Florida Doctor Charged in Two More Overdose Deaths
Originally Posted at:http://www.painandthelaw.org/palliative/wiley_0219c03.php
By Lindsay F. Wiley
February 15, 2003 - Prosecutors have charged Dr. Asuncion M. Luyao, of Port St. Lucie, Florida, with two additional counts of manslaughter arising out of the overdose deaths of her patients. Dr. Luyao is currently free on $455,000 bail while she awaits trial on six counts of manslaughter.
State officials suspended Luyao's medical license last March when she was arrested for trafficking in oxycodone and several other prescription pain drugs. Prosecutors added manslaughter charges upon further investigation into the overdose deaths of several of her patients.
At least one of the patients' families has filed a civil suit alleging that Luyao failed to order appropriate tests to determine the necessity of continued treatment with narcotics and also failed to warn patients against mixing the prescription drugs. The family alleges that the doctor prescribed 1,080 doses of narcotic drugs for the patient even after relatives asked her to reduce the amount of the patient's prescriptions.
Dr. Luyao's office is located at:
Internal Medicine 561-335-8363
9474 South US1
Port St. Lucie 34952
Originally Posted at:http://www.sun-sentinel.com/news/local/southflorida/sfl-oxydocsmainmay13.story
Doctors must consider dangers of addiction, overdose
By Fred Schulte and Nancy McVicar
May 13, 2002
Patients under the care of Dr. Asuncion M. Luyao, a pain specialist in Port St. Lucie, began dying from overdoses of legal drugs two years ago.
Bradley Towse, 23, who lived with his mother in Palm Beach Gardens, died in June 2000, a day after Luyao prescribed the potent narcotic methadone for him, according to police records.
An autopsy found that Julia Hartsfield, a 52-year-old antiques dealer from Fort Pierce who suffered back pain, died in March 2001 from a concoction of pills prescribed by Luyao.
In addition, 12 other Luyao patients died from drug overdoses during the past two years, a Sun-Sentinel investigation of medical examiner, police, court and state records found.
State health officials suspended Luyao's medical license in late March while an investigation into the deaths of her patients proceeds. State prosecutors also have charged her with drug trafficking for allegedly prescribing too many narcotics, charges she denies.
The string of deaths under Luyao's watch is extraordinary.
But Florida Attorney General Bob Butterworth said they illustrate the growing dangers inherent in dispensing heavy doses of narcotics for pain control -- a method of care encouraged by patients' rights groups, Florida health officials and the state Legislature since the late 1990s as a humane means to ease suffering.
"We don't want to take these drugs away from patients who really need them, but we're very concerned about doctors without the proper training handing out these drugs. [Pain treatment] is a real specialty," Butterworth said.
The Sun-Sentinel's analysis of medical examiner, police and state medical licensing records documented 393 prescription drug-related deaths in the past two years in seven southeastern Florida counties, including Broward, Palm Beach and Miami-Dade.
Few of those patients had a life-threatening illness, autopsy reports show, and many who died were under treatment by specialists in the rapidly growing field of pain management.
The Sun-Sentinel investigation also traced drugs involved in those deaths to more than 200 South Florida doctors or clinics. It is thought to be the first effort to track the source of fatal prescription narcotics.
Among other findings:
39 physicians or pain clinics had two or more patients die from prescription drug overdoses in the past two years. Three doctors each had four such deaths.
In 36 fatal cases, some drugs on the scene had been prescribed only one, two or three days earlier.
In 38 instances, police found drugs prescribed by three or more doctors at the scene. In a third of those deaths, pills came from six or more doctors.
"Unfortunately, we see a lot of these prescription factories," said Dr. Rafael Miguel, a Tampa pain management specialist who also serves on the Florida Board of Medicine. "They're not just practicing bad medicine, they're causing a public health problem."
Most prescription drug deaths receive little notice from state authorities, even when they are linked to a single physician. Police and medical examiners across the state lack any formal means for reporting such deaths to medical licensing officials, and they can sometimes pile up before anyone notices a trend.
Deaths in Luyao's practice, for instance, spanned two years before the state took any action, and that was prompted by an investigation by the attorney general's Medicaid Fraud Unit.
