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How high the cost for killing pain? Rise in addiction, deaths from prescription drugs is raising concerns locally and nationally

Dr. Eugene J. Gosy in Amherst prescribes more controlled substances than any other physician in New York State.

With a busy waiting room filled with patients suffering from back conditions, arthritis and other painful ailments, Gosy writes scripts for more painkillers, including addictive opioids, than any doctor even in the most populous downstate communities.

Gosy says that's because Gosy & Associates Pain and Neurology Treatment Center is the largest of its kind in the region, and perhaps in the state, with 2,700 doctors referring patients to his office.

Gosy describes his center as a "model" practice that has helped thousands of patients from as far away as Jamestown and Rochester with chronic pain return to work and improve their quality of life.

But with rising numbers of prescription painkiller addictions and deaths locally and nationally, and in the wake of the recent arrest in Niagara Falls of the second-largest prescriber of controlled substances in the state, concern is growing about the vast amount of these powerful drugs being dispensed.

"There's been a huge increase in abuse and dependence for prescription drugs," said William R. Burgin, a drug treatment professional who is executive director of Alcohol and Drug Dependency Services in Buffalo. "I'd like to tell you everyone who goes to a doctor for pain medication goes for drugs for themselves, but there is a big street trade The higher the amount of drugs in the community, the higher the potential of having problems."

"Are we pushing pills? No," Gosy said of the greater availability of painkillers. "There are standards for prescribing pain medication, although we should always be refining those standards."

Gosy's practice has come under some criticism in recent years.

He was sued twice in the past six years on behalf of current or former patients who fatally overdosed.

In one case, a jury found him negligent for causing the patient pain and suffering, but not for her death.

In the other, a jury cleared him, but questions linger over his use of methadone for treating an addicted patient's pain and withdrawal.

A physician can use methadone to treat pain, but needs special government registration to prescribe methadone for detox, according to U.S. Drug Enforcement Administration regulations. Gosy, who does not have the special registration, said the methadone he prescribed was for both pain and a tapered withdrawal in preparation for an alternative treatment, not primarily for detox, and was therefore permitted.

The DEA declined to comment on Gosy's case, but in general, a DEA official said, a prescription for a tapering dose of methadone for pain and withdrawal could be viewed as "circumventing the DEA regulation."

Gosy was also fined $1,000 in 2009 by the state Health Department for improper record-keeping related to controlled substances.

Gosy characterized the fine as a minor administrative issue and defended his work in both lawsuits.

Gosy is also among the Buffalo-area doctors a gang of street dealers scammed last year into prescribing painkillers they would sell on the streets.

"Pain clinics like ours are like magnets for prescription drug abusers," Gosy said. "We are known to be scrupulous, compassionate and strict. I believe we were doing as much as possible to monitor patients."

>Saw a need

The Hungarian-born Gosy, 50, joined the Dent Neurologic Institute in 1992 as an attending neurologist.

In 1999, he opened his own practice, working at Windsong Medical Park in Amherst. He expanded his practice in 2003, when he opened Gosy & Associates Pain and Neurology Treatment Center, on College Parkway, off Youngs Road. His medical staff of 11 includes two doctors, nurse practitioners and physician assistants.

Gosy traces his interest in pain management to experiences during his specialty training, a time in medicine when doctors were reluctant to prescribe opioids for chronic noncancer pain and many patients suffered.

"Patients were in pain for days on end, waiting for pain specialists to arrive," he said. "I saw the need and found that helping someone in pain is extremely rewarding."

Gosy is now the top prescriber of controlled substances in the state, The Buffalo News confirmed from multiple sources. The ranking is based on government tracking of prescriptions for controlled substances dispensed by pharmacies in the state.

Gosy said he believes his center also is the largest in the state -- in number of patients, which he declined to disclose, and medical professionals who provide care.

Gosy's No. 1 status means the two largest prescribers of controlled substances in New York are located in the Buffalo Niagara region. Controlled substances include stimulants, depressants and such commonly abused opioid painkillers as hydrocodone, oxycodone and fentanyl.

