When Doctors Ignore Drug Tests for Opioid Patients

(Bloomberg) -- In April 2014, state and federal drug agents raided Jeffrey Campbell’s medical clinic in Jeffersonville, Indiana. Police cars blocked the parking lot as bewildered patients scattered and the agents carted off boxes of records from the doctor’s office.

Some of the seized records would show that Campbell endangered patients by prescribing opiates without any medical need, according to federal prosecutors. Campbell, who collected millions of dollars from Medicare for urine tests run at his office lab, also failed to act when test results revealed that patients were abusing prescription and illegal drugs, according to a government medical expert’s report.

Four patients died from drug-related causes under his watch, the report said, and others flunked two dozen or more urine tests while the clinic kept prescribing them pills. One patient with a history of overdoses failed 46 urine tests and was never confronted about it. Campbell denied wrongdoing.

The nation’s opioid crisis has prompted an explosion in urine testing. The scourge has driven huge profits for many pain clinics across the U.S., an ongoing investigation by Kaiser Health News shows. Spending on urine screens and related genetic tests quadrupled from 2011 to 2014, to an estimated $8.5 billion a year—more than the entire budget of the Environmental Protection Agency, according to an analysis of billing data from Medicare and private insurance billing from the Mayo Clinic.

Medicare and other insurers pay for urine tests with the expectation that clinics will use the results to detect and curb dangerous abuse. But some doctors have taken no action when patients are caught misusing pharmaceuticals or taking street drugs such as cocaine or heroin. Federal pain guidelines say doctors should discuss test results with patients and taper medication, if necessary. Medicare and private insurers acknowledge that they lack the resources to routinely verify that doctors who order a high volume of drug-related tests do so to improve patient care, not fatten the bottom line.

“This is a big issue,” said Louis Saccoccio, who heads the National Health Care Anti-Fraud Association, a group formed by private insurers and government officials. “There are abusive practices out there.”

­In nearly a dozen recent criminal cases, prosecutors have cited evidence that doctors supplied opiates to patients with repeated abnormal urine test results. One such doctor was Alabama pain specialist Shelinder Aggarwal, who billed Medicare and private insurers more than $9 million for urine tests solely “because he served to profit,” according to prosecutors in Alabama. He pleaded guilty to illegal prescribing and health-care fraud. Earlier this year, a judge sentenced him to 15 years in prison.

Theodore Parran, who has served as an expert witness for the federal government, predicted more doctors could face fraud charges or discipline by state medical licensing boards over lab testing that appears to be profit motivated. “This is certainly on their radar,” said Parran, a professor of medical education at Case Western Reserve University School of Medicine.

An investigation by KHN earlier this year found that dozens of pain doctors with their own labs took in $1 million or more in 2015 from Medicare for running urine and, in some cases, genetic drug tests. Some doctors derived at least 80 percent of their Medicare income this way.

Campbell’s office in Indiana was among the clinics billing Medicare the most in the country, according to analysis of Medicare billing records by KHN. The doctor and his staff at Physicians Primary Care PLLC billed the government agency a total of nearly $6 million for urine testing during 2014 and 2015.

In June, more than three years after the raid, a federal grand jury indicted Campbell and two associates. The charges include multiple counts of illegally distributing prescription drugs and health care fraud; one fraud count accuses Campbell of ordering costly genetic tests through an outside lab that were “not medically necessary and never interpreted.”

Neither Campbell nor his attorney, Page Pate, would comment for this story. However, in an interview several months before his indictment, Campbell said the government’s case was “without merit.” He denied he ran a “pill mill” and said he relied on his “state-of-the-art” lab, which serves the Jeffersonville clinic and a branch just across the Ohio River in Louisville, to help keep patients safe.

“We do a lot of drug testing for patients and we do it appropriately,” Campbell said.

Indeed, deciding how often to order these tests, and for which patients and drugs, can be a judgment call. Doctors also sometimes disagree over what action they should take against patients with “dirty” urine: Some doctors kick out drug abusers, while others argue doing so is unethical and counsel these patients toward substance abuse treatment.

Donald White, a spokesman for the U.S. Department of Health and Human Services’ Office of the Inspector General, said that, if test results are disregarded, “why is the test being ordered in the first place?” He said inaction gave reason to suspect that a “doctor’s treatment of the patient may fall below the standard of care.” 

Timothy King, the Indiana anesthesiologist who wrote the government medical expert’s report in the Campbell case, examined 19 patient files this year for his report. He concluded that Campbell “fails to practice medicine according to generally accepted medical principles and standards of care,” and “routinely” prescribed opiates “without a medical purpose.”

King said Campbell gave four patients a brew of pills known as the “Holy Trinity,” which King called “a street-popular combination of opiate, sedative and muscle relaxant that produces a heroin-like euphoria.” These four patients were prescribed refills despite repeated abnormal urine tests. Two failed two dozen or more urine screens, according to King’s report.

All 19 patients repeatedly failed their tests, which King described as an obvious warning sign that they were ingesting prohibited drugs or possibly peddling unused pills on the street. The four people who died showed telltale signs of trouble such as admitting they had diverted some of their medicine or had been visiting other doctors to feed pill habits according his report. 

A 25-year-old woman identified only by the initials “CM” had “vague” complaints of lower-back pain and used drugs “for purposes of abuse and diversion,” according to King. She died three days after the clinic issued her a prescription for painkillers methadone and hydrocodone, King wrote. “EL,” who was homeless and disabled, died from a drug overdose in July 2014, according to the report, three days after her office visit.

King also said Campbell appeared to order unnecessary tests, including X-rays, “to optimize billing.”

Less than a month after prosecutors received King’s report, a federal grand jury in Louisville indicted Campbell and nurse practitioners Dawn Antle and Mark Dyer. All have pleaded not guilty, and attorneys for Antle and Dyer also had no comment. No trial date has been set.

Indiana officials quickly suspended their licenses to practice. Prosecutors also are seeking forfeiture of Campbell’s Jeffersonville office building and other proceeds.

Campbell, in his interview preceding the indictment, argued that his practice attracts many difficult patients who have “no other option” to seek relief from pain. “Nobody else will see these people,” he said.

He ordered tests for a slew of substances because none of his drug-abusing patients “ever just uses one drug. They use everything they can get their hands on.”

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

To contact the editor responsible for this story: Aaron Rutkoff at arutkoff@bloomberg.net.

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