1 2 3 4 5

BEFORE THE OREGON MEDICAL BOARD STATE OF OREGON In the Matter of THOMAS JOHN PURTZER, MD LICENSE NO. MD12B80 ) ) COMPLAINT & NOTICE OF PROPOSED ) DISCIPLINARY ACTION )

9 10 11
12

The Oregon Medical Board (Board) is the state agency responsible for licensing, regulating and disciplining certain health care providers, including physicians, in the state of Oregon. Thomas John Purtzer, MD (Licensee) is a licensed physician in the state of Oregon.
2.

13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

The Board proposes to take disciplinary action pursuant to ORS 677.205(2), to include the revocation of license, a $ 10,000 civil penalty, and assessment of costs, against Licensee for violations of the Medical Practice Act, to wit: ORS 677.190(l)(a) unprofessional or dishonorable conduct, as defined in ORS 677.188(4)(a), (b) and (c); ORS 677.190(13) gross or repeated acts of negligence; ORS 677.190(17) willfully violating any rule adopted by the Board or any Board order or any Board request; ORS 677.190(23) violation of the federal Controlled Substance Act; and ORS 677.190(24) prescribing controlled substances without a legitimate medical purpose, or prescribing without following accepted procedures for examination of patients, or prescribing controlled substances without following accepted procedures for record keeping. 3. Licensee is a board certified neurosurgeon who treats chronic pain in Medford, Oregon. On October 8, 2009, Licensee and the Board entered into a Corrective Action Agreement in which the Board agreed to close its investigation in regard to Licensees treatment of chronic pain patients, to include his manner of prescribing narcotic pain medications, and Licensee agreed to enter into and successfully complete PEER (Physicians Education Evaluation and Renewal) program. Licensee satisfied the terms of this agreement, and the Board terminated the Page 1 - COMPLAINT & NOTICE OF PROPOSED DISCIPLINARY ACTION Thomas John Purtzer, MD

1
2 3 4 5
6

agreement in 2011. In September 2012, the Board opened an investigation subsequent to the overdose death of a patient who had been receiving significant narcotics from Licensee. That investigation was closed in December 2012 and the Board notified Licensee of its concern-that he should obtain prior medical records before treating any chronic pain patient with opioids. The Board subsequently received a complaint and opened an investigation in regard to Licensees treatment of patients for opioid addiction with Suboxone in an office based setting, as well as his treatment and management of patients with chronic pain. Licensees acts and conduct alleged to violate the Medical Practice Act follow: 3.1 The Board conducted a review of cases in which Licensee transitioned opioid

7
8 9
10

dependent patients that had been maintained on methadone to buprenorphine & naloxone (Suboxone, Schedule III). The Boards review of charts for Patients A - D reveals a pattern of practice where Licensee, in an office based setting, failed to obtain or review his patients prior medical records before instituting treatment with Suboxone, failed to risk stratify patients with histories of multiple failed attempts at sobriety, and failed to assess the impact of his patients home situations on the decision to initiate opioid prescribing. Licensee initiated high dose opioid bridging therapy (by using morphine sulphate IR (Schedule II), 30 mg) to transition patients from methadone (Schedule II) to Suboxone in the absence of medical evidence to support this treatment, in the face of active opioid addiction and in violation of the Drug Addiction Treatment Act o f2000 (DATA2000). Licensee repeatedly ignored signs o f aberrant behavior, to include requests for early medication refills and patient self-initiated use of marijuana and other opioids. Licensee also prescribed benzodiazepines, such as diazepam (Valium, Schedule IV) and alprazolam (Xanax, Schedule IV) during the same time that he prescribed Suboxone, without addressing the risk of over-sedation and without providing patients with material risk notification. Licensees charts reveal that he failed to respond to inconsistent urine drug screens (UDS) and other evidence of drug abuse and diversion, and frequently authorized early refills. Licensees practice failed to conform to the standard o f care and subjected his patients to the risk of harm. ///
Page 2 - COMPLAINT & NOTICE OF PROPOSED DISCIPLINARY ACTION ~ Thomas John Purtzer, MD

11
12

13 14 15 16 17 18 19 20 21

22
23 24 25 26 27 28

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

3.2

Patient D presented to Licensee in January 2012 with a multi-year history of

opiate addiction by misusing prescription narcotics and heroin. Patient D reported IV heroin use while receiving treatment from the local methadone clinic. Patient D was unemployed, living at home and with no other source of income. Licensee started Patient D on morphine sulfate Immediate Release (Schedule II) 30 mg and was instructed to determine his own appropriate dose. In February 2012, Licensee received a phone report that Patient D was selling his Suboxone and Klonopin on the street. Several of Patient Ds UDS results were inconsistent with Licensees prescriptions, to include a UDS in October 2012 indicating recent heroin use and not detecting the prescribed Klonopin. Nevertheless, Licensee continued prescribing Suboxone and Klonopin to Patient D at his last office visit on November 8,2012. Patient D died from an apparent IV heroin overdose on November 11,2012. Post mortem toxicology indicated recent use of heroin and did not report the recent use of Suboxone. Law enforcement investigation into the overdose determined that Patient D was selling or trading the Suboxone and Klonopin he was receiving from Licensee and obtaining heroin. 3.3 The Board also reviewed Licensees treatment of chronic pain patients (Patients E

