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A Maine nurse practitioner recently agreed to temporarily surrender her nurse practitioner license after a series of prescribing complaints filed against her resulted in a Board of Nursing (BON) investigation. Her case illustrates the sometimes unusual complexity of controlled substances prescribing.
Virginia Ann LaNoce, NP, has owned NP Family Medicine in New Portland since 2004, and her practice serves 2,500 patients within a 75-mile radius. She took ownership of the business (and renamed it) when the physician she had been working with retired.
LaNoce temporarily closed her doors in June after a circuitous series of legal and political events. They began when she was accused of writing an excessive amount of prescriptions for controlled substances. LaNoce, an NP for 9 years and a nurse for 33, was treating about 100 patients for chronic pain, and most of those had been patients of her physician predecessor, Christopher Smith, MD.
"I didn't get into this to do pain management - I just happened to have a family practice that I inherited pain patients from. I had patients who had pain that no one would treat," LaNoce said in an interview with ADVANCE. "I know this is every nurse's nightmare, and I am living it."
 Complaints Spur Investigation
LaNoce believes that healthcare providers in the New Portland area were uncomfortable with her practice because she was one of few NPs working alone in Maine. "I was a white elephant. The providers in the area didn't know what to do with that," she said in the interview.
Three providers lodged complaints during 2007 and 2008. One of them, psychiatrist Arthur Dingley, MD, submitted three complaints. She believes that turf issues might have been a motivating factor.
"I was working with a clinical psychologist at the time and she and I were treating children with bipolar disorder . this psychiatrist [Dingley] and psychologist didn't agree . were having a tug-of-war, and we were here on his turf [organizing a conference] without his input. His first complaint came in a month after we sent out the brochures for the conference, in 2007."
Dingley told ADVANCE that local providers have seen a "flood" of patients taking narcotics since LaNoce's practice closed, and he expressed displeasure with how the BON handled the case. "My initial complaint to them was made in April of 2007. Despite an obvious and dangerous situation, and despite subsequent complaints by me and others, the [BON] essentially floundered for more than 2 years. In that time, the problems with nurse LaNoce's inappropriate prescribing continued, and probably increased."
After the initial complaints, LaNoce asked a state-appointed consultant to audit her charts. The consultant, a physician assistant, provides free assessments of pain management treatment practices through the Maine Board of Licensure in Medicine. LaNoce said the PA told her she "was doing well."
"These patients have been on narcotics for 10 years or more, and back when they were put on narcotics, that was the way to treat pain," LaNoce explained. ". I was in the process of weaning them down."
Because of the complaints against LaNoce, the BON investigated. Eventually, representatives from the Drug Enforcement Agency (DEA) and the attorney general's office visited LaNoce's practice, which has an attached pharmacy.
Although the site inspection found everything was in order, the DEA made a few recommendations, which LaNoce subsequently followed. These included removing "Pharmacy on Site" signage, ceasing to dispense controlled substances at the on-site pharmacy, and disposing of expired medications using a reverse distributor.
At the BON's request, LaNoce attended an informal conference with board members. At this meeting, the BON recommended that LaNoce surrender her license pending additional education. LaNoce described the content of that discussion as attacks on her documentation and assessment skills rather than her prescribing practices. The BON had asked an NP to critique some of LaNoce's charts. "In her critique, she went so far as to criticize me for things like writing that someone's throat was reddened instead of erythematous," LaNoce told ADVANCE.
"One specific nurse [on the BON] was very adamant that my assessment skills and documentation were totally inadequate, that I was a threat to the community, and that I needed to be taken out of practice until I could get this education," LaNoce recalled. "[The BON] felt that a thorough pain assessment needed to be done with each prescription that was given out. Again, these patients had been on medications for up to 12 years and I had seen them for the past 9 years. I knew them; I knew what their problems were and what their symptoms were. Things were not going to change much. But if they [the board] feel that is what is supposed to be done, I will do it from now on."
After the BON recommended that she surrender her NP license, LaNoce asked to keep her RN license so that she could continue working. The board agreed.
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