The Seattle Times, by Michael J. Berens and Ken Armstrong

By Michael J. Berens and Ken Armstrong

Seattle Times staff reporters

Map the deaths and you see the story.

Assign a dot to each person who has died in Washington by accidentally overdosing on methadone, a commonly prescribed drug used to treat chronic pain. Since 2003, there are 2,173 of these dots. That alone is striking, a graphic illustration of an ongoing epidemic.

But it’s the clusters that pop out — the concentration of dots in places with lower incomes.

Everett, whose residents earn less than the state average, has 99 dots. Bellevue, with more people and more money, has eight. Working-class Port Angeles has 40 dots. Mercer Island, upscale and more populous, has none.

For the past eight years Washington has steered people with state-subsidized health care — Medicaid patients, injured workers and state employees — to methadone, a narcotic with two notable characteristics. The drug is cheap. The drug is unpredictable.

The state highlights the former and downplays the latter, cutting its costs while refusing to own up to the consequences, according to a Seattle Times investigation that includes computerized analysis of death certificates, hospitalization records and poverty data.

Methadone belongs to a class of narcotic painkillers, called opioids, that includes OxyContin, fentanyl and morphine. Within that group, methadone accounts for less than 10 percent of the drugs prescribed
— but more than half of the deaths, The Times found.

Methadone works wonders for some patients, relieving chronic pain from throbbing backs to inflamed joints. But the drug’s unique properties make it unforgiving and sometimes lethal.

Most painkillers, such as OxyContin, dissipate from the body within hours. Methadone can linger for days, pooling to a toxic reservoir that depresses the respiratory system. With little warning, patients fall asleep and don’t wake up. Doctors call it the silent death.

In Washington, the poor have been hit the hardest. While Medicaid recipients make up about 8 percent of Washington’s adult population, they account for 48 percent of the methadone deaths.

A case from 2009 epitomizes this divide. Two sisters, injured in a car accident in South King County, needed pain relief. One, with private insurance, received OxyContin, an expensive drug. The other, on Medicaid, received methadone — and within a week, overdosed and died.

“I kept telling her not to go on methadone,” said the surviving sister, who asked that the family’s name not be used, for privacy.

Washington’s methadone death rate ranks among the country’s highest. California, with more than five times the people, has fewer deaths.

But year after year, Washington health officials have proclaimed methadone to be just as safe as any other painkiller. They have disregarded repeated warnings, obscured evidence of harm, and failed to adopt simple lifesaving measures embraced by other states, the Times investigation shows.

Jeff Rochon, head of the Washington State Pharmacy Association, says pharmacists have long recognized that methadone is different from other painkillers. “The data shows that methadone is a more risky medication,” he says. “I think we should be using extreme caution to protect our patients.”

Washington’s methadone deaths tell a story of the politics of health care in a slumping economy. Tight budgets force tough cuts. Often, those hurt the most can afford it least. And often, the suffering is met with silence, with public officials more inclined to rationalize than reckon.

Losing it all

Doctors expected Angeline Burrell’s surgery to be routine. But when Burrell, a 911 dispatcher for King County, had her gall bladder removed in 2004, she was left with excruciating pain, mystifying physicians.

Doctors prescribed painkillers, but the pain wouldn’t go away. The more Burrell sought help, the more doctors suspected she was a pill seeker, a prescription addict scamming for drugs.

“She tried to find a doctor to believe her,” says her mother, Sara
Taylor. “She became depressed, and it just kept getting worse.”

Co-workers pitched in, donating sick days to Burrell.

Two years passed before doctors diagnosed surgical-related nerve damage. By then, Burrell had lost her job, her house in Spanaway and her private insurance. She moved into her mother’s home in Renton, destitute and on Medicaid.

Her pain made walking unbearable. She gained weight. Her eyesight dimmed. She spent long hours in bed, reading Patricia Cornwell crime novels, anguishing over her lost prospects of ever becoming a sheriff’s deputy.

The Roosevelt Clinic at the University of Washington Medical
Center prescribed drugs for her pain, insomnia, nausea, depression and anxiety, according to medical records Burrell’s family provided to
The Times.

“I was so scared about what all the pills were doing to her,” Taylor says.

One of those drugs was methadone.

Federal regulators say it can be dangerous to give methadone to someone on anti-anxiety medications. Burrell was. They say methadone can disrupt breathing and heart beat, especially if a patient has a respiratory disorder. Burrell did. State guidelines warn against giving methadone to someone also receiving other long-acting painkillers. Burrell was.

In early 2008 Dr. Anna Samson doubled Burrell’s methadone dose to 10 milligrams every six hours, according to her medical notes.

Samson’s notes also said she would be tapering Burrell off oxycodone, a more expensive painkiller that she began taking while on private insurance. But in the meantime Burrell remained on both.

Samson’s notes made no mention of Burrell’s sleep apnea — involuntary pauses in breathing. Methadone can compound apnea’s effects; federal regulators have tied combining the two to hundreds of preventable deaths.

But Samson’s notes did mention the dangers of Burrell’s pharmacological mix: “I advised her that combinations of these medications can depress her respiratory rate and cause her to stop breathing.”

Samson’s notes were dated Feb. 13, 2008.

Two days later, Burrell was found in a nightshirt, slumped on her bed, arms dangling with open hands. She had stopped breathing, her respiratory muscles paralyzed with stunning speed.

The King County Medical Examiner’s Office found methadone and three other prescription drugs in her body, consumed at normal doses. The medications had combined into a toxic cocktail. The case was ruled an unintended death.

University hospital officials reviewed Burrell’s case and concluded her care was “appropriate,” according to a written statement to The Times.

At age 32, Angeline Burrell became another dot on the map.

The origins of Washington Rx

Starting a decade ago, states discovered a new way to save money on prescription-drug costs, which were increasing about 17 percent a year. All but four created a Preferred Drug List, a register of medications the state will pay for in cases where it covers a patient’s care.

The goal is to steer patients toward less expensive drugs without sacrificing safety; plus, by consolidating purchases, states can often negotiate better deals with drug companies.

Washington’s list took effect in 2004, the year after Gov. Gary Locke signed the state’s new prescription-drug program, Washington Rx, into law.

Often, in state government, the most important decisions get made not by legislators on the House or Senate floor, but by easy-to-miss committees meeting in mundane places. That’s the case with Washington’s Pharmacy and Therapeutics Committee — or P&T committee, for short — a group with enormous influence over patient care.

Under Washington Rx, a P&T committee comprising doctors, pharmacists and other medical experts evaluates drugs in various classes, weeding out any found to be less safe or effective. After that initial cut the state draws up its list, taking into account cost.

No state officials sit on the committee, an arrangement designed to protect the panel’s independence.

But the committee’s members are hand-picked by the three state agencies or programs with a financial stake in the panel’s winnowing process: Medicaid; Labor & Industries, which handles workers’ compensation; and the Health Care Authority, which administers medical benefits for state employees.

Though not committee members, officials from these three entities attend committee meetings and often dominate discussions. With methadone, two doctors in particular — Jeff Thompson, chief medical officer of the Washington Medicaid program, and Gary Franklin, medical director for L&I — have repeatedly deflected concerns about the drug, a review of meeting transcripts shows.

In May 2004, when Washington’s preferred drug list for long-acting painkillers took effect, only two drugs were included: morphine and methadone.

