Westborough psychiatrist loses license over hospital incident

By Scott O'Connell/Daily News staff

MetroWest Daily News

Posted Mar 15, 2008 @ 12:49 AM

Last update Mar 18, 2008 @ 03:20 PM

WESTBOROUGH —
The state Board of Registration in Medicine last week stripped the license of a Westborough psychiatrist accused of assaulting two police officers and a nurse at UMass Memorial Medical Center last spring.

Dr. Perveen Rathore, 51, voluntarily agreed not to practice medicine shortly after the May 2007 incident. The state suspended her medical license indefinitely on March 5.

Rathore worked as an on-call psychiatrist at UMass and also had a private practice in town called Child and Family Services of Westboro.

According to the board's order, on Sunday morning, May 20, 2007, Rathore was working on-call at UMass when she failed to appear at the hospital to perform a requested patient evaluation. When a medical director at UMass contacted her later that morning, Rathore refused to come in until the conclusion of a party she was attending at the time.

The medical director then informed Rathore she was relieved of her call duty for that day and the rest of the week, and went to the hospital to evaluate the patient. That afternoon, Rathore arrived at the hospital and saw the patient as well. The medical director saw her and told her to leave the hospital.

When Rathore refused to leave, a nurse called UMass police, which sent two officers to escort her out of the hospital. The officers approached Rathore as she was sitting at a computer and told her to leave, but police said she ignored them and continued typing.

"The police officers then informed the respondent that she was under arrest," the board's order states. "When one of the police officers placed their hands under the respondent's elbow to place her under arrest, the respondent began to scream and resisted the officers. A physical altercation ensued."

Rathore also struck the nurse supervisor and continued to resist even after the officers placed handcuffs on her, the board's order reads. She was charged with three counts of assault and battery with a dangerous weapon (shoe), disorderly conduct and trespassing, charges that were later dismissed, according to Worcester Central District Court records.

The order concluded that Rathore's behavior "places into question the physician's competence to practice medicine," and accused her of practicing medicine while "impaired by alcohol, drug, physical disability or mental instability."

Sometime during or shortly after the arrest, Rathore complained of chest pain and was taken to the UMass Emergency Department for evaluation. When attempts to calm Rathore were unsuccessful, she was committed to Wing Memorial Hospital and released two days later.

According to UMass Memorial spokeswoman Allison Duffy, Rathore "hasn't worked (at the hospital) since the event." The phone number at her West Main Street private practice has been disconnected.

The board's sanction states that Rathore can have her license restored if she performs a treatment program and undergoes follow up evaluation. Rathore, a 1980 graduate of the King Edward Medical College at the University of Punjab in Pakistan, had held her medical license in Massachusetts since 1997, according to the board's order.

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Ex-drug salesman: We lured docs with gifts

Ex-drug salesman: We lured docs with gifts Companies recruit ‘beautiful people’ as reps

Boston Herald

By Christine McConville

We all want to think that our doctors prescribe pain pills for our aching backs because it’s what we need, and not because a charming ex-cheerleader turned drug company sales rep has invited him to a Red Sox game.

But, according to a former drug salesman, that second scenario may be closer to the truth.
“We were the beautiful people,” Shahram Ahari, a former Eli Lilly “drug detailer,” told a group of Boston University medical students last week.

Ahari, who spent two years promoting drugs such as Prozac and Zyprexa, is telling the medical students what to watch out for when the sales reps come calling.

He is working with The Prescription Project, a group fighting the impact of pharmaceutical marketing on physicians’ prescription decisions.

The group contends that aggressive marketing to physicians by pharmaceutical companies creates conflicts of interest in the medical profession and raises questions about the appropriateness of treatment choices.

Many blame drug companies’ aggressive marketing efforts for a portion of the rise in health-care costs, because physicians are swayed into prescribing newer, more expensive medicines instead of older, less expensive brands.

To push their products, Ahari said, drug companies hire former models, cheerleaders and athletes to promote the new drugs to doctors.

His co-workers, he said, “were all beautiful, vivacious and fun,” but none of them had more than a high-school level science education.

Still, each day, they’d visit scores of medical offices, armed with gifts for the doctors, their staff and their family members, and samples of the drugs they were pushing.

When they weren’t treating the entire office to lunch, or handing out free tickets to sporting events, they’d wine and dine the doctors.

Ahari said he was allowed to spend $60,000 a year on meals.

Eli Lilly spokeswoman Judy Moore disputed Ahari’s account, saying that the company’s sales reps provide a “value-added resource for physicians.”

Ahari said most physicians think they are too smart to be influenced, but drug companies have learned otherwise from experience.

