Thursday, November 9, 2017
Even at age 64, Steven Hoyt knows how to throw his weight around. Given what he’s up against — the State of California’s Board of Pharmacy and mounting public outrage over the nation’s opioid epidemic — he’d better if he hopes to survive.
When not working his day job, Hoyt teaches judo at UCSB and Santa Barbara City College. Back in 1972, he was good enough to try out for the U.S. Olympic team. While he didn’t make it, he still managed to win a couple of gold medals and a bronze in national competitions. Today he’s on the verge of achieving his sixth-degree black belt. But it’s Hoyt’s day job that’s now in peril.
For the past 17 years, Hoyt has owned and managed Montecito’s quaint and neighborly San Ysidro Pharmacy. Early last month, he was notified by California’s Board of Pharmacy — via legal papers served — that its executive officer, Virginia Herold, is out to revoke his license to dispense pharmaceuticals.
According to the complaint, dated October 4, Hoyt and his pharmacy failed to exercise the due diligence required by state law in dispensing narcotics. Specifically, the complaint alleged that Hoyt failed to heed the warning signs and filled prescriptions for two patients — both of whom subsequently died — then under the care of Dr. Julio Diaz, known in media accounts as “The Candyman.” Diaz was sentenced to 27 years behind bars in 2015 for the illegal sale of narcotics. The federal indictment against Diaz charged that 12 of his patients died of overdoses as a result of his illegal prescriptions. That number would double after a subsequent investigation.
Hoyt’s pharmacy is not the first to be charged, only the most recent. Earlier this year, the lights went out at two Peter Caldwell pharmacies in the face of such litigation. Three years ago, the owner of the Sansum Pharmacy — then owned by an independent operator other than the clinic that bore its name — had his license revoked. Likewise, The Medicine Shoppe franchise once located at 1435 State Street did not go unscathed.
Hoyt, however, is not going quietly into the Board of Pharmacy’s good night. He is aggressively disputing the details of the state’s claim against him. But even more aggressively he’s also waging a spirited attack on what he terms the “witch hunt” precipitated by the staggering overdose deaths attributed to opioids — 61,000 a year nationwide — whether prescribed or not.
“I’m not saying there’s not an opioid epidemic; obviously, there is,” he said. “But I went into pharmacy school to learn to help people. I did not go to become a cop. And I did not go so I could treat my patients like criminals. That’s not compassion. There are many people out there suffering from serious chronic pain, and opioids are effective in treating that pain. To make it harder for these people to get treatment is not compassion.”
Hoyt may be vehement in expressing such concerns, but he’s hardly alone. “To a certain extent, physicians are more apprehensive and anxious in prescribing opioid pain medications,” said Dr. Paul Erickson, head of Cottage Hospital’s psychiatry department. “There probably are individuals out there experiencing difficulty getting their pain needs met. It’s a real phenomenon.” Erickson is part of an ad hoc task force of South Coast medical professionals dealing with pain management and mental-health issues. Opioids are successful not only in quelling physical pain but also in subduing anxiety, depression, and other psychological conditions. “It’s clear for some people opioids are highly effective and helpful,” said Erickson. “For others, they cause real harm. The challenge is figuring out in advance which patients will be helped and which ones will be harmed.”
Fifteen years ago, America’s doctors embraced pain management as an urgent, unmet need. Pain soon became the fifth vital sign, routinely taken of all patients. But unlike other vital signs, pain cannot be independently measured. This makes it challenging for medical professionals to gauge the actual need. Not all pain is the same, either; chronic pain differs sharply from acute pain. Most doctors, Erickson noted, are trained to deal with the acute variety. Far fewer know how to manage chronic pain, of which there may be several types. Companies like Purdue Pharma, maker of Oxycontin, went into hyperdrive, mass marketing synthetic opiates that delivered potent pain relief and proved even more addictive than they were effective. Hundreds of thousands died from overdose. Even more joined the ranks of the walking wounded.
About three years ago — as the bodies piled up — the pendulum began to swing the other way. Operations like Sansum Clinic found Drug Enforcement Agency agents breathing down their necks, checking out whether there were enough cancer and hospice patients — high narcotic consumers — to justify the quantity of opioids prescribed. Doctors became more cautious about writing prescriptions; pharmacies got gun-shy about filling them. And in Santa Barbara, the Board of Pharmacy started going after some of the pharmacies that filled Dr. Diaz’s prescriptions.