Three patients, including Towse, died in 2000. The others were a 39-year-old body shop manager whose death on April 5 resulted from methadone toxicity, and a 48-year-old prescribed painkillers to relieve leg and foot pain resulting from a motorcycle accident.
In the first week of January 2001, a 56-year-old man overdosed from the narcotics hydrocodone and oxycodone. Hartsfield died in March of that year. Another death occurred in April from "poly drug toxicity." Patients also died in July, August and October from drug toxicity.
Deaths shot up in late November 2001, when four Luyao patients died from drug overdoses.
A fifth, who was 24, died from methadone toxicity on Dec. 6, 2001.
That same day, authorities raided her office and confiscated files as part of a state investigation based on the large amounts of OxyContin she had prescribed for patients.
On Dec. 7, Dr. Roger Mittleman, chief medical examiner for Indian River, Martin, St. Lucie and Okeechobee counties, asked the state Agency for Health Care Administration office in West Palm Beach to investigate Luyao's "prescribing patterns" because of "numerous recent deaths encountered at this office," records show.
On March 22, the health-care agency issued an emergency order suspending her license. The order declared Luyao "an immediate and serious danger" to the public and asserted that she lacked medical justification for handing out large quantities of narcotics.
State officials acknowledge that their investigation was sparked not by the pattern of deaths in Luyao's practice over two years, but by the volume of prescriptions she wrote.
Dr. John Agwunobi, secretary of the Florida Department of Health, called such cases "very worrisome" and said he supports proposed legislative changes that would allow for more careful monitoring of doctors who may be overprescribing dangerous drugs.
"I think cases like this are the reason why we are working very closely now with the Attorney General's Office and the Agency for Health Care Administration to find strategies to prevent these before they become a problem," Agwunobi said.
Luyao's attorney, Joel Hirschhorn, of Miami, called the state's investigation of the doctor "one-sided." Some of her patients were also getting drugs from other doctors without her knowledge, he said, while others violated written agreements with the doctors not to abuse their medicines.
"This is sad for the doctor and the patients," Hirschhorn said. "She is a very trusting and believing person. ... She accepted people's word at face value," he said.
Hartsfield's family argues in a lawsuit that Luyao failed to order medical tests to show a continued need for narcotics, or to warn Hartsfield that mixing medications could prove disastrous.
Family members said they asked the doctor to lighten Hartsfield's pill load. But Luyao prescribed five medicines for her -- about 1,080 doses in all, including methadone -- in a 42-day period before Hartsfield died on March 3, 2001, according to medical files cited in a lawsuit.
Hartsfield died from alprazolam, methadone and fluoxetine, the generic name for Prozac, an autopsy found -- the same drugs Luyao had prescribed.
For Towse, Luyao ordered 200 doses of methadone and the sedative chlordiazepoxide, according to police records. His mother, Susan Bucherie, said he was addicted to prescription pills and sought Luyao's help to wean himself from them.
Bucherie told police Luyao prescribed Towse's sedative in her name because she had health insurance, which her son lacked.
State law says that a doctor may be disciplined for "making deceptive, untrue or fraudulent representations in or related to the practice of medicine."
After taking methadone, Towse left home about 8:30 p.m. on June 26, 2000, to play pool, according to a police report. Four hours later, appearing lethargic and with slurred speech, rescue workers took him to Palm Beach Gardens Hospital. Discharged about 4 a.m. on June 27, he went home to bed.
About 11 a.m. his mother found him foaming from the mouth and nose, a telltale sign of drug overdose. He had stopped breathing.
Doctors aren't tracked
Police and medical examiner death reports in Florida usually identify the drugs that caused deaths, but not always the doctors who prescribed them. This seemingly routine chore often goes undone because the dead person had a prescription for the drugs, and police rarely seek to hold doctors accountable for a patient's misuse of a legal medication.
The Sun-Sentinel, by collecting reports from both police and medical examiners, was able to identify 200 doctors who wrote 767 prescriptions for the medications that were found at the scenes of 129 overdose deaths during the past two years -- most in Broward and Palm Beach counties.
They ranged from family practitioners to highly trained specialists in the pain control field, such as anesthesiologists, to doctors who staffed walk-in clinics and, in a handful of cases, emergency room doctors.