After a drug manufacturer took a group of physicians to an all-expenses-paid conference in the Caribbean, those same physicians began prescribing that drug in earnest.

“Physicians can be influenced like everyone else,” Ahari said. “We paid for that conference with all the prescriptions that came in the next month.”

Moore countered that Lilly’s sales reps help very busy physicians learn more about the cutting-edge products.

“Our reps know the products inside and out. They are professional, passionate and hard-working,” she said.

Here in Massachusetts, the state Senate has just rolled out its plan to contain the growth in health-care costs. The plan calls for an outright ban on pharmaceutical marketing gifts.

If approved, Massachusetts will be the first state to prohibit pharmaceutical sales reps from offering gifts and will ban physicians, their family and staff from accepting them. The bill also calls for uniform, electronic medical records and other cost-saving measures.

A prescription against death

The Daily News

As drug overdoses overtake traffic fatalities as top killer in New Hampshire, officials left seeking answers

By Angeljean Chiaramida

They kill more people in New Hampshire than car crashes.

Drug overdoses claimed 168 lives in the Granite State last year. And methadone, a prescription drug, caused more deaths than any other drug.

Methadone even surpassed heroin — the illegal demon perceived for decades to be the biggest killer of drug users, according to New Hampshire Chief Medical Examiner Dr. Thomas Andrew.
It's the second straight year that drug deaths have topped fatal traffic accidents in New Hampshire. And the gap is widening.

In 2007, there were 129 traffic deaths and 168 drug deaths, 57 caused by methadone. In 2006, the news was almost as bad: 127 traffic fatalities compared to 142 drug overdose deaths, 53 traced to methadone.

This isn't a fluke, Andrew said. It's a deadly trend.

While the rate of traffic fatalities has remained fairly constant since 1995, except for a brief hike in 2004 and 2005, drug deaths have been steadily rising since 1999, increasing from 40 to last year's high of 168.

"That drug deaths have exceeded traffic deaths in this state is absurd," Andrew said. "I do not know of another jurisdiction of one million people or more where this is true.

"Although those in public safety will tell you that's too many traffic deaths, that's about the same number we've had in New Hampshire for years," he said. "(The number of) traffic deaths has been pretty steady. But drug deaths have been climbing every year, and methadone deaths as well."

New Hampshire is not alone. Drug overdoses are reaching critical levels across the country, according to statistics from the Centers for Disease Control and Prevention. In Massachusetts, a CDC report found death rates attributed to unintentional and undetermined poisoning increased by 228 percent between 1990 and 2001.

Salisbury police Chief David L'Esperance, who lost his son to a methadone overdose in May 2007, called the statistics disturbing, but, tragically, not surprising.

"A lot of people think the biggest drug problem is heroin or (the prescription drug) oxycodone, but it isn't," L'Esperance said. "It's methadone; I've been saying that for years."

New Hampshire — with a population of about 1.3 million — has another distinction. It ranks in the top five in the nation for overdose deaths attributed to methadone abuse, according to 2005 CDC statistics. The Granite State is tied for fourth with Nevada.

Massachusetts ranks somewhere in the middle, with 1.4 methadone deaths per 100,000 people, compared to New Hampshire's 3.9. Maine, meanwhile, is at the top of the list, with 4.6 deaths per 100,000 people.

The high ranking of both New Hampshire and Maine is a mystery, Andrew said, especially when their size and location are factored into the equation. Both are typically rural states with relatively small populations.

The drug tide in New Hampshire began to turn in the late 1990s from illegal drugs like heroin, cocaine and marijuana to prescription drugs, which took over as the biggest killer in New Hampshire around 2002, Andrew said. While heroin is still around and dangerous, he said, prescription drugs have become easier to acquire and use.

New Hampshire public health and law enforcement officials suffered a setback in their battle against prescription drug abuse this legislative session. For the third time, lawmakers defeated a statewide prescription drug monitoring program that health officials and authorities hoped would help them catch abusers.

New Hampshire is the only state in New England without a prescription drug monitoring system.
House Bill 630 proposed developing a database of prescription drugs — such as highly addictive and often abused drugs like OxyContin and methadone. It died in the House of Representatives this year by a three-vote margin.

Without a drug database, N.H. Assistant Attorney General Philip Bradley said, convicting drug abusers and dealers is very difficult. Bradley and the state attorney general's office have lobbied for the bill for years because of the growing problem with illegal trafficking and use of legal prescription drugs.

Andrew blamed the "privacy issue" for the bill's failure. In the "Live Free or Die" state that prides itself on its protection of citizens' personal rights and freedoms, opponents feared the collection of prescription data would pose a possible intrusion into people's lives.

