Part 4 in a series about medical path-breaker Dr. Punyamurtula Kishore
This is the fourth in a series of articles about Dr. Punyamurtula S. Kishore, the Christian physician who innovated the Massachusetts Model of addiction treatment. Conventional addiction therapies, based on the administration of substitute narcotics (Methadone and Suboxone®), have a miserable track record: after a year of treatment, only 2% to 5% of the patients haven’t relapsed back into full-scale addiction—and most are still being prescribed the substitute narcotic, creating other issues for the patients.
In contrast, Dr. Kishore’s sobriety-based approach is non-narcotic in orientation. His method doesn’t lead to a miserable 2% to 5% success rate after a year, but a 37% success rate based on hard test data.1
While other states sought to emulate the Massachusetts Model, Massachusetts itself took a different tack: it incarcerated Dr. Kishore in September 2011 and withheld Medicaid payments to his fifty-two medical practices. The resulting collapse of this network put his patients at considerable risk (250,000 people had passed through his program by that point). Please read the three earlier articles in this series to gain an understanding of this gripping standoff between the state and the doctor, as those articles contain too much material for us to repeat here. We must move on to newer developments as the battle intensifies.
Dignity-Hungry Emperors with Invisible Clothes
In earlier articles in this series, we made reference to the opioid addiction crisis ravaging the state of Massachusetts as acknowledged by various state officials. Since those articles appeared, things have advanced. On March 27, 2014, the governor himself declared a public health emergency in his state.
The death of actor Philip Seymour Hoffman on February 2, 2014, may have played a part in increasing cultural awareness of the addiction problem. However, the fact that Hoffman had Suboxone® (a trade name for buprenorphine, one of the two major anti-addiction “remedies”) in his apartment at the time of his death has been largely overlooked. He had been prescribed Suboxone® and became, in effect, a part of today’s “acceptable damage” statistics. He was one of the 95% of patients who dive back into their drug of choice within the first year of treatment under conventional strategies of addiction management.
With large pharmaceutical interests at risk, nobody dares mention that other treatment regimen that achieves far more than an “inevitably low” 5% success rate. This high-profile failure of a conventional anti-addiction program was easily hidden—by never mentioning the alternative program that achieves a 37% success rate without expensive narcotics. An uninformed populace will then tolerate an “inevitable tragedy,” oblivious of the fact that there was a vastly superior way to prevent such tragedies in the first place. Once this factor is grasped, thereal tragedy is seen for what it is: why wasn’t the best treatment strategy exported out of Massachusetts for people like Hoffman to use? Why was Dr. Kishore’s real-world success dismantled, brick by brick, by a state that later declared that its citizens were being overtaken by a deadly crisis of epidemic proportions?
Too Little, Too Late
By June 10, 2014, Massachusetts suddenly “got religion” and jumped on the we-can-do-better bandwagon, as if the sobriety maintenance model promoted by Dr. Kishore was an innovation that the appointed task force experts had just now concocted in response to the state’s addiction epidemic.2 In reality, the state task force had belatedly reinvented the wheel—the wheel Dr. Kishore had already put into practice in Massachusetts years earlier.
This is evidenced by the task force report’s support for Vivitrol (naltrexone), a key element in Dr. Kishore’s Massachusetts Model. This would have been a strong vindication of Dr. Kishore’s pioneering work with Vivitrol, except that his name is conspicuously absent from the report. Such credit would have been embarrassing for the task force to include, as it would have had to appear in words like this: “We recommend $2.3 million be allocated to do what that doctor was doing with Vivitrol before you destroyed his fifty-two practices in 2011, and we recommend $500,000 to create a sober home accreditation program like the program created by the doctor who must not be named, etc., etc.”) Besides, if the mission is to discredit somebody, the last thingyou want to do is publicly give that individual credit for his achievements.
The state and its media, however, did know the first thing they needed to do to discredit Dr. Kishore: get the man’s medical license suspended before the main Medicaid fraud trial. As mentioned in the second article of this series, the state would see considerable media value in vilifying Dr. Kishore in advance of the trial. Exactly as predicted in that article concerning the two actions pending against Dr. Kishore, the media instantly broadcast the result of the railroaded suspension of April 9, 2014. But now that the cause for that suspension has been obliterated by facts that have since come to light, we wait upon the media to publish the necessary corrections. We likely wait in vain: we don’t expect to see any follow-up stories in print, as it appears to us that local journalists only publish what furthers the Attorney General’s agenda (perhaps the reason they get inside access3 other journalists seem not to get). You won’t get the facts from these allegedly impartial local journalists, but you will know the facts as you read further here.