Most doctors had a single patient die. For instance, Donald Azbell, 47, died of an overdose a day after seeing a Lake Park family physician, Dr. Robert Greer, for treatment of back pain stemming from a beating he suffered in the Palm Beach County Jail in 1999, according to police reports.
Greer prescribed hydrocodone and Xanax, an anti-anxiety drug, on Oct. 10, 2001, for Azbell, a homeless veteran who used a cane and wheelchair to get around and who slept on a blue air mattress wherever he could flop it down. A day later, police found the pill bottles in a backpack next to Azbell's body in an abandoned, trash-strewn trailer at the edge of Old Military Trail in West Palm Beach.
Greer could not be reached for comment despite repeated attempts.
A Riviera Beach doctor, Timothy Toward, told police that he warned his patient, Thomas Mollineaux, that OxyContin, a brand form of the narcotic oxycodone, and Xanax were addictive when he prescribed them for pain from an old traffic accident.
Two days later, on July 30, 2000, Mollineaux was dead.
Mollineaux was staying with his mother in West Palm Beach. She said he often seemed groggy, so when he fell asleep at the dining room table, she let him lie there and went to bed, according to a police report. The next morning she found him still seated at the table, vomit on his pants and the carpet.
He died from "oxycodone toxicity," an autopsy found.
Toward said he has since stopped prescribing OxyContin and uses other painkillers such as Percocet or methadone instead.
"OxyContin really is a very good drug, for people who really need it, but the potential for abuse is too great," he said.
The Sun-Sentinel review found that 13 of the 200 southeast Florida doctors whose patients died from overdoses had previously been disciplined by the Board of Medicine, at least four of them for prescription drug-related infractions.
Boom in the industry
Since the late 1990s, state health policy has encouraged the use of narcotics for pain control, arguing that "unrelieved pain can have harsh and sometimes disastrous influence on the quality of life for patients and their families."
That directive was followed by changes in state law, brought at the insistence of patients' rights groups and pain specialists, codifying that pain relief is a right. While envisioned mainly as a means to ensure that the terminally ill or those with severe chronic pain did not suffer needlessly, the state has helped spur growth of a profitable new pain-management industry.
Nobody knows how many of Florida's about 30,000 practicing physicians are engaged in pain control -- because no state agency keeps tabs on the industry.
But experts agree the field is growing quickly, both because of the more relaxed attitudes toward pain treatment and because some drug abusers have learned to exploit the system.
"Pain weighs on patients. Every aspect of their life is affected," said Dr. Lawrence Gorfine, of Lake Worth, a past president of the Florida Academy of Pain Medicine.
"Others, quite frankly, have a drug problem. They find that if they complain of pain they can find a fairly ready supply of medication," he said.
In South Florida, at least a dozen pain clinics specialize in dispensing narcotics for pain control, some from in-office pharmacies. Hundreds of other doctors have entered the field, ranging from hospital-based group practices to solo doctors running storefront offices -- all of them operating with almost no state oversight.
State law allows doctors not only to prescribe drugs, but also to sell them from their offices. All that's required is $100 for a state dispensing permit and an agreement to submit to an annual inspection.
A bill to require doctors to take a one-hour course in the use of narcotics failed to win approval in the Florida Legislature in 2001. It still is pending in the current special session.
Doctors who prescribe narcotics "in good faith" have no need to fear disciplinary action from the state.
"Each case of prescribing for pain will be evaluated on an individual basis. The physician's conduct will be evaluated to a great extent by the treatment outcome," Florida medical practice guidelines state.
But the outcome in hundreds of cases has been death, according to the Sun-Sentinel analysis.
Some patients who died could document their pain with medical evidence; others appear to have been longtime drug abusers who manipulated the medical system to procure drugs.
Overall, one in three patients who died from overdoses while undergoing pain-control therapy in South Florida had felony convictions, often for use of illegal drugs such as heroin and cocaine.
Five of the 14 patients under Luyao's care when they overdosed, for instance, had previously been convicted of using or selling illegal drugs such as cocaine.