The No. 2 prescriber, Pravinchandra V. Mehta, a Niagara Falls physician, was arrested in late January and accused of operating his medical office as if he were a drug dealer. At the time, the DEA said there were 40,303 prescriptions for controlled substances written during a recent 2 1/2 year period from Mehta's prescription pads -- that's more than 3 million pills.

Gosy declined to comment on Mehta, an internist and endocrinologist operating out of a one-doctor office with no other medical personnel.

But he described as "eye opening" the arrests last July of 34 people from Buffalo and its suburbs who are accused of attempting to dupe doctors into prescribing them painkillers. Several of the drug ring members obtained prescriptions from Gosy's office, according to federal sources.

"We have to choose our patients very cautiously," Gosy said. "Those who sell the drugs we prescribe them are greedy. That greed will eventually show up when they overstep."

Doctor-shopping for narcotic prescriptions is a major problem around the country that has grown with the movement in recent decades to treat chronic pain more aggressively with opioids, the man-made versions of opium.

The greater availability of such drugs as OxyContin, an extended-release version of oxycodone, has brought relief to many pain sufferers. But it has led to emergency room visits for prescription drug abuse to double over the past five years, and fatal overdoses involving narcotic painkillers to more than triple from 1999 through 2006.

"Doctors are not necessarily attempting to get people addicted, but there is a tendency with these drugs to become addicted to them," said Burgin of Alcohol and Drug Dependency Services. "If we have more narcotics distributed in Western New York, it makes more sense we'll have more addiction issues."

Gosy said his patients are carefully monitored, and few -- less than 1 percent, he estimated -- become addicted to their medication.

Those who do get addicted are generally patients who take more drugs than prescribed, Gosy said. He estimated that 5 percent of the patients coming into his office misuse their medication.

"You have to strike a balance between prescribing pain medication to those who need it and being aggressive to weed out those who don't," he said.

Among Gosy's addicted patients was Alane Butler.

>Case of addiction

Butler was 46 when she began seeing Gosy in 2003, seeking relief from her lower back pain.

The hydrocodone, or Lortabs, he prescribed initially helped, but by early 2005, the pain worsened, and Butler began buying additional Lortabs off the Internet, according to court papers.

She was taking three times the amount Gosy prescribed and quickly became addicted.

Butler knew she needed help. She told Gosy her insurance wouldn't cover inpatient detox, a claim her family later questioned, and asked Gosy to treat her as an outpatient, according to court documents.

Gosy prescribed a tapering dose of methadone, according to court papers. That was Sept. 29, 2005. When Butler became sick from withdrawal on Oct. 3, she returned to Gosy's office.

Gosy suggested inpatient detox, but Butler preferred outpatient treatment, the doctor said in papers.

Butler's mother, Loretta Jones, who went with her daughter to Gosy's office, said it was she, not Gosy, who suggested hospitalization.

Gosy and his staff gave Butler a shot of Dilaudid -- hydromorphone -- for pain, as well as anti-nausea medication, and prescribed a low, tapering down dose of Lortabs -- hydrocodone -- to take with her methadone. Butler was then sent home.

On the morning of Oct. 4, Butler was found unresponsive, sleeping in a chair in her home. She was hospitalized, and remained in a coma until her death two days later, according to records filed with the court.

An autopsy found Butler died from lack of oxygen likely resulting from a drug overdose. No one drug was blamed, but rather multiple drugs in her system. They included hydromorphone, hydrocodone, methadone, anti-depressants, anti-nausea medication, cocaine and marijuana, according to the autopsy report. The autopsy report also says it was likely Butler had been comatose since Oct. 3.

A jury cleared Gosy of negligence in a malpractice suit filed by Alane Butler's husband, Thomas Butler.

"The most that can be said of Dr. Gosy's activities, as maintained by the plaintiff, was that the activities were self-serving, in other words, that he wished to bill for detoxifying Mrs. Butler rather than allow a hospital to do it," Judge Timothy J. Drury wrote in an opinion issued during the case. "But, as pointed out by the defendants, he was attempting to help Mrs. Butler by detoxifying her and at the same time continuing treatment for her underlying chronic back condition."