Across the country, 31 states have methadone on their preferred list. But most offer a broad inventory of other pain medications, expanding the options available to physicians, according to a Times survey of these formularies.

Committee meets: 2004-05

To Dr. Stuart Rosenblum, a pain specialist in Portland, what he had to say was worth the six-hour round trip.

In June 2004, Rosenblum drove to the Holiday Inn SeaTac and told
Washington’s P&T committee that Oregon had seen a 400 percent increase in deaths associated with methadone. He advised the committee to exclude the painkiller from Washington’s preferred drug list.

“Virtually no response,” he says of the reaction. “It was like, ‘Thanks for testifying.’”

The committee ruled that methadone was as “safe and effective” as any other painkiller, allowing the state to keep it as a preferred drug.

In June 2005, at the Radisson Hotel near SeaTac, Oregon’s methadone deaths came up again. One member of the P&T committee, Dr. Carol Cordy, asked the right question: “And does Washington have numbers like Oregon?”

But Jeff Thompson, of Washington Medicaid, sidestepped it. He talked about measures the state was taking to address overdoses for painkillers in general — “We’re doing a lot. ... In my mind, I think it’s working” — but provided no numbers for methadone-related deaths.

One committee member seemed to think Washington had nothing to worry about, saying: “I know with methadone we don’t really encourage it as a preferred drug.” Citing “issues” with doctors not knowing how to use methadone, she claimed physicians were directed to morphine instead.

Another member wondered if any effort was being made to look at Washington’s methadone overdose rate. But then he dismissed the thought: “Sounds like in our state, methadone’s just not used much. ... So it may be just a moot point.”

In fact, the point was anything but moot. Washington’s problems with methadone weren’t minor compared to Oregon’s. Washington’s were much worse.

In 2004, the amount of methadone used in Washington had soared to about 224,000 grams. Oregon, meanwhile, used about 157,000 grams.

While Oregon’s methadone-associated deaths leveled off in 2002, Washington’s became a dramatic fever chart, shooting up. Deaths linked to methadone went from 140 in 2002, to 166 in 2003, to 256 in 2004, according to a Times analysis of death certificates. Oregon, by comparison, had 99 deaths in 2004.

Washington’s deaths were among the highest in the country — surpassed, in 2004, by only North Carolina and Florida, both more populous states.

In May 2005, the month before the meeting at the Radisson, 28 people in Washington died from poisonings linked to methadone. They included a 30-year-old nursing assistant from Spokane, a 43-year-old waitress from Puyallup and a 44-year-old welder from Vancouver.

The day after the committee met, a 38-year-old database specialist from Shelton who was on both methadone and antidepressants overdosed and died.

A methadone primer: cheap but complex

For decades, methadone — a synthetic opioid developed in the 1930s by a German company — was associated not with pain relief but with weaning addicts off heroin and other drugs. The word summoned an image of clinics, often in seedy parts of town.

But when the medical community’s philosophy on pain shifted, so did its take on methadone.

As recently as the mid-1990s, Washington discouraged doctors from prescribing narcotic painkillers to noncancer patients. Pain was considered a symptom, not an ailment. But in the late ’90s, as patients protested, the health-care system switched course, viewing untreated pain as unnecessary suffering. By 2001, the nation’s top hospital-accreditation agency mandated treatment of pain.

In this new environment, methadone emerged as an attractive option. Less than a dollar a dose, the drug was three to four times cheaper than its closest competitor and 12 times cheaper than brand-name OxyContin.

From 1999 to 2005, the use of methadone in the United States went from 965,000 grams to 5.4 million grams, according to the
U.S. Drug Enforcement Administration.

But then there are the drug’s complicating factors.

While the pain relief from methadone might last four to eight hours, the drug’s half-life can extend for days. Various studies have placed the high end at 59 hours, or 91 hours, or even 128 hours. That means the drug’s dangers — mainly, its effect on the respiratory system — last long after its benefits have worn off. A patient in pain might be tempted to take another pill without being aware of the toxic buildup.

Most prescription drugs harbor risks when mixed with alcohol or other medications. Methadone can be particularly hazardous when combined with drugs called benzodiazepines, used to treat anxiety disorders.

Patients struggling with pain often become depressed or anxious, doctors say, making this risk factor a critical one. For 2009, The Times documented 274 methadone-related deaths in Washington. Death certificates show that 119 patients, or 43 percent, also consumed prescription medications for anxiety or other mental-health disorders.

In its regulation of addiction clinics, the federal government has long recognized methadone’s dangers. Under the mantra “start low, go slow,” federal law requires tight controls. Addicts, for example, must visit the clinic daily at the beginning of treatment. That’s because the drug’s effects on individuals can vary dramatically.

But with pain patients, many doctors prescribe a month’s worth of methadone, with little or no follow-up.

As the use of methadone has climbed, so have the overdoses. From 1999 to 2005, methadone-associated deaths in the United States climbed from 786 to 4,462, according to the Centers for Disease Control and Prevention.

Of course, not all those deaths can be attributed to prescribing practices. Some overdose victims obtain methadone without a prescription or combine it with illegal drugs such as cocaine. The Times found that up to 20 percent of methadone-related deaths in Washington involved a combination with illicit substances, suggesting the overdoses were a byproduct of abuse.

In November 2006, the U.S. Food and Drug Administration sounded an alarm about methadone, following an investigative report in a West Virginia newspaper, The Charleston Gazette. The FDA lowered its dosage guideline for methadone and issued a public-health advisory with this headline: “Methadone Use for Pain Control May Result in Death and Life-Threatening Changes in Breathing and Heart Beat.”

Committee meets: 2006

Once again, committee member Carol Cordy asked the right question.

When the P&T committee met in December 2006 at the Seattle Airport Marriott, it had been three weeks since the FDA issued its methadone alert. Cordy, a family physician in Seattle, brought up methadone and morphine — the state’s choices as preferred painkillers — and asked: “Has there been any increase in accidental overdoses?”

Gary Franklin, L&I’s medical director, cited a study of workers’ compensation recipients that found 32 overdose deaths between 1995 and 2002. “They were half methadone and half oxycodone,” Franklin said.

But those numbers didn’t answer Cordy’s question. The L&I study applied only to a small population. More important, its time span preceded the start of Washington’s preferred drug list. “No,” Cordy said. She wanted to know about any increase after 2003.

“Yeah, I guess we haven’t looked at that,” Franklin said. He kicked the question to L&I’s pharmacy manager, who talked up the challenges of doing such analysis, saying death certificates often list more than one drug: “So it’s kind of hard to divvy out, you know, the particular.”

Cordy’s question was not an impossible one to answer. The state Department of Health analyzes death certificates and reaches conclusions even when multiple drugs are listed. The Times did the same and found these numbers: In 2003, the year before the preferred drug list took effect, the state recorded 166 deaths linked to methadone; by 2006, that number had more than doubled, to 342.

Just as telling, those 342 deaths were three times the number attributed to any other long-acting painkiller.

Cordy wasn’t the first to question methadone in 2006. A doctor from the Seattle Cancer Care Alliance, Dermot Fitzgibbon, appeared at a P&T committee meeting that summer and urged the state to offer more choices than methadone and morphine, calling methadone “particularly problematic.” But Washington refused to change course.