He said while that argument sounds noble, it's harmful rhetoric. The bill, he said, included safeguards preventing the database from being used by law enforcement officials on a "fishing expedition" and violating citizens' privacy.

Andrew also said prescription data already exists in pharmacy databases across the state and country. The statewide data collection system would simply gather the information in one place so public health authorities could detect abuse trends.

For example, the monitoring system would spot multiple methadone prescriptions written by different doctors for one individual and filled at different pharmacies within the state.

Claims the bill would cost millions to administrate are also completely false, Andrew said. "This was an epidemiological public health tool that we need and we lost," he said.

By bringing attention to New Hampshire's drug crisis and the scope of its prescription drug problem, Andrew and Bradley hope residents will urge their legislators to take a stand in helping to fight it, including eventually passing the monitoring system.

Without it, many officials now fear residents of surrounding states with systems in place will seek out New Hampshire to illegally acquire and sell prescription drugs.

There's good reason to be fearful, Andrew said. There's clear evidence, he said, that states without drug monitoring systems see increases in abuse because people feel they won't get caught.

"It's not a guess. It's not a fear. It happens," Andrew said. "Word gets around there's less heat in New Hampshire."


Methadone: A deadly power

Methadone is basically a stronger, synthetic form of morphine. It is best known as a treatment for heroin addiction. It is given in a regulated format at substance abuse treatment facilities and clinics as a replacement drug to wean addicts off heroin.

New Hampshire Chief Medical Examiner Dr. Thomas Andrew said methadone also has a beneficial medicinal purpose. With pain-relieving properties more powerful than morphine, it has frequently been prescribed to manage very severe and chronic pain.

But Andrew said the use of methadone for pain relief and in substance abuse programs and clinics, like the one recently proposed for Seabrook, isn't what's causing the problem.

The problem is that methadone — as well as other prescription drugs like OxyContin and Vicodin — has become more easily obtainable in recent years, allowing it to be sold, then diverted to individuals without prescriptions or pain-management needs.

Catching, prosecuting and convicting individuals who divert or sell prescription drugs for illegal use is very difficult, according to both Andrew and law enforcement officials. Where the simple possession of heroin, cocaine or methamphetamine is illegal, methadone is legal as a prescription drug. Unless police catch distributors of prescription drugs in the act of selling them, no law is being broken.

Methadone's effect on drug pleasure-seekers is legendary. Salisbury police Chief David L'Esperance said previously his son, Christopher, who died of a methadone overdose in May 2007, described methadone's lure as "an incredible high." While Christopher L'Esperance could kick the physical need for methadone, his father said, he could not overcome the strong psychological addiction.

L'Esperance said the powerful chemical nature of methadone makes it prime for overdose when used recreationally. After taking too much, he said, drug abusers simply fall asleep, drifting away without a sound.

When Lloyd Chapin Jr. died of a methadone overdose in Seabrook in February 2006, his parents didn't know until the next morning when they went into his room and couldn't wake him.

Andrew blames the 40-milligram, long-acting, quarter-size wafers of methadone that were previously available in part for the skyrocketing number of overdose deaths among recreational users.

Intended only to treat the most severe chronic pain, the large-dose wafers, Andrew believes, became increasingly prescribed by doctors unaware of the intricacies and fine points of severe pain management or the power of the medication. From there, it became available for illegal use.
According to Andrew, the Centers for Disease Control recently ranked New Hampshire third in the nation for its prescribed use of the 40-milligram methadone wafer.

As a result of the overdose epidemic, federal authorities recently banned the 40-milligram wafer and also limited the number of 5- and 10-milligram methadone tablets a doctor can prescribe at one time.

That, however, has created problems for patients with severe pain being treated with methadone. They are being forced to return to their physicians sometimes more than once a week for prescriptions.

"The abuse of this drug by those who have no business taking it has harmed the well-being of those in severe pain who need it," Andrew said.

Ethics questions arise as doctors pitch to colleagues

USA Today
By Valerie Bauman, Associated Press

ALBANY, N.Y. — Dr. Daniel Carlat sank into a choice seat at Lincoln Center, surrounded by other psychiatrists, all staying at the same four-star hotel in Manhattan and attending the same show for free. His deal with a pharmaceutical company to provide testimonials to other doctors had paid off well.

"It just kind of gave me a feeling of euphoria," said Carlat, a practicing psychiatrist and assistant clinical professor of psychiatry at Tufts University in Boston. "Sort of like you've made it into the upper crust of society."