"Certain doctors will give [patients] drugs without clarifying their medical history," said Mittleman, a Florida medical examiner for more than two decades. "Any doctor that does that is not practicing the best medicine."
Patients can be challenging
As a new and fast-growing specialty, pain-control medicine is still developing quality standards.
The goal of guidelines recommended by several national groups, including the Federation of State Medical Boards, is to ensure that patients with chronic pain improve their ability to function, such as getting back to work after a painful injury.
The guidelines also strive to protect the public from drug-abusing patients who either sell or trade some of their medicine on the illegal street market.
For instance, many clinics and doctors require patients to sign contracts agreeing to use their medications only as directed and not to give any away or sell it.
Doctors can require periodic urinalysis to verify that patients are steering clear of street drugs such as heroin, or cut supplies they give to untrustworthy patients to take unsupervised. They can also study a patient's history, particularly for signs of previous drug abuse, before trusting them to handle narcotics responsibly.
Many specialists argue that these voluntary standards, if closely adhered to by doctors, allow most patients to greatly improve their lives without posing any hazard to themselves or the public.
But the Sun-Sentinel found that voluntary safeguards apparently can't prevent abuses, especially if patients mix legally prescribed drugs with other intoxicants, including other prescriptions, illegal drugs or alcohol.
Some patients are adept at faking or exaggerating pain to con doctors into feeding their habits, and may become belligerent if denied. Even highly experienced practitioners readily admit they can be fooled or intimidated.
"There are a lot of patients who are conniving. It puts the doctor in a terrible situation," said Dr. Branislav Stojanovic, a Fort Lauderdale psychiatrist who treats drug abusers. "You can't get into his body to confirm the patient's pain."
Some drug abusers find other ways to take advantage of doctors.
For instance, at least 38 people who died during the past two years in South Florida were seeing more than one doctor in order to obtain narcotics prescriptions, a practice known as "doctor shopping."
A 41-year-old Deerfield Beach man with a past felony conviction for obtaining prescriptions through fraud died at home in September 2000. In his possession were 14 pill bottles, prescribed by seven doctors, in three patient names, police said.
In another case, a Fort Lauderdale man who became addicted to narcotics after open-heart surgery died alongside 26 medicine vials prescribed by four physicians, according to police records. Officers also found a syringe, which he used to inject drugs, in the apartment where he died in January of last year.
Sometimes patients try to trade their medicines for illegal drugs or pilfer those prescribed for others.
In May 2000, Fort Lauderdale physician Jose A. Prieto wrote Marshall Prog a prescription for methadone. Prog, a former resort desk clerk who lived in Pompano Beach, tried to swap his methadone for heroin, according to police records.
Prog, 48, died from an overdose of heroin, methadone and an anti-depressant after injecting heroin in the Lauderdale Lakes apartment of a friend.
In at least 20 other fatal cases, pills prescribed by doctors fell into the hands of drug abusers, often a roommate or relative. Among those who died was a 13-year-old eighth-grader in Port St. Lucie who killed himself with methadone he took from his father.
A 17-year-old boy with a history of drug abuse died at his grandparents' home in Boca Raton, where he was staying while his parents were away on vacation, from an overdose of drugs, including morphine. Police suspect the youth obtained the morphine from a terminally ill patient who lived nearby.
Dr. Anthony Rogers, a pain specialist in West Palm Beach who has had three patients die from overdoses, said many problems arise because insurance companies don't pay enough to provide adequate care to patients in pain.
For instance, he said, insurance companies won't cover routine urine screens, or weekly monitoring visits, which could help him detect patients who are abusing drugs.
When he's only receiving about $30 for a patient visit and it costs him $20 for a urine test, he said, there's little left. "It's a reimbursement issue," he said.
In other cases, he said, pain specialists may get fooled and prescribe drugs to an addict because medical records from other doctors that might document the patient's medical history are slow to arrive.
"I'm here to do medicine, not to be a cop. We try to do our best. It's unfortunate. Some people are going to get you. They know what to say and how to look," Rogers said.
Dr. Richard Sabates, medical director of the Pain Management Center, with offices in North Miami Beach and Delray Beach, agreed that deciding which patients to treat, and how to monitor them, is a constant battle.