At the end of the December 2006 meeting, Siri Childs, pharmacy administrator for Washington Medicaid, told the committee what she called a “good story.”

“Do you all want me to tell you how many OxyContin users we have in Washington nowadays?”

“Sure,” came the answer.

“You’re going to be just amazed, because when we started the preferred drug list with the long-acting opioids, OxyContin represented 70 percent of our utilization. Today ... we’re down to less than 3 percent.”

Washington’s death toll from methadone was soaring. But the state was realizing its goal of moving people off more expensive painkillers.

‘Very little data’

In evaluating drugs for safety and effectiveness, the P&T committee is required to rely on the best available science. To find it, the state hired Oregon Health & Science University, a teaching hospital and research center based in Portland.

The OHSU researchers collect and analyze medical studies, looking for the best clinical trials, ones that compare drugs head-to-head and are randomized, controlled and of long duration.

In the case of long-acting opioids, however, researchers have had only a few studies of poor or fair quality to consider.

At a P&T committee meeting in 2005, Dr. Roger Chou of OHSU told members there is “a continued lack of good study on methadone.”

In 2006 he said, “There’s no evidence that one long-acting opioid is superior to others,” to which the committee’s vice chair said, “Thank you, Roger, that was excellent.” In 2008 Chou said, “We really have very little data on methadone’s use.”

In the absence of top-notch clinical trials, Washington officials adopted the position that methadone is just as safe and effective as other drugs in its class.

Franklin, the L&I medical director, told The Times that “if it wasn’t methadone killing people” in Washington, it would be another long-acting painkiller — oxycodone or fentanyl or something else. He said prescribers and patients have become too quick to turn to long-acting painkillers in general, a shift fueled by “weak science” and support from the pharmaceutical industry.

“The overall problem — the public-health emergency in this country — is a dosing problem,” Franklin said. “It is not a methadone problem.”

Thompson, the Medicaid chief medical officer, said: “If you’re looking for a single villain, you could make methadone that villain. But I think it’s more complex than that.”

Methadone, he said, “is a safe drug if used correctly. ... If it’s an unsafe drug, why have we been using it for 40 years?”

For Washington, the preferred drug list has yielded financial rewards. In fiscal year 2008, the Medicaid program’s estimated savings came to $45.5 million, according to an audit by the state’s Joint Legislative Audit & Review Committee. Looking only at long-acting opioids — the class with methadone — that year’s savings amounted to $3 million.

Some other states, meanwhile, have treated methadone’s mortality figures and complex properties as sufficient grounds to urge caution.

New York issued a health advisory in January 2009 about methadone’s dangers. Five months later, Oregon alerted doctors that methadone’s “safety is of increasing concern,” and the drug “should not be considered a first-line agent.”

Fifteen states have left methadone off their preferred drug lists, despite its low cost. North Carolina, like Washington, has consistently ranked among the top five states in methadone-associated deaths. When North Carolina adopted its first preferred drug list last year, the state rejected methadone.

North Carolina had analyzed the drug’s toll and did not want to “encourage its use,” said Dr. Lisa Weeks, chairwoman of the state’s Preferred Drug List Review Panel.

Committee meets: 2009

“Quite frankly, I’m at a loss of what to do,” Thompson told the committee at its February 2009 meeting.

His consternation traced to a recent Department of Health study that produced some alarming numbers about Medicaid.

Analyzing all prescription-opioid fatalities in Washington from 2004 to 2007, department researchers discovered that a stunning 64 percent involved methadone.

And of the people whose deaths were linked to methadone, 48 percent were on Medicaid.

The findings highlighted methadone’s “prominence” in opioid overdoses, the Health Department study said, and indicated “the Medicaid population is at high risk.”

“I think this is a distinction that we don’t want, and it just keeps growing,” Thompson said of the Medicaid population’s disproportionate share of the state’s prescription-drug deaths.

In medical circles, the department’s findings about methadone and Medicaid broke new ground. In the fall of 2009, the Centers for Disease Control and Prevention — the federal agency assigned to protect public health — published the study in its Morbidity and Mortality Weekly Report.

But in Washington, state officials have done little to spread the word.

When the P&T committee met in December 2009, Bill Struyk, a pharmaceutical representative, brought up “Generic News,” a newsletter produced by state Medicaid officials for health-care professionals. He said the newsletter told only half the story of methadone: Officials publicized how cheap it was, without saying how many deaths it was linked to.

“Without disclosure of that fact, are we making informed decisions?” Struyk asked.

Thompson jumped to methadone’s defense, pointing to other drugs — for example, ones used in mental-health treatment — also linked to fatal overdoses. The state should be “very careful” about “picking on a drug,” he said.

“If you look at the dangers, it’s not just methadone,” Thompson said.

How about a note, Struyk suggested, advising methadone prescribers to be cautious?

“It’s not only due just to methadone,” Thompson said. “No,” Struyk said. “But 64 percent are.”

Thompson said he would include methadone’s toll in a future newsletter. “Because it is important,” he said. But he never did.

Alarmed by the Health Department study, state officials launched an internal monitoring program to track practitioners who prescribe high volumes of narcotics to Medicaid patients, Thompson told The Times. In addition, the state now educates hundreds of Medicaid patients on the risks and use of potent painkillers.

One of the state’s broadest initiatives to save lives, Thompson said, is a “lock-out” program that requires about 3,800 Medicaid patients to use only one practitioner for prescriptions in order to avoid “doctor shopping.”

‘Elephant in the room’

In December 2010, Dr. Michael Schiesser, a pain specialist in Bellevue, wrote a letter to the P&T committee, retracing the state’s history with methadone and crying foul.

When it comes to methadone, Schiesser is the closest thing the state has to a whistle-blower. Three years ago he joined a Health Department work group on accidental poisonings. After that he became involved in legislative deliberations about pain management.

He reviewed transcripts of P&T committee meetings and swept up reports about methadone. The more research he did, the more troubled he became.

Schiesser uses the word “creep” to describe methadone’s grip on Washington. As more years passed with the P&T committee saying the drug was as safe as any other, the harder it became for the state to reverse course or hedge by issuing special alerts to physicians of potential complications with methadone.

“So you start to ignore the elephant in the room, which is the mounting evidence,” Schiesser says.

His letter challenged a 2008 report that Oregon Health & Science University provided to the committee, saying it “contains errors, deficient logic, and relevant omissions.”

The report said one study “found no differences” between methadone and other drugs for overdose risk, when, in fact, the opposite was true, Schiesser wrote. The report mentioned a “black-box warning” from the FDA about OxyContin but not one from the same agency about methadone, he wrote.

In a written reply, an OHSU doctor downplayed Schiesser’s points, saying, for example, that FDA black-box warnings are “not evidence.”

To Schiesser, such hyper-selectivity has allowed the state to keep saying there’s no evidence of methadone being especially risky — and to the state, no news is good news. He describes the result as: “Because we don’t know, therefore it ain’t so.”

In Washington, medications can go on and off the Preferred Drug List as more evidence develops. The P&T committee meets later this month, when its members will evaluate — once again — the safety of methadone.

SIDEBAR: Methadone: What patients need to know

Methadone can be more difficult to manage than other drugs. Experts say it’s important to tell your health-care provider and pharmacist about all drugs you are taking, including vitamins.