For the record, Dr. Kishore regards the two attempts to put his medical license in jeopardy as “smoke screens” designed to take attention off the primary issues. While quite true, an understanding of the state’s overreaching in these hearings, smoke screen or not, will prove instructive. If state officials are not faithful in little things, they won’t be faithful in big things (Luke 19:17).
As we step through the facts, we’ll see that “faithful” and “Massachusetts officials” are terms that do not belong in the same sentence. We will also better understand why the state has continued to postpone Dr. Kishore’s main trial (apparently until after the 2014 elections) and why Massachusetts continues to have such a tragic addiction epidemic on its hands. We will conclude with the first major crack in the state’s “Medicaid fraud” claims: a major court decision handing the prosecution a massive setback in a case remarkably parallel to Dr. Kishore’s.
Medical License: The First Jeopardy
The first attempt to jeopardize Dr. Kishore’s license was discussed at length in the second article of this series. The reader will quickly realize the utterly specious nature of the charges, particularly in regard to the state’s efforts to block the 1,700 members of the Massachusetts Psychiatric Society from standing in solidarity with Dr. Kishore. Read the earlier article to get the details of the state’s objections to Dr. Kishore having four women taken to the hospital who arrived at a sober home under the influence.
Dr. Kishore appealed that first attempted suspension, and we expected progress on this front to finally clear Dr. Kishore’s name and license. On May 12, 2014, Dr. Kishore’s attorney filed a response in the ongoing appeal of that suspension. On June 24, 2014, the state’s response was due, but the state’s documentation exceeded the 21-page limit set by the Superior Court, so a delay has been interposed in resolving this case.
You read that correctly: the appeal is being delayed because the state’s legal team was unable to count the number of pages comprising its submission to the court.
Medical License: The Second Jeopardy
The next attempt to jeopardize Dr. Kishore’s license to practice medicine was also mentioned in the second article of this series. This case involved the alleged loss of medical records as a result of the Attorney General’s actions against Dr. Kishore and his practices. When last reported here, two records out of a quarter million were not accessible by Dr. Kishore, and so the Board of Medicine decided to proceed with hearings to suspend his license based on these missing records. (The other part of this second case, involving Dr. Kishore’s alleged failure to alert his patients that his practices were being closed by state action, has been shown by Dr. Kishore’s attorney to be devoid of truth.)
The furtive nature of the state when it operates in an underhanded way came to light when the hearing on these missing records began on April 2, 2014. John Costello railed against Dr. Kishore (who hasn’t practiced medicine since his September, 2011, arrest), demanding his license be suspended because he is a serious, urgent threat to the health of the people of Massachusetts. Mr. Costello was to be given ten minutes for his presentation, and then Dr. Kishore’s attorney would have ten minutes to respond—even time for both sides (in theory). What happened was something different.
Five minutes into Mr. Costello’s arguments for suspending Dr. Kishore, something unusual happened: the Board accepted a phone call. After taking the phone call, the Board declared that the proceedings would have to be postponed a week, to April 9, 2014. Then they could take up the issue of the two missing patient records.
On April 9, Mr. Costello apparently decided he had received a full “do-over,” and took ten minutes to make his presentation. At this point, he’d already spoken for fifteen minutes against Dr. Kishore (five minutes on April 2 and ten minutes on April 9). Dr. Kishore’s attorney could only speak for ten minutes. The “equal time” principle was apparently something that could be dispensed with when the outcome has been predetermined. For his part, Dr. Kishore’s attorney was able to produce one of the two missing records, a document which had been withheld from Dr. Kishore on the grounds that it was now “the property of the Attorney General.” Think about that last point: you can’t produce a document because someone has declared it to be the Attorney General’s property, and you are now going to lose your medical license because you don’t have it in your possession.
Thanks to a well-crafted subpoena by his attorney, Dr. Kishore was able to produce one of the two missing records. That left the suspension to rest entirely upon one “missing” record out of 250,000 records, records rendered inaccessible to Dr. Kishore by the actions of the state against him. Since he didn’t have that final record, the Board moved to suspend his license (temporarily). He promptly appealed.
But he did more than appeal. After prayer and counsel with other Christians, he mounted a last-ditch attempt to find the missing record. Providentially, it came to light on June 6, 2014. What also came to light with that medical record was even more remarkable, as his attorney pointed out in his June 10, 2014, response to the authorities that suspended Dr. Kishore’s medical license.