- J), which raised serious questions in regard to the manner o f the Licensees overall clinical management of chronic pain patients. This review revealed a pattern of practice that breached the standard of care in his treatment and management of chronic pain patients, to include the following: Licensee treated high risk patients with dangerous combinations of opioids, such as morphine sulphate (Schedule II) and oxycodone (Schedule II), with benzodiazepines such as clonazepam (Klonopin, Schedule IV), diazepam (Valium, Schedule IV), and alprazolam (Xanax, Schedule IV), as well as with carisoprodol (Soma, Schedule IV), a medication that is chemically related to barbiturates; Licensee failed to risk stratify his chronic pain patients before initiating high dose opioid therapy; Licensee failed to address the efficacy of the treatment provided (to include assessing patient function and pain status) and failed to adequately manage patient progress in follow up clinical visits; After initiating high dose opioid therapy, Licensee failed to conduct effective surveillance measures, to included pill counts and more frequent clinic visits after aberrant behavior; Licensees charts failed to address evidence of patient aberrant behavior, Page 3 - COMPLAINT & NOTICE OF PROPOSED DISCIPLINARY ACTIONThomas John Purtzer, MD

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

to include inconsistent UDS reports and the concurrent use of tetrahydrocannabinol (THC); and Licensee failed to set forth clinical findings to support the treatment of his patients with escalating higher dosages of opioid therapy. Specific examples of substandard care include the following: a. Licensee initiated a high dose combination of opiate, benzodiazepines and Soma

for Patient E, a 48-year-old female, for chronic non-malignant pain that Licensee attributed to fibromyalgia syndrome and low back and bilateral leg pain of undetermined etiology. Additionally, Licensee reports a prior diagnosis of bipolar disorder for Patient E. Bone scans and an MRI were negative. Although Patient E was high risk, Licensee continued Patient E on a regimen of controlled substances, to include oxycodone (Schedule II), 30 mg, 10 a day, #300 per month, clonazepam (Klonopin, Schedule IV, a benzodiazepine), 1 mg, 3 times a day, #90, and carisprodol (Soma, Schedule IV) 350 mg, 4 times a day #120 per month, while failing to maintain effective surveillance measures. Licensee also continued Patient E on regular doses of lithium 300 mg, 2 a day, without obtaining periodic labs for lithium levels or monitoring thyroid or kidney functions. b. Licensee maintained Patient F, a 58-year-old male, on a high dosage of

methadone (Schedule II), morphine (Schedule II), hydrocodone (Schedule III), methylphenidate (Schedule II) and diazepam (Schedule IV) for complaints of chronic lower back pain. Patient F exhibited repeated episodes of aberrant behavior, to include requests for early refills, inconsistent UDS, dosage escalations, and concurrent use o f self-initiated THC. Nevertheless, Licensee continued Patient F on the medication regimen without adjustment, increased surveillance measures, or counseling of the patient. c. In 2009, Licensee started Patient G, a 54-year-old male, complaining of chronic

hip and lower back pain secondary to a 1982 motor vehicle accident, on MS Contin (Schedule II), 30 mg twice a day, and hydrocodone & acetaminophen (Norco, Schedule III) 10/325, 8 tablets every day, without conducting a formal risk stratification (to include taking an addiction history). Licensee transitioned Patient G to methadone, 80 mg per day, and oxycodone (Schedule II), 120 mg per day. Patient G engaged in repeated aberrant behavior, to include asking for early Page 4 - COMPLAINT & NOTICE OF PROPOSED DISCIPLINARY ACTION Thomas John Purtzer, MD

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

refills, reporting that he ran out of medications early, and inconsistent UDS. Nevertheless, Licensee did not increase surveillance measures, and did not refer Patient G to a pain specialist or to recommend tapering o f the opioid medications. d. Patient H, a 28-year-old male patient, presented to Licensee with complaints of

low back pain and depression, with a personal and family history of drug abuse. Licensee initially treated Patient H with oxycodone & acetaminophen (Percocet, Schedule II), 10/325, 1 2 tablets every 6 hours. Licensee subsequently transitioned Patient H to methadone, 80 mg a day, and lorazepam (Ativan, Schedule IV). Patient H requested early refills of his controlled substance medications, his UDS was often inconsistent with his prescribed medications and he admitted he was using THC and Xanax, but Licensee did not risk stratify this patient or increase the surveillance measures in response to the aberrant behavior, to include more UDS, pill counts, or more frequent clinic visits. e. Patient I, a 20-year-oid male presented to Licensee in June of 2011 with

