From the License Lookup for Dr. John Bulette, Nassawadox, VA
License Number 0101051010
Occupation Medicine & Surgery
Name JOHN L BULETTE
Address Nassawadox, VA 23413
Initial License Date 07/01/1994
Expire Date 11/30/2020
License Status Probation - Current Active
From Public Disciplinary Proceedings (Excerpt)
BEFORE THE VIRGINIA BOARD OF MEDICINE
IN RE: JOHN LAWRENCE BULETTE, M.D.
License Number: 0101-051010
Case Numbers: 175338,179170
JURISDICTION AND PROCEDURAL HISTORY
Pursuant to Virginia Code §§ 2.2-4019 and 54.1-2400(10), a Special Conference Committee (“Committee”) of the Virginia Board of Medicine (“Board”) held an informal conference on January 30, 2019, in Henrico County, Virginia, to inquire into evidence that John Lawrence Bulette, M.D., may have violated certain laws and regulations governing the practice of medicine and surgery in the Commonwealth of Virginia.
John Lawrence Bulette, M.D., appeared at this proceeding and was represented by Douglas E. Penner, Esquire, and Bonnie P. Lane, Esquire.
Upon consideration of the evidence, the Board adopts the following Findings of Fact and Conclusions of Law and issues the Order contained herein.
FINDINGS OF FACT AND CONCLUSIONS OF LAW
- John Lawrence Bulette, M.D., was issued License Number 0101-051010 to practice medicine and surgery on July 1, 1994, which is scheduled to expire on November 30,2020. At all times relevant to the findings contained herein, said license was current and active.
- Dr. Bulette’s prior Board history includes the following:
a By Order entered April 1, 2008, the Board required Dr. Bulette to complete continuing medical education in the subject of treatment of psychotic disorders. This action was based on findings that Dr. Bulette prescribed Adderall (C-II) to a patient who had a long history of psychotic disorder, substance abuse, and incarcerations although agitated states and drug abuse were listed as contraindications for use of Adderall and that Dr. Bulette continued to prescribe Adderall despite the patient demonstrating psychotic symptomology and relational problems and aggression which required multiple hospitalizations and incarcerations.
b. By Order entered June 8,2009, the Board prohibited Dr. Bulette from prescribing methadone (C-II) to patients until and unless he is qualified and registered to dispense narcotic drugs for maintenance or detoxification treatment in compliance with federal law. This action was based on findings that Dr. Bulette prescribed methadone to ten (10) patients for maintenance or detoxification treatment for periods of up to a year each, though he was not qualified or registered to dispense narcotic drugs for such treatment, as required by federal law and regulation.
- Dr. Bulette violated Virginia Code § 54.1-2915(A)(3) and (13) in his care and treatment of Patient A, a 24-year-old female whom he treated for opiate addiction with Subutex (C-III) from September 2014 through July 2016. During the treatment period, Dr. Bulette failed to properly monitor Patient A to ensure compliance with his treatment regimen. Specifically, Dr. Bulette failed to order any urine drug screens that included buprenorphine (C-III), failed to conduct any pill counts, and except on February 4, 2015, failed to query the Prescription Monitoring Program (“PMP”).
- Dr. Bulette stated to the Committee that Patient A reported a history of opiate addiction and not being successful in getting intervention and that Patient A appeared serious about recovery.
- Dr. Bulette violated Virginia Code § 54.1-2915(A)(3) and (13) in his care and treatment of Patient B, a 36-year-old male whom he treated for opiate addiction with Subutex from April 2015 through March 2017. During the treatment period, Dr. Bulette failed to properly monitor Patient B to ensure compliance with his treatment regimen. Specifically, Dr. Bulette failed to order any urine drug screens, failed to conduct any pill counts, and except on July 7, 2015, failed to query the PMP.
- Dr. Bulette violated Virginia Code § 54.1-2915(A)(3) and (13) in his care and treatment of Patient C, a 44-year-old male whom he diagnosed with post-traumatic stress disorder and treated for chronic opiate dependence with Subutex from August 2010 through March 2017. Specifically:
a. Although Patient C reported that he was treated with narcotics for several years for a back problem and that his use of opiates increased due to a hand injury. Dr. Bulette failed to obtain any prior treatment records or perform a physical examination of Patient C at any time in order to justify his prescribing of Soma (C-IV) from September 2010 through March 2017.