The patient whose record had been “lost” by Dr. Kishore had been treated between September 2003 and March 2005—as the missing record itself attests. The law that Dr. Kishore supposedly violated states that the physician must produce the record if the patient requests it up to seven years after “the last patient encounter.” However, this patient requested his record after March 2012, meaning that even if Dr. Kishore had lost the record, he had done nothing wrong as the statute of limitations for producing the record had already run out.
But there’s more: the record itself includes the patient’s signed request, dated August 31, 2005, to provide his medical records to UMASS Correctional Health. These were duly sent within thirty days of the patient’s signed request. At that point, the patient’s new doctor had the clock ticking on him for production of records. One can’t help but wonder how it is that the patient had recently come to request his records from Dr. Kishore (after the seven year statute had run out) and not from his later physicians, despite his having signed the request for record forwarding in 2005. As a result of this misdirected patient request, Dr. Kishore had his medical license suspended and that suspension gleefully spread all over the state media outlets. The campaign to discredit Dr. Kishore marches on.
In any case, the final missing record, sealed per legal protocol, was sent to the Board, despite the fact that (1) Dr. Kishore had no legal obligation to produce the record after seven years had expired, and (2) Dr. Kishore had already forwarded the patient’s record to UMASS Correctional Health in the fall of 2005.
There are no missing records. Therefore, there is no basis for a suspension of Dr. Kishore’s medical license. It appears that his license was suspended for political reasons. Of course, if the Board would care to share the contents of the phone call that bizarrely interrupted the April 2, 2014, hearing, we would be happy to print that information here. (Whether the Massachusetts media will publish the fact that these attempted suspensions of Dr. Kishore’s license will have all been thwarted by the truth is unknown. Their pattern of conduct suggests they will never correct the record, because these suspensions were intended to be in place when the main trial starts. We’ll be ecstatic to report otherwise, but come the fall we expect we’ll feel nothing but disappointment in the media watchdogs.)
Insights From Within the State
One of my authoritative sources for this series of articles is a Massachusetts addiction expert (not Dr. Kishore) who will remain nameless. His insights into the ongoing crisis in his state, which serves as the backdrop for the trial of Dr. Kishore, shed considerable light into the otherwise inexplicable actions of the state. The following is a paraphrase of comments made during my phone discussions with this source.
One factor driving the wrong-headed prosecution of Dr. Kishore is the fact that the state’s lawyers and judges have a very narrow definition of how substance abuse should be treated. They rely entirely on amedical model for treatment rather than a public health model for treatment. The disdain for alternate (drug-free) models arises from the perceived “high maintenance” nature of these alternatives. People addicted to heroin, cocaine, etc., need a lot of support in dealing with chronic relapsing disease. A drug-free approach requires other methods not considered part of the playing field by the state.
One of the things quite alien to the state’s thinking is the notion of the recovering community. One needs to provide a social context for healing, and this is something the state simply can’t do: it is something that churches and communities can do, however, in their work with addicts. Such recovering communities (as are found in sober houses) provide support in the same way that immigrant communities support their members: that support comes frompeople like themselves, and persists until they can move on.
The notion of residential treatment, of sober houses, is an important one. Sober houses must be clean or they undermine sobriety. People relapsing at a sober house will trigger contagious craving among the others. Sober houses need to have the built-in protections to hold the line. Unfortunately, the state has no conception of any of this, and continues to promote its medical model, centered predominantly upon the prescription of methadone and Suboxone® (buprenorphine) for treating substance abuse.
Doctors prescribing such drugs are unwittingly flooding the streets with them, making the drug problem worse. This is one reason Dr. Kishore was so popular with the communities of Massachusetts: because he broke the back of the drug-centered model, setting forth the concept of a drug-free community. His non-narcotic approach is a far better solution, but the state is not used to seeing such drug-free solutions in action. If it’s not methadone or Suboxone, then it’s neither fish nor fowl. For this reason, we continue to see public officials advocating in the wrong direction: “We need more methadone, we need more buprenorphine.”4 Yet even back in 2011 Massachusetts already ranked third in the nation as measured by grams of Suboxone® dispensed per opioid user.5 Massachusetts was pouring gasoline on the fire even back then, while those “gasoline” companies made big money as the fire they fed consumed yet more human lives.
Historically, methadone came on the scene in America during the Nixon Administration. Based on controlled clinical comparisons with heroin, it was hailed as “the answer” to opioid addiction when those treated seemed to wake up (rather than nodding off into limbo). Thus methadone maintenance was born, but the safeguards back then (regular urine testing, oral administration, counseling, etc.) are now gone. Our era now confronts the two worst downsides of methadone use: (1) those who use it stay on it forever; (2) the widespread diversion6 of drugs permits addicts to sell the methadone (and now Suboxone®) on the street to fund the purchase of their actual drug of choice (e.g., heroin).