complaints of right shoulder pain and chronic non-focal pain. The patient reported that he was addicted to and actively used heroin, as well as oxycodone and Xanax. Patient I disclosed a current 1 year history of IV heroin use. Patient I underwent a UDS, and tested positive for THC, opiates, and benzodiazepines. Patient I reported that Suboxone did not help his pain, but wanted it to help him clean up his life. Licensee started Patient I on Suboxone, 8 - 2 mg, #120, as well as Xanax, 1 mg, 4 a day, #120 and oxycodone, 15 mg, 5 a day, #150. In February 2012, Licensee added morphine, 15 mg, 1-2 tablets every 6 hours for breakthrough pain and methadone, 10 mg, 1-2 tablets every 6 hours. In April of 2012, Licensee prescribed Xanax, Img, 4 a day, #120; Suboxone, 8 - 2 mg, 4 a day, #120; and oxycodone, 15 mg, 5 a day, #150. In April of 2013, Licensees prescribing regimen for Patient I included Suboxone 8 - 2 mg, 4 a day, #120, and oxycodone HCL, 30 mg, 1 every 6 hours, #120. Licensee failed to conduct a formal risk stratification for Patient I, and initiated opioid therapy for pain, instead of referring this patient for treatment of his addiction. Despite Patient Ts continued use of THC and Xanax, and despite his repeated requests for early refills and inconsistent UDS, Licensee increased the dosage for oxycodone to 30 mg, four times a day. After accessing the prescription drug Page 5 - COMPLAINT & NOTICE OF PROPOSED DISCIPLINARY ACTIONThomas John Purtzer, MD

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

monitoring program and determining the Patient I was receiving opioids (Oxycontin, oxycodone, and hydromorphone in December 2012 and January 2013) from three separate providers, Licensee did not address this issue in his chart note or alter the treatment regimen. f. Patient J, a 33-year-old female, presented to Licensee on December 3,2012, with

complaints of chronic left knee pain and a history that included gastric bypass surgery and seizures, although a scan performed on her knee was negative for abnormalities. Another provider had prescribed methadone, 10 mg, 4 times a day. Patient J reported that her pain is better controlled with oxycodone. Patient J admits using oxycodone that she obtained from family and friends, but had not previously been prescribed this medication. Licensees diagnostic impression was severe chronic knee syndrome. Licensee prescribed oxycodone 15 mg, 1 - 2 tablets, every 6 hours, #200 (which was supposed to be a 1 month supply). On January 2, 2013, Licensee prescribed oxycodone, 15 mg, 1 - 2 tablets, every 6 hours as needed, #200. On January 10,2013, Patient J reported that she lost her oxycodone in the washing machine and Licensee initiated treatment with Suboxone, 8-2 mg, 2 tablets a day. On January 17,2013, Licensee prescribed oxycodone, 15 mg; 1 - 2 tablets every 6 hours, #240; and methadone, 5 mg, 1 - 2 tablets at bedtime. Licensee continued to prescribe this dosage over the course of the next several months, with the prescription for oxycodone increasing to 15 mg, 1 - 2 tablets 8 times a day. Licensee did not adjust the dosage when Patient J engaged in aberrant behavior, to include inconsistent UDS and deviating from the treatment plan or claiming to have lost her medications. In addition, Licensee prescribed a dangerous and unorthodox mixture of controlled substances to treat Patient Js complaint of chronic pain. 4. Licensee is entitled to a hearing as provided by the Administrative Procedures Act (chapter 183), Oregon Revised Statutes. Licensee may be represented by counsel at the hearing. If Licensee desires a hearing, the Board must receive Licensees written request for hearing within twenty-one (21) days o f the mailing of this Notice to Licensee. Upon receipt of a request for a hearing, the Board will notify Licensee of the time and place of the hearing. ///
Page 6 - COMPLAINT & NOTICE OF PROPOSED DISCIPLINARY A C TIO N Thomas John Purtzer, MD

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
21

5. If Licensee requests a hearing, Licensee will be given information on the procedures, right of representation, and other rights of parties relating to the conduct of the hearing as required under ORS 183.413(2) before commencement of the hearing. 6. NOTICE TO ACTIVE DUTY SERVICEMEMBERS: Active duty servicemembers have a right to stay these proceedings under the federal Servicemembers Civil Relief Act. For more information contact the Oregon State Bar at 800-452-8260, the Oregon Military Department at 800-452-7500 or the nearest United States Aimed Forces Legal Assistance Office through http://legalassistance.law.af.mil. 7. Failure by Licensee to request a hearing or failure to appear at any hearing scheduled by the Board will constitute waiver of the right to a contested case hearing and will result in a default order by the Board, including the revocation of his medical license and assessment of such penalty and costs as the Board deems appropriate under ORS 677.205. If a default order is issued, the record of proceeding to date, including Licensees file with the Board and any information on the subject of the contested case automatically becomes a part of the contested case record for the purpose of proving aprima facie case per ORS 183.417(4).

DATED this__ 0 __ day of

, 2014.

22 23 24 25 26 27 28

OREGON MEDICAL BOARD State of Oregon

KATHLEEN HALEY, JD EXECUTIVE DIRECTOR

Page 7 - COMPLAINT & NOTICE OF PROPOSED DISCIPLINARY ACTIO NThomas John Purtzer, MD