The practice of using doctors to pitch products to other doctors is legal, though several states — including New York — are trying to curb it. They are opposed by the pharmaceutical industry, which argues the practice is a kind of professional consultation.

Carlat was on the "speakers' bureau" for the pharmaceutical companies, speaking to large groups of doctors, or holding intimate, expenses-paid meals with a pharmaceutical representative and one or two doctors. In one year, he earned $30,000 — about one-fifth of his salary. Ultimately, his conscience started nagging him and he quit.

"My role in the company was not by any means to serve as a source of unbiased medical information," he said. "But my role was really simply to be a part of their marketing machinery and that was the value I had for them."

Pharmaceutical companies argue that doctors are an essential part of educating colleagues as new drugs are developed.

"The information about medicines provided by technically trained company representatives, some of whom are health care professionals themselves, is important education for physicians who must understand side effects and the proper use of potent prescription pharmaceuticals," Ken Johnson, senior vice president of Pharmaceutical Research and Manufacturing of America, said in a written statement.

At the end of January, PhRMA, the drug industry's lobbying arm, said it is considering scaling back on smaller gifts to doctors, including pens, coffee mugs and other items. Johnson said the idea is not a response to pressure about its marketing practices.

In a survey published last year by the New England Journal of Medicine, 95% of doctors said they had contact with drug or device companies, and 35% were reimbursed for costs associated
with professional meetings. Another 28% accepted consulting or lecture fees, while 7% took free tickets to games and other events.

Some doctors see a benefit to the practice.

Wayne Weart, a professor of clinical pharmacy and outcome sciences at the Medical University of South Carolina in Charleston, has a clinical doctorate of pharmacy and has long worked on speakers' bureaus for drug companies. He says the industry has changed its ways in recent years.

When drug companies pay Weart to speak at a medical school or conference, he said, "they can't influence the topic, the speaker, the venue, any of these things." He said the drug companies provide unrestricted grants for his speaking engagements and he must disclose to the audience the connection he has to the company.

Weart, who said the side work pays "a fair amount," won't participate if he is expected to promote one drug over the other, or if he feels the research is unsatisfactory.
Dr. Paul Root Wolpe, a senior fellow at the University of Pennsylvania Center for Bioethics, said there's nothing wrong with doctors speaking about pharmaceuticals, but a conflict of interest can arise when they are paid.

"Best intentions go astray among the pressures of money and relationships," Wolpe said. "I don't think it's intrinsically unethical, but you are creating a situation in which it's very difficult to retain ethical integrity."

"The best way to teach people about new drugs and their impact is to get the experts in the field to talk about it," said Wolpe. "What I didn't hear anywhere in that process is that that has to be sponsored by the drug companies."

Some hospitals and medical schools ban doctors from accepting gifts from drug reps, including the University of Pennsylvania, Yale University and Stanford University.

The Physician Payment Sunshine Act, currently in the Senate Finance Committee, would create a database disclosing the names and addresses of doctors who receive gifts or payments. It would also include pharmaceutical company names and the value of the gift or payment. The measure co-sponsored by New York Sen. Charles Schumer was referred to committee in September and hasn't budged since, despite support from medical ethics groups.
Drug companies oppose the act.

PhRMA adopted voluntary rules in 2002 that limit the value of gifts to $100 or less and says that all forms of free entertainment, including sporting events and golf outings, are inappropriate. The group argues that these rules cut the risk of problematic relationships between drug reps and doctors.

Measures similar to the Physician Payment Sunshine Act have passed in New York's Assembly, but either did not have a counterpart in the Senate or were unsuccessful in that chamber. State Senate Health Committee Chairman Kemp Hannon said such bills are being considered.
Another bill in the Assembly would prohibit pharmaceutical companies from buying data on the prescribing habits of doctors — information used for direct marketing and to recruit a sales force, sponsors say.

At least eight states and the District of Columbia have laws or resolutions related to pharmaceutical marketing, including California, Florida, Maine and Minnesota.
Initially, Carlat didn't have a problem with the work he was doing, but he gradually became concerned.

"I stopped because I decided that it was unethical to alter and to tweak information that would ultimately affect patients' welfare and patient safety," he said.

Vermont spent millions on suspect drug Zyprexa

The Times Argus

By Daniel Barlow - Vermont Press Bureau

MONTPELIER – As the lawsuits against Eli Lilly over its top-selling anti-schizophrenia drug Zyprexa began piling up in 2006, Vermont’s state-run insurance program spent nearly $4 million on the drug, according to documents.

