Texas Medical Board Shuts Down Pill Mills
Law Feature – July 2011
Tex Med. 2011;107(7):41-45.
By Crystal Conde
Texas has fewer pill mills churning out massive volumes of prescriptions for powerful narcotics thanks to the Texas Medical Board (TMB).
"We're seeing blatant violations," said TMB Executive Director Mari Robinson, JD. "This is crime, pure and simple; it's not the legitimate practice of medicine. Pill mills are the largest problem TMB must tackle in Texas right now."
The "blatant violations" Ms. Robinson cites include clinics registered to a physician who has never visited the site, clinics run by unlicensed foreign medical graduates, midlevel practitioners working at pain clinics with no physician oversight, and doctors who see 300 people a day and issue each one the same three prescriptions.
"What the board is doing right now is cutting off drug dealers' sources of income," she said.
Since Sept. 1, 2010, pain management clinics must be TMB-certified to continue operating. The board has been busy enforcing the law. At press time, TMB had suspended 11 pain management clinic certificates and five physicians' medical licenses because of rule violations. The board had received 491 applications for pain clinic certification. Of those, the board denied 26 and granted 362, while 34 were withdrawn and 69 were pending.
Ms. Robinson says the board may deny applications if the physician owner has a restricted license, a felony on his or her criminal record, or has been disciplined by the board for past nontherapeutic prescribing violations.
When it comes to disciplining physicians for violating pain management clinic regulations, Ms. Robinson says, the board pursues the most egregious offenses first.
According to the U.S. Drug Enforcement Administration (DEA), diversion of hydrocodone products and pseudoephedrine continues to be a problem in Texas. Primary methods of diversion are illegal sale and distribution by health care professionals and workers, "doctor shopping" (going to a number of doctors to obtain prescriptions for a controlled pharmaceutical), forged prescriptions, pharmacy theft, and the Internet.
Cris Schade, MD, PhD, a Garland pain medicine specialist and past president of the Texas Pain Society, says the state is in the midst of "Generation Rx," a national public health crisis of more overdoses from prescription medications than from heroin, cocaine, and inhalant use combined. For example, Scientific American reported in 2010 that a West Virginia University School of Medicine study of deaths and hospitalizations caused by prescription drugs between 1999 and 2006 showed that "overdoses of opioid analgesics alone … were already causing more deaths than overdoses of cocaine and heroin combined."
According to Dr. Schade, physicians involved in pill mill activity often share the following common characteristics:
- They're self-declared experts in pain management with little or no training in the field.
- They're not up to date on pain management literature.
- They don't attend pain management education courses or conferences.
- They have ethical problems and cognitive impairment.
In the long run, the law relating to the certification of pain management clinics will benefit Texas' health care system and the state's residents, Dr. Schade says.
"The law addresses this serious prescription pill pandemic affecting Texas. We'll always have addicts, but as physicians, we want to treat them, not enable them," he said.
Law Provides Balance
Dr. Schade testified for TMA in 2009 in support of Senate Bill 911 by Sen. Tommy Williams (R-The Woodlands). The law, which took effect Sept. 1, 2010, directs TMB to adopt rules to ensure quality of patient care and to establish personnel requirements at pain management clinics.
The regulations require the owner of a pain management clinic to be a physician practicing in Texas with an unrestricted license who is on site at least 33 percent of the clinic's operating hours and to review at least 33 percent of the patient files, including files belonging to a clinic employee or contractor authorized to care for patients. In addition, the clinic owner must not have been disciplined for inappropriately prescribing, dispensing, administering, supplying, or selling a controlled substance.
Senator Williams says accidental poisoning from prescription drugs continues to rise in all parts of Texas, with the state's pharmacies reporting a 24-percent increase in sales of hydrocodone for the first nine months of 2010 compared with the same period in 2009.
"The misuse of prescription drugs presents enormous costs to Texas since most overdose cases are presented through emergency rooms. Treating physicians first must determine what patients have taken, increasing the cost of treatment. Many of these cases end up in the ICU covered by taxpayers through Medicare, Medicaid, or other government programs," Senator Williams said.
Dr. Schade says SB 911 responded to a need for a balance between access to quality pain medicine care and preventing narcotic diversion. Before SB 911, TMB had no rules on ownership and operation of pain management clinics.
"The action taken by TMB under the new law has been very positive. The board is doing an excellent job, and the law is working as we'd envisioned," he said.
The law applies only to clinics that issue prescriptions for opioids, benzodiazepines, barbiturates, or carisoprodol monthly for at least 50 percent of their patients. Suboxone isn't included. Medical and dental schools, hospitals, hospices, and some other entities aren't subject to regulations. (See "Pain Management Clinic Certification Facts.")
