After the N.C. Medical Board suspended his psychiatrist for writing inappropriate prescriptions, Douglas “Chip” Kimel III found a new doctor to continue his treatment for attention deficit disorder – oxycodone, a powerful and potentially addictive painkiller.
About 18 months later, Kimel filled a one-month prescription from Dr. James Jacobs for 300 oxycodone pills. Six weeks later, a friend found Kimel dead in a Raleigh apartment.
An autopsy revealed Kimel, 36, died on May 2, 2014 from a heroin overdose. Law enforcement and acquaintances told his parents he was selling his prescription drugs and buying heroin.
Experts say Kimel’s death illustrates how too many physicians have failed to heed warnings from the federal government and leading medical organizations about the addiction risks from OxyContin, Percocet and other widely used painkillers. Jacobs was reprimanded by the North Carolina Medical Board.
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In a push to curb mounting drug overdose deaths in North Carolina, the Medical Board is poised to adopt national guidelines that recommend doctors prescribe opioids with extreme caution.
The proposed change is the latest step in a shift from previous decades for the agency, which oversees 45,000 licensed doctors and other health professionals and sets discipline statewide. Opioid prescriptions surged in 1990s and early 2000s with North Carolina and other state medical boards warning physicians they could face discipline for failing to adequately treat patients’ pain.
But documents in Kimel’s case and interviews with experts suggest that changing how opioids are dispensed poses a major challenge. Doctors have grown accustomed to prescribing painkillers for a variety of ailments – for patients who often demand them.
For example, when the N.C. Board of Pharmacy looked into a complaint filed by Kimel’s father against the pharmacist who filled the prescriptions, the board determined that it would take no disciplinary action.
In a letter explaining the decision, the agency wrote, the pill “quantities were not abnormal as surrounding pain clinics prescribed large amounts like those prescribed to patient Kimel.”
A troubled life
Less than two weeks before Kimel died, his parents believed he had turned a corner.
He had just returned from a 30-day drug treatment program in Florida in the spring of 2014. For the first time, his parents said, he had voluntarily attended rehab.
Kimel graduated from High Point University in 2004 with a degree in marketing. He later started his own home repair and remodeling business.
His family described him as affable, outgoing and loyal to his friends. At his funeral, his parents say, a man described how Kimel helped him beat drug addiction.
But Kimel could not escape his own demons. He began drinking and abusing drugs in high school. He relapsed after multiple stints in recovery programs.
“He had an addictive brain,” said Gray Kimel, his father. “From the first time he tried alcohol, we had our hands full.”
Before Kimel’s death, his parents say, he was treated by a psychiatrist.
Records show the state Medical Board suspended the psychiatrist’s medical license indefinitely after multiple complaints about his prescribing.
In October 2012, Kimel began seeing Jacobs, an internal medicine doctor in Cary, according to disciplinary records from the state Medical Board. Jacobs co-managed Kimel’s treatment with a psychiatrist, who is not named in the documents.
Jacobs started Kimel’s ADD treatment with plans to gradually reduce the narcotic medication and investigate other ways to remedy the condition, records show.
Jacobs, however, increased drug dosages for Kimel despite behavior indicating the patient was possibly diverting his medication, state Medical Board records show.
Doctors have an ethical responsibility to closely monitor prescriptions for patients like Kimel who have a history of substance abuse because of the risk of dependency. A half-dozen physicians, pharmaceutical scholars and addiction experts told the Observer they have never seen a case in which an opioid painkiller was used to treat Attention Deficit Disorder.
Before Kimel died, his father, Gray Kimel, said he met Jacobs. The father said he warned the doctor that his son had a history of substance abuse and would need close monitoring, according to a complaint Gray Kimel filed with the Medical Board.
“This prescribing was egregiously bad,” said Don Teater, a Waynesville physician who helped the federal Centers for Disease Control and Prevention set new guidelines for opioid prescribing. “It was bad medicine.”
On March 21, 2014 – about six weeks before he died – Kimel received a 30-day prescription for 30-milligram oxycodone tablets with instructions to take nine to 12 pills a day. He also obtained a prescription for 60 tablets of amphetamine salts with instructions to take a pill twice a day.
Teater said that amount of oxycodone would normally be reserved only for cancer patients or the terminally ill.
Kimel’s parents said their son appeared in excellent physical condition. He competed in Tough Mudder events, where participants navigate military-style obstacles courses.
