Four days after a routine tonsillectomy, 24-year-old Riley Martin called his doctor. He was in pain, he said, and had run out of medicine.
Over the next five days, he visited or called the Raleigh physician’s office at least two more times seeking painkillers.
After each conversation, Dr. Mark Clarkson and one of his partners wrote new prescriptions for opioids – 145 pills in all.
On Feb. 12, 2012, nine days after his surgery, Martin’s roommate in Boone found him lying in bed without a pulse.
An autopsy revealed Martin had overdosed from a toxic mix of cocaine and prescription medications, including the types of opioids obtained from his doctors.
Overdoses now claim more than 1,000 lives a year in North Carolina, about a 75 percent jump in the state’s drug death rate since 2002. Nearly half the cases involve prescriptions filled within 60 days of the victim’s death, according to a state report.
Experts called Martin’s actions classic drug-seeking behavior. For example, he sought a new prescription because he said he forgot to bring his medicine when he returned home to Boone. Many physicians refuse to write new prescriptions when patients report lost or stolen medication because they fear that drugs will be abused or sold on the streets.
But when the North Carolina Medical Board investigated complaints filed by Martin’s mother against Clarkson and Bridget Thompson, a physician assistant who also treated Martin, the board determined that it should not take public disciplinary action, which can range from a warning to revoking a doctor’s license.
“I just don’t understand,” Peggy Martin said.
The North Carolina Medical Board investigates relatively few doctors over improper prescription practices, a review of records shows – even as the agency calls the rising overdose death rate a public health crisis.
The issue stems in part from the agency’s approach to oversight. The board typically has investigated only after receiving complaints, even though technology has existed for years that gives regulators the ability to potentially spot dangerous prescribing before patients are harmed.
In North Carolina, there are about 45,000 licensed doctors, physicians assistants, physician residents and other medical professionals the agency oversees. But in 2015, the board investigated only about 100 complaints in which prescribing was the primary issue, resulting in 24 public sanctions for improper prescribing.
How does that compare to other states? It’s hard to tell. The organization that tracks such information – the Federation of State Medical Boards – stopped releasing state-by-state data on doctor discipline four years ago. That’s because state officials and doctors complained that the report cast a negative light on boards that issued the fewest sanctions.
N.C. Medical Board spokeswoman Jean Fisher Brinkley said that increasing the number of investigations into improper prescribing is a goal for the board, given the urgency of the opioid epidemic.
In an effort to toughen its oversight, the board last month opened investigations on doctors who had two or more patients die from prescription painkiller overdoses in a one-year period.
The board also expects to open more investigations by targeting doctors who frequently prescribe commonly abused drugs.
Brinkley would not directly answer questions about Peggy Martin’s complaints concerning her son’s death, saying agency policy prohibits comment on individual cases.
However, if Martin’s son died under the same circumstances today, it’s possible the board’s investigation could have turned out differently. Current accepted practices have evolved and now call for greater vigilance when prescribing opioids than in the past, Brinkley said.
“The way the Board looks at these cases has changed dramatically from four years ago,” Brinkley said. “Awareness has changed dramatically.”
A life cut short
Riley Martin’s death shocked his family.
Relatives knew he partied as a student at Appalachian State University – but say they saw no indication he was abusing narcotics or taking illegal drugs.
Growing up in rural Johnston County, about 30 miles outside Raleigh, he liked to hunt and spend time at the beach. He excelled in three sports in high school. He was close to his mother, a teacher’s assistant at a middle school, and his dad, who worked up to three jobs to support the family.
Martin graduated from Appalachian in 2010 with a degree in criminal justice, but a drunken driving conviction in April 2011 made it less likely he could get a job as a police officer.
He found work at a Ralph Lauren store in Blowing Rock and got a good performance review.
Martin was usually affable and laid back, but friends told police they began noticing troubling behavior in the months before his death. He seemed constantly tired, a friend said, and took naps up to five hours long throughout the day.
About six months before he died, Martin sought treatment for panic attacks and folliculitis, a skin infection, documents show. On Aug. 17, 2011, he saw Thompson, a physician assistant who practiced in Boone at the time.
At his visit, Martin told Thompson that he suffered anxiety about his next step after college, stress from his retail job and had difficulty concentrating.
Records show Thompson’s exam of Martin found no major neuropsychiatric problems. There were no signs of depression, delusions or suicidal thoughts.
Thompson gave Martin a prescription for a low dose of lorazepam, a benzodiazepine anti-anxiety medication, and referred him to counseling, records show.
Over the next four months, Martin would call or visit Thompson’s office five times. Here’s what happened, according to a letter submitted on behalf of Thompson by her lawyer to the medical board:
By Oct. 20, 2011, Martin had not seen a counselor as Thompson had recommended. A patient’s failure to follow a treatment plan can be evidence of drug-seeking behavior, experts say.
Thompson examined Martin and determined that he was using the medications as prescribed. Due to his increased anxiety, Thompson continued the anti-anxiety medicine Klonopin and increased the number of pills.
On a Dec. 29 visit, Thompson increased Martin’s dosages for both Zoloft and Klonopin after Martin complained that he still suffered anxiety.
Martin called Thompson’s office two weeks later and complained about side effects from the Zoloft. He was told to taper the medicine to come off it safely. Additionally, he was instructed to call back to discuss other options and to schedule an appointment. He never did.
