Pharmacists denied service to embattled Rosalia nurse

March 01--A Rosalia nurse practitioner who was stripped of her license last week by the state complained to Spokane pharmacists last summer after some stopped filling her prescriptions for painkillers.

"It seemed to me they thought I didn't know what I was doing," Susan Bowen-Small said this week. "I thought that they thought I was some young thing that had never had experience with doing what I was doing."

A state panel stripped her of her credentials and charged her with unprofessional conduct Feb. 19 after three of her patients died of drug overdoses.

Bowen-Small had been licensed as a health care provider with Washington since 1984. Her practice, the Rosalia Health Clinic, is now closed.

Responding to the accusations she prescribed painkiller dosages exceeding in some cases 15 times the amount of opiates that require a specialist consultation, Bowen-Small said the state Department of Health ignored her efforts to wean patients off prescriptions, disregarded her acceptance of poor patients other clinics wouldn't take, and failed to acknowledge that stringent regulations stretched thin her clinic's skeleton crew of nurses.

"I would tell everyone when they come in, 'I am not a pain doctor. I am a primary care provider doctor,'" Bowen-Small said. "And in that, I want you to get better, to take care of yourself."

In her response to allegations that she didn't craft pain-management contracts with many patients, as required by state law, Bowen-Small said, "sometimes my documentation was crappy."

Almost all of her patients were on Medicare, Medicaid or other low-income health coverage, Bowen-Small said. She suspected some of them of abusing other substances or mixing medications, but said her clinic conducted regular urine tests and stopped services to more than 200 patients as a result of screening.

"One of my patients that died, I asked him how often he was taking his insulin," she said. "And he admitted to me, probably half of the time."

The state says the patients, who are not named in charging documents, all died from January to March 2013 of various levels of drug toxicity. Bowen-Small was not informed of their names, but was able to deduce their identities based on her records, she said.

Shortly after the final investigated death, some Spokane pharmacies refused to fill Bowen-Small's prescriptions, prompting her to write a letter voicing her frustrations.

"I do not know how to get expensive drugs and treatments paid for by (the state Department of Social and Health Services) and all their intermediaries," Bowen-Small wrote. "In this tiny little clinic there are four of us serving a lot of very comprehensive patients ... A huge amount of unwarranted hours are spent trying to get things 'authorized.'"

William Fassett, a professor of pharmacy law and ethics at Washington State University and executive vice president of the Spokane Pharmacy Association, said he was aware of Bowen-Small's case but couldn't talk about it specifically. He said, however, that it would be within a pharmacist's authority to decline to fill prescriptions because the pharmacist is open to law enforcement investigations and civil claims in the event of overdoses.

The federal Drug Enforcement Administration discovered negligence from a Florida pill distributor for retail giant Walgreens last year and fined the company $80 million. That case has made pharmacists more wary, Fassett said.

"What usually happens is the pharmacist says, 'We're not going to fill that prescription,'" he said. Pharmacists are looking out for signs of prescription abuse, including what are termed in the industry "three-baggers" and "home runs," when the same combination of three or four powerful painkillers are prescribed to patients regardless of other circumstances.

The Walgreens case in Florida came to light because so many of the prescriptions were finding their way to the black market. Bowen-Small said her screening processes were designed to detect if patients were selling their pills on the street, but she could never be certain it wasn't happening.

She said she received a text message from a former patient saying at least one of the rash of Spokane pharmacy robberies in January could have been an indirect result of the closure of her clinic late last year.

Spokane police spokeswoman Monique Cotton said investigators have found no information to suspect the closure and robberies were linked. But Fassett said it wouldn't surprise him.

"Many of the patients who get these prescriptions don't really take the drugs," he said.

Bowen-Small has a little less than two weeks to formally respond to the charges against her. She said this week she has not hired a lawyer, but that's probably in her future. In the meantime, many of her low-income patients are left dealing with insurance companies and doctors who will likely refuse them care, she said.

"They're saying, take them off their pain meds, but they're not going to give them anything else," Bowen-Small said. "Is that fair? Is that nice? Do we as a society just say, 'Too bad, you poor people?'"

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