• Methadone can slow your breathing even long after the drug’s pain-relief effect wears off. Never take more methadone than your doctor has prescribed. Death can occur if breathing becomes too weak.
• Drinking alcohol while taking methadone can cause serious side effects, even death.
• Without your doctor’s approval, don’t take methadone with other narcotic painkillers, sedatives, tranquilizers, or any medicines that slow breathing or make you sleepy.
• Methadone may not be the right drug for you if you have certain medical conditions. Let your doctor know first if you have asthma; sleep apnea; other breathing disorders; diseases of the liver, kidneys or gallbladder; underactive thyroid; a history of head injury or brain tumor; seizure disorders; low blood pressure; adrenal-gland disorders; enlarged prostate; or mental illness.

If you have questions, contact the state Department of Health’s Customer Service Call Center at 360-236-4700 or [email protected].

Database reporter Justin Mayo and news researchers David Turim and Gene Balk contributed to this report. Michael J. Berens: 206-464-2288 or [email protected]; Ken Armstrong: 206-464-3730 or [email protected].

It was meant to curb rising overdose deaths. But Washington's new pain-management law makes it so difficult for doctors to treat pain that many have stopped trying, leaving legions of patients without life-enabling medication.

By Ken Armstrong and Michael J. Berens

Seattle Times staff reporters

Charles Passantino stared at his doctor in disbelief.

A 64-year-old patient with a crippling liver disease, Passantino had received treatment for eight years for chronic pain. He took small doses of oxycodone, a generic painkiller, to free his muscles from stiffness and swelling.

With the pills, he got by. Without them, just walking from bedroom to living room proved unbearable.

Now, with little explanation and no warning, he was being dumped.

In March, Passantino’s doctor told him that his Pierce County clinic, part of the Community Health Care network, was no longer treating chronic-pain patients. The doctor wrote one last oxycodone prescription — 25 pills, 5 milligrams each, good for maybe a week — and suggested that Passantino cut the tablets into pieces, to make them last longer.

Good luck finding another doctor, the physician said.

What happened to Passantino is a scene that has played out in medical offices across Washington, thanks to new state rules governing the prescribing of painkillers. Those rules — which, among other things, impose restrictions upon doctors once certain dosage levels are reached — have driven so many health-care providers from the field that many pain patients now struggle to find care.

State officials say Washington’s new pain-management law will help reverse a rising tide of overdose deaths.

But the law does nothing to specifically address the risks of methadone — by far, the state’s number-one killer among long-acting pain drugs.

What’s more, hundreds if not thousands of patients have been denied life-enabling medications, cut off or turned away by doctors leery of the burdens and expense imposed by lawmakers, according to hospital representatives and consumer advocates.

At least 84 clinics and hospitals now refuse new pain patients, and some have booted existing patients, The Times found.

The growing legion of untreated pain patients has become so troublesome that some clinics, like one in Everett, post signs that ward off walk-ins: “We do not treat pain patients.”

Across the nation, the annual death toll from prescription painkillers continues to escalate, more than tripling from 1999 to 2008, according to statistics that federal health officials released last month.

Confronted with this epidemic, health officials in other parts of the country have been eying Washington’s groundbreaking law with special interest, says Dr. Lynn R. Webster, medical director of a Utah pain-research center and a national expert on preventing abuse of narcotic painkillers.

But Washington’s approach, he says, is not a model worth emulating. He told The Times: “If other states follow suit, many patients could suffer needlessly.”

Unanswered pleas

Desperate to ration what pills he had left, Passantino quartered his oxycodone tablets into tiny, chalky nuggets, each one good for just a single milligram of relief.

But by April, his supply ran out.

Most days he curled up in bed. Even simple pleasures — watching television or reading a book — became unbearable.

His wife, Jennifer, hunted down a list of 60 physicians and clinics that work with Medicaid patients. With help from a relative she called every provider on the list, pleading for someone to treat her husband. She tallied the answers in a journal. Every answer was no.

They once could have afforded good care and expensive medication. Jennifer earned a six-figure income as an executive for a consumer health company. Charles home-schooled their two daughters.

But in his 40s, Charles was diagnosed with diabetes. By his 50s, he developed end-stage liver disease — the kind associated with non-alcoholics — linked to fatty deposits that cause inflammation and scarring.

Struggles at work pushed Jennifer into unemployment. She later landed two part-time jobs — neither with health insurance — at a local department store and an accounting firm.

Today, they are poor by every state standard. Charles is enrolled in Medicaid to cover his $2,700 to $3,200 monthly prescription costs. To stay in the program, the couple’s annual income cannot exceed $35,000.

In May, a month after Charles finished his last pill, Jennifer wrote to Gov. Chris Gregoire. Though not yet in effect, the state’s pain-management law was creating a devastating impact, her letter said.

“Please help me get the care my husband needs,” she wrote.

Charles had never felt more depressed or hopeless, the letter said, and his condition was “continuing to deteriorate.”

Then, after months of closed doors, Charles secured an appointment at Seattle’s Swedish Medical System.

But the examination came to an abrupt halt when a nurse practitioner refused to write a prescription for oxycodone. Instead, she suggested methadone, Passantino says.

With Medicaid patients, the state saves money by restricting their access to costlier drugs. Washington designates methadone, which costs less than a dollar a dose, as a preferred painkiller. Oxycodone, three to four times more expensive, isn’t on the list.

But Passantino recognized the danger placed before him. He knew methadone could kill him.

Unlike other narcotic pain drugs, or opioids, which dissipate from the body within hours, methadone lingers in the bloodstream for days, potentially building to toxic levels. The drug can paralyze respiratory muscles; victims fall asleep and stop breathing.

Doctors had warned Passantino that his damaged liver couldn’t process drugs with such extended duration. That was why the state had allowed him to get oxycodone in the first place.

The nurse practitioner apologized, said there was nothing more to be done, and sent Passantino home with no relief.

Lawmakers argue from experience

When the state Legislature deliberated over the pain-management bill in 2010, the most striking voice of opposition belonged to Sen. Darlene Fairley, D-Lake Forest Park, a paraplegic whose spine had been crushed in the 1970s in an accident with a drunken driver.

“I worry that this legislation gets in the way of longtime patients and their doctors,” Fairley warned her fellow lawmakers.

Fairley feared her medication — 5 milligrams of oxycodone daily — would become difficult to obtain. Supporting herself on a crutch, she said, “It worries me because obviously I take pain medications — and I can tell what may happen in later years as the pain gets worse.”

But the bill’s supporters assured the public that longtime patients — like Fairley, like Charles Passantino — would not be turned away and made to suffer.

Lawmakers heard testimony about patients’ growing reliance on narcotic pain drugs, which contributed to addiction and diversion. Other medical experts cited a steep climb in prescription-drug deaths, surpassing the state’s annual toll of traffic fatalities.

The law’s co-sponsor, Rep. Jim Moeller, D-Vancouver, recounted his experience as a chemical-dependency counselor helping people hooked on prescription drugs.

Sen. Karen Keiser, D-Kent, rallied support with her account of receiving a prescription for vast amounts of OxyContin, a powerful narcotic painkiller, after she slipped and broke a knee.

“I didn’t need that much medication,” she said of her 2009 accident. “Doctors pass out pain medications almost without thinking. What we’re trying to do is put guidelines in place and give doctors pause.”