Massachusetts pushes these drugs: it’s their hair of the dog solution to the problem. The epidemic grows further in scope because doctors are writing more than just prescriptions for methadone or buprenorphine. If addicts claim they’re “in pain,” they get more narcotics. When they say they have trouble sleeping, they get sedatives and tranquilizers. If they say they have Attention Deficit Disorder (ADD) and can’t focus, they’re prescribed amphetamines. These addicts either use these additional drugs, or sell them on the street.
This is why the communities of Massachusetts supported Dr. Kishore: none of these problems arise when the Massachusetts Model dominates a region because narcotics and other addictive drugs simply aren’t part of the treatment program. As my contact stated explicitly, “Dr. Kishore doesn’t give additive drugs to drug addicts. That’s why his treatment centers don’t become magnets for people who want to use drugs.”
Resistance to drug-free approaches such as Dr. Kishore’s method boils down to pure politics. The view of state officials can be reduced to one basic mission statement: “Our job is not to stop people from using drugs. Our job is to make sure they don’t hurt themselves.” (See the first article in this series regarding the fourth week of treatment, the looming suicide risk that crops up in that week, and how Dr. Kishore still managed a perfect zero-death record for all who were under his care.)
Clearly, someone who skirts the state’s implicit mission statement so radically (like Dr. Kishore, whose mission IS to see people stop using drugs) represents a challenge to the state’s claim of operating in good faith for its people.
Regarding the Medicaid Fraud Case
My Massachusetts contact also had strong opinions about the Medicaid fraud allegations against Dr. Kishore. In my contact’s view, the state wants to drag the proceedings out, because state officials are trying to make it impossible for him to continue. The intent is to force him to cop a plea, and the state is not averse to using the fact that “he’s a foreigner” against him.
Various testing labs had been paying off sober houses for years. When caught, the accused accepted the state’s plea-bargain deal and paid the designated fine. Nobody went to jail. Nobody fought the charges. Taking the state’s deal was a business decision, pure and simple.
However, unlike previous defendants, Dr. Kishore isn’t making a business decision. He is making a moral decision, because he is innocent of all the charges. Because he won’t play along, the Attorney General has been working to wear him down.7
My contact concludes that, despite Dr. Kishore’s innocence, the cards remain stacked against him. He’s now considered a Medicaid fraud doctor, so the system responds by saying: We need to get rid of him; he gives us a bad name. (Perhaps this motivates, at least in part, the Board’s actions against his medical license. – MGS.)
Beyond the Smoke Screen
As pointed out above, Dr. Kishore is correct in characterizing the Board actions against his medical license as a smoke screen. Nonetheless, the Board actions against his medical license may well prove a good indicator of what might await Dr. Kishore after the elections when the charge of Medicaid fraud is adjudicated. (Read the first and second articles in this series to understand how the state so badly interpreted the data directly in front of it.)
Those close to the Massachusetts situation believe that the postponement of Dr. Kishore’s trial until after the November elections is politically motivated. (In fact, it is hard to find any decisions made in Massachusetts that aren’t politically motivated.) On that hypothesis, the trial is positioned after the elections because the state officials are aware of the consequences of losing the trial. Once it becomes known how state officials dealt with the pioneer of addiction medicine working sacrificially in their midst, the political futures of those who spearheaded this case would implode. The state will be seen as the monster that stole $4 million from the treatment centers that were changing lives more successfully (37% versus 5%) than the state programs could, killing those practices off and taking the innovator out of circulation for nearly three years.
Perhaps the state is aware of the rotten foundations of its case against Dr. Kishore and his fifty-two medical practices. One certainly wonders why the main prosecutor against Dr. Kishore, Assistant Attorney General Nancy Maroney, resigned8 her position on April 2, 2014 (the same day as the first hearing on Dr. Kishore’s medical license concerning missing records), and subsequently dropped off the map without warning or explanation. Did she decide to distance herself from these benighted proceedings and buy herself plausible deniability? We can only speculate: she may have had personal reasons unrelated to the case. Could her resignation have been the point of that unexpected phone call in the middle of the license hearing? Again, nobody knows. We are left with the bald fact that the lead individual battling against Dr. Kishore has suddenly disappeared from the scene before the main trial.