That amount may seem like a drop in the bucket when compared to Zyprexa’s 2007 sales of $4.8 billion in the United States, but the payments through Vermont’s Medicaid program came at a time when 10 states and upwards of 30,000 people were suing the company over the drug.
Launched in 1996, Zyprexa has become the top-selling medication for drug-maker Eli Lilly. But those sales are dropping as lawsuits and leaked corporate documents reveal a decade-long effort to downplay the side effects, including weight gain and an increased chance of diabetes, in the company’s promotion of the drug.

Just this week the state of Alaska, population 670,000, settled its lawsuit against Eli Lilly for $15 million over what it claimed were increased Medicaid costs due to health problems associated with taking Zyprexa. That was the first state to settle with the company in the lawsuits.

Vermont is not one of the states now suing Eli Lilly. But on Thursday, the Vermont Association for Mental Health, a Montpelier-based advocacy organization, urged the state to pursue that legal option. Executive Director Ken Libertoff said this case was a “sad commentary” on the influence of the pharmaceutical industry.

“No one doubts that psychotropic medications can be an important part of treatment, but as this case will show, improper marketing, concealment of important health information and huge financial payments have polluted the environment,” Libertoff said.

While it may not be suing Eli Lilly, Vermont is investigating how the company marketed its drug to doctors and others here, according to Julie Brill, Vermont’s assistant attorney general. She said the state subpoenaed marketing materials and internal company documents detailing its marketing plan in January 2007.

Brill said that inquiry is still on-going and she was mum on further details. She said she did not know when more informa-tion on their investigation could be made available to the public.
“We do have an ongoing consumer protection investigation,” she said.

The $3.96 million spent on Zyprexa by Vermont in 2006 appears to be an unusually high number – and impacted because that financial year was the start of the new federal Medicare Part D program that subsidized the cost of prescription drugs, according to Ann Rugg, the deputy director of the Office of Vermont Health Access, which oversees the publicly-funded insurance programs.

The spending has since dropped, although it is still in the millions. In 2007, $1.5 million was paid by the state and during the first three quarters of the current financial year, the state is on track to pay about $1 million.

Michael Hartman, the commissioner of the Vermont Department of Mental Health, said Thursday that all medications have potential side effects, but the situation with Zyprexa is especially troubling due to the allegation that the company went out of its way to downplay its health consequences.

He faulted the Food and Drug Administration for its lax authority over the testing of new drugs, saying the federal organization needs to rely more on independent tests as opposed to the ones submitted by the drug-makers.

“A patient needs to understand and have all the information about the medication to make an informed decision,” he said.

Hartman said Zyprexa was likely marketed in Vermont in the same way that the drug was marketed in other states. He said there is an “awful lot of trust or acceptance that the information provided” to mental health professionals in the field is accurate.

“If we can find that there is reason to believe that this wasn’t done properly … show a purposeful pattern of deceiving people, that is a door that could be explored,” Hartman said when asked if Vermont should join other states in the Zyprexa lawsuits. More than 23 million people have taken Zyprexa since it hit the market as a medication to soothe hallucinations and delusions. But company documents leaked to the New York Times show that the company encouraged doctors to prescribe the drug “off-label,” meaning for uses not approved by the FDA.

Federal law prohibits such off-label marketing, although doctors are allowed to prescribe drugs more freely.

Tens of thousands of lawsuits have also been filed over the side effects of the drug, which include massive weight gain and blood sugar boosts – all known risk factors for diabetes. So far, the company has paid out $1.2 billion to settle many of the lawsuits.

So far, Eli Lilly has maintained its innocence. The company did not return a phone call for comment Thursday, but an executive told the New York Times this week that “a settlement helps us get back to what we want to focus on as a company …”

Zyprexa has been an effective medication for some patients, but its use has dropped in recent years once reports of the side effects surfaced, according to Jonathan Wecker, a Montpelier psychiatrist.

“I don’t remember any talk of these side effects when the drug first came out,” he said. “And clearly, the association we’ve seen since to diabetes has caused this drug to drop off a bit.”
The ironic twist to the surge and fall of Zyprexa is that a government-funded study has shown that the older antipsychotic medications can be just as effective as the newer, more expensive medications, according to Adrianne Fugh-Berman, an associate professor in the Department of Physiology and Biophysics at Georgetown University School of Medicine.

“The pharmaceutical companies have really gone out of their way to cast doubt on this government-funded trial in order to decrease its credibility in physicians’ minds,” said Fugh-Berman, who is also the director of PharmedOut, an independent, physician-led organization that provides information on pharmaceutical drugs.

Contact Daniel Barlow at Daniel.Barlow@rutlandherald.com.