Sabates said new clients at his center need not document a history of pain on their first visit before they can be prescribed drugs. But he said he would never dispense a potent drug, such as OxyContin, before knowing the patient's history.
He also said he obtains, after an initial visit, the patient's previous medical records or other documentation of pain, such as an X-ray, or a referral from a primary care doctor.
Still, Sabates concedes the center "draws a great deal of people who are drug seekers" and he sometimes struggles to weed them out.
In the past 18 months, Sabates kicked out about 150 patients suspected of abusing drugs, he said, and denied admission to many others who he concluded were faking discomfort to get high, or were abusers.
One of Sabates' pain patients died last year from mixing his medicines with other drugs, including cocaine, Broward medical examiner records show.
A roommate found Frank Ramos, 50, sitting dead on the couch in his Davie apartment on Dec. 8, 2001. An autopsy found he died from "multiple drug toxicity" of the narcotic oxycodone, alprazolam, a sedative, cocaine and diazepam, also a sedative.
Nine days before he died, Ramos filled three prescriptions from Sabates. One was for generic oxycodone. A second was for OxyContin, a brand form of the drug. The third was for alprazolam, according to medical examiner records.
Sabates said Ramos was a patient "in good standing."
Limiting deaths from prescription narcotics will require doctors to more carefully balance the risks of overdose and addiction against their duty to relieve chronic pain, said Broward County Chief Medical Examiner Dr. Joshua Perper. The vast majority of doctors find that balance, but others lack proper training in the field.
"There's going to be a need for regulatory steps to make sure that a person running a pain clinic is qualified," he said.
"People sometimes abuse their medications," Perper said. "The question is whether the doctor is making a maximum effort to keep this from happening."
Fred Schulte can be
reached at email@example.com or 954-356-4591.
Nancy McVicar can be reached at firstname.lastname@example.org or
April 27, 2002 - VERO
BEACH An anguished Vero Highlands mother cried
out for justice Friday.
Justice for her
OxyContin-addicted son, Frank "Tony" Barnard Jr., 26,
who went into a coma Monday and died of acute renal failure Wednesday
Indian River Memorial Hospital, she said.
Justice for her brother, Floyd Baker, 44, an OxyContin addict who died March 29, 2001.
And justice for all the other patients of a Port St. Lucie doctor accused of trafficking in prescription drugs and continuing a criminal enterprise.
At a news conference in her living room, Connie Sue Velie, 46, blamed Dr. Asuncion Luyao for the deaths of her children. Both were patients of Luyao and had received multiple prescriptions for OxyContin and other drugs, including, in her son's case, methadone and Xanax, she said.
Velie also called on prosecutors to press murder charges.
"I had three children. Now I have one left," she said. "(Luyao) should be held accountable."
State attorneys have said they are considering homicide charges against Luyao. Prosecutors could not be reached Friday for an update.
Velie's remaining son, Jeremiah Barnard, 24, said his brother broke his ankle about three years ago and had several screws and pins implanted. The injury must have been the reason his brother sought treatment for pain, he said.
The younger brother said Frank Barnard started taking OxyContin about 2 years ago and was on methadone treatment to kick the habit when he died.
Luyao, 60, was arrested March 26 after months of investigation and is in the St. Lucie County jail unable to post $1.83 million bail.
More than 50 people including patients, members of the local Filipino community and her family have appeared at court hearings to support Luyao, a native of the Philippines.
Barnard died the day
his mother filed a malpractice suit against Luyao
for her daughter's death, said attorney Philip DeBerard, of Stuart, who
is handling the case. He anticipates a lawsuit will be filed in her
BOONE CO., WV, Feb.
19 - A drug problem in Boone County is costing some
people their lives. Since November at least 5 people have died because
of incorrect drug use. Police say these victims were all drug addicts
one point trying to kick the habit.
When you're addicted
to a narcotic like oxycontin or cocaine sometimes
you're given a prescription for methadone. That can come in the form of
a pill. Some people are prescribed a duragesic patch. Both these
are used to lesson the effects of the withdrawal you experience when
give up your drug of choice. The problem comes in when you combine the
patch or methadone with the narcotic. The combination can be deadly.