b. During the treatment period of August 2010 to March 2017, Dr. Bulette failed to properly monitor Patient C to ensure compliance with his treatment regimen. Specifically, Dr. Bulette failed to order any urine drug screens, failed to conduct any pill counts, and except on February 15,2017, failed to query the PMP.
c. By failing to properly monitor Patient C, Dr. Bulette ignored available information indicating Patient C’s drug-seeking behavior. For example:
i. Patient C’s PMP report reflects that he was issued four prescriptions from four different providers for the following controlled substances: #60 carisoprodol (C-IV) on August 7, 2014; #12 hydrocodone-acetaminophen (C-II) on September 30, 2014; #30 oxycodone-acetaminophen (C-II) on October 28,2014; and #60 hydrocodone-chlorphen ER susp (C-II) on November 11,2016.
ii. According to a progress note entered on February 16, 2016, Patient C contacted Dr. Bulette’s office stating that he wanted to cancel his February 24,2016 appointment for an earlier appointment. On February 17,2016, Patient C contacted Dr. Bulette’s office again stating that he did not have enough of his prescribed medication to last until his February 24,2016 appointment because he was taking extra medication for pain after having sinus surgery. On February 17, 2016, Dr. Bulette
authorized an additional prescription of #25 Subutex without assessing Patient C or confirming the procedure.
iii. As indicated in the chart below, Patient C contacted Dr. Bulette’s office three other times in 2016 to reschedule appointments with Dr. Bulette for earlier dates. In each instance, Patient C’s appointment was rescheduled for an earlier date resulting in the prescription of Subutex and Soma before the time Patient C would have received a renewal if he had taken his medication as prescribed:
Date of call Original appointment Rescheduled
January 25,2016 February 2,2016 January 27,2016 #25 Subutex #60 Soma
April 6,2016 April 13,2016 April 6,2016 #23 Subutex #60 Soma
July 26, 2016 August 2,2016 July 26,2016 #19 Subutex #60 Soma
- Dr. Bulette violated Virginia Code § 54.1-2915(A)(3) and (13) in his care and treatment
of Patient D, a 3 3-year-old female whom he treated for chronic opiate dependence with Subutex from approximately September 2014 through December 2014 and October 2015 through December 2015. During these treatment periods, Dr. Bulette failed to properly monitor Patient D to ensure compliance with his treatment regimen. Specifically:
a. Dr. Bulette failed to order any urine drug screens, failed to conduct any pill counts, and failed to query the PMP.
b. By failing to properly monitor Patient D, Dr. Bulette ignored available information indicating Patient D’s drug-seeking behavior. For example. Patient D’s PMP report reflects that Patient D was issued five prescriptions from three different providers for the following controlled substances: #30 hydrocodone-acetaminophen on September 23,2014, October 24,2014, November 11, 2014, and December 8,2014 and #16 tramadol (C-IV) on November 7,2014.
- Dr. Bulette informed the Committee that he discharged Patient D from his practice in December 2015.
- Dr. Bulette violated Virginia Code § 54.1-2915(A)(3) and (13) in the care and treatment of Patient E, a 40-year-old female whom he treated for substance abuse with Subutex from approximately September 2013 through May 2015 and February 2016 through March 2017. During these treatment periods, Dr. Bulette failed to properly monitor Patient E to ensure compliance with his treatment regimen. Specifically:
a. Dr. Bulette failed to order any urine drug screens, failed to conduct any pill counts, and except on June 7,2016 and July 27,2016, failed to query the PMP.
b. By failing to properly monitor Patient E, Dr. Bulette ignored available information indicating Patient E’s drug-seeking behavior. Patient E’s PMP report reflects that during the treatment periods, Patient E was issued five prescriptions from four different providers for the following controlled substances: #90 oxycodone HCL (C-II) on August 4,2014; #12 oxycodone-acetaminophen on March 1, 2016; #60 oxycodone-acetaminophen on March 2, 2016 and March 9, 2016; and #30 hydrocodone- acetaminophen on February 7,2017.
- Dr. Bulette violated § 54.1-2915(A)(12) and (18) and 18 VAC 85-20-26(C) of the Regulations Governing the Practice of Medicine, Osteopathic Medicine, Podiatry, and Chiropractic in that most of his handwritten progress notes concerning Patients A-E are not legible.
- Dr. Bulette stated to the Committee that he provides patients with an overview of his treatment program, i.e., buprenorphine is used to stabilize patients, and with structured psychotherapy, he instructs patients on how to become less self-destructive. However, the Committee noted that Dr. Bulette’s actual practice contradicted his own practice protocols, particularly regarding the use of urine drug screens and the PMP.
