BEFORE THE NORTH CAROLINA MEDICAL BOARD In re: ) ) Marcono Raymond Hines, M.D. ) CONSENT ORDER ) Respondent. ) This matter is before the North Carolina Medical Board ( Board ) regarding information provided to the Board concerning Marcono Raymond Hines, M.D. ( Dr. Hines ). Dr. Hines admits and the Board finds and concludes that: STATUTORY AUTHORITY The Board is a body duly organized under the laws of North Carolina and is the proper party to bring this proceeding under the authority granted it in Article 1 of Chapter 90 of the North Carolina General Statues and the rules and regulations promulgated thereto. FINDINGS OF FACT On June 13, 1978, the Board issued Dr. Hines a license to practice medicine, license number 22578. During the times relevant herein, Dr. Hines practiced in New Bern, North Carolina. In September 2016, the Board received information from the Department of Health and Human Services ( DHHS ) in accordance with 21 NCAC 32Y.0101 related to Dr. Hines s controlled substance prescribing. Consent Order Marcono Raymond Hines, MD Page 1 of 12
The Board subpoenaed several of Dr. Hines s patient records and reviewed his care. An expert pain management physician was retained by the Board to provide an opinion as to whether Dr. Hines s care of Patients A through D conformed to standards of acceptable and prevailing medical practice in North Carolina. The Board s reviewer opined that it did not. The Board adopts the external reviewer s opinion as its own. Dr. Hines manages chronic pain patients. Primarily, and almost exclusively, Dr. Hines manages these patients by means of high dose opioid therapy. In so doing, Dr. Hines departs from standards of acceptable and prevailing medical practice in significant ways. Patient A is a 46-year-old female who was treated by Dr. Hines for generalized pain, fibromyalgia, and scoliosis. Treatment begins in 2006 with opioids, a benzodiazepine, and physical therapy. Over time, opioids are increased to 675 milligrams of morphine equivalents ( MME ) per day. This increase is not accompanied by any documented improvement in pain scores or function. Dr. Hines documents the following in his chart: pain medication does not help her pain, medication no longer works, and methadone doesn t help control her pain. Dr. Hines has an opioid treatment agreement wherein his patients agree that should the patient test positive for illegal drugs or drugs not prescribed by Dr. Hines, the patient is subject Consent Order Marcono Raymond Hines, MD Page 2 of 12
to being discharged from the practice. Another provision in the agreement states that tolerance or failure to respond well to opioids may cause Dr. Hines to choose another form of treatment. Patient A tested positive to benzodiazepines not prescribed by Dr. Hines. There is no record of Dr. Hines checking the North Carolina Controlled Substance Registry ( NCCSR ) to determine if the benzodiazepines were prescribed or obtained illegally. There is no documentation in the record showing whether Dr. Hines counseled Patient A about the increased risk of respiratory depression when prescribed both an opioid and a benzodiazepine. Dr. Hines prescribed opioids to Patient A for a controversial pain diagnosis of fibromyalgia. The opioid dose was significantly increased with no reported or documented improvement in pain score or function. Urine drug screens repeatedly showed the presence of another controlled substance not prescribed by Dr. Hines. For these reasons, Dr. Hines s care of Patient A departed from standards of acceptable and prevailing medical practice. Patient B is a 65-year-old male treated by Dr. Hines for right upper extremity pain following trauma and surgery to the shoulder, elbow, and hand. By 2014, Patient B was being prescribed more than 500 mg of MME per day. Patient B is morbidly obese. Morbidly obese patients are more likely than normal weight patients to have obstructive sleep apnea and obesity hypoventilation syndrome. Patient B s obesity coupled with the high volume of opioids he Consent Order Marcono Raymond Hines, MD Page 3 of 12
took every day placed Patient B at high risk for opioid induced respiratory depression and death. It is not recorded or documented in the record that Dr. Hines took this risk into account or that he counseled Patient B on the increased risk. Dr. Hines failed to evaluate and reassess the efficacy of his prescribing to Patient B. From 2014 to 2015, there are at least 15 consecutive office notes where the documentation for each visit was identical. There were multiple drug screens that were positive for oxycodone, which was not prescribed to Patient B, and no documented positive results of hydromorphone, which was prescribed. There is no explanation for these inconsistent results. Drug screens which showed the presence of non-prescribed benzodiazepines were not addressed. Dr. Hines failed to conform to standards of acceptable and prevailing medical practice in his care of Patient B. Patient C is a 61-year-old male treated by Dr. Hines for low back pain and post-laminectomy pain syndrome. By November 2015, Patient C is being prescribed more than 780 MME per day. Patient C is obese and suffers from sleep apnea. It is not clearly documented in the patient chart whether Patient C was counseled about the high risk of respiratory depression and death he faced being on such high doses of opioids. Patient C s prior history of substance abuse does not appear to have been monitored adequately by Dr. Hines. Urine drug screens Consent Order Marcono Raymond Hines, MD Page 4 of 12
