One doctor traded prescriptions for sex.

A pharmacist illegally popped pain pills while filling prescriptions.

And a dentist huffed nitrous oxide until he lost the feeling in his fingers.

They are among 46 doctors, nurses, pharmacists and dentists practicing in this area with records marred by substance abuse and, in some cases, criminal convictions, a five-month Bristol Herald Courier investigation shows.

Virginia shuffles addicted professionals through a five-year monitoring plan called the Health Practitioners’ Intervention Program. It’s a secretive program meant to keep participants sober and in the health care business, but it lacks the statistics to prove if it keeps working doctors off drugs and alcohol, or merely protects their careers.

There might be more area cases of addicted health care professionals who have remained beneath the public’s radar. State licensing boards keep some cases secret, even if physicians abuse alcohol or painkillers at work. Such addictions usually become public only after patients are endangered during a relapse.

Program supporters argue that secrecy is the only lure to voluntarily attract addicts. Otherwise, troubled doctors would battle addictions on their own, and lose. In the end though, the program pits the rights of patients against their doctors’ own medical confidentiality.

The Herald Courier uncovered 10 cases kept under wraps until repeated relapses forced licensing boards to intervene. Careers ended in half the cases. The others still work in health care.

One nurse abused oxycodone while working at a nursing home.

Another nurse, despite expulsion from multiple drug-rehabilitation programs, worked a year with an expired nursing license.

And a doctor continued his cocaine habit at the expense of patient care.

Backing them is a state law that allows health care workers great leeway before licensing boards deem them dangerous.

Secrets

Dr. Ram Singh traded prescriptions at his general practice in Norton, Va., for sexual favors and freely handed prescriptions over to patients with known drug addictions, a 1993 federal conviction revealed. He even penned fictitious patient names on prescriptions so police couldn’t trace the drugs back to his clients, state medical licensing records show.

The Virginia Medical Board yanked his license in 1997, three years after his federal prison stint. They gave it back to him two years later, and it remains valid, records show.

Unlike the secret cases, Singh’s drug history is known because he passed through a federal court, which keeps open records readily available to the public for the asking. He could not be found for an interview. A man who answered the phone at Singh’s home in Norton said he was out of the country and might not return this year.

Singh’s medical practice also could not be located, despite a Virginia law that requires doctors of medicine, osteopathic medicine and podiatry to list their current business addresses with the state’s Department of Health Professions. The address he provided the department eight years ago is no longer a medical establishment. The building is now the City Hall for Appalachia, a Virginia town that borders Kentucky.

Virginia law paves the way for anyone with a criminal background, such as Singh, to work in a licensed profession. Unless the licensing board determines that the criminal history poses a danger, applicants simply must be approved for the job. Child care and child-protection services are the only exceptions.

“What we look at in determining a physician’s fitness to practice is not only his or her technical skills, but whether that person jeopardizes not only the health, but the integrity, of the citizens of the commonwealth,” Steve Heretick, Board of Medicine president and a lawyer in Portsmouth, Va., said of the statutory guidelines.

State law also paves the way to keep an addiction secret through the Health Practitioners’ Intervention Program, which began in 1997. The program is Virginia’s main post-rehab monitoring system for health care professionals with drug or mental health problems, with oversight by the Department of Health Professions and monitoring by Virginia Commonwealth University. Professional licensing fees support the monitoring program’s roughly $2 million annual budget.

Most states fund similar programs, said Dr. Greg Skipper, who heads Alabama’s impaired physician monitoring program and authored a national study that tracks program success rates. Tennessee’s 31-year-old program is known as the Physicians Health Program. Only Nebraska and North Dakota lack such programs, while California abolished its 27-year-old program in 2007 after deeming it a failure and a public danger.

In Virginia, patients must undergo monthly, unannounced drug tests, stick with a rehab program, and follow any other medical board orders for five years. Usually, the monitoring program returns program participants back to work in their health care job six months after enrollment.

Retired lawyer and former Virginia state Sen. John S. Edwards, of Roanoke, proposed the law in 1997 that created the monitoring program after a legal client lost her nursing job over an addiction to painkillers prescribed following her own surgery.

“Virginia needed to do something like this for public safety reasons and to save careers,” Edwards said. “I’ve had more people tell me, who went through the program, that they don’t know what would have happened to their lives.”

Troubled health care providers can join the monitoring program without an alert going to a licensing board. Department of Health Profession investigators make the call of whether to keep the information secret based on whether the professional is deemed a danger to patients. Secrecy, program proponents say, is why the program works.

“It’s going to look like a safe haven, and you don’t get that if you go to the board,” Heretick said.

But this approach is questionable, said Jerry Flanagan, of the Santa Monica, Calif.-based Consumer Watchdog. He said the state board is choosing to remain ignorant about its own licensees.