For lawmakers, there was also a financial incentive. The Department of Labor & Industries, which oversees medical compensation for injured workers, predicted the new law would result in fewer prescriptions for opioid medications, saving the state an estimated $13 million a year, according to legislative fiscal notes.

The law passed with minimal opposition, 96-1 in the House and 36-12 in the Senate.

Coupled with new rules passed by medical licensing boards, the law requires practitioners to document patient backgrounds and track behavior; conduct random urine screenings; and — most important of all — consult with a pain specialist if daily doses exceed the equivalent of 120 milligrams of morphine. Cancer and hospice patients are exempt, as are post-surgical patients and those with pain from sudden injury.

The law already applies to all medical providers except for doctors and physician assistants. The two remaining groups will be covered as of next month, although many doctors have already begun reacting to the law.

The requirement to consult a specialist whenever daily doses climb above 120 milligrams has caused the most anxiety among medical providers.

Washington has at least 1.5 million people who struggle with chronic or acute pain, the American Academy of Pain Management estimates. The state has thousands of practitioners with prescribing privileges. But as of last month, the state’s sanctioned list of pain specialists numbered just 13.

Moeller told The Times that he’s heard from frustrated patients, mostly on Medicaid or Medicare, who have been denied pain medications since the law’s passage. Most had been taking doses below the 120-milligram threshold. “We’re kind of scratching our heads, thinking, ‘Why are they being denied then?’ We don’t understand,” Moeller said.

At the same time, he’s heard from medical providers grateful for being able to point to the new rules as a basis for refusing large amounts of painkillers. Moeller said he thinks patients are being turned away not because of the law, but because prescribers have become frustrated with trying to distinguish patients in legitimate pain from addicts or scammers. “I think this is a change in the right direction, not the wrong one,” he said of the law.

Moeller called it “unfortunate” that Medicaid covers narcotic painkillers but not such alternative treatments as acupuncture, physical therapy and massage.

Lawmakers plan to hold a work-study session on the state’s new pain-management framework in the coming months, hearing from patients and from providers who helped write the rules. “With the rules,” Moeller said, “I think you’d have to live under them for a while before you’d know exactly what to change.”

Warnings about methadone

While lawmakers embraced anecdotes of patient abuse and provider excess, the state’s new rules sidestepped any special measures to account for methadone’s complexity and risk.

Dr. Sean Emami of the American Academy of Pain Management urged legislators to consider additional restrictions or public warnings when methadone was prescribed for pain.

“Methadone deserves special attention here,” he testified.

At least 2,173 people died in Washington by accidentally overdosing on methadone between 2003 and 2010, a Seattle Times analysis of death certificates shows. Among long-acting painkillers — a group that includes OxyContin, fentanyl and morphine — methadone accounts for less than 10 percent of the drugs prescribed but more than half the deaths, The Times found.

The drug has taken a particularly dramatic toll among the poor, who account for about half of the fatalities. To save money, the state steers Medicaid patients and recipients of workers’ compensation to methadone, one of only two long-acting painkillers on the state’s list of preferred drugs.

Emami detailed a federal study that found for every 1,000 pain patients given methadone, two died within the first two weeks.

Methadone victims often die within the first days of use — sometimes after just one 5-milligram dose — and at levels far below the new law’s 120-milligram threshold, according to autopsy findings by the King County Medical Examiner’s Office.

Other physicians submitted research that showed many patients — even family practitioners — were unaware of methadone’s unique risks, such as how it lingered in the body for days or its volatility when combined with other common medications.

The state’s new rules, passed by licensing boards, give a nod to methadone — but in an odd way that suggests the drug is different without treating it as so. The rules say “long-acting opioids, including methadone, should only be prescribed” by medical providers “familiar with its risk and use.” Anyone prescribing long-acting opioids “should” complete at least four continuing-education hours relating to the topic, the rules say.

The rules single out methadone by name but do nothing to demand additional warnings or training when the drug is prescribed. And the rule’s language — using “should,” not “shall” — turns the rule’s elements into a suggestion rather than a requirement. Doctors and other medical providers should pursue continuing education about prescribing long-acting opioids — but they don’t have to.

Hopes raised and dashed

Charles Passantino’s wife, Jennifer, continued to work the phone, determined to find a way to relieve her husband’s pain.

She enlisted the American Pain Foundation, which provided a contact to Dr. Jeff Thompson, who oversees Medicaid prescription programs for the state.

Informed of Passantino’s plight, Thompson was stunned and sympathetic, Jennifer says. He became an advocate for the family and reported back with good news: He’d convinced Community Health Care to reinstate Passantino as a pain patient.

“After talking to both parties, I got them hooked back into the system,” Thompson told The Times.

Passantino, hopes raised, showed up for an appointment at Community Health — only to have a practitioner refuse to provide oxycodone or any other opioid. The state couldn’t order otherwise; Community Health is a private clinic. Once again, Passantino was turned away.

“There was no light in my life, no happiness,” Passantino says. He thought of suicide, but his faith sustained him. A plaque over his front door was a talisman: “Jesus is The Head of this House.”

Desperation led to one more option: medical marijuana. Without hesitation, a doctor authorized a state-required patient card.

“The irony did not escape us,” Jennifer says. “We can’t get a legal pain drug anywhere in the state of Washington. But we can have all the pot we want.”

‘They saw a responsible patient’

Passantino’s quest for care became a crusade for Elin Bjorling, who oversees the Washington office of the American Pain Foundation, a nonprofit group that serves as an advocate for patients.

This fall, Bjorling released a survey that found dozens of health clinics have adopted new policies refusing to treat chronic-pain patients.

“This is a crisis that is causing widespread and needless suffering,” she says.

In Passantino’s case, Bjorling canvassed dozens of doctors and marshaled her organization’s forces to alert the Governor’s Office and lawmakers to Passantino’s situation. In September, she broke through: A University of Washington clinic agreed to examine Passantino.

“They took a look at me and saw a responsible patient who had taken small doses of pain pills — no more than what they give infants — for more than eight years without problems,” Passantino says.

The clinic agreed to treat Passantino — and put him back on oxycodone, six months after he’d been cut off.

Once more, with each dose, Passantino is temporarily freed from pain. He enjoys short walks with his wife along their tree-lined neighborhood.

“As happy as I am,” Jennifer says, “I know that we had extraordinary help in finding care. We’re an exception. Others won’t be able to follow in our footsteps.

“There are many other people suffering in pain out there, and there’s nobody to help them.”

News researchers Gene Balk and David Turim contributed to this report. Michael J. Berens: 206-464-2288 or [email protected]; Ken Armstrong: 206-464-3730 or [email protected]

The clinic's high doses — "Take 10 every 6 hours," one painkiller prescription said — reveal murky regulations and Washington state's anemic response.

By Ken Armstrong and Michael J. Berens

Seattle Times staff reporters

The first time Alina Heywood accompanied her mother to the Payette Clinic in Vancouver, she didn’t see anything amiss. The place was quiet, her mom the only patient there. The woman treating Heywood’s mom wore a lab coat. Heywood assumed she was a doctor.

But as the months passed, Heywood witnessed a dramatic change. By the summer of 2007, so many pain patients packed Payette’s waiting room that the crowd overflowed into the parking lot. Some patients were slumped over, looking ready to pass out. Others appeared glassy-eyed and jumpy.

“I started thinking, ‘Why do all these people in here look high?’ ” Heywood says.

