By Taylor Knopf
For Courtney Cates, pain medication is the difference between taking short walks or staying in bed.
It’s the difference between talking with her 8-year-old son or passing him notes.
Cates, 37, suffers from chronic pain in her back, leg and jaw resulting from car accidents, failed surgeries and a painful jaw disease. She relies on strong pain medications for simple activities, like eating breakfast or washing dishes.
Yet now, Cates is one of 34 patients who cannot find treatment for their pain because their doctor can no longer prescribe pain killers. More broadly, the Raleigh woman is among many pain patients affected by a nationwide crackdown on opioids aimed at stopping drug overdoses.
Her doctor, Thomas Kline, 76, who specializes in chronic, painful diseases, said he was asked to sign over his DEA license to prescribe controlled substances during an impromptu visit from the N.C. Medical Board last month.
The board launched an investigation into the Raleigh doctor last spring after receiving a complaint from Julie Roy, whose 26-year-old son died from a heroin overdose. She lives in rural New York and doesn’t know him personally.
Their paths crossed on Twitter, where Roy became concerned about some of Kline’s tweets.
Roy uses Twitter to share her son, William’s, story as a cautionary tale, while Kline uses the platform to rebuke what he believes are misconceptions about opioids.
Kline claims that only 1 percent of people have the genetic makeup to become addicted to opioids and that the addiction rate has not changed through the years.
Roy, 54, takes exception to that claim.
“Then why are all these people dying?” Roy said in an interview with NC Health News. “I saw opioids spill into my community. I live in a very small community. We’ve had over two dozen deaths of 20-something-year olds, one being my son.”
To Roy, Kline’s tweets were a sign of reckless behavior — the kind that could result in death.
So she filed a complaint with North Carolina’s medical board. Kline “is giving out information regarding opioids that is not correct and could cause harm,” Roy wrote. “He uses Twitter to do this. I’m very concerned that his pain patients believe what he says.”
Lone, defiant voice
Kline is very active on Youtube and Twitter. His following has grown to 31,000 in recent years, as he’s become an outspoken advocate for chronic pain patients.
Since Kline lost his DEA license, pain patients around the country are rallying around him, raising money for legal fees so he can fight to reinstate his license.
As more and more doctors become reluctant to prescribe opioids, some patients have become desperate for pain management. Some have taken their own lives because they couldn’t find relief from their pain.
Kline wants to help prevent these deaths and help his patients function best they can. Patients travel from as far as Wisconsin and Kentucky to see him. He said he has a specialized practice where he takes what he calls “pain refugees.”
“I have 34 of the hardest cases,” he said. “To get into my practice, they need to have seen at least 10 other doctors and have been turned down for pain treatment.”
Kline frequently criticizes the opioid prescribing guidelines created by the Centers for Disease Control and Prevention in 2016. He says the CDC and DEA should not be telling doctors how to treat their patients.
But when he got a letter from the medical board last spring, Kline said he cooperated. Investigators came to his office and questioned him. They asked for the medical charts of nine patients and took them away for review.
“I think everything’s going fine with the board, and I got a phone call from the investigators: ‘I’m coming over to ask you to surrender your license,’” he said. “That’s pretty serious. I figure some serious thing is going on with the DEA.”
There were 818 voluntary and involuntary DEA license surrenders in 2018 across the United States, that’s up from 786 in 2016, according to a DEA spokesman. There are 1.8 million registrants nationwide, which includes practitioners, pharmacies, hospitals and analytical labs.
Kline signed a voluntary surrender of his DEA license, meaning he can no longer prescribe controlled substances, including opioids.
“But I didn’t read the form. In the form, it says you’ve committed a crime and this was voluntary,” he said. “But they don’t tell you that, so the doctors are trapped into signing these things.”
Kline said he asked the investigators to see a list of charges against him but was not given any.
How investigations work
“Under North Carolina law, medical board investigations are confidential,” said board spokeswoman Jean Brinkley. She said she could not comment on Kline or confirm the existence of an investigation.
Speaking generally about the medical board’s investigative process, she said if a case stems from a complaint, the doctor or physician assistant being investigated receives a copy of it and is required to provide a written response.
Medical records of one or more patients will be reviewed if the investigation involves a quality of care issue. The physician is asked to give a written response explaining their treatment decisions.
What is chronic pain?