- Dr. Bulette stated to the Committee that based on prior history of use with urine drug screens, he had been leery of their effectiveness due to problems with testing labs but he now understands the importance of such screens.
- Dr. Bulette stated to the Committee that the PMP was somewhat new at the time of these cases and did not connect with Maryland. He stated that several of his patients on the Eastern Shore might have filled prescriptions in Maryland and those prescriptions would not have been reflected in the PMP. He explained that he did not fully trust the information collected in 2014-2016 by the PMP due to its relative newness and lack of information from border states. However, the Committee noted that the Virginia PMP has been live statewide since June 2006 and that the Virginia PMP obtained connectivity with Maryland in May 2017. Dr. Bulette stated that he now understands that the PMP connects with Maryland and is a useful tool. He also stated that he is currently using the PMP regularly and working on a process to better implement urine drug screening, possibly through an in-house system but explained that there is not a lab near him and that the hospital that used to handle screens that he ordered has moved.
- The Committee heard from Martin Buxton, M.D., Dr. Bulette’s expert on medication- assisted treatment (“MAT”). Dr. Buxton described the Harm Avoidance Model and explained that physicians now must balance evidence of patient noncompliance or aberrant behavior against the potential harm of overdose or death that could result from dismissal from MAT. He stated that many doctors in MAT refer patients for counseling but are not able to ensure the quality or regularity of that counseling. He stated that Dr. Bulette, a board-certified psychiatrist, provided therapy to his patients and that Dr. Bulette knewr his patients very well. When asked by the Committee about the higher dosages Dr. Bulette prescribed for some of the patients in this case, Dr. Buxton stated that the common practice is to start a patient on 8mg of buprenorphine and that an average maintenance dose is 16mg. Dr. Buxton opined that a 56mg dose, as was the case with Patient A, is highly unusual. Also, consistent with Dr.
Bulette’s statement to the Committee that Dr. Bulette would usually schedule an appointment to see a patient within a week of authorizing a prescription refill based on the patient’s request by telephone, Dr. Buxton explained that Dr. Bulette had follow-up visits scheduled in response to telephone-call requests for prescription renewals.
- Dr. Bulette stated to the Committee that he is dealing with a very high-risk population, an evolving approach to medicine in this area, and thoughts on “harm avoidance.” Dr. Bulette acknowledged that there is room for improvement, that his practice was deficient in some regards, and that he is limited in his environment regarding urine drug screens, but that he is working on solutions. Dr. Bulette stated to the Committee that the goal for his patients is to be drug free, not on maintenance medication for life.
See Confidential Attachment for the names of the patients referenced above.
Based on the foregoing Findings of Fact and Conclusions of Law, the Virginia Board of Medicine hereby ORDERS as follows:
- John Lawrence Bulette, M.D. is REPRIMANDED.
- Dr. Bulette’s license is placed on INDEFINITE PROBATION, subject to the following terms and conditions:
a. Within three (3) months of entry of this Order, Dr. Bulette shall provide written proof satisfactory to the Board of successful completion of fifteen (15) hours of continuing medical education (“CME”) credits on the subject of proper prescribing for addiction. Such CME credits shall be approved in advance of registration by the Executive Director of the Board and shall be completed through face-to-face, interactive sessions (i.e., no home study, journal, or Internet courses). Any CME credits obtained through compliance with this term shall not be used toward compliance with the Board’s continuing education requirements for license renewal.
b. Within twelve (12) months of entry of this Order, Dr. Bulette’s practice shall be subject to an unannounced audit during normal business hours by an investigator of the Department of Health Professions. During such audit, Dr. Bulette shall provide complete patient records randomly selected by the investigator. Dr. Bulette shall be responsible for the payment of an audit fee of $500.00 to be paid to the Board within thirty (30) days of the audit. Any fee not paid in a timely manner will be sent for collection. If the audit reveals a possible violation of the laws or regulations pertaining to the practice of medicine and surgery in Virginia, including but not limited to PMP and urine drug screens, the Board may notice Dr. Bulette to appear for an administrative proceeding.
c. Within thirty (30) days of entry of this Order, Dr. Bulette shall certify in writing to the Executive Director that he has read and will comply with the Board’s laws and regulations on prescribing, including 18 VAC 85-21-10 et seq. of the Regulations Governing Prescribing of Opioids and Buprenorphine.
- Upon receipt of evidence that Dr. Bulette has complied with the foregoing terms and conditions of this Order, the