PART TWO OF TWO

Talking with Controversial Pain Specialist Dr. Boris Pilch

"There is no other place for [these patients] to go. If we don't treat them, no one else will…"

‘…It doesn't take too many people to start spreading the rumors and saying things…’

‘…We treat patients with legitimate pain problems, who won't be treated by other doctors in the community.’

–Dr. Boris Pilch

‘I wouldn’t be walking today. I would not have a life if it weren’t for [Pilch’s] knowledge.’

–Donna Linville,

cancer patient

BY DANIEL BLACKBURN

Editor’s note: Pain management is a relatively new medical specialty. It appeared on the SLO scene in 1992, when Dr. Boris Pilch set up the county's first pain management program at French Hospital. Within five years, Pilch's efforts were netting huge profits for himself and the hospital, as well as creating a deep chasm between the Russian-born anesthesiologist and many physicians, nurses, and administrators in the SLO medical community.

To some, Pilch is a pioneer whose bold, narcotics-centered treatments offer rare relief to people who have found no other solution to debilitating, never-ending pain.

Others willingly paint a vividly different, darker, picture of Pilch. In last week's first installment of "Pioneer, or Profiteer?" Pilch's detractors expressed to New Times their dismay and concern about Pilch's controversial methods, philosophies, and procedures.

This week, Pilch responds to that criticism.

After five years as director of French Hospital's Pain Management Center, Dr. Boris Pilch resigned his operating room privileges in May 1998.

Pilch's resignation ended French Hospital's internal inquiries into his practice, and effectively spiked any formal action that might have been taken against him.

Immediately upon his departure from French Hospital, Pilch opened the doors of his private clinic, Interventional Pain Management, only to discover that controversy not only dogged him, but intensified.

Angered by his treatment at the hands of numerous former medical associates at French Hospital during his tenure there, Pilch in November 1998 filed a $39 million federal lawsuit claiming Sherman Act and RICO violations, unfair competition, intentional interference with productive economic advantage, fraud, deceit, trade libel, libel, slander, and conspiracy.

Among the 25 defendants cited in the November 1998 court filing were French, Arroyo Grande Hospital, an array of administrators, managers, medical centers, and 13 physicians.

Included among medical personnel named in the lawsuit were Dr. James Skow, a prominent heart surgeon at French; Dr. Brendan McAdams, former surgery center director; Dr. Larry Baldwin, former head of the surgical quality review board while Pilch was at French; and physicians George Ward, Theresa Brechner, Peter Leeson, Brent Baharie, Robert Hetzel, Anthony Sheplay, Julie Nako-Smeltser, and Sundarampillai Jeyanandarajan.

Pilch alleged in his complaint that professional jealousy of his financial successes on the part of his critics caused them to spread falsehoods about him and his associates, Dr. Dale G. Kiker and Dr. Russ Levitan.

Pilch's court documents detailed his complaint that unfounded rumors were spread about him, to the effect that Pilch (1.) "overdosed a patient"; (2.) "supervises the care of junkies and druggies"; (3.) "intended to inappropriately implant morphine pumps"; (4.) "is committing Medicare fraud"; (5.) "is under investigation by the FBI"; and (6.) "is under investigation by the California Medical Board and is going to lose his license to practice medicine."

Pilch labeled the statements "libel and slander."

Last month, a federal judge dismissed the last of the defendants from the action. Pilch said he is considering refiling the complaint under state statutes.

Pilch's departure from French Hospital was painless for him. He accepted privileges from Sierra Vista Regional Medical Center without missing a beat.

But French Hospital endured an economic nightmare, because Pilch's program, while controversial, was immensely profitable.

Pilch had been earning, in his own words, "a substantial [personal] profit" from the beginning of his directorship at French. When the pain management program was terminated, it cost French an annual revenue source topping $2 million.

Pilch claimed in court documents that his practice had accounted for 30 percent of French's entire facility fee income.

Former French Hospital administrator Scott Gross concurred, telling a reporter last year that the only unit at French to turn a greater profit is the heart program.

"Stopping that [pain] program was a huge–and I mean huge, adverse financial impact on the hospital," Gross told reporter Silas Lyons of The Tribune in January 1999.

Gross was quoted as saying, "In this day and age, hospitals don't make that much money. For French Hospital to be willing to forego an economic benefit of that magnitude, it had to do it for good reason. And jealousy is not a good reason."

Additionally, French has paid attorneys' fees of at least $1.5 million to date to defend itself in the wave of litigation that followed Pilch's departure.