The definition of chronic pain varies. The CDC defines it as “pain that typically lasts more than three months or past the time of normal tissue healing. Chronic pain can be the result of an underlying medical disease or condition, injury, medical treatment, inflammation, or an unknown cause.”
The CDC says that about 11 percent of American adults report feeling pain on a daily basis and that between 9 and 11 million U.S. adults were prescribed long-term opioid medication in 2005.
The National Academy of Medicine states that pain is a public health issue that affects more than 100 million Americans.
Most investigations end in a settlement agreement, Brinkley said. The medical board presents the physician and their attorney with evidence of the problem found, and the physician agrees to do some kind of action to resolve it, such as more education or stopping certain practices.
“There are times a licensee doesn’t feel they did anything wrong,” she said. “They can defend themselves at a hearing. A minority of cases go to a hearing. The vast majority are settled.”
Kline believes his case should have gone to a hearing. But he said he wasn’t aware of his options.
“If something is going to affect the patients, there needs to be a different standard,” Kline said.
“Every one of my patients needs their medicine in order to stay alive and functional. It’s no different than yanking medicines from a diabetic,” he said.
Searching for relief
Cates is now feeling the effects of life without her medication. As her remaining pills dwindle, she’s taking a small amount each day to make them last as long as possible. She says the low dose doesn’t do much for the pain, but it helps stave off withdrawal symptoms.
Before Cates became a patient of Kline in 2019, she had trouble finding a doctor to treat her. Cates receives disability and is on Medicaid. After one surgery, the doctor said she should do physical therapy, but Medicaid wouldn’t cover it.
Basic household chores were simply too painful. Cates said pain shot through her back as she leaned over the sink to wash dishes or vacuum the floor. She lives with her mother, who would often do the cleaning.
But on the pain medications, Cates said she could accomplish these tasks more easily, taking short breaks in between. She started taking short walks with her walker around the neighborhood, starting with 10-minute periods working up to 25 minutes.
“My walks are coming to an end. Playing with my son like I was doing, that’s ending,” she said.
During the snow day in Raleigh last month, she used her last fentanyl patch to build a snowman with her son. She said she wanted to let her pain medication run out “with a bang” and give her son a fun, memorable experience.
“Not only am I physically in pain but emotionally I’m in pain. Because I can’t do anything. I can’t be the fun mom,” she said through tears.
Finding new doctors
Kline said he is working to find doctors to cover his patient load, but it’s difficult. Few will take patients with complex pain issues.
He said he found a doctor in Charlotte and another in Virginia who are willing to see some of his patients temporarily while he fights to get his DEA license back. He’s still looking for someone to cover about 25 percent of his patients.
Kline said he will help reimburse some of his patients’ travel costs to see the new physicians.
N.C. Medical Board Investigations
The N.C. Medical Board opened 2,680 investigations in 2018, out of nearly 50,000 licenses. Of those, only 586 resulted in any action from the board, according to the board’s most recent annual report.
Nearly half of all investigations stem from a public or patient complaint.
In 2016, the North Carolina Medical Board launched its Safe Opioid Prescribing Initiative. The board investigates prescribers who have many patients on high doses of opioids, and those who have two or more patients die of an opioid overdose in one year’s time.
None of Kline’s patients have died.
But prescribers can also come under scrutiny if they meet several other criteria, such as a significant number of patients who are self-pay, who are on the same cocktail of prescriptions or who travel more than 100 miles for treatment.
Only 15 cases were opened under the Safe Opioid Prescribing initiative in 2018, according to the board.
The physician in Charlotte has a practice treating pain and addiction, Kline said, declining to name the doctor.
“And he was not concerned about prescribing these high doses,” he said. “Out of love for patients, he just volunteered.”
Roy, the concerned woman who filed the complaint, said she hoped Kline’s patients could find new doctors to help them. Roy said she can relate to their struggle because she used to be on long-term opioid treatment for a failed back surgery.
But last year, she decided to get off. Her prescriptions weren’t working anymore, and Roy said she woke up every day with withdrawal symptoms. Her doctor switched her to buprenorphine — typically used as an addiction treatment drug — and Roy said it works well for her.
“I do feel bad for the patients that were affected,” she said. “I’m not against those in need of using them.”
As for Cates? On Wednesday, she boarded a train with her walker to meet a new doctor in Charlotte. She’s not crazy about traveling and putting her body through more discomfort just to get the care she needs.
But for now, it’s her only option.