Heywood’s mother, Eileen Crothers, had endured pain for almost 20 years. She’d lost an arm after a traffic accident — caused by a drunken motorcyclist — and a botched surgery. When her family doctor retired, Crothers had gone to Payette in hopes of being tapered off methadone, a potent painkiller.

Instead, Heywood says, Payette increased Crothers’ dosage.

On Sept. 11, 2007, Crothers, 48, was found dead in her Vancouver apartment. An autopsy determined that she had overdosed on methadone. She was the fourth patient treated at Payette to fatally overdose that year — and the third death linked to methadone, a long-acting narcotic.

By then, state health regulators had received more than a dozen complaints against Payette practitioners, some involving allegations of dangerous over-prescribing.

In time, the Washington State Department of Health would become aware of at least six overdose deaths of women and men prescribed painkillers at Payette. All but one had taken methadone, a drug the state steers Medicaid patients toward because of its low cost.

Records gathered by the Health Department and others would show that Payette had been prescribing painkillers and other drugs in often extraordinary amounts.

One patient’s pharmacy tab — had he paid full price — exceeded $209,000 in one year, with more than 100 prescriptions for OxyContin and other drugs, according to pharmacy documents.

But despite the six deaths — and despite receiving more than 100 complaints about Payette from pharmacies, medical providers, patients, the county sheriff, the U.S. Drug Enforcement Administration and others — state regulators have, to date, taken action against only one of the clinic’s practitioners. And even that sanction took nothing away that she hadn’t in effect already surrendered.

At its pinnacle, Payette prescribed more narcotics to Medicaid patients than any other private clinic in Washington, state records show.

The clinic’s extraordinary rise, coupled with the state’s anemic response, highlights one of medicine’s most bitterly debated specialties, one centered on an ailment — pain — that defies measurement. That Payette stayed open for years speaks to the murky landscape that regulators encounter when confronting painkiller prescriptions.

The clinic’s story also reveals the dangers of the state’s insistence on directing prescribers and patients to methadone, an unpredictable painkiller that can become lethal if used with anything other than the utmost care.

“Too unpredictable and dangerous”

The driving force behind the Payette Clinic was Kelly Bell, an advanced registered nurse practitioner with boundless confidence and a checkered employment history.

Bell, 53, has a master’s degree in nursing from Washington State University and a résumé that includes stints as a nursing supervisor and pharmacology lecturer. She holds strong views on treating pain — “it is my passion,” she once wrote — traceable to her six years as a nurse at the Oregon Burn Center in Portland.

Nurses “are the silent witness at the bedside oftentimes to the callous indifference of a physician,” Bell has written. She described how one patient, with burns on 70 percent of her body, had been denied pain relief despite obvious suffering. “She finally died, horribly disfigured and without any pain medication with a silent scream permanently etched on her face,” Bell wrote, adding: “There should be penalties for the lack of treatment of pain. They should be swift and severe.”

In 2001 Bell went to work at the Clark County Jail in southwestern Washington, helping treat hundreds of adults and juveniles. But she lost that job in 2004 when a dispute with a supervisor resulted in her jail security clearance being pulled.

A month later, in April 2004, Bell went to work at Fisher’s Landing Urgent & Family Care in Vancouver. Within months she started a pain-management program at the clinic. Bell says she was authorized to do so. The clinic’s owner says she was not. Either way, Bell’s practice took off, growing to 40 pain patients.

As a provider of pain treatment, Bell could be both combative and self-assured.

In December 2004, she wrote a letter chastising a health plan that refused to cover a prescription she’d written for an increased dosage of OxyContin, an expensive painkiller. Bell acknowledged that an alternative painkiller, methadone, was cheaper, and that Washington and Oregon encouraged its use in cases where a patient’s care was publicly subsidized. But Bell said she wanted nothing to do with the drug.

“I absolutely will not prescribe methadone for pain. It’s too unpredictable and dangerous and has caused many deaths in both the states of Washington and Oregon,” Bell wrote.

At Fisher’s Landing, Bell had her first run-in with state regulators. In February 2005 a pharmacy manager at Walgreens filed a complaint against Bell for prescribing 2,216 oxycodone pills to a patient in about two months. “I cannot believe this could be for legitimate medical purposes,” the manager wrote to the Health Department.

After receiving the complaint, the state examined Bell’s overall prescribing practices. State officials cited 23 instances of “exorbitant amounts” of narcotics prescribed, but ultimately decided against disciplinary charges, saying there was insufficient evidence to show Bell had violated any specific rule governing patient care.

The clinic fired Bell in March 2005 for “unprofessional conduct,” according to Health Department records. The clinic’s owner told regulators that Bell had been reprimanded for using profanity or abusive language in front of patients.

After Bell’s departure, a physician at Fisher’s Landing re-examined Bell’s pain patients. Many were tapered off pain drugs, which were no longer deemed necessary.

6 deaths in 12 months

After losing her second job in about a year’s time, Bell struck out on her own. In April 2005 she established the Payette Clinic with Scott Pecora, a fellow nurse practitioner whom Bell would marry three years later.

A job posting on Craigslist called Payette “a very unique and groundbreaking practice solely owned and staffed by nurse practitioners,” adding: “This is not a practice for a timid, or lax practitioner ….”

The absence of a physician did not preclude Payette from treating pain patients. Under Washington law, nurse practitioners can receive prescribing privileges, even for such narcotics as OxyContin.

The clinic, on the corner of a strip mall, began attracting more pain patients, reaching, at its peak, about 800. Bell told the Health Department that “probably 50 percent” were on methadone — a surprisingly high figure, given what she’d written about the drug in 2004.

Bell would attribute her about-face to seeing new patients who were already on methadone — and getting the relief they needed. From a practical standpoint, many patients, whether on Medicaid or private insurance, were more likely to get coverage for methadone than for other, more costly painkillers.

To the Health Department, Bell described methadone as a “fabulous drug” but one that was “extremely unforgiving” and “very deadly to work with.”

On Jan. 12, 2007, a former Payette patient, Susan Nelson, died in Clark County, after overdosing on methadone. Nelson, 51, had been prescribed the drug while at Payette.

Nelson had received treatment there for three months, starting in July 2006. At first, she had been reluctant to take methadone, her medical records show. In chart notes, Bell wrote of Nelson: “She absolutely was frightened about trying any methadone whatsoever.” But on a subsequent visit Nelson “finally consented” to start methadone, at five milligrams every eight hours, the chart notes say. The notes added: “I warned her that if she decided to overtake this drug we would be reading about her in the paper because she could very easily die.”

Bell also prescribed Nelson other painkillers, Health Department records show.

Under a pain-management law passed last year, the state calls for extra precautions once a patient’s combined daily dosage of painkillers reaches the equivalent of 120 milligrams of morphine. In this case, Health Department records show, Bell upped Nelson’s daily morphine equivalent from 140 milligrams to 780 milligrams to 880 to 1,170 to 1,440 to 1,800 to 2,160 — all in two months.

Within nine days of Nelson’s death, two other Payette patients also died from accidental overdoses linked to painkillers.

Eight months later, Eileen Crothers died, becoming patient No. 4. Crothers’ daughter, Alina Heywood, says: “I lost my mom way too soon.”

Crothers was treated by Penny Steers, a nurse practitioner who had been hired at Payette in 2006.