* * *

Boris Pilch, M.D., hesitated before acknowledging his controversial stature within the SLO medical community. Then he shrugged.

"We are on the Central Coast," he said. "We are separated from larger communities, and it doesn't take too many people to start spreading the rumors and saying things."

Pilch sat uncomfortably in his Bishop Street office, situated at the rear of his spacious but modestly appointed clinic, as he grudgingly endured a reporter's questions. Pilch had just been chided by an assistant for slipping out the back door to smoke a cigarette; he's on medical leave himself, having suffered a mild heart attack recently. "I'm trying to take it easy," he said.

Those "rumors," he said, are willingly repeated by many people, and "it doesn't take long for attitude to develop, one way or the other."

Pilch was referring to allegations made by physicians and nurses that he and associates at his SLO clinic, Interventional Pain Management, prescribe too many narcotic painkillers to too many people, primarily for profit.

During the interview, Pilch was flanked by his public relations representative, Steve Jaffe, of Beverly Hills, and an attorney Joel Douglas, of Los Angeles.

Pilch said he has support in the community despite–or perhaps because of–his cutting-edge position in the world of pain management

"In my estimation, there are about a third of the physicians [in SLO County] who for different reasons are just negative toward me," he said. "Then there is about a third who are very supportive of me. And then there is the middle third who swing the way the newspaper articles go."

Pilch and his associates at Interventional Pain Management believe they are providing a public service, no less.

"We treat patients with legitimate pain problems who are not being treated–won't be treated–by other doctors in the community," he said. "A third of our patients probably could be treated by community [primary care] doctors, if they were just willing to address the [patients'] pain. We are not predators looking to bring patients in."

Pilch noted that patients' pain is becoming an ever more important factor in their medical care and treatment, but suggested the "conservative" medical community is still moving slowly in its acceptance of narcotic-based pain treatment regimens.

"I'd like to work less," he said. "Unfortunately, no one else in this community will treat these patients and I cannot just tell them 'no, go away', because there is no other place for them to go but to us. If we don't treat them, no one else will."

Pilch is describing the central issue in a heated national debate about how best to treat chronic pain, and the use of powerful narcotics toward that end. It is an issue no less incendiary in SLO County, and Pilch and Co. are right at the core of local animus as rumors simmer about pending governmental investigations.

"This is what happens when a profession tries to police its own members," said one anesthesiologist, a longtime observer of Pilch.

Not all of Pilch's current legal issues are directly associated with his practice.

In early June, Heather Norby of Pismo Beach sued Pilch and one of his partners in Interventional Pain Management, Dr. Dale Kiker, alleging that the two physicians drugged, raped, and sodomized her.

Norby, a former girlfriend of Kiker’s, said she awoke the morning of Nov. 23, 1999, to discover that the men, while having sex with her, had videotaped the encounter. The physicians also "used a hodge-podge concoction of mouthwash and other common bathroom solvents as a spermicide" following the alleged assault, Norby charged in a civil complaint filed by SLO attorney James McKiernan.

According to the complaint, "Both doctors are well versed in the effects of, and the administration of hypnotic, stupefying and stultifying drugs and potions."

Norby also said Kiker "prescribed an emergency morning-after pill for Norby to take to prevent conception."

A bizarre occurrence following the alleged rape also was recounted in Norby's complaint.

To extract a measure of revenge, Norby said she arranged with a female friend to "set up" Pilch. According to the lawsuit, "…the friend tied up a naked Dr. Pilch to his kitchen cooking center island and left him there overnight to stew."

Norby contends an audiotape captured Pilch's subsequent threats to her safety and well-being, and that the San Luis Obispo County Sheriff's Department now has the tape.

Sheriff's Department spokesman declined comment on the matter, as did Pilch.

Also, Pilch and an investment group have been actively trying to buy hospitals, first County General and then French Hospital Medical Center itself.

But it is primarily Pilch's pain management practices and procedures that shape his reputation, for better or worse.

* * *

Alan Bond is a former cop. He was on the Santa Ana Police Department for eight years, and is a former SLO City council member. He also was with the SLO County Sheriff's Department for three weeks before he was shot and wounded by a murder suspect in Templeton. Now Bond is a SLO private investigator specializing in complex litigation.

One of the cases Bond is familiar with is that of Edward Stewart.

Stewart, 41, who died in February from an accidental overdose of narcotic painkillers, had been under the care of Pilch's Interventional Pain Management since injuring his back in an automobile accident last year. An autopsy showed he succumbed after accidentally mixing a fatal combination of pain-killing drugs.