County Chief Deputy Rodney Miller says, "we're learning ourselves along
the way as to how this drug will interact with other drugs, but the
is coming at the cost of other lives apparently because we're seeing
taken place after the fact."
US FL: Luyao Charged In 4 Deaths URL: http://www.mapinc.org/drugnews/v02/n1165/a11.html Newshawk: chip Pubdate: Tue, 25 Jun 2002 Source: Port St. Lucie Tribune (FL) Copyright: 2002 The E.W. Scripps Co. Contact:HREF="http://email@example.com< firstname.lastname@example.org">BR">email@example.com > Website: http://www.tcpalm.com/tcp/tribune
Details: http://www.mapinc.org/media/2049 Author: Mark PollioLUYAO CHARGED IN 4 DEATHS FORT PIERCE -- A Port St. Lucie doctor previously charged with providing potentially lethal doses of OxyContin to patients was charged Monday with four counts of manslaughter. The State Attorney's Office charged Dr. Asuncion Luyao, 60, with 12 counts of trafficking OxyContin, 4 counts of manslaughter and one count of continuing criminal enterprise. Twelve patients under Luyao's care died of suspicious causes, according to a medical examiner's report. The manslaughter charges filed Monday are tied to the deaths of Janice Byers, Robert Gustaf, Julia Hartsfield and Tina Smith. All four died in 2001 -- Byers on Nov. 17; Gustaf on Oct. 29; Hartsfield on June 12 and Smith on July 13. Luyao turned herself in at the St. Lucie County Jail shortly before 11 a.m. on Monday, and walked out within minutes of being booked. She spent 49 days in jail after her first arrest March 26 and her bond did not change despite the manslaughter charges. Prosecutors said the original $455,000 bond took into account the possibility of the additional manslaughter charges. Luyao was arraigned on all 17 counts in court. Circuit Court Judge Dwight Geiger entered not guilty pleas for Luyao on all counts. "These four charges were appropriate to file at this time," Tom Bakkedahl, assistant state attorney. said. "We took our time because we wanted to provide her with every benefit of the doubt. These new charges are based on the strength of proof." Bakkedahl said his office is still reviewing two of the 12 suspicious deaths to determine if additional manslaughter charges are warranted. Luyao's attorney, Joel Hirschhorn of Miami, said he has talked at length with prosecutors and was aware the new charges were coming. "I am pleased the State Attorney's Office is acting responsibly," Hirschhorn said. "A less responsible office would have thrown all the deaths in the mix and let the court sort them out. "Not that I'm conceding the state is right." Both sides agreed to an order that protects Luyao's patients from having their medical records made public. They also agreed to change Luyao's curfew if she finds a new job. At present, the conditions of Luyao's bond restrict her from leaving home between the hours of 7 p.m. and 9 a.m. In March, the state Health Department stripped Luyao of her medical license following her first arrest. Luyao has been out of work since local law enforcement officials shut down her medical office at 9474 S. U.S. 1 in Port St. Lucie following her first arrest. A lengthy investigation of the doctor began after Treasure Coast Regional Medical Examiner Dr. Roger Mittleman wrote a letter to the state Health Department late last year in which he detailed his concerns over the deaths of 12 of Luyao's patients. An undercover state investigator posed as a patient to determine what type of care Luyao was providing. Luyao treated the investigator for phony back pain on six visits in 2001. After Luyao's arrest, the investigator testified in court that Luyao prescribed him large doses of OxyContin and other prescription medications without being fully examined. Investigators served a search warrant on her office in December 2001. Cash totaling $63,000 was found in a bag in a filing cabinet, investigators said. Prosecutors said she pocketed cash in exchange for OxyContin prescriptions. St. Lucie County Sheriff deputies arrested Luyao, a Philippine native, and Geiger originally set a $1.89 million bond. The Fourth District Court of Appeals ruled the bond was too high and Geiger reset it at $455,000. Luyao has been free on bond since May 14. Both sides said the discovery process would take months. Geiger wanted to set Luyao's trial for August, but both sides said that did not allow enough time. Bakkedahl said there are at least 7,500 pages of evidence to review, mostly medical records. Geiger rescheduled the trial for Sept. 4.