Whether Gosy was permitted under DEA regulations to prescribe methadone to Butler was not addressed in the lawsuit.

Physicians can prescribe methadone for the treatment of pain and can administer it on an emergency basis while drug-addicted patients wait to get into rehab to detox. But only registered detox centers can prescribe methadone to detox patients and help them through withdrawal, according to Drug Enforcement Administration regulations.

"If someone needs emergency detox, the doctor can administer methadone for up to three days while waiting to get into a program. But the doctor cannot prescribe," said Denise Curry, deputy director of the Office of Diversion Control at Drug Enforcement Administration headquarters in Washington, D.C.

Giving methadone for pain and withdrawal "is circumventing the DEA regulation," Curry said.

Neither Gosy nor his Gosy & Associates Pain Center has a DEA license to prescribe methadone for withdrawal and detox, according to a Buffalo News review of DEA registrations.

But Gosy told The Buffalo News that the treatment he offered Butler was acceptable under the DEA regulations because it was for both pain and addiction, and not "strictly detox."

A tapering dose of methadone was prescribed to stop the withdrawal symptoms and help the patient escape her pain before transitioning her to an alternative pain medication, he said.

Without addressing Gosy's case, Curry said the DEA is "quite aware many doctors do circumvent the law, under the guise of treating addiction." But, she added, "they run the risk of a visit from the DEA."

>Second fatal overdose

The other malpractice suit against Gosy involved the fatal overdose of Sandra Waltz, a Tonawanda woman, who died in July 2003, at age 33.

Waltz suffered from migraine headaches for years and had past addiction problems, but she was not taking painkillers when she was referred to Gosy in October 2001, according to court papers. Gosy was not told of Waltz's history with prescription drugs, and began treating her with narcotics, the papers state.

In March 2003, Waltz overdosed on her medication and was hospitalized. Gosy didn't prescribe Waltz any further medications, according to court documents.

Court papers say Waltz continued buying painkillers over the Internet and eventually saw Dr. Yasmin Pervez, a Niagara County physician. Unaware of Waltz's history of prescription pill addiction, Pervez prescribed Soma, a muscle relaxant. Two days later, Waltz called complaining of a migraine, and the doctor prescribed Darvocet, a non-opioid painkiller.

The next day, Waltz died from an overdose of the medication Pervez prescribed.

While Waltz had been working and taking care of her son when she first went to Gosy, she was "on heavy-duty pain medication," was no longer working, her phone and her heat were shut off, she was depressed and her son was living with her ex-husband at the time of her death, according to court papers.

A malpractice claim was filed against both doctors by Waltz's mother and sister, on behalf of Sandra Waltz's son.

A jury found Waltz largely responsible for her own death, but found that her doctors were also negligent -- Gosy for contributing to pain and suffering in Waltz's life, and Pervez for contributing to her death.

Pervez was ordered to pay a $180,000 judgment. The judge ordered Gosy to pay $62,500.

Gosy defended his actions in both the Waltz and Butler cases, and said he's proud that there are so few complaints against his practice.

"Given the large number of patients, there have been very few complaints," he said.

>More caution urged

There is a push nationwide for more caution in pain management, and Gosy said his practice has evolved with the changing attitude. He cited such measures as stricter monitoring of patients, turning away from the use of higher opioid doses in patients who fail to respond to a medication, and making functional improvement a key goal rather than seeking the elusive elimination of all pain.

Gosy estimated 95 percent of his patients take opioids, a rate studies show is not unusual in pain management centers. He said opioids represent 40 percent of all the prescriptions written at the center, a percentage that has declined as a result of relying on other therapies.

"Five years ago would have been the peak of the liberal use of (opioids)," he said. "Now, I do more downgrading of dosages than starting patients on new drugs and stronger medicines.

"One of our mantras as physicians," he added, "is to alleviate pain. But we have to be self-critical enough to realize that these medications are double-edged swords."

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