During his interview with New Times, Pilch said Stewart no longer was a patient of Interventional Pain Management at the time of his death.

A toxicology report prepared subsequent to Stewart's autopsy revealed his system contained three times the fatal dosage of a drug commonly known as "Norco" in his system. Norco is hydrocodone, a morphine drug. Stewart's last prescription of Norco was ordered Sept. 20, 1999, by Pilch partner Dr. Dale Kiker, and filled at Los Osos Pharmacy.

During the last weeks of his life, Stewart began keeping an audio record of his battle with pain, and his growing discomfort with the drugs that had been prescribed for him. A tape recorder captured his dying words, a rambling commentary during which he questioned the heavy load of prescription drugs he was taking.

When sheriff's deputies searched Stewart's home following his death, they found 13 vials of different prescription drugs.

Bond also believes Pilch is responsible for the traffic fatalities of two SLO County women and a two-year old child in April.

Antoinette Butler, 26, of Atascadero, a patient of Pilch's, was observed driving erratically and passing vehicles unsafely northbound on Highway 41 near Kettleman City. She lost control of her 1995 pickup truck when the vehicle veered onto a gravel shoulder. Butler apparently overcorrected and slammed head-on into a vehicle driven by Donna Armstrong, 56, of San Luis Obispo.

Killed were Armstrong, Butler, and Katelin Butler. Marissa Butler, 7, was critically injured and is now recuperating with an aunt out of state.

Antoinette’s husband, Brian Butler, has retained San Luis Obispo attorney Jim McKiernan to represent him in a wrongful death suit against Pilch. According to McKiernan, his client told investigators that his wife had visited Pilch’s office earlier on the day she died.

Blood tests following her death revealed she had toxic levels of narcotics diazepam, nordiazepam, and carisoprodol, and intoxicating levels of meprobamate in her system.

Bond was retained by local attorney Jim Duenow, who represents several former Pilch patients and their families, "to investigate the Pilch matter thoroughly, and it has been one unique experience," said Bond.

"I've seen some strange cases–this is by far the strangest," he said. "I've never been involved in an investigation where so many people are calling me with information."

Bond said he was asked by his client "to cooperate with medical board, law enforcement and other official inquiries" regarding Pilch, "and I am doing that."

The investigator said he was "surprised" by the results of his own probe.

"When I was first hired," he said, "I had no idea what would be involved, and [the case] has expanded a lot further than I ever expected."

Bond said he is baffled by the state medical board's lack of action on the evidence it is now said to possess.

"One of the things I find really disturbing," said Bond, "is that these patients of [Pilch's] are allowed to leave the clinic all drugged up. They are not capable of driving, yet there they go."

Nurses at both French and Sierra View hospitals told New Times that "on many occasions" they have personally witnessed Pilch's patients departing the hospitals under the influence of pain-killing narcotics. Some nurses told of having called local police to report the intoxicated drivers.

Medical Board of California spokeswoman Candis Cohen declined comment on any official investigation by her agency.

* * *

Central to the issue of competent pain management under any medical program is the eventual result of such treatment.

Pain treatments can be local or invasive. A physician specializing in pain management may or may not utilize powerful narcotic drugs on a patient. Any results can be short-term or long-term–or nonexistent.

But always, said Pilch, there is the need for close and organized monitoring of patients and the narcotic dosages they are taking.

This is accomplished through the use of "triplicate" prescription slips that include the state of California in oversight routines. Fewer than 30 percent of California physicians are allowed to write narcotic prescription drugs.

According to Pilch, this helps prevent the abuse and improper diversion of narcotics.

Pilch said his office also maintains a wary eye on patients' use–and abuse–of drugs.

When patients first come to his office, said Pilch, they are required to fill out a 16-page questionnaire describing their pain and creating a complete patient history.

"We find out what works and what doesn't," Pilch said. "Not everybody needs a narcotic medication right away. Also, many [patients] already come [to his clinic] on narcotic medications."

He's willing to believe patients about their pain, said Pilch, adding, "That is something many doctors in this community are reluctant to do. If a patient comes in and says he's had two or three surgeries and he's in pain, I believe the patient. Okay?"

Before treatment begins, said Pilch, a patient signs an agreement specifying that he or she knows the risks of narcotic medication–short-term and long-term–and receives strict instructions on its use.

"We use nationally-recognized model guidelines for ourselves," said Pilch. "We tell [patients] the risks of drugs interacting with other medications, such as Tylenol, and how drugs interact with alcohol."

