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Date Posted: 09:42:48 12/20/03 Sat
Author: Jolly
Subject: Easy access to powerful drugs is becoming increasingly deadly
In reply to: Billy 's message, "Online drugs a health risk, officials warn" on 03:29:51 12/16/03 Tue

Easy access to powerful drugs is becoming increasingly deadly

By David Hasemyer
UNION-TRIBUNE STAFF WRITER

December 20, 2003



DAN TREVAN / Union-Tribune
Dr. Jon Opsahl poses for a photo in his company's Colton office. Opsahl had his medical license revoked in February after writing prescriptions for the antibiotic cipro that drew the attention of the California medical board.

From her nondescript office in a strip mall on Paradise Valley Road, Dr. Dianna Norman prescribed potentially deadly doses of stimulants and other powerful drugs to people she had never seen, much less examined.

Sitting at her computer, she used the Internet to prescribe hundreds of thousands of pills to people from Minnesota to Florida. For $99 a month, court records show they could buy a supply of Phentermine, Xenical or Meridia addictive weight-loss pills.

The only "examination" Norman performed on her cyber patients was instructing them to fill out a questionnaire about their medical history.



Online doctors retained licenses despite troubles




"Please be truthful," the online registration form urged.

Cyber doctors throughout the United States are prescribing drugs for people who sometimes get hooked on them, try to commit suicide with them or, increasingly, overdose and die on them.

The 2001 death of Ryan Thomas Haight, an 18-year-old from La Mesa, has been connected to prescriptions filled via the Internet. So has the April death of a 47-year-old Sacramento man.

"You send in the money, they send out the drugs. That's all there is to it," said Nancy Harler, a South Carolina nurse who was hooked on narcotic pain medication and fed her addiction with pills prescribed over the Internet by a San Bernardino County doctor.

The ease with which Internet prescriptions are written and filled and the lack of government resources to control the practice has state regulators across the country worried that more people will die.

"From our perspective, Internet prescribing has become one of the biggest threats to public safety," said Dr. James N. Thompson, president of the Federation of State Medical Boards, which represents 70 medical and licensing boards across the country.

There are no federal laws to regulate Internet prescribing and no way of knowing how many doctors are doing business online or how many customers they are attracting.

So far 28 states, including California, have passed legislation regulating the practice. The California law states, in essence, that doctors must physically examine their patients before prescribing medication.

Some states are overwhelmed by the task of penetrating the layers of cyberspace that shield doctors.

Kristine Smith, spokeswoman for the New York State Department of Health, said her agency hasn't even begun to craft rules for the Internet, because "it's almost impossible to find the doctors doing this."

As frustrated authorities scramble to police the Internet, doctors continue to set up cyber offices where they e-mail prescriptions to anyone with a credit card and a self-diagnosis.

"Rather than see three patients in one hour, a doctor can sit on the Internet and prescribe to 600 people in an hour and make a lot more money," said Dr. Hazem Chehabi, president of the California medical board.

Since California's law went into effect in 2001, 12 California doctors have had their licenses revoked or faced other discipline for prescribing over the Internet. The medical board also has fined six out-of-state doctors millions of dollars for prescribing to Californians.

Since June, however, the board's job has become more difficult. That's when it lost its only investigator dedicated to tracking cyber doctors.

Paul Nasca, a former Sacramento cop with degrees in genetics and biology, nabbed 24 doctors some whose cases are pending in the two years he held the job.

But when Nasca left for a higher-paying job, the board couldn't replace him because of a state hiring freeze. Board officials acknowledge that catching cyber doctors is now more likely to happen by chance than by investigative scrutiny.

Shutting down every doctor who prescribes over the Internet is an impossible task, said Ron Joseph, the medical board's executive director. There are simply too many of them and too few investigators to go after them.

"We can't come close to getting them all," Joseph said.

Other states also are scrambling for money to fund cyber investigations, which can be painstakingly slow and sometimes fruitless.

"States have to get the most bang for their bucks," said Dale L. Austin, chief operating officer for the Federation of State Medical Boards.

"It's like looking for a needle in a haystack," Austin said. "So state boards are putting their resources into investigations that yield more results."


DEA launches sting
Authorities stumbled onto Dianna Norman's Internet doctoring during a routine review of U.S. Drug Enforcement Administration records covering drug purchases by doctors in 1999.
They found that the South Bay Terraces doctor was buying enough weight-loss drugs to qualify as a distributor, according to a medical board accusation filed in administrative law court here. They also discovered that Norman, who has been licensed to practice medicine in California since 1981, had a Web site offering diet drugs for sale.

The DEA notified the medical board and launched a sting.

An investigator rented mailboxes in Valley Center, Holtville and Santa Ysabel under different names. Then she went online and filled out the doctor's questionnaire.

On some of the forms, the investigator listed a weight that clearly indicated she was not obese and therefore not a suitable patient. On other forms, she indicated she was taking drugs that would have a deadly reaction if mixed with the drugs Norman was prescribing.

Norman sent the drugs anyway. When the DEA searched her office and home, they found nearly 2,000 charts. One 89-pound drug addict told investigators that Norman had sent her Phentermine, an amphetaminelike drug used for weight loss.

Through her lawyer, Norman, who is 50, declined a request to discuss the case.

"She wants to put this behind her and get on with her life, and talking about it further stirs up the emotions," attorney Keith Greer said.

Instead of facing a hearing, Norman agreed last year to a two-month suspension of her license, five years' probation and an assessment of her medical skills. She'll also have to take an ethics course and a medical refresher course on prescribing.