Dr. Schade says that exemption is essential for surgeons and oncologists, for example, who prescribe controlled substances and pain medicine to many, if not all, of their patients.
To register a pain clinic, click here [PDF] to fill out the form. At press time, processing for certification was typically two weeks after TMB receives the form.
Board Exercises Authority
The most severe penalty TMB can levy against a physician for violating pain management clinic rules is revocation of a medical license. At press time, TMB had not revoked any licenses, but Ms. Robinson said it was seeking revocation of licenses for some physicians with temporarily suspended licenses.
Leigh Hopper, TMB public information officer, says the board cannot comment on revocation cases while they're in progress. She adds that to permanently remove a physician from practice, TMB must either file the case with the State Office of Administrative Hearings (SOAH), or the licensee must sign an agreed order of surrender of the license.
In addition to disciplining physicians for violations related to pain management clinics, the board disciplines physicians for nontherapeutic prescribing violations. To date, Ms. Robinson says one physician has surrendered her license because of such a violation.
On Feb. 18, a disciplinary panel of the board temporarily suspended, without notice, the medical license of Annie Christine Z. Walker, MD, of Forney. The panel found Dr. Walker inappropriately prescribed controlled substances to seven patients, including one who died from an overdose Jan. 1. Dr. Walker acknowledged that she had no medical records for any of the seven patients, according to TMB.
In addition, the board says Dr. Walker admitted prescribing to her daughter, son-in-law, and grandson, and kept no medical records for them. Dr. Walker, 88, who cannot walk unassisted, saw patients in her home, where she kept prescription pads unsecured and charged patients $20 per prescription, according to TMB.
She voluntarily surrendered her license April 8.
Ms. Robinson says complaints are the primary way TMB becomes aware of potentially illegal prescribing of pain medications and controlled substances. Anyone can file a confidential complaint on the TMB website by filling out a short form.
In addition, she says, media coverage or contact from the Texas Department of Public Safety (DPS) or other law enforcement agencies can alert the board to possible criminal activity. Board rules stipulate that unless it would jeopardize an ongoing investigation, TMB will give at least five business days notice before an on-site investigation. In addition to inspecting a pain management clinic, TMB rules authorize the board to examine a physician's documents, such as medical records.
TMB has conducted education and outreach for physicians related to the pain management clinic regulations. Ms. Robinson says the board has included information about the rules on its website, www.tmb.state.tx.us, and in its bulletin.
Ms. Robinson also spoke at a pain medicine continuing medical education (CME) seminar hosted by the Texas Pain Society at TexMed 2011 in Houston. The seminar, "Pain Clinic or Pill Mill – What's the Difference?" informed attendees about the rules and updated them on what the board is doing to stop the illegal flow of prescription drugs and save lives.
Houston Hot Spot
All of the 11 pain clinic certificates TMB had suspended at press time were in the Houston area.
On Jan. 11, a TMB disciplinary panel temporarily suspended the pain management clinic certificate of Houston's Spring Wellness Center, barring it from operating until further notice, after determining it was a continuing threat to the public.
The board found the clinic violated state law requiring it to be owned and operated by a medical director who is a physician practicing in Texas with an unrestricted license; requiring the owner of the clinic to be on site at least 33 percent of the clinic's operating hours; and requiring physician assistants to be supervised by a physician.
TMB investigators and DEA agents inspected the clinic. They learned it is owned and managed by Jillian S. Graham and Derrick Z. Goodwill, both licensed Texas physician assistants, even though the pain management certificate had been issued to Jesus Caquias, MD, of Brownsville, in 2010. But, according to Mr. Goodwill and the evidence, Dr. Caquias does not own and has never visited the clinic.
In February, the medical board entered a final order for the voluntary and permanent surrender of Dr. Caquias' certificate for the clinic.
This was TMB's second enforcement action against a pain clinic.
The first order came in October 2010 when the board temporarily suspended the medical license of David Shin, MD, and temporarily suspended the pain management clinic certificate of Better Life Pain Clinic LLC in Houston.
On Oct. 26, 2010, the clinic resumed operating with a suspended pain management certificate until DEA officers searched it on Nov. 4. An investigation by a Harris County Sheriff's and the DEA Task Force revealed employees who weren't licensed physicians, physician assistants, or advanced practice nurses had been administering prescriptions for controlled substances to patients.
On Nov. 19, Dr. Shin was indicted in Harris County on a felony count of engaging in organized criminal activity. On Dec. 7, a TMB disciplinary panel suspended Dr. Shin's medical license and his pain management clinic certificate.
Since then, the board has continued cracking down on pill mill activity. In February, it temporarily suspended the certificates of four clinics, three in Houston and one in The Highlands, barring them from operating until further notice.