Ten days before his death, Martin visited his doctor in Raleigh. He had been suffering with tonsillitis and opted for surgery.
On Feb. 2, a day before the operation, Clarkson, a Raleigh otolaryngologist, wrote a prescription for 50 pills of Percocet, an opioid, to help Martin cope with post-surgery pain, according to state records detailing his treatment.
With instructions to take 1 to 2 tablets every 4 to 6 hours, the Percocet would last from 4 to 12 days.
Four days after his Feb. 3 surgery, Martin called Clarkson complaining that he was in pain and had run out of medicine. Clarkson wrote a prescription for 40 Vicodin, another opioid, to take at the same frequency as the Percocet.
On Feb. 10, Martin was seen by Dr. Matt Gerber, a partner of Clarkson’s, at a post-op visit and obtained a prescription for 30 Percocet.
Two days later, on Feb. 12, Gerber got a phone call from Martin who said he had returned home to Boone but left his Percocet in Johnston County. He requested Percocet be called into a Boone pharmacy.
Records show that Gerber discussed pain management options and instead of prescribing Percocet as Martin requested, Gerber called a prescription for 25 Vicodin to a Boone pharmacy.
Around 10:30 that night, Boone police found Martin unresponsive at his apartment. Police seized five packages or bottles that included opioid and anti-anxiety medications at the scene, a police report says.
Experts warn that taking prescription painkillers and addictive anti-anxiety drugs at the same time can increase the risk of overdose.
Clarkson could have known about the anxiety medicine if he had checked the state prescription drug database, which allows physicians to see if patients are obtaining drugs from other providers.
Doctors have an ethical responsibility to ensure the drugs they prescribe are not diverted for illegal use. They are supposed to take extra precautions when prescribing medications to patients like Martin who have shown behavior that suggests the potential of abusing drugs or who have reported mental health problems.
In this case, Clarkson says he was not made aware of Martin’s prescriptions from Thompson in Boone, according to the letter his attorney submitted to the medical board. He could not have reasonably anticipated Martin would abuse cocaine, the letter says.
Experts who reviewed medical documents from Martin’s case at The Charlotte Observer’s request were divided about whether Clarkson and Thompson prescribed medicine appropriately.
Former N.C. Medical Board President Dr. Janice Huff and Dr. Joshua Landau, former president of the Greater Greensboro Society of Medicine, said their actions fit within standard medical practices. They said Riley Martin deserves blame for failing to disclose previous illicit drug use.
Huff said most doctors rely on information they receive from patients and it is difficult to determine when someone is lying. In this case, Huff said, they probably assumed they could trust Martin because he had received treatment in the office as a child.
Two other experts said they were alarmed Clarkson and Gerber prescribed Martin so much medication following his tonsil surgery. Repeated requests for more medicine is evidence of possible drug abuse, both said.
“This was a textbook case of drug-seeking behavior,” said Lynne Grey, an addiction expert who helps coordinate drug treatment at Partners Behavior Health Management in Statesville, which is focusing on reducing overdose deaths in the North Carolina mountains and foothills.
Dr. Robert Monteiro, a former president of the North Carolina Medical Society, said Clarkson and Gerber should have been more vigilant after Martin’s surgery. They should have questioned why he would still be experiencing acute pain nine days after the procedure, he said.
Dr. Thomas Tape is a Nebraska internist who helped develop new guidelines for prescribing opioids for the federal Centers for Disease Control and Prevention.
Tape said doctors should try to limit most patients to a three-day supply of opioid pills for acute pain following surgery. The most severe pain following surgery usually diminishes after three days, Tape said. In some cases, he said a prescription for one refill is necessary.
Told Martin was prescribed 145 opioid pills by Clarkson and Gerber after a tonsillectomy, Tape said “that’s an incredible amount of drugs.”
Neither Clarkson nor Gerber returned phone calls seeking comment about opioid prescriptions they wrote for Martin.
In a May 2013 letter to the state medical board, Clarkson’s attorney said Martin was not honest about his drug use. Martin listed his only medication as a nasal decongestant, the letter says.
“Each prescription was appropriately prescribed given the circumstance presented by Riley himself,” Lori Abel Meyerhoffer wrote. “All physicians, including Dr. Clarkson, rely on their patients to present an honest and complete history and to take medications only as prescribed.”
Thompson did not respond to written questions from the Observer.
“At all times Ms. Thompson fully complied with all rules and regulations and always rendered care which was appropriate and within applicable standards of practice to all patients,” her attorney, Norman Klick said in a written statement. “Ms. Thompson has had her care reviewed by the North Carolina Medical Board and the Board found that Ms. Thompson’s care was appropriate and fully complied with the applicable law and regulations.”
A mother’s quest
Peggy Martin said she plans to ask the state medical board to reconsider its 2013 decision. “If Riley’s story can save another mom and dad and a brother from this going through this, then I have to go for it,” she said.
Mementos of Riley Martin’s life surround his mother’s home. An Adopt-A-Highway sign that stands down the street is dedicated to his memory. And a bedroom is filled with framed pictures, ribbons and awards from childhood.
“It’s awful,” she said of the Medical Board’s decision not to issue sanctions. “It shouldn’t be this way.”