After the arrest of Dr. Richard Teh last month on a murder charge for prescribing drugs to a patient who subsequently died, Dr. William Van Tobel sent an incensed email to fellow physicians in the Las Vegas Valley.
"It is not just Richard Teh on trial for murder. We are all on trial," he wrote. "We need to protest. ... Talk to our federal representatives. ... Until this ridiculous and outrageous charge of murder is dropped ... why would I or any primary care provider prescribe any chronic pain medication? I know, and even briefly worked with, Dr. Teh. He is not a cash for drugs doctor."
Nothing, other than the cost of malpractice insurance, has galvanized the local medical community more in recent years than Teh's arrest.
A Drug Enforcement Administration task force arrested the 49-year-old internist March 8 for prescribing pain medication that authorities say led to 39-year-old Lisa Blythe's death in 2007. Charged with murder, Teh is free on $50,000 bail. A preliminary hearing is set for May 18. The Nevada State Medical Board has not taken any action against his license.
An angry Dr. Mitchell Forman, president of the Clark County Medical Society, recently wrote in the society's bulletin: "The accounts that I heard from a reliable source was that five armed DEA and law enforcement officers entered the doctor's office, handcuffed him and escorted him to the Clark County Detention Center in front of his patients and staff."
Forman has no doubt that the raid would have consequences far beyond Teh's arrest. He wrote:
"I predict that many more patients in chronic pain will not be treated."
Primary care doctor after primary care doctor, including the family practitioner Joseph DiPalma and the internist Ivan Goldsmith, say they have backed away from prescribing pain medication. Any prescription, they note, may be used in an unauthorized, illegitimate way, opening them up to an expensive criminal defense and a possible life sentence behind bars.
Patients who suffer from chronic pain now are often forced to visit expensive pain specialists who are so overburdened that it may take several weeks to get an appointment.
Rich Knowles, now mobile but initially paralyzed for eight months from a sports mishap, is upset.
"I'm having to go all over town trying to find someone who can help me get through the day," he said. "I don't blame the doctors for being afraid, but I need the pain medication. Pain specialists cost more, and they don't really help you any more. I just need a few pills, not a procedure."
Teh's attorney, Mace Yampolsky, said he doesn't understand the murder charge, because Teh never intended to harm a patient by prescribing pain medication.
"There was no malice, no intent to kill," said Yampolsky, who has advised Teh not to talk with reporters. "If he's prosecuted for murder, does this mean that every doctor that prescribes medication is potentially going to be charged with murder?"
His argument rings true to area physicians.
Yet murder, as defined under Nevada law, can be "caused by a controlled substance which was sold, given, traded or otherwise made available to a person."
But Teh was a doctor legally prescribing medications, "not a drug dealer on the street," DiPalma said. "We can't control people misusing our prescriptions. We're doing the best we can with patients. We want to help them."
Physicians concede that Teh may have made errors and exercised poor judgment, but they see the proper enforcement mechanism as civil litigation or actions by licensing boards, not the DEA, which they note derives a substantial part of its budget from assets it seizes through raids.
"This kind of arrest certainly can raise questions regarding a conflict of interest on the DEA's part," Forman said.
DEA IN SPOTLIGHT
Rusty Payne, a DEA spokesman based in Washington, D.C., said he could not speak about Teh's case because it hasn't gone to trail. But he said the reason the agency investigates some physicians is simple:
"There are some doctors who knowingly do things that are not legal."
Some doctors prescribe to addicts, knowing the drugs will be abused or sold on the street, he said. Other times doctors will neglect to check a patient's history, which could reveal a pattern of "doctor shopping."
Payne said their motivation is the almighty dollar. Doctors receive a chunk of change for every prescription they write, he said. In at least one case, a doctor has been charged for prescribing drugs in return for sexual favors.
Las Vegas physicians have complained to federal officials about the DEA's behavior, and there are indications their concerns are being taken seriously.
"I think the way this was handled is unprecedented," said Rep. Joe Heck, R-Nev., a doctor himself who says he has listened to many physicians' concerns on the matter.
Heck said he is asking the federal agency for an explanation of its conduct.
Rep. Shelley Berkley, D-Nev., said she will be looking into the issue because of messages sent to her office by physicians, said her spokesman David Cherry.
What particularly irritates doctors about Teh's case is that the agency based its murder charge, not on an independent investigation, but rather on information brought forward by a lawyer who filed a malpractice case.
Authorities typically investigate the criminality of a case before a civil case is filed, not vice versa.
Doctors often are urged to settle malpractice cases by their insurance companies, which contend it will cost more to litigate the case even if the doctor did nothing wrong.