“The weird thing about [the Virginia] program is that it’s keeping itself blind from the problem,” Flanagan said. “The board has a duty to know and a responsibility to make the decisions when to release the information.”

Escape

Before the monitoring program, drug-addled health care providers had the option of signing into a rehab facility and risking discovery and discipline by a licensing board, or not seeking help at all.

Recovering addict and Big Stone Gap, Va., dentist Neal Davis contends that treatment, at the risk of exposure and losing a health care license, looks good only when death is near. That’s why secrecy is the best thing for problem-plagued professionals, he said.

Davis huffed nitrous oxide in the mid-1970s and quit only after a temporary loss of feeling in his hands. From there, Board of Dentistry records show a descent into alcoholism, and that he pilfered Valium and Hydrocodone from his office.

It wasn’t until 1990 that he decided his career had to take a back seat to his life.

“I’d probably have died from an overdose or a suicide” without some sort of intervention, Davis said. “This thing really had me. … I didn’t know what to do.”

A grassroots, drug-recovery support group made up of Virginia dentists directed Davis into a rehab program. By then, Davis was desperate and didn’t care if his career was over. He was still in the rehab clinic when the Board of Dentistry received an anonymous call about his predicament. Instead of settling with hefty disciplinary action, the board helped monitor his recovery.

Even though the board worked with Davis, his case still made it into a public record because state law at the time did not offer health care providers confidentiality.

Now, even if a licensing board does learn of an addiction, it can send a person to HPIP and withhold disciplinary action – the trigger to make a case public. So, keeping addictions confidential is at the discretion of either a Department of Health Professions investigator or a licensing board.

“Really, what you do is protect the public by making sure the individual is identified and investigated, set for an evaluation and treatment, and continue with monitoring,” said William Harp, executive director of the Virginia Board of Medicine.

“They [the Virginia monitoring program] will not OK a doctor to go back into practice until he or she is believed to be safe,” he said.

Davis described the promise of confidentiality as the only safety net that can catch addicts, simply because the drugs blind them to the danger of their situations.

It was only after achieving sobriety that Davis could clearly deal his demons: “You reach a point where it doesn’t matter who knows. By then, you just want treatment,” he said.

Wants and needs

Julianne D’Angelo Fellmeth, of the University Of San Diego School Of Law’s Center of Public Interest Law, describes such doctor-recovery programs as necessary evils – but only if they work. She headed a 2005 audit that exposed flaws in California’s recovery program and helped kill the program two years later.

Like Virginia’s program, the California plan ran on the premise that confidentiality would lure addicted doctors to recovery. Drug screens and close monitoring would keep program participants in check.

“It sounds good, doesn’t it?” Fellmeth said. “But what we found was that none of it was working like the medical board said it would.”

Physicians quickly deciphered the timetables of the random drug tests and office inspections, Fellmeth’s study revealed.

Virginia’s program might have similar problems.

The addiction of former Abingdon, Va., doctor Patrick C. Wallace was a board secret until it involved patients. Months before losing his medical license in 2004, Wallace stole the very pain medication he prescribed for a patient, Virginia Board of Medicine records show. Wallace met the patient in a pharmacy parking lot, asked to check the just-filled bag of medicine, and pocketed one of the drug vials. The patient didn’t notice the vial was missing until after arriving home.

Still, one of the last straws for the medical board was discovering that Wallace might have used a batch of clean urine to cheat drug screens.

Wallace could not be located for this story. Internet phone records and a private background check list his home address as the Abingdon medical office where he used to work. Calls to a family member were not returned, and phone numbers listed for Wallace in Washington County civil and traffic court records are no longer valid.

Wallace landed on the medical board’s radar long before pocketing the patient’s prescription. On May 1, 2000, a drug-rehab facility diagnosed his problems with marijuana, cocaine, Hydrocodone and alcohol, board records show.

Months after that diagnosis, he contacted Virginia’s monitoring program, then a relatively new project. Wallace’s case eventually went to the Board of Medicine, where it remained a secret for more than four years.

The board deemed him a danger in early 2004, when state reports say he repeatedly responded late or not at all to hospital pages, forgot to follow up on patients’ tests results, and skipped a drug screen. Finally rousing the board’s suspicions, a report shows, was a police traffic stop that yielded a bag of urine in Wallace’s car.

A notation in an Aug. 14, 2004, report states that Wallace never had a witness present when he supplied urine samples for drug screens. His license was revoked the day of the report – four years after he joined the monitoring program.

Neither Wallace, nor any physician with a similar relapse history, will appear in the monitoring program’s statistics. No one tracks the numbers to show whether the Health Practitioners’ Intervention Program succeeds or fails for addicts.

“We’re not looking for a success rate. We’re doing it to return them back to practice,” said Peggy Wood, intervention program manager with the Department of Health Professions.