Two crucial questions
The anonymous cloak of the Internet raises two crucial questions:
Are the doctors who they say they are? And do their patients really need the drugs?

Doctors "need to know if they are prescribing Viagra to a 17-year-old boy or Phentermine to a 120-pound woman looking for an amphetamine rush," said San Diego-based Deputy Attorney General Mary Agnes Matyszewski, one of four lawyers statewide who handle Internet prosecutions for the medical board. "They have no idea."

Dr. Jim Knight, president of the San Diego Medical Society, said patients seeking medical help from a computer instead of in a doctor's office take an even bigger risk because they can't verify the credentials of the person who is writing the prescription.

If a doctor doesn't fully understand a patient's illness and medical history, the drugs being prescribed could have deadly interactions with other medications or aggravate existing medical conditions.

Dr. Steve Green, chairman of family practice at Sharp Rees-Stealy, used the example of a man getting Viagra without a physical exam. What seems to be a sexual problem could actually be a sign of a pituitary tumor or of high blood pressure, he said.

"Letting people do these things outside of a clinical setting no matter if the motivation for the patients is to save time and money is potentially dangerous," Knight said. "You're really blind on the Internet."


Feeding addictions
Cyber doctors ignore medicine's basic principles: to know their patients and do them no harm.
Dr. Jon Opsahl, a San Bernardino County doctor who prescribed to Nancy Harler, Amanda Bridges and Barbara Benoit, neither knew his patients nor cared about them, state medical officials said in the accusation that led to the revocation of his license in February.

Harler turned to the Internet two years ago after her family doctor refused to continue prescribing Lortab, an addictive painkiller, for her arthritis. With just a few keystrokes and a Google search, she found Opsahl. Getting him to prescribe Lortab was easy, she said.

"I could have said anything (on the questionnaire). The doctor had no way of knowing," Harler said in an interview from her home in Columbia, S.C. "The only thing he asked was how many do you want."

Opsahl fed Harler's escalating addiction from his office in Colton, 2,000 miles away. An Internet pharmacy filled the prescriptions from Las Vegas.

Harler introduced her daughter, Bridges, to the Web site, and soon Opsahl was prescribing Lortab to both mother and daughter, according to court records.

At one point, Opsahl agreed with Harler that she needed to reduce her dependence on the drug, and Harler decided to quit. But she continued getting Lortab for her daughter, according to her declaration filed with an administrative law judge.

Eventually, Harler said she realized her daughter's life was being ruined by the narcotics and asked Opsahl to wean Bridges from the drugs.

"I ... was surprised when she informed me that Dr. Opsahl continued to fax new prescriptions for her even when he was aware of her addiction," Harler said in her declaration.

"We are a good family, but we got caught up in this mess before knowing how devastating it could be," Harler wrote to Opsahl.

When Benoit hooked up with Opsahl last year, she was looking for someone to feed her addiction to the narcotic sleep aid Temazepam.

Opsahl didn't ask much about her medical history, and Benoit told him only that she had trouble sleeping and was in pain from a back injury.

"It was pretty simple," Benoit said in a telephone interview from her home in Wisconsin.

Benoit, 47, can't remember the day she almost died, but the details are preserved in police reports.

Her father found her in a stupor, so sedated she couldn't control her bodily functions or tell paramedics how many pills she had taken.

The instructions on the prescription she had obtained a couple of days earlier said to take one tablet a day for insomnia. But police reports stated that she had swallowed as many as 28 of the maroon and blue capsules.

Benoit, who was hospitalized for several days, said her addiction is now under control.


'Office in a Snap'
Opsahl came to the attention of the California medical board's Internet investigator shortly after the Sept. 11, 2001, terrorist attacks, when he used the Internet to sell Cipro, an antibiotic that is effective against anthrax.
He later linked up with the Internet site "Office in a Snap," which he used to prescribe the painkiller Vicodin and anxiety reducers Valium and Xanax.

Opsahl also operated another Web site, which he used to draw attention to his mother's murder in 1975. Myrna Opsahl was shot to death in Sacramento during a failed bank robbery by the Symbionese Liberation Army.

According to the medical board, Opsahl "repeatedly prescribed excess quantities of dangerous drugs" to 2,300 Internet patients in 2001 and 2002.

In an interview with The San Diego Union-Tribune from his office, Opsahl insisted that Internet medicine poses no risk to patients as long as they are being treated for a limited number of pre-existing disorders such as chronic pain.

"For some patients it's not in their best interests to turn to the Internet," he said. "But for others, let's make medicine convenient and available."

Although Opsahl, 43, didn't examine his patients, he told the medical board that he reviewed their medical records and talked with those who had previously diagnosed problems.

In a declaration filed in court, he said "no actual harm was caused to these patients by my actions."

"When it comes down to it, if a patient lies to you and denies that they are an addict and wants these meds, it's on them," Opsahl told the medical board through his lawyer. "It's their responsibility. What am I supposed to be, a mind reader? Even if I met them in my office, they might lie to me. So what's the difference?"

Opsahl told The Union-Tribune he stands by that statement.

"It sounds callous and uncaring, but that is how I feel," he said.

In February, the medical board stripped Opsahl of his medical license, and he now works as a sports medicine consultant.

The investigation that resulted in his punishment was led by Paul Nasca, the former cyber detective whose job with the California medical board remains unfilled.

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  • Despite troubles, doctors retained licenses for years -- Peter Mesen, 09:43:57 12/20/03 Sat
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