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Unbelievable. Incompetent *****s.
http://seattletimes.nwsource.com/html/localnews/2017000915_silent13.html
12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 1/18
Winner of Eight Pulitzer Prizes
Local News
Originally published December 12, 2011 at 8:00 PM |
Page modified December 12, 2011 at 8:01 PM
Vancouver pain clinic leaves
behind doubts, chaos and
deaths
The clinic's high doses "Take 10 every 6 hours," one
painkiller prescription said reveal murky regulations
and Washington state's anemic response.
By Michael J. Berens and Ken Armstrong
Seattle Times staff reporters12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 2/18
Top comments Hide / Show comments
This is not about the risks and benefits of
methadone, but about medical malpractice. ...
(December 13, 2011, by From the Margins) Read
more
It's tough working at a pain clinic. When I
worked for one, it was hard to really find...
(December 13, 2011, by TroyProuty) Read more
"Nurse practitioners and PAs should not be
working without physician supervision...
The
first
time12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 3/18
Read all 66 comments > Post a comment >
(December 13, 2011, by cdt1) Read more
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 she12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 4/18
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.12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 5/18
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 has12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 6/18
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.12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 7/18
"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 months12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 8/18
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, Susan12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 9/18
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, becoming12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 10/18
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 Steers12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 11/18
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."12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 12/18
"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.12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 13/18
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 one12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 14/18
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.12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 15/18
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.12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 16/18
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 placed12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 17/18
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, saying12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 18/18
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.
Michael J. Berens: 206-464-2288 or
[email protected];
Ken Armstrong: 206-464-3730 or
[email protected]
http://seattletimes.nwsource.com/html/localnews/2017000915_silent13.html
12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 1/18
Winner of Eight Pulitzer Prizes
Local News
Originally published December 12, 2011 at 8:00 PM |
Page modified December 12, 2011 at 8:01 PM
Vancouver pain clinic leaves
behind doubts, chaos and
deaths
The clinic's high doses "Take 10 every 6 hours," one
painkiller prescription said reveal murky regulations
and Washington state's anemic response.
By Michael J. Berens and Ken Armstrong
Seattle Times staff reporters12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 2/18
Top comments Hide / Show comments
This is not about the risks and benefits of
methadone, but about medical malpractice. ...
(December 13, 2011, by From the Margins) Read
more
It's tough working at a pain clinic. When I
worked for one, it was hard to really find...
(December 13, 2011, by TroyProuty) Read more
"Nurse practitioners and PAs should not be
working without physician supervision...
The
first
time12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 3/18
Read all 66 comments > Post a comment >
(December 13, 2011, by cdt1) Read more
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 she12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 4/18
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.12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 5/18
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 has12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
seattletimes.nwsource.com/html/localnews/2017000915_silent13.html 6/18
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.12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
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"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 months12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
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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, Susan12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
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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, becoming12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
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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 Steers12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
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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."12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
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"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.12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
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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 one12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
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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.12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
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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.12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
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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 placed12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
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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, saying12/13/11 Local News | Vancouver pain clinic leaves behind doubts, chaos and deaths | Seattle Times Newspaper
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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.
Michael J. Berens: 206-464-2288 or
[email protected];
Ken Armstrong: 206-464-3730 or
[email protected]