A malpractice suit filed after Blythe's death resulted in a $400,000 settlement from Teh in 2009. The settlement went to her husband, Stuart Wilhoite. His attorney, William Brenske, brought in Dr. Michael Mullins of St. Louis, Mo., and Dr. Robert White of Las Vegas to examine Teh's records.
Brenske provided the doctors' testimony to police, who reopened a 2007 investigation that the DEA-led task force had closed because it lacked resources to investigate Teh's records.
Neither Wilhoite nor Brenske was available for comment.
Lawyers pay doctors about $500 an hour for such a review in malpractice cases, said Dr. Robert O'Dell, a Las Vegas pain specialist concerned about how Teh has been treated.
"You have to worry about a biased review in malpractice cases," O'Dell said.
Even Mullins, who said Brenske paid him for five to eight hours of analysis, had a difficult time believing Teh was charged with murder.
"I was surprised," he said. "I thought murder was a deliberate attempt to cause harm to another person."
Mullins surmised that there was additional evidence to support the murder charge. Told that the arrest report focused on the findings that he and White brought forward in the malpractice suit, he paused.
"Maybe they're trying for a plea bargain," he said.
White, the other doctor providing analysis, refused comment.
WAR ON DRUGS
It didn't surprise Ronald T. Libby, a University of North Florida political science professor, that the DEA would bring a murder charge against a doctor when it wasn't based on an independent investigation.
"I know it sounds astonishing that they would do such a thing. But that's the way the DEA works," said Libby, who analyzed the relationship between the DEA and doctors in his book "The Criminalization of Medicine: America's War on Doctors."
"It's totally unethical. It's an egregious violation of your rights. But they want a notch in their belt. That's the way it is when your war on drugs has been a failure. Doctors are easy targets for them to get some convictions."
Dr. Jane Orient, of the Association of American Physicians and Surgeons, also wasn't surprised by the DEA's tactics. She said it is absurd to think a doctor would run drug deals out of his office for profit and then document each drug deal with a prescription so he could easily be caught.
In order to avoid trial, Orient said, doctors often plea bargain to a much lesser offense and the DEA still gets a conviction.
It's not clear whether the Clark County district attorney's office is comfortable with the murder case against Teh. Clark County prosecutor David Stanton wouldn't comment because the case is in its early stages.
But another Las Vegas doctor, Harriston Bass, was prosecuted for murder after he was arrested by a DEA-led task force. His patient, Gina Micali, 38, died from an overdose of painkillers in 2005. Bass was convicted of second-degree murder and sentenced to 25 years to life in prison.
Authorities said it was the first time in Nevada's history that a doctor was charged and convicted of murder for illegally dispensing prescription medications to a patient who later overdosed and died.
Bass, 54, ran a mobile medical service called Docs 24-7 for years in Southern Nevada. He often made house calls to patients at their homes or in their hotel rooms, and authorities said he would sometimes sell hundreds of doses of drugs such as Lortab, a strong prescription painkiller. He used his PT Cruiser, which was outfitted with a portable refrigerator, as a mobile pharmacy.
Although Bass had a license to prescribe drugs, he didn't have a license to dispense and sell the strong prescription painkillers, authorities said.
At his sentencing in 2007, Bass was described as "worse than a common street dealer" by state district Judge Jackie Glass.
Doctors say any comparison of Teh to Bass is outrageous. Teh's patients see no similarity between him and Bass.
Teh's case does draw some similarities to that of Dr. Kevin Buckwalter of Henderson, whose medical license was stripped in 2008 after he was linked to eight patient deaths by overdose. Although the DEA investigated, Buckwalter was never charged with a crime.
Rhonda Brinkerhoff, 44, was particularly upset by Teh's arrest. She said her entire family -- husband, kids, mom and dad -- have been patients of Teh for a decade,
"I wouldn't take my kids anywhere else, not even a pediatrician. I wouldn't let anyone else see them," she said
Brinkerhoff said Teh always stressed eating healthier and taking vitamins before he would write a prescription. He hated drugs, which were always his last resort, she said.
CASE AGAINST TEH
That description of Teh does not seem to square with the treatment that the DEA accuses Teh of giving to Lisa Blythe.
According to an arrest report, Teh prescribed his patient several narcotics, including Demerol, OxyContin and Valium, from February 2001 to February 2006 to combat migraines, even though other doctors described her symptoms as "stable."
In October 2001, according to the report, Teh prescribed Demerol for Blythe's migraines, though a neurologist was already treating her. By February 2002, Teh diagnosed Blythe with "chronic pain syndrome" without explanation, and began prescribing more narcotics, including injections of Demerol.