It’s difficult to gauge how many HPIP participants relapse like Wallace and drop out. In addition to its addiction specialty, HPIP also monitors health care providers with mental health issues and possible medical impairments, such as diabetes, which gave one dentist the shakes when left untreated.

Numbers are broken down on how many participants complete the program each year versus those expelled. But the monitoring program does not further break down those numbers by addict, mental health and physical health.

HPIP reported an average 35 percent success rate for all of those categories from 2003-07. Again, the success rate includes participants who initially joined not just for addictions, but also for mental health and physical health reasons.

By comparison, Tennessee’s program, which treats addictions only, boasts a 90 percent success rate. Most state programs average a 78 percent success rate, according to a national, five-year study released in November by Skipper, who heads Alabama’s drug-monitoring program. Both Virginia and Tennessee were included in Skipper’s study.

The remaining 22 percent either relapse and drop out of the program, retire from practice, move out of state without notifying licensing boards, commit suicide or die of an overdose or natural causes.

California Board of Medicine President Dr. Richard Fantozzi has relapse in mind when questioning whether any state licensing board should be in the business of monitoring addicts. California ended its monitoring program in 2007 after audits revealed loopholes that allowed doctors to stay in medicine for years despite chronic relapses.

“What are you, as the state of California, going to say? That it’s just a program and sometimes it fails?” he said. “That’s not a good answer coming from the state.”

Any idea of offering secrecy for doctors and other professionals who stick with the program is ridiculous, Fantozzi said, unless legislators can guarantee a perfect success rate.

California licensing boards still keep tabs on addictions by ordering problem doctors to join private programs. This way, the state is out of the addiction business, but still makes sure health care professionals are treated.

Patient rights

Health care insiders contend the key consideration to keeping an addiction secret lies in balancing a doctor’s medical confidentiality with a patient’s right to information about a physician.

Skipper, author of the national study, argues that medical privacy applies to doctors just as it does to patients.

“If a substance abuse problem is really a health issue, should it be possible for someone to be able to have information on all their doctor’s health problems?”

Skipper asked. “That could be extended to every professional you work with: Do you have a right to know their health history, because it can affect their performance?”

Another philosophy is that patients don’t need to know. An American Medical Association report suggests that patients might lack the medical know-how to decide if a doctor’s drug addiction is relevant.

“… Such disclosure would place patients in the inappropriate role of having to determine whether a physician is safe, when the determination is most appropriately the responsibility of the profession,” the AMA states in its report “Physician Health and Wellness.” The manifesto first was issued by the AMA’s Council on Ethical and Judicial Affairs in 1992 and reaffirmed as an official position in 2004.

But health care critics like Dr. Sydney Wolfe, with the Washington D.C. -based consumer advocacy group Private Citizen, counter that such secrecy blatantly favors doctors over patient safety.

“We take the side of the patient – if you’re going to a doctor who has a drug or alcohol problem, you probably don’t want them to operate on you,” Wolfe said.

What danger signs

When it comes to labeling a doctor as dangerous, Virginia law leaves Department of Health Profession investigators and board members empty-handed. The board has not developed any guidelines on how to make that call. It’s left to the person in charge of either the investigation or the board hearing.

Flanagan, of Consumer Watchdog, finds the law too gray.

“You need an objective standard that is consistently applied, and that the public knows, so … you know what the line is,” he said.

Virginia law sets the bar high when labeling health care professionals as dangerous. There must be clear and convincing evidence of a violation – a stricter standard than the reasonable-doubt rule used in courtrooms.

“If you can’t connect the substance use with patient safety, then the connection fails,” the Board of Medicine’s Harp said.

An example of that high bar is found in the case against Dr. Olimpo F. Fonseca, who worked at a medical practice in Big Stone Gap, Va., when called before the board in 1994.

Scrutinized on allegations of over-prescribing pain medication, Fonseca admitted during questioning that he occasionally owned marijuana, an illegal substance.

Yet the board eventually concluded there was not enough evidence to prove his owning marijuana ever harmed his patients. The board dismissed the case.

Fonseca did not return multiple calls to his home. Telephone receptionists at the business he listed with the Department of Health Professions said he left the practice four years ago.

This high standard for bringing a disciplinary charge is also one reason that Dr. Singh, who served time in a federal prison for drug diversion, and others with criminal backgrounds are able to work in Virginia again.

“The board’s general thinking is that if a physician can be remediated, then he ought to be remediated,” Harp said. “You don’t want to throw out the baby with the bath water.”

Fellmeth, on the other hand, contends that boards need a specific limit for a physician’s chances at redemption. Otherwise, she argues, a drug-recovery program is little more than an excuse to avoid jail.

“How many bites at the apple are they going to get?” Fellmeth asked.

Contact the author at: [email protected] or (276) 645-2549