drugs. But the medical community is concerned, too, about doctors who overprescribe narcotics. Medical schools do little to train doctors in prescribing narcotics, and many primary care physicians do not understand them, experts said.

To combat drug abuse, the Nevada Pharmacy Board maintains a database detailing every prescription in the state for certain controlled substances. The database is intended to flag doctor shoppers, not police the prescribing habits of physicians.

By law, patients have a right to their own prescription and medical records, so Hammond was able to request them from the Pharmacy Board and Buckwalter so the Sun could verify his claims.

Hammond said he had selected Buckwalter as his primary care physician. After a neck injury the doctor began an intense regimen of painkillers, including hydrocodone and oxycodone, without explaining their potential for addiction and overdose, Hammond said.

Hammond said that within months, he had no more pain complaints — but by then was addicted to the drugs. Hammond says the change was subtle, and that he didn’t realize he was addicted to the pills until he had been taking them for many months. He says he took them because they made him feel good, and he trusted the doctor.

“I didn’t know what I was taking,” Hammond said. “I should’ve googled it. I blame nobody but myself.”

Hammond is more upset about this: Buckwalter’s prescriptions continued even after he nearly died from an overdose of the pills in August 2007.

Pharmacy records show that Buckwalter prescribed medications to Hammond from January 2005 to June 2008. In that period he was prescribed about 1,530 doses of alprazolam, an anti-anxiety drug known by the brand name Xanax; 11,350 oxycodone, many of them under the brand name Endocet; 5,740 hydrocodone pills; and 1,440 doses of hydromorphone, a type of morphine.

In June 2007, Hammond was prescribed 1,290 pills — a daily average of 34 narcotic painkillers, five Xanaxes, three Somas, a muscle relaxer, and one Ambien, a sleep aid.

Hammond insists he was taking the drugs at the levels prescribed by Buckwalter.

“I was taking his prescriptions on his word,” Hammond said. “He’s the professional. I trusted him.”

Buckwalter graduated with a medical degree from Ross University in the West Indies in 1993. In 1997 he received his Nevada medical license to practice pediatrics and family medicine. He has no record of being disciplined.

The newspaper made multiple visits to Buckwalter’s office on St. Rose Parkway in Henderson and delivered a letter that included Hammond’s name and the allegations in this story.

Bryce Buckwalter, the doctor’s brother and attorney, would not comment other than to say Buckwalter had rendered the appropriate treatment for the symptoms Hammond presented.

The experts who reviewed Hammond’s medical records at the Sun’s request were unanimous in their conclusions, which they expressed with varying degrees of alarm.

Dr. Andrea Trescot, a Florida pain specialist who wrote a guide for prescribing opiates for the American Society of Interventional Pain Physicians, said Hammond may have grounds to sue Buckwalter.

The records, Trescot said, show:

• No legitimate medical need for the narcotics.

• Multiple prescriptions at the same time for the same or equivalent medications.

• Quantities of pills “far above” a reasonable amount.

Under Buckwalter’s care, Hammond apparently became addicted to the medications “either through maliciousness or blatant disregard of the dangers of this class of medicines” — which equates to malpractice or criminal behavior, she said.

Trescot said Buckwalter’s patient records for Hammond are so incomplete that there’s no clear medical reason for the prescriptions. Buckwalter did order imaging of Hammond’s back and neck but the findings were unremarkable, she said. And there should be a log of the medications prescribed with a justification for each, she said.

After Hammond began requesting the drugs, it was the doctor’s responsibility to ensure they were necessary, she said.

The use of prescription narcotics in Las Vegas has reached crisis proportions, experts have told the Sun. The newspaper’s analysis of Drug Enforcement Administration data showed that Nevadans per capita consumed more hydrocodone — also known as Vicodin or Lortab — than residents of any other state. They were ranked fourth per capita in the use of methadone, morphine and oxycodone, the main ingredient in OxyContin.

The increasing use of prescription narcotics is linked to an increase in overdoses of the drugs, which now exceed the number of fatal overdoses of illicit drugs.