One person in his office is assigned exclusively to tracing medications, he said, "and a local computer group logs every refill. We work closely with pharmacies, and a patient can only go to one pharmacy, making sure that our prescriptions are not altered or lost. We keep a very accurate record. If a patient has not achieved pain relief with the medication prescribed then we ask them to come into the office and we adjust and try to work with them and find what level of medication they need."

The physician stoutly defended his use of controversial morphine pumps in non-cancer patients.

He also took issue with estimates that he and his associates have caused the pumps to be implanted in as many as 300 patients.

"I don't have the exact numbers," he said. "But if you asked me how many people from this area have received the pumps, I'd guess 100—120. We may have close to 200 patients [with pumps] but a lot of them moved into this area with the device."

Referring to local criticism of his use of the implant device, Pilch related discussions he had with other physicians at a recent international pain management conference in San Francisco.

"I asked, percentwise, what [other doctors] are doing [regarding morphine pump implantation]. We are pretty much consistent with what the rest of the country is doing. We have about 3,000 patients, so that's only five percent…but a big deal is made out of it."

Added Pilch, "A majority of insurance companies require preauthorization of a pump's placement."

The amount of medication needed with the pump, claimed Pilch, is "about 300—400 times less [than with oral administration] because it goes directly to the spinal fluids."

To illustrate the advantage of the pump, Pilch said "patients taking 1,000 or so milligrams of morphine a day whose pain is controlled [can get by] with 5—6 milligrams a day [injected directly] into the spinal fluid."

Part of the controversy surrounding his practice, said Pilch, is due to a lack of education on the part of other physicians.

"People do not understand the differences between addiction, drug dependency, and tolerance," he said. "That is something which requires additional education.

"For example, if you take narcotic medication in order to get high, a boost, some kind of pleasure–that's addiction. Less than one percent of the chronic pain patient population are addicts, according to national studies."

Then again, patients may develop a tolerance to drugs, requiring a heavier dosage.

"This is different from addiction," said Pilch. "Tolerance is something that develops in the receptors, in the nerve endings, [which] get used to certain medications. Compare that to a diabetic who needs insulin, maybe in a smaller amount, and [over] time requires more and more insulin. We don't call these people ‘insulin addicts.’ They have just developed tolerance."

As to the amount of drugs that may be prescribed, Pilch said, "There is no limit–no such numbers that you can quote. It's all [an] individual patient's response."

* * *

While differences between experts abound regarding the use of narcotics in the management of pain, there is one group of people who spare no adjectives in their praise for Pilch: satisfied patients.

Ed Bowie, director of nursing at Pilch's surgery center and coordinator of pump implantations, said the first patient in SLO County to receive a pump was operated on by Dr. Harold Segal in 1989. Today, Segal performs most of Interventional Pain Management's pump installation surgeries.

"Many of these people [clinic patients] are close to suicide when they arrive here," said Bowie. "Some tell stories of actually measuring the rope, they were in so much pain. When you have people desperately seeking relief, you have desperate behavior."

Bowie said that most people who find relief "want to stop the meds right away. Someone who is 'jonesing" and wanting some drugs isn't going to go through the crap they have to go through with us," he said. "Boris is doing it by the book."

Donna Linville, a cancer patient who lives in a SLO retirement home, said she was one of Pilch's first patients in 1992.

"He worked with me with [conservative measures] until five years ago, but my pain was getting unbearable."

Linville's doctors told her she should consider the morphine pump, "to get my life back," and she visited Pilch. She was 63 at the time.

"Dr. Pilch required examination by a variety of doctors before he would install the pump. I went to my own doctors, just to be sure, and they all agreed that I should get the operation," she said. "I did, and the improvement has been 100 percent.

Linville said she thought she knows why Pilch is controversial.

"Dr. Pilch has no bedside manner whatsoever. He's Russian, he's abrupt, he's impatient. However," she said, "I respect his knowledge beyond words. I have nothing but admiration for the man. But because of his personality, sometimes his office has been horribly hectic. Too many patients, mass confusion."

But, Linville emphasized, "I would not be walking today, I wouldn't have a life if it weren't for his knowledge. Most of the time when I was really down and needed him, he was there. He had a kind side at the beginning. I feel he grew too fast, he was mixed up in too many things.

"And with his personality, he really couldn't handle it." Æ

Dan Blackburn lives in Paso Robles and is a weekly contributor to New Times. He has been a newspaper editor and crime reporter for over 25 years, and is the author of "Human Harvest," published by Knightsbridge Press.

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