When contacted by the Observer, Jacobs gave a statement, but would not answer specific questions. “I'm aware of the North Carolina Medical Board guidelines regarding opioid prescribing and I have tried to do my best to apply all of the guidelines in my practice,” he said.
During the state Medical Board’s investigation, Jacobs had an independent expert review medical records for Kimel and another patient. The expert found that both were “difficult and complicated” patients and that Jacobs’ treatment conformed to prevailing standards.
But the board earlier this year went on to reprimand Jacobs. His prescribing, the board said, “may have constituted a departure from or the failure to conform to, the standards of acceptable and prevailing medical practice.”
Jacobs acknowledged that he could have more closely monitored the patient’s use of prescription medicine, records say.
He agreed to make several changes to his practice. They include regular drug testing for patients on chronic narcotic medications, checking a state prescription drug database to ensure patients are not getting drugs from another provider and same-day drug screens for patient who show suspicious signs of abusing drugs.
Teater said many physicians who attend seminars where he speaks about opioids are unaware of the devastating harm caused by excessive prescribing of painkillers.
Overdoses kill more than 1,000 people a year in North Carolina, about a 75 percent jump in the state’s drug death rate since 2002, which experts largely attribute to opioids. Nearly half the overdose deaths involve prescriptions filled within 60 days of the victim’s death, according to a 2014 state report.
“I tell (doctors) how many patients die and say it is because of prescribing,” Teater said. “They are surprised. All the doctors think, ‘It’s not my patients.’”
Lynne Grey, an addiction expert who helps coordinate drug treatment at Partners Behavioral Health Management in Gastonia, said it’s common to see patients with prescriptions for high quantities of opioids.
“I see this all the time, where clients come in with these massive prescriptions,” she said.
Excessive opioid prescribing is widely blamed for a surge in heroin addiction. Medical experts and law enforcement officials say it is common for drug addicts to sell prescription drugs and buy heroin, which is cheaper but offers the same euphoria.
The state Medical Board is considering guidelines that call for doctors to choose alternatives to opioids whenever possible when beginning treatment for chronic conditions. That could include ibuprofen, exercise regiments and behavior therapy.
The guidelines suggest a three-day supply of opioids for short-term acute pain from surgery or injuries, the lowest dose possible and close monitoring for addiction.
The proposed change would update the board’s 2014 position statement, which also urged greater caution when prescribing opioids.
The release of the CDC recommendations in March prompted worry among some patients and physicians, who argue they could deny patients with legitimate pain access to needed medicine.
In North Carolina, patients have been left searching for new doctors because some physicians have stopped prescribing opioids out of fear of increased scrutiny, said Robert Rich, medical director for Community Care of North Carolina, a health-care advocacy group.
“At first we were told we were undertreating pain,” said Rich, who helped CDC develop the guidelines. “Now we are being told that we went too far the other way. What’s the happy medium?”
Scott Kirby, chief medical officer for the state Medical Board, said most physicians prescribe opioids responsibly.
But he said given the on-going public health crisis, more action is needed to stop unscrupulous doctors or those unaware of the dangers.
“It may be necessary for measures that would otherwise not be preferred by the medical community,” Kirby said.
States such as New York and Massachusetts have set mandatory seven-day limits on opioid prescriptions following a patient’s initial visit to a doctor.
Kimel’s parents said they are sharing their story with hopes it will help prevent excessive prescribing of opioids.
That means holding doctors and pharmacists accountable, the couple said.
They remain frustrated that the state Board of Pharmacy decided not to take action against the pharmacist, Robert Wheeler, who worked at the Creedmoor Drug Company.
A letter the board sent to explain its decision says that Wheeler contacted Jacobs the first time Kimel presented prescriptions for oxycodone and amphetamine salts to make sure they were legitimate.
Reached by phone, Wheeler said he would consider answering questions but did not respond to later calls and a certified letter.
But Kimel’s parents said it was unusual that their son would drive 25 miles from his Raleigh home to Creedmoor to obtain medicine. Experts say traveling long distances to fill prescriptions suggests pharmacy shopping.
The state Medical Board reprimanded Jacobs, but that did not impact his ability to practice medicine or prescribe narcotic drugs. Kirby, the agency’s medical director, said officials took into account that Jacobs had never previously been the subject of a complaint and promised to make changes to his practice.
Kimel’s mother, Susan, said unanswered questions have worsened her grief.
She worked for 25 years as a registered nurse. She said she had never seen that amount of oxycodone prescribed for a patient.
“We will never know why,” she said. “I ask myself, ‘Why did he have our son on that treatment plan?’” Justine Miller contributed to this story.