routinely failed to confirm the presence of certain prescribed medications. These results possibly suggest Dr. Hines s urine drug screens failed to include assays that would show the presence of all the medications he prescribed, thus making urine drug screens an inadequate monitoring tool. Patient D is a 55-year-old male treated by Dr. Hines for right foot and ankle pain following trauma and surgery to that ankle. By 2014, Dr. Hines is prescribing more than 550 MME per day. Dr. Hines also prescribed a benzodiazepine to Patient D. Patient D suffers from sleep apnea. There is no documented discussion in the chart of Dr. Hines counseling Patient D regarding the high risk of respiratory depression and death Patient D faced being on high doses of opioids and a benzodiazepine while suffering from sleep apnea. Dr. Hines failed to address aberrant urine drug screen results. Patient D routinely tested negative for the benzodiazepine he was prescribed, suggesting either the patient wasn t taking the medication or that Dr. Hines drug screen did not appropriately test for the medication. There is little checking of the NCCSR. Dr. Hines reportedly prescribed alprazolam to Patient D for anxiety, however, this diagnosis is not supported in the record. Furthermore, Dr. Hines did not attempt a trial of non-controlled Consent Order Marcono Raymond Hines, MD Page 5 of 12
medications to treat Patient D s reported anxiety, such as an SSRI (serotonin selective reuptake inhibitor). For months, Dr. Hines s clinic notes were identical regarding the subjective portion wherein Patient D reports his symptoms (ROS). Many times, the physical examination was also identical. The similarity in the record keeping from visit to visit suggests a lack of true follow up regarding Patient D s status, function, and compliance with treatment. For these reasons, Dr. Hines s care of Patient D departed from standards of acceptable and prevailing medical practice. With regard to each of Patients A, B, C and D, Dr. Hines agrees that their patient charts reflect issues with drug screen results that are not, but should have been, addressed in these charts. Dr. Hines's practice lab is CMS CLIA certified and employs a qualified lab technician and a qualified pathologist as the lab director. When problematic results are reflected, e.g., not consistent with prescribed medications as in the cases of these four patients, Select Laboratories, a clinical reference lab, is used to confirm the screen results. If the confirmatory tests validate that a problem exists, Dr. Hines states that it would be addressed with the patient consistent with the opioid treatment agreement. Dr. Hines states that this confirmatory action was Consent Order Marcono Raymond Hines, MD Page 6 of 12
taken but agrees that there was a failure to document this in these patient charts. CONCLUSIONS OF LAW Dr. Hines s treatment of Patients A through D, as described herein, constitutes unprofessional conduct including, but not limited to, departure from or the failure to conform to the standards of acceptable and prevailing medical practice, irrespective of whether or not a patient is injured thereby, within the meaning of N.C. Gen. Stat. 90-14(a)(6), which is grounds for the Board to annul, suspend, revoke, condition, or limit Dr. Hines s medical license to practice medicine and surgery issued by the Board or to deny any application he might make in the future. PROCEDURAL STIPULATIONS 1. Dr. Hines acknowledges and agrees that the Board has jurisdiction over him and over the subject matter in this case. 2. Dr. Hines knowingly waives his right to any hearing and to any judicial review or appeal of this case. 3. Dr. Hines acknowledges that he has read and understands this Consent Order and enters into it voluntarily. 4. The Board has determined it to be in the public interest to resolve this matter as set forth below. 5. Dr. Hines would like to resolve this matter without the need for more formal proceedings. Consent Order Marcono Raymond Hines, MD Page 7 of 12