Within four months of Crothers’ death, two other people who had been treated at Payette also fatally overdosed on methadone. One patient, Deborah Reid, 42, had been prescribed a combined daily morphine equivalent of 3,880 milligrams — a dosage 32 times higher than the cautionary threshold set by the state, records show.

Kafka or Schweitzer?

In April 2008, state health officials initiated their first large-scale investigation of Payette after being deluged with complaints of excessive prescriptions and suspicious deaths.

DEA agents said a family of three — all patients at the clinic — had received enormous amounts of narcotic medications and paid cash for the drugs at pharmacies, up to $7,000 at a time.

Additionally, state officials from Medicaid and Labor & Industries forwarded “a large number of additional complaints” that led health investigators to the six overdose deaths involving Payette patients.

The 2008 complaints would be accompanied by a host of others against Payette’s nurse practitioners. To date, Bell has been the subject of 69 complaints and Steers 35, according to state records.

Many accuse the two women of prescribing dangerous amounts of painkillers — an allegation that would seem straightforward, but can be difficult to prove. When it comes to prescribing painkillers — in Washington and nationally — there’s no universally accepted standard of care.

Until this year, the state explicitly prohibited disciplining medical providers based solely on how many painkillers they prescribed.

With painkillers, two philosophies compete within medical circles. Bell represents one end of the spectrum. The other is represented by Gary Franklin, medical director for the state Department of Labor & Industries, the agency that handles workers’ compensation claims.

Franklin urges caution and advocates limits. He quotes Franz Kafka from “A Country Doctor”: “To write prescriptions is easy, but to come to an understanding with people is hard.”

Bell, meanwhile, writes that she models her life after Albert Schweitzer, quoting him: “Pain is a more terrible lord of mankind than even death itself.”

Bell’s philosophy comes through in her extensive letters to the Health Department. “There is no ceiling on opioids. Period,” she writes. She decries an “unparalleled and unjustified prejudice against pain sufferers.”

“When you compare what I do to that of the ‘regular’ physicians in the community I look to be an ‘outlier’ and ‘out of control,’ ” she writes.

With pain management, Bell describes herself as largely self-taught — saying she reads voraciously about developments in the field — and as selfless, calling the practice “barely profitable.”

Bell, Steers and Pecora declined through their attorney to speak with The Times because of pending Health Department complaints and civil cases. Their lawyer, Donna Lee of Portland, cautioned that state investigative records reveal an incomplete picture of the Payette Clinic and patient care.

The DEA steps in

On Dec. 9, 2008, the death of a teenage girl in a Portland suburb ratcheted up the scrutiny of the Payette Clinic.

Rachel Daggett, an 18-year-old high-school senior, died after crushing and smoking an oxycodone pill. Police discovered the oxycodone had originally been prescribed to a Payette patient.

The prior deaths of six adults on the economic margins hadn’t captured the public’s attention. But Daggett’s death was different. Now, the Payette Clinic was being featured in news stories in Oregon and Washington, lending new urgency to the work of investigators.

By the time Daggett died, the Washington Health Department’s investigation of Payette had been under way for about eight months. Despite dozens of open complaints against Bell and Steers, no disciplinary charges had been filed; nor had either practitioner been suspended in the interim — a power the department possesses.

At the request of the DEA, the state investigation was slowed to give federal officials more time to assemble their own case and to secure a warrant allowing them to gather records from the Payette Clinic, state officials told The Times.

Meanwhile, officials at several pharmacies filed complaints against Payette, including a Fred Meyer pharmacy manager who alleged Bell was engaging in experimental treatment, prescribing morphine for a patient to take home and crush and mix with cold cream and apply to painful extremities.

Some pharmacies began refusing to fill prescriptions written at Payette. On Dec. 29, 2008, three weeks after Daggett’s death, the Payette Clinic sent written notification to its pain patients that Rite Aid and Kmart pharmacies would no longer serve them. The letter directed patients to an Oregon branch of Assured Pharmacy, which has heightened security measures and caters to pain patients.

But even Assured, at some point, appeared hesitant to deal with Payette. Law-enforcement officials rounded up two email messages left at an Assured branch — one by Bell, the other by Steers.

Bell’s message referred to Payette patients being turned away and said: “Quite frankly, if this continues, I’m pulling all my business from Assured, and I’m sure that’s worth about a million dollars … .”

Steers’ message was even blunter: “If I want to order every two hours, I can order it every goddamn two hours. It doesn’t make any difference.”

On March 19, 2009, DEA agents raided the Payette Clinic and seized patient records. Soon after, Bell, Steers and Pecora agreed to surrender their DEA licenses to prescribe controlled narcotics. Unless those licenses were reinstated, the three could no longer write prescriptions for such drugs as OxyContin and methadone.

Eight days after the DEA raid — and nearly a year after the Health Department’s investigation started in earnest — state regulators issued formal disciplinary charges against Bell.

In each of nine cases, the charges said, Bell prescribed “extremely high doses” of narcotic painkillers, placing patients “at risk of serious physical harm or death.”

By the time Bell was charged, the Payette Clinic had been open for nearly four years.

Washington health officials might have detected evidence of aberrant prescribing practices years earlier. In 2007, lawmakers approved a prescription-drug monitoring program, but didn’t fund it.

Since the 1990s, a majority of states have launched programs to track the prescribing and dispensing of such narcotic drugs as oxycodone and methadone. But as of this year, Washington remained one of 13 states yet to establish a working program, according to the Alliance of States with Prescription Monitoring Programs.

Jump-started by two federal grants, Washington plans to begin using a monitoring program next year. For the first time health practitioners will be able to analyze patients’ prescription histories, providing a warning of duplicate prescribing, possible misuse or harmful interactions.

“Take 10 every 6 hours”

In March 2009, the Payette Clinic decided to quit using narcotics to treat pain patients.

“I declare Uncle!” Bell wrote to the Health Department. She recounted all the work she had done on behalf of pain patients and wrote: “We are not a ‘pill mill.’"

Hundreds of Payette’s former patients turned to hospitals and other pain clinics for help, straining Clark County’s medical resources. Doctors and addiction specialists dealt with the chaos by forming a committee that alerted other medical providers of the need to wean patients off the painkillers.

At least two former Payette patients took to robbing pharmacies, threatening to shoot employees unless given OxyContin.

A Portland law firm, Kafoury & McDougal, filed a string of lawsuits in Oregon and Washington against the clinic and its practitioners, alleging their prescribing practices had resulted in people being killed or hurt.

The lawyers turned up cases beyond those investigated by the Health Department, including that of Thomas Pike Jr., 40, who overdosed on methadone in September 2009. Although Pike had last visited Payette seven months earlier, investigators found pill bottles for morphine and methadone — prescribed by Steers — in Pike’s house and garage. Several medications, including methadone, were discovered in a margarine tub next to the couch where Pike died.

Medical records showed Payette had prescribed Pike a morphine daily equivalent that reached 2,160 milligrams — 18 times the state of Washington’s warning level. One of Pike’s pill bottles, for 1,200 10-milligram pills of methadone, said: “Take 10 tablets every 6 hours.”

The lawsuits against the clinic may go to trial next year.

