This Pain Clinic Nurse Gave a Patient 51 Pills a Day. And She Kept Her License.

The prescription was a literal handful of pills — more than enough to kill.

It began with 32 tablets of methadone, a powerful opioid painkiller, swallowed eight at a time throughout the day. Then the patient was instructed to take two Roxicodone, another opioid, four times a day. Then a tablet of Soma, a potent muscle relaxer, four times a day. Six Xanax were sprinkled in between.

And finally, at bedtime, the patient was supposed to take a small pink Ambien, like the cherry on the top of a pharmaceutical sundae.

This massive prescription — 51 pills a day with an opioid dosage more than 31 times the current recommendation of the government — was issued eight years ago by Christina Collins, a Knoxville-area nurse practitioner who was once one of the top opioid prescribers in Tennessee.

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This prescription would have almost certainly killed anyone who actually tried to consume it, state officials say, but Collins regularly issued prescriptions like this one in 2011 and 2012, sending hundreds of thousands of pills into the communities of eastern Tennessee, where the opioid crisis hit hard. In state records, the Department of Health has said that Collins' contributions to the epidemic are "obvious and appalling" and that her prescriptions were “so colossal” that their only reasonable use would be drug trafficking or suicide.

An excerpt from a Bearden clinic document shows the 51 pill-per-day prescription that nurse practitioner Christina Collins prescribed to a patient in 2011. State officials say this prescription is so large it could only be used for suicide or drug trafficking. (Photo: Tennessee medical discipline records)

“In short, Mrs. Collins was a machine that dispensed prescriptions without regard for any professional responsibility,” Mary Katherine Bratton, a Health Department attorney, wrote in state documents. “Her own lawyers argued that Ms. Collins engaged in patient-led prescribing, simply giving patients whatever dangerous drugs they requested.”

Health officials attempted to revoke Collins' nursing license last year, but the effort failed. Instead, the Tennessee Board of Nursing put Collins on professional probation but allowed her to keep the ability to write prescriptions. Today, Collins is still a nurse practitioner, working in doctor's offices and nursing homes in the Knoxville area, not far from where she once prescribed opioids by the handful.

Christina Collins, a Knoxville-area nurse practitioner, is accused by state attorneys of prescribing "colossal" opioid doses that would kill almost anyone.Ayrika L Whitney, The Tennessean

But this nursing board decision, state attorneys argue, cannot be allowed to stand. Earlier this year, the Health Department and the attorney general’s office asked a state court judge to intervene in the case and command the nursing board to reconsider Collins' case. Samantha Fisher, a spokeswoman for the AG’s office, called the request “rare but not unprecedented.”

For this story, The Tennessean reviewed more than 4,000 pages of state records and disciplinary documents, some of which were obtained through a public records request to the secretary of state. Records include a full transcript of Collins' nursing board disciplinary hearing and extensive documentation of some of her prescriptions and patient visits.

The records were redacted to protect the privacy of patients but still reveal details of Collins’ prescriptions: In addition to prescribing opioids in whopping dosages, Collins continued those prescriptions even after patients failed drug tests, lost pills, overdosed, or told suspicious stories about why they needed drugs in the first place.

In one case, Collins told a 47-year-old woman to wear three fentanyl patches at once in addition to prescriptions for two opioids, Opana and Roxicodone, and at least three drugs that can be dangerous to mix with opioids — Soma, Restoril and gabapentin.

This patient, identified only as S.B., later tested negative for many of these medications, suggesting she may have been transferring them to someone else. Collins continued the prescriptions anyway.

Collins' attorney, Eric Vinsant, declined to comment on specific prescriptions like this one, but stressed that state attorneys presented "no real evidence" that his client's prescriptions had ever been resold on the black market.

In a phone interview with The Tennessean, Vinsant described his client as a well-intentioned nurse whom the state was attempting to punish under modern opioids standards even though her prescriptions are at least 6 years old.