ORDER NOW, THEREFORE, with Dr. Hines s consent, it is ORDERED that: 1. Dr. Hines is hereby REPRIMANDED. 2. Dr. Hines agrees not to prescribe any Schedule II and III controlled substances after sixty (60) days following the date of this Consent Order. Should Dr. Hines prescribe Schedule II and III controlled substances after sixty (60) days from the date of this Consent Order, Dr. Hines agrees the Board shall have grounds pursuant to N.C. Gen. Stat. 150B-3(c) to summarily suspend his license, and Dr. Hines further agrees to waive his right to a prompt hearing on the summary suspension. 3. Within thirty (30) days from the date of this Consent Order, Dr. Hines shall select a physician monitor(s) approved by the Board s Medical Director. The physician monitor(s) shall perform chart reviews for six months as follows: a review of 100 percent or Dr. Hines s charts for the first month, thereafter, ten randomly selected charts each month throughout the remaining five months. As necessary, the physician monitor(s) shall provide feedback and recommendations to Dr. Hines. Dr. Hines shall comply with all recommendations made by the physician monitor(s). Dr. Hines and the physician monitors(s) will have at least two face to face meetings, one within the first month and at least one other face to face meeting during the next five months. They will meet at other times as necessary to discuss patients of interest, CME Consent Order Marcono Raymond Hines, MD Page 8 of 12
requirements, and medical record documentation. The physician monitor(s) shall submit a report after the first thirty days and another report at the end of the six month mentoring period. The reports shall provide an opinion regarding whether Dr. Hines s overall care, his prescribing of controlled substances, and his medical record keeping are within the standard of care. 4. Within six (6) months of the date of this Consent Order, Dr. Hines shall complete ten (10) hours of Category I Continuing Medical Education ( CME ) in each of the following subject areas: medical record keeping and controlled substance prescribing. The CME courses must be pre-approved by the Board s Medical Director. Dr. Hines shall submit evidence of the completion of CME courses to the Board s Compliance Department within thirty (30) days of completing the courses. 5. Dr. Hines shall query the North Carolina Controlled Substance Reporting System ( NCCSRS ) for every prescription for Schedule IV and V controlled substances he issues. 6. Within thirty (30) days of the date of this Consent Order, Dr. Hines shall read the Board s Position Statement entitled Policy for the use of opiates for the treatment of pain. Dr. Hines shall submit a written attestation that he had read the Position Statement to the Board s Compliance Coordinator within thirty (30) days after doing so. Consent Order Marcono Raymond Hines, MD Page 9 of 12
7. After completing all of requirements contained in enumerated paragraphs #3-6, Dr. Hines may petition the Board to modify this Consent Order to allow Dr. Hines to prescribe Schedule II and III controlled substances. The Board is under no obligation to approve any such request. 8. Dr. Hines shall obey all laws. Likewise, Dr. Hines shall obey all rules and regulations involving the practice of medicine. 9. Dr. Hines shall meet with the Board or members of the Board for an investigative interview as such times as requested by the Board. 10. Should Dr. Hines fail to comply with any requirement contained in enumerated paragraphs #3 6 of this Consent Order, Dr. Hines agrees that such noncompliance shall constitute grounds for the Board to immediately suspend Dr. Hines s remaining controlled substance prescribing privileges. 11. If Dr. Hines fails to comply with any of the terms of this Consent Order, that failure shall constitute unprofessional conduct within the meaning of N.C. Gen. Stat. 90-14(a)(6) and shall be grounds, after any required notice and hearing, for the Board to annul, revoke, suspend or limit his license or to deny any application he might then have pending or might make in the future for a license. Consent Order Marcono Raymond Hines, MD Page 10 of 12
12. This Consent Order shall take effect immediately upon its execution by both Dr. Hines and the Board and it shall continue in effect until specifically ordered otherwise by the Board. 13. Dr. Hines hereby waives any requirement under any law or rule that this Consent Order be served on him. 14. Upon execution by Dr. Hines and the Board, this Consent shall become a public record within the meaning of Chapter 132 of the North Carolina General Statutes and shall be subject to public inspection and dissemination pursuant to the provisions thereof. Additionally, it will be reported to persons, entities, agencies and clearinghouses as required and permitted by law. By Order of the North Carolina Medical Board this the 3rd day of August, 2017. NORTH CAROLINA MEDICAL BOARD By: Eleanor E. Greene, MD President Consent Order Marcono Raymond Hines, MD Page 11 of 12