One thing, however, is not a matter of speculation. It is beyond doubt that the Attorney General’s case against another laboratory charged with Medicaid fraud has just fallen apart in a most spectacular way.
On June 27, 2014, Franey Medical Lab Inc.’s principals were found not guilty of all charges leveled at them by the state of Massachusetts.9 The Attorney General had accused the owners of securing illegal kickbacks to the tune of $590,000 (which is more than what is being charged against Dr. Kishore in alleged kickbacks). The parallels between the Franey and Kishore cases are stunning, the most notable being that the alleged kickbacks are inferred from various circumstances that have nothing whatsoever to do with illegal activity.10
As in Dr. Kishore’s case, the state had withheld more money from the Franey defendants (over $1 million) than what the state had accused that laboratory of illegitimately charging. With Dr. Kishore’s case, the situation is even more egregious: after interest is added in, the magnitude of the appalling actions taken against one of the state’s medical heroes will become blatantly obvious to all.
Unless journalists friendly to the Attorney General decide not to report the story. For example, The Boston Globe has said nothing about the Franey acquittal, which constitutes an embarrassing defeat for its favorite law enforcement official. That acquittal was duly reported by Cape Cod Online’s Amy Anthony, but not (yet) by the Globe’s Patricia Wen. Emulating Joseph Heller’s fictional corporal in Catch-22, the state Attorney General monitors two categories of career achievements: “Feathers in the Cap!” and “Black Eyes!” The Boston Globe journalists often seem to drag their feet in reporting Black Eyes suffered by their Attorney General.
The last line of Cape Cod Online’s story on the Franey acquittal might cast some light on this issue: “The attorney general’s office declined to comment on the trial.” It seems that a well-worn religious maxim has been modified and pressed into service by the journalists of record in Boston: “Where the AG speaks, we speak. Where the AG is silent, we are silent.”
If justice is even remotely done in Massachusetts, many entrenched interests will take notice that Dr. Kishore’s Massachusetts Model for addiction treatment will be put back on its feet. Perhaps, then, something won’t have to be put back on Dr. Kishore’s feet: the GPS ankle bracelet that tells the Attorney General where he is every moment of the day. The Christian virtue of sobriety will regain stolen ground from today’s failing models that merely switch people to another enslaving addiction. Liberation ultimately acts upon all the facets of personhood. As a result, people once thought to be lost to society can be made whole.11
The mountain of obstacles the state has erected against Dr. Kishore’s work will one day be leveled (Zech. 4:7). Then the serious work of rebuilding the lives of those ravaged by substance addiction can be resumed without further interference from an oblivious, overreaching state protecting interests other than those of its ill-served citizens.
1. Read the second article in this series for the pertinent documentation.
3. One example of apparent privileged access will suffice: The Boston Globe’s Patricia Wen covered the surprise arrest and appearance in Suffolk Superior Court of Dr. Kishore on October 6, 2011. The arrest was a surprise to Dr. Kishore, but not to Wen. Other examples can be found in earlier articles in this series.
4. If these opiate substitute approaches were the road to success, why do they look to be such tragic failures? Perhaps the principle of Ecclesiastes 5:10 applies: a hunger for silver cannot be satisfied with silver. Therefore, it’s no surprise that legislators elsewhere are learning that blocking physicians from prescribing addicting drugs actually saves lives. See http://www.latimes.com/local/l...
5. Lisa M. Lines MPH and Robin E. Clark PhD. “State-level Influences on Buprenorphine Utilization: Variations in Opioid Addiction Treatment,” AcademyHealth. Seattle, WA. June 2011. Available at: http://works.bepress.com/lisa_...
6. The task force report in the second endnote makes some attempt at addressing this issue, but it’s only an issue when you don’t pursue a drug-free approach to solving addiction.
7. Dr. Kishore might consider applying to the Guinness Book of World Records for consideration for the longest interval a Massachusetts defendant has been forced to wear a GPS ankle bracelet. He may or may not win such recognition, but he warrants nothing less than an honorable mention in that ignominious category.
8. A putative witness for the prosecution insists that Ms. Maroney’s departure wasn’t voluntary. The smoke has yet to clear from this mysterious situation.
10. While Dr. Kishore was always in full compliance, in all particulars, with both federal and state laws governing kickback arrangements and safe harbor provisions, it is interesting to note that the American Bar Association itself is now questioning the value of so-called “anti-kickback” legislation as currently being applied across the land. See http://apps.americanbar.org/bu...
11. See the first article in this series for a detailed discussion of this process and the Biblical context undergirding it.