“This case stretches from 2011 and 2012, which was a time before Tennessee really began looking at the prescribing of opioids and other controlled substances for pain, and there was really a very limited amount of guidance for practitioners on what was expected and what were best practices,” Vinsant said.

He added later: “She became a victim of her environment and the medical community and the ideas that were floating around out there at that time period.”

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Tennessee's ninth-highest opioid prescriber

Collins, 43, got her nursing license in 2001 and gained the ability to prescribe medication when she became a nurse practitioner in 2007. Three years later, she started working at Bearden Health Associates, a Knoxville-area pain clinic where she prescribed somewhere between 275,000 and 470,000 pills to hundreds of patients in a span of two years, according to medical disciplinary documents filed with the state.

Collins has admitted under oath that she came to Bearden with no experience in pain management and began issuing prescriptions on her fourth day. She said she prescribed controlled substances to every patient she saw and often wrote prescriptions for patients she never examined.

Nurse practitioner Christina Collins often prescribed her patients a worrisome mix of opioids and other drugs like muscle relaxers. This photo shows a daily dose of methadone, Roxicodone, Soma and Xanax, which Collins prescribed to a patient in 2011. (Photo: Lacy Atkins / The Tennessean)

By the end of 2012, Collins was the ninth-highest opioid prescriber in the entire state, according to the Health Department.

The overprescription of painkillers is largely viewed as one of the primary causes of the ongoing opioid crisis, which over the past five years has killed more than 5,000 people in Tennessee and 130,000 nationwide. Many of these unnecessary prescriptions came from shady doctors’ offices, colloquially known as “pill mills,” that prescribe painkillers in huge doses with flimsy justification, fueling addiction and supplying drug dealers who sell pills on the black market.

The Tennessee Department of Health has made it clear that is what it believes occurred at the Bearden clinic in the early 2010s, and the agency has gone to great lengths to discipline the doctors and nurses who worked there at that time.

Stephanie Hines protests with family members outside the Bearden clinic Sept. 22, 2011. Hines said the clinic overprescribed pills to her husband, who died that year. The clinic is also where Christina Collins and others once prescribed painkillers by the handful. (Photo: Michael Patrick/Knoxville News Sentinel)

Dr. Frank McNiel, who ran the clinic for decades, surrendered his license earlier this year. The state also pushed to revoke the license of Brandy Burchell, a Bearden nurse practitioner who admitted to overprescribing. And yet another Bearden nurse practitioner, Teadora Neagu, was permitted to keep her license after she cooperated with an investigation into the other prescribers at the clinic.

Today, the Bearden clinic operates out of a new office near the Knoxville suburb of Farragut. McNiel's wife, Janet, still works there as a doctor.

When asked for comment on this story, Bearden issued an email statement noting that Collins, McNeil and the other disciplined employees worked for the clinic years ago and that the pain management industry as a whole has undergone a significant overhaul in the time since they left.

The clinic closely monitors its prescription usage, the statement said. The clinic currently has no disciplinary infractions on its public record.

“What our clinic learned — what all responsible pain management clinics have learned — over the last few years is that past approaches required change,” the Bearden statement said.

Collins has defended her prescribing at Bearden by arguing that she was only following the lead of her colleagues, and insisted that many of her larger prescriptions were simply refills of prescriptions that previously has been issued by McNiel.

Collins left Bearden in 2012 after she became suspicious that McNiel’s prescriptions were too large, she told the nursing board during a hearing last year.

“When I initially started there … obviously I did not think that there was anything below the standard of care or anything wrong with the patients or the prescriptions they were taking,” Collins said, according to a hearing transcript. “If I were looking at doses like that in today’s time after the guidelines and everything that I’ve learned, yeah, I would think that was very high amounts.”

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Drug tests, overdoses and a man with a magic spine

It was the summer of 2011 when a young man walked into the Bearden clinic with an unlikely story to tell.