Hammond realized he was addicted when he moved from Las Vegas but then flew back to get more narcotics from Buckwalter. He admits to lying to Buckwalter about being in pain to get drugs. The encounter sheets in Hammond’s medical file show visit after visit in which his chief complaint is “Rx refill.”

The addiction resulted in the loss of several jobs, Hammond said. He said he plans to file a complaint with the state Medical Examiners Board.

Hammond’s drug use may not have been flagged by the Pharmacy Board’s prescription tracking system, primarily because he was not doctor shopping.

Pain management experts say one of the challenges in prescribing narcotics is that pain is impossible to verify. However, doctors are expected to conduct physical examinations and search for the source of the pain, or refer the patient to a specialist if the problem is ongoing.

Hammond said he did not understand the dangers of narcotics when Buckwalter started prescribing them in January 2005. He said he would describe his pain to Buckwalter but did not undergo a physical examination.

“He’d write scripts for oxycodone, Xanax, Endocet and Vicodin and say, ‘Take whatever you need,’ ” Hammond said.

Records show monthly visits for prescriptions with the volume of drugs reaching a peak in mid-2007.

• In May 2007 Buckwalter prescribed Hammond 1,020 doses of narcotic painkillers, plus 30 doses of the sleep aid Ambien and 90 of Soma, a muscle relaxant.

• In June Buckwalter signed prescriptions for 1,020 doses of narcotics, 30 of Ambien, 90 of Soma and 150 of Xanax.

• In July, Buckwalter approved 1,170 doses of narcotics.

On August 7, 2007, Buckwalter added a stimulant to the mix, Dextroamphetamine, probably because Hammond was heavily sedated by the narcotics, experts speculated.

Hammond said he took the drugs as prescribed and by summer 2007 was up to about 40 pills a day. He was working in another state on August 23, 2007, when he almost died from a drug overdose.

Toxicology tests from Hammond’s four-day hospital stay showed he’d overdosed on amphetamines, opiates and Xanax.

Hammond says the doctors at the hospital informed Buckwalter about the overdose. And on his next visit with Buckwalter, the two discussed the overdose, he says. Buckwalter downplayed the experience, Hammond contends, saying it was caused by the amphetamines, not the opiates.

Medical records do not indicate whether the two talked about the overdose.

In September, records show, Buckwalter stopped Hammond’s prescription for amphetamines but continued prescribing 620 narcotic painkillers. The next month the number of narcotic doses climbed to 820, records show.

Trescot called it alarming that Buckwalter continued prescribing Hammond narcotics after his overdose, if in fact Buckwalter was aware of it. “To continue to write medicines for this patient in the face of a severe side effect of the medicine in unconscionable,” she said.

A Las Vegas primary care doctor who specializes in pain management reviewed Hammond’s records and called the number of pills “staggering,” “scary” and “horrible.”

“Somebody should investigate this,” the doctor said after insisting he not be identified. “They should look at (Buckwalter’s) records and look at his practice and make sure he’s not hurting people. In this particular case I’m concerned that he might have hurt this man.”

Kloth, the Connecticut pain specialist, said Buckwalter’s record-keeping was so poor it is impossible to justify the treatment — and it could be against the law to bill insurance companies based on such insufficient records.

In other cases, medicating a patient inappropriately to the point it leads to addiction has been used as grounds for malpractice, he said.

A Las Vegas pain specialist, who demanded anonymity, agreed with Kloth.

He said Buckwalter’s records of Hammond’s care show no diagnosis or attempt to figure out why Hammond was in pain, no assessment of his improvement, complications or condition, and that in addition to excessive opiate use he prescribed only short-acting narcotics.

“In addition to the risk of overdose and dangerous and unpredictable drug interactions, the amount of acetaminophen was excessive” and potentially toxic to the liver, the doctor said

“A complaint to the Nevada Board of Medical Examiners is certainly in order and should initiate an investigation which should result in a reprimand and the requirement for more education,” the Las Vegas pain specialist said.

Hammond recently went through a supervised outpatient addiction recovery program and said today he is drug-free.

Sun reporter Alex Richards contributed to this story.