In the following months, Teh prescribed Percocet and Valium to Blythe, despite receiving a letter from an allergist noting Blythe's previous addiction to cocaine and history of addiction to habit-forming drugs.
In 2003, Teh referred Blythe to Dr. Daniel Kim, a pain specialist who recommended that Blythe cut back on medications. But police say Teh ignored Kim's recommendations and increased her doses.
Though Teh agreed with Blythe's husband in 2006 that she should undergo detoxification, he continued to write her prescriptions for injectable Demerol. Early that year, Blythe sought counseling at Montevista Hospital for drug dependence, telling hospital officials she needed "to get off my current meds to find a clean base to find correct treatment."
In January 2007 she was dead. The coroner ruled she died of multiple drug intoxication, as well as acute renal failure and an enlarged heart, which can be caused by drug abuse.
To the layman, what Teh prescribed seems over the top. But Forman points out that far too often doctors around the country may get indicted for murder because of "misinterpretation of forensic drug level measurements."
Chronic pain patients build up a tolerance to large, but appropriate doses of opioids, he said. Some medical examiners erroneously attribute their deaths to opioid overdose.
"This has led to unwarranted criminal charges against prescribing physicians by overzealous prosecutors," Forman said.
Yampolsky is disputing the cause of Blythe's death.
Officials at Valley Hospital and Medical Center, where Blythe died, initially said the cause of death was from bilateral pneumonia and sepsis, Yampolsky said.
"According to them, it wasn't an overdose."
RISE OF PRESCRIPTION DRUGS
According to the Centers for Disease Control and Prevention, prescription drugs are now responsible for more overdose deaths across the nation than "street drugs" such as cocaine, heroin and amphetamines. That holds true in Clark County.
In 2009, the last year in which Clark County Coroner Mike Murphy said he has complete statistics, 304 people died of overdoses of prescriptions narcotics, compared with 108 deaths from street drugs. Teenage deaths from the drugs generally occur because of teens stealing drugs from their parents' medicine cabinets.
Sometimes, the elderly overdose because they become confused about their medications, according to Dr. Dale Carrison, head of University Medical Center's Adult Emergency Department.
Murphy said he often learns when drug overdose deaths are investigated that individuals have thought that "if one pill is good, then two or three must be better."
"That's why they end up with me," he said.
Though the misuse of prescription painkillers is a huge problem for drug enforcement, DEA spokesman Payne said, "Dirty doctors are a very small part of the overall problem."
Doctors are rarely charged in most cases, he said, and a murder charge in a patient's death is rare.
WAR ON DOCTORS
Libby testified to Congress about what he called "The DEA's War on Doctors" in 2004.
Congress criticized the DEA, saying it had doubled its budget to $1.5 billion in 1999 but there was no measurable proof it had reduced the supply of illegal drugs in the country.
The Department of Justice responded by claiming prescription drug abuse had soared, charging that doctors and pharmacists were primarily responsible for the diversion of legal drugs to addicts, Libby said.
"The agency had thus created a new mission for itself; a less dangerous and easier mission to provide proof of success," he said.
In order to carry out the mission, Libby said, the DEA hired more than 500 diversion investigators and multiplied its forces by deputizing nearly 2,000 state and local officers from police departments around the country. There are now more than 207 task forces, like the one that arrested Teh, in the nation. The task forces account for about 40 percent of all DEA cases and seizures.
Libby, whose wife is a physician, told Congress that there are fewer than 4,000 doctors in the country who are willing to risk prescribing high dosages of narcotics to chronic pain patients.
"Many innocent physicians who are dedicated to treating chronic pain sufferers have become targets of the DEA's war on drugs," he said.
That is frightening, he said, when you understand how little law enforcement personnel know about medicine. So often, the federal agency talks about the number of pills in a way that makes it seem doctors are doing something wrong.
"People are afraid of drugs, and the DEA takes advantage of that," Libby said.
Libby and most doctors believe state medical boards should be providing oversight for what doctors do.
Forman, of the county medical society, said, "The appropriateness of prescribing could be addressed by a group familiar with patient care issues."
In circumstances where physicians' prescribing habits fall outside of acceptable standards, their license could be suspended or revoked.
If the state medical board suspects criminal activity, Forman said the cases could be forwarded for criminal investigation. And doctors wouldn't be afraid to prescribe adequate opioid therapy for chronic pain for fear of inappropriate criminal indictments, he said.
Goldsmith said most doctors keep up to date with a website run by the Nevada State Board of Pharmacy which keeps track of patients who are receiving powerful pain medications.
"It helps us understand who may be doctor shopping in order to get more medication," he said.
What is critical, Goldsmith said, is that physicians who prescribe in good faith should not be criminally liable for the actions of their patients who divert or abuse prescribed drugs.