By any reckoning, Diaz had been a profligate overprescriber, writing pharmaceutical scrips for junkies willing to pay cash. If he didn’t do it, he figured, his patients would have to buy their drugs on the street. According to one tabulation, Diaz was responsible for more than 400 overdoses between 2010 and 2011. State medical boards were reportedly alerted many times; nothing happened. Finally, the federal government took action in January 2012.
In the aftermath of Diaz’s prosecution, four Santa Barbara pharmacies, Hoyt’s included, were sued by the families of two men — known as A.M. and S.M. in the state board’s filing — who died while under Diaz’s care. Though the four pharmacies agreed to settle out of court, the amounts were relatively small, just $37,500 per pharmacy. The case was inflammatory but hardly ironclad. S.M. reportedly died from acute alcohol poisoning, his body ravaged by a head-spinning number of industrial accidents that rendered him unable to work for more than 10 years. He had been under doctor’s care and had been a model patient, taking his medications only when prescribed. Under Diaz’s instruction, Hoyt made special fentanyl lozenges for S.M. In 2009, three months after the last prescription had been filled, S.M. died. Two years later, a 27-year-old man with lower back troubles who had his painkiller prescriptions filled at San Ysidro Pharmacy died of an overdose of street heroin. It was alleged his addiction had been nurtured by the opiates prescribed by Diaz and filled by Hoyt. The defense alleged A.M.’s appetite for street drugs preceded his use of prescription painkillers by many years.
The Board of Pharmacy’s case against Hoyt is that he failed to take proper precautions; specifically, he failed to avail himself of California’s statewide database showing who’s getting what prescriptions filled from what pharmacies. This database — known as CURES, Controlled Substance Utilization Review and Evaluation System — was established in 2009 to help pharmacies spot customers shopping around for narcotics. Making matters worse for Hoyt, he was frequently paid in cash, regarded by state officials and many in the health community as a “red flag.”
Hoyt claims he tried many times without success to access CURES beginning in March 2011. Only on May 2, 2012, he stated, did he finally make connection. “I tried repeatedly,” he insisted. “It wasn’t up.” The state was then in the throes of a massive fiscal crisis, and the CURES system wouldn’t become fully operational until 2012, he stated. Department of Justice spokesperson Jennifer Molina said the system was fully operational by 2009. One of the 16 pharmacists on the South Coast also targeted by the Board of Pharmacy in the wake of the Candyman case stated he, too, had experienced extreme difficulty accessing the system until 2012. He requested his name not be used.
Hoyt said he’d heard rumors by 2011 that Diaz might have issues. “I wanted to find out what he was doing, so we had breakfast,” he said. “He told me he subjected his patients to police background checks. He told me everything he was doing. He was very convincing. I got fooled. But I went to the trouble of meeting with him. I was the only one.” As far as the cash payments, Hoyt makes no bones. “We have many patients who pay cash. They’re not covered by insurance, but they’re legit,” he said.
In the meantime, Santa Barbara’s opioid task force continues meeting on a monthly basis, as it has for the past year. Dr. Joseph Frawley said he’s working with nurses and other medical professionals to help them better screen the emotional histories and any family addiction issues of those experiencing chronic pain. All this takes more time, and time is something few primary care doctors have in any abundance. Emergency rooms are now dispensing fewer pills to patients receiving pain medications, and large pharmacy chains are reportedly requiring those on narcotics to refill their prescriptions on a weekly basis.
Hoyt uses the word “compassion” a lot. For the past 10 years, he’s been part of Adventures in Caring, a group that dispatches volunteers dressed as Raggedy Ann and Raggedy Andy into hospitals and nursing homes. It trains his staff in the art of compassionate listening skills so they can better hear “beyond the anger” of clients for the pain and frustration they are experiencing. He’s talking about putting together a consortium of pharmacists to discuss how chronic pain patients can still get relief. “This is a tough, tough time. People in our line of work can’t survive out there alone.”
Does Hoyt think he might have gotten sideways with state health authorities because of excessive compassion on his part? If so, he’s not buying it. “That’s what’s missing in the world right now,” he exclaimed. “Compassion.”
Editor's Note: This story was corrected on November 13, 2017, to state that it was the Medicine Shoppe franchise at 1435 State Street that went out of business in the wake of enforcement action initiated by the California Board of Pharmacy. The Medicine Shoppe located at 3605 State Street, aka the Medicine Shoppe Uptown Pharmacy, very much remains in business and has never been the focus of any Board of Pharmacy action.