On Aug. 20, 2010, TMB had issued four pain management clinic certificates to Akili Graham, MD, as owner and operator of the clinics. However, on Jan. 6, 2011, during an investigation of prescribing habits at the clinics, board staff obtained information that neither Dr. Graham nor any other physician owned the clinics.
The clinics investigated were:
- Imed Clinic Inc., in Houston, owned by Danny A. Muhammad, a nonphysician;
- Preferred Medical Clinic in Houston, owned by Durce Muhammad, a nonphysician;
- The Oaks Medical Clinic Inc., in The Highlands, owned by Danny A. Muhammad; and
- UMAT Clinic, LLC, in Houston, owned by Tamu Muhammad, a nonphysician.
TMB said the clinics were prescribing large amounts of dangerous drugs and controlled substances and were a threat to the public.
April was also a busy month for the board. On April 15, TMB temporarily suspended without notice the Texas medical license of Rosemary Ann Stogre, MD, as well as the two pain management certificates she held for two clinics: South Houston Treatment Center, LLC, in Webster, and Alliance Treatment Center LLC, in Houston.
DEA and TMB investigators visited Dr. Stogre in her office at South Houston Treatment Center the previous month to discuss reports of nontherapeutic prescribing and pill mill-type activities. Dr. Stogre voluntarily surrendered her DEA and DPS controlled substance privileges, barring her from prescribing them in Texas.
According to TMB, pharmacy records showed, however, that Dr. Stogre continued to prescribe controlled substances to several patients after March 1.
On April 25, the board temporarily suspended the medical license of Victoria physician Uma Rani Gullapalli, MD, and certificates for two Houston pain management clinics that had been issued to her for Winrock Medical Clinic and Houston Pain & Rehabilitation Clinic after determining a physician did not own them.
According to TMB, Dr. Gullapalli admitted someone else owns the clinic and pays her $20,000 a month with a bonus of $5,000 "if business has been good." Dr. Gullapalli said she saw patients for their initial visit only.
TMB discovered the clinic employed two unlicensed foreign medical graduates who examined patients and wrote prescriptions, which Dr. Gullapalli signed. In addition, Dr. Gullapalli charged patients $200 to $300 for monthly follow-up visits, though the patients are not actually seen but instead received their prescriptions through the mail, according to TMB.
To access board orders issued to pain management clinics, visit the TMA website.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email .
Pain Management Clinic Certification Facts
A pain management clinic may not operate in Texas unless the owner and operator is a medical director who:
- Is licensed to practice medicine in Texas;
- Has an active, unrestricted medical license; and
- Holds a certificate of registration for the pain management clinic.
In addition, the owner and operator of a pain management clinic, a clinic employee, or a person with whom the clinic contracts for services may not:
- Have been denied, by any jurisdiction, a license issued by the Drug Enforcement Administration (DEA) or a state public safety agency under which the person may prescribe, dispense, administer, supply, or sell a controlled substance;
- Have held a license issued by the DEA or a state public safety agency in any jurisdiction, under which the person may prescribe, dispense, administer, supply, or sell a controlled substance, that has been restricted; or
- Have been subject to disciplinary action by any licensing entity for conduct that was a result of inappropriately prescribing, dispensing, administering, supplying, or selling a controlled substance.
A pain management clinic may not be owned wholly or partly by a person who has been convicted of, pled no contest to, or received deferred adjudication for:
- A felony offense; or
- A misdemeanor offense related to the distribution of illegal prescription drugs or a controlled substance.
The medical director of a pain management clinic must annually ensure that all personnel are:
- Properly licensed (if applicable);
- Trained with, but not limited to, 10 hours of continuing medical education related to pain management; and
- Qualified for employment.
Certificates are valid for two years. Certificate holders have a 180-day grace period from the expiration date to renew the certificate; however, a clinic may not continue to operate while the certificate is expired.
Regulations regarding the registration and operation of pain management clinics do not apply to:
- A medical or dental school or an outpatient clinic associated with a medical or dental school;
- A hospital, including any outpatient facility or clinic of a hospital;
- A hospice established under state or federal law;
- A facility maintained or operated by the state of Texas;
- A clinic maintained or operated by the United States;
- A nonprofit health organization certified by the Texas Medical Board under Chapter 177 of board rules;
- A clinic owned or operated by a physician who treats patients within the physician's area of specialty who personally uses other forms or treatment, including surgery, with the issuance of a prescription for a majority of the patients; or
- A clinic owned or operated by an advanced practice nurse licensed in the state who treats patients in the nurse's area of specialty and uses other forms of treatment with the issuance of a prescription for a majority of the patients.
Source: Texas Medical Board
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