Internal documents from the Bearden clinic describe patient D.L., who was prescribed opioids after he claimed broke his back in a snowboarding accident then abruptly regained the ability to walk. State attorneys have argued this impossible story should have been a red flag. (Photo: Tennessee medical discipline records, highlighting added for clarity)

The man, identified only as D.L., claimed he had been paralyzed from the waist down in a snowboarding accident near Nashville, then two years later he spontaneously regained the ability to walk without surgery or physical therapy. Sensation returned to his legs, he said, but now there was a constant burning pain that ran through his body, leaving him unable to sleep or work.

Medicine, he insisted, was the only answer.

This unbelievable story of recovery should have been a red flag for any medical professional, but this patient got medicine anyway. On his first visit, McNiel gave D.L. a monthlong prescription for 270 tablets of Opana, an opioid three times as strong as morphine, and 60 max-dosage tablets of Soma, the muscle relaxer.

Collins later upped the prescription by an additional 150 Opana and added 90 tablets of Klonopin, an anti-anxiety drug, medical records show. Within a year of coming to Bearden, the snowboarder was being prescribed 23 pills a day.

Medical records reviewed by The Tennessean also reveal the case of P.C., a longtime Bearden patient who was prescribed opioids despite an apparent history of prior drug abuse. State records show that Bearden staff knew this patient had a prior arrest for drug trafficking and an active arrest warrant when he came to the clinic for the first time in 2010.

P.C. also tested positive for illegal drugs during one of his first visits to Bearden. Clinic records make this clear because somebody scribbled a simple message in giant letters across his drug test results — "Cocaine. Not good."

Despite these results, P.C. was still prescribed Xanax, Soma and a large dosage of morphine.

"Cocaine. Not good" is scribbled on drug test results of P.C., a patient at the Bearden clinic. Despite this positive drug test, this patient was given a morphine prescription more than 16 times the dosage currently recommended by the government. (Photo: Tennessee medical discipline records)

About six months later, in March 2011, P.C. was hospitalized at Mercy Medical Center in Knoxville after a mix of those three drugs slowed his breathing to dangerous levels. Hospital staff, shocked by the patient's prescriptions, lowered his morphine dosage as he left Mercy Medical.

But it didn't stay lowered.

During P.C.'s next visit to Bearden, Collins tripled his dosage. Despite his recent overdose, she prescribed him more than 2,000 milligrams of morphine a day — 16 times what is currently recommended by the Centers for Disease Control and Prevention. One year after that, Collins added a quadruple dose of Actiq, a fentanyl lozenge, to his prescription.

Collins defended this prescription as appropriate during her discipline hearing last year.

“I think that for him, he was doing fine,” Collins said, according to a hearing transcript. “He was doing fine on the dose he was on.”

Prescriptions like this one worried the Board of Nursing, but board members would not agree to the state's request to revoke Collins' license. Instead, a panel of three board members decided in February to put Collins' license on probation for two years. She also was fined $5,500 and forbidden from working in another Tennessee pain clinic.

Three weeks after that decision, the Health Department petitioned board members to reconsider, insisting in written arguments that Collins was a “dangerous prescriber" and that probation was “little more than a slap on the wrist.”

The board had 20 days to act on the petition but never did. It was automatically denied.

The Board of Nursing would not comment for this story. Chairman Brent Earwood, one of three board members who decided Collins' case, declined to speak about the particulars of the allegations against her. The two other officials who heard the case, current board member Janell Cecil and former member Lee Ann Stearnes, did not respond to calls to their places of work or cellphones.

However, at least some insight into the board members' thought process can be gleaned from a transcript of their deliberations.

That transcript shows that board members agreed that Collins was guilty of dramatic overprescribing but believed that she had not done so intentionally. Members wavered on how much Collins was to blame for blindly following her supervising doctor, but insisted it should have been obvious that the prescriptions were excessive.

“Do I think she is a danger?” said Stearnes, herself a nurse practitioner, during deliberations. “No. I think she stopped when she realized that this is not correct. I just think it should have been recognized sooner.”

https://www.tennessean.com/story/news/2018/10/11/opioid-epidemic-tennessee-pill-mills-christina-collins/1488026002/