In December 2009, the Health Department and Bell reached a settlement on her disciplinary charges. Citing a lack of clear and convincing evidence, health officials agreed to drop the language about “extremely high doses,” along with all references to patients being placed at risk of dying. The new, softer language allowed for lighter punishment, which turned out to be a two-year suspension from prescribing narcotics such as OxyContin or methadone.

Of course, Bell had already lost those prescribing privileges when she surrendered her DEA license, meaning the state didn’t take away anything she hadn’t already forfeited.

The case against Bell was complicated by a lack of definitive medical standards involving the treatment of pain patients, state officials said. As a result, investigators focused on evidence that she failed to properly monitor her patients or document their care.

Steers has not been the subject of any disciplinary charges by the state. However, Health Department officials said last week that some investigations of Bell and Steers remain open.

Ten days after Bell’s charges were settled, a Health Department lawyer wrote an email in which he expressed misgivings. “In retrospect,” he wrote to colleagues, he was “afraid” the allegations against Bell had been handled “too narrowly.”

Mark McDougal, the lead Portland attorney for the families suing the clinic, said of the state’s handling of the charges: “I think it’s nothing more than sheer incompetence.”

This year, Bell and Pecora filed for bankruptcy, saying they were more than $200,000 in the hole and facing foreclosure on their home.

After Payette closed, Bell and Steers both remained in the field of pain management. Steers went to work for a medical-marijuana authorization clinic. Bell and Pecora opened a new clinic in Vancouver that, according to its website, offers a pain-relief therapy using injections of blood platelets mixed with a numbing agent.

Washington state will issue a public health advisory that singles out the unique risks of methadone, a commonly prescribed pain medicine that's linked to the most accidental overdose deaths.

By Michael J. Berens and Ken Armstrong

Dr. Jeff Thompson, left, chief medical officer for state Medicaid, confers with Duane Thurman, a program manager with the state's Health Care Authority, during a meeting of the panel authorizing the advisory. (Mike Siegel/The Seattle Times) 

Alarmed by evidence that hundreds of patients die each year from accidental overdoses of prescription pain drugs, the state of Washington will issue a public-health advisory that singles out the unique risks of methadone, a narcotic medication linked to the most fatalities.

The emergency measure, adopted Wednesday by unanimous vote of a committee of state-appointed medical experts, follows a Seattle Times investigation, “Methadone and the Politics of Pain,” which detailed Washington’s troubled history with methadone, a potent and cheap painkiller.

To save money, the state steers Medicaid patients, workers’ compensation recipients and state employees toward methadone, a long-acting painkiller that costs less than a dollar a dose. Since 2003, at least 2,173 people in Washington have died from unintended overdoses linked to the drug, The Times found.

The poor have paid the highest price. Medicaid recipients represent about 8 percent of the adult population and 48 percent of methadone deaths.

Beginning early next week, state Medicaid officials will fax a health advisory to more than 1,000 pharmacists and drugstores about methadone, as well as oxycodone, fentanyl and morphine. That move will be followed by a written advisory from the state Department of Health to about 17,000 licensed health-care professionals.

The health advisory marks the first public acknowledgment by a powerful state committee that methadone can be more unpredictable than other pain drugs, or opioids. State officials had previously resisted attempts to single out methadone for special treatment, insisting the drug was as safe and effective as any other narcotic pain drug.

The Pharmacy and Therapeutics Committee — or P&T committee, for short — evaluates drugs for safety and effectiveness, a key step in the state’s creation of a preferred drug list. On Wednesday, the committee gathered for what in years past had been a routine review and approval of methadone and morphine, the two long-acting pain drugs on the state’s preferred registry.

But after a representative from the Health Care Authority — a state agency that oversees Medicaid and medical benefits for state employees — recounted Washington’s “severe problem” with painkiller overdoses, the panel postponed any decision on methadone’s status as a preferred drug and decided to authorize the advisory.

Duane Thurman, a program director for the Health Care Authority, told the committee that state senators were “extremely concerned” about methadone-related deaths as reported by The Times. He encouraged the committee to approve the health advisory and said, “I think it’s important to do something immediately.”

Dr. Barak Gaster, chairman of the committee, said during the meeting: “I think there is some sense that there are features that are unique to the way methadone needs to be prescribed and for it to be done safely.”

Compared with other painkillers, methadone has a long half-life. OxyContin dissipates from the body within hours while methadone can linger for days, pooling to a toxic reservoir that depresses the respiratory system.

“Is methadone different? Yes,” Dr. Jeff Thompson, chief medical officer of the state’s Medicaid program, told a Times reporter during a break in the daylong session.

Last week, the state Senate Health & Long-Term Care Committee held a work group to get an update on Washington’s new pain-management law. But much of the discussion focused on methadone, with lawmakers pressing for answers about the narcotic’s pharmacological makeup and risks.

Committee Chairwoman Karen Keiser, D-Kent, became frustrated with Dr. Gary Franklin, medical director for the Department of Labor & Industries, which handles workers’ compensation.

Keiser asked Franklin — a principal defender of the state’s decision to designate methadone as a preferred drug — if the painkiller is more difficult to manage than other long-acting narcotics. When Franklin responded by discussing the toll of long-acting opioids in general, Keiser said: “Dr. Franklin, answer the question about methadone.”

She later told him: “That’s something I’d like to get a straight answer on. And I’m not getting a straight answer.”

Franklin told lawmakers that methadone is not at the heart of the state’s struggle with painkiller overdoses. “It’s dose, not a specific opioid,” he said.

“Almost no one dies from a single opioid. When you look at death certificates, and I’ve reviewed many of these at L&I, you never see just methadone or just OxyContin or just fentanyl listed,” he told the committee.

“Coroners, in fact, will not ever say on a death certificate that this death is from methadone. It is always a combination of multiple opioids plus other drugs.”

But a Seattle Times analysis of death certificates turned up 443 cases since 2003 in which methadone was the only drug listed when someone fatally overdosed. And this was using a conservative sift, excluding cases where the deceased had so much as a history of alcoholism.

Sen. Cheryl Pflug, R-Maple Valley, told Franklin that she was troubled even by those cases in which methadone had combined with other drugs to cause a fatal overdose.

“I don’t really care that the coroner isn’t willing to say this was caused by methadone,” she said. “If the person has a toxic level, and they were taking methadone and other drugs known to have a synergistic, respiratory depressive effect, and they quit breathing, it doesn’t take a rocket scientist to know we might have a problem.”

She urged the state to create a list of factors that would caution against prescribing methadone in particular instances — for example, if a patient is taking another drug that doesn’t mix well with the painkiller. “We should say, ‘you can use it if,’ rather than, ‘you must use it unless,’ ” Pflug said.

A spokeswoman for the department of Labor & Industries said Wednesday that Franklin would not be available for an interview with The Times.

At the committee meeting, Sen. Mike Carrell, R-Lakewood, said two graphics distributed to the lawmakers — one showing methadone with the longest half-life, the other linking it to the most deaths — raised the question: “How could we end up pushing methadone?”

“Maybe we need some horse sense here rather than expertise on how well some of these things work,” Carrell said.

Afterward, several committee members told The Times the Legislature will push to get more information about methadone and its risks.

“Across the political spectrum, I think everybody on that committee was concerned,” Carrell said.

Michael J. Berens: 206-464-2288 or [email protected]; Ken Armstrong: 206-464-3730 or [email protected]. Database reporter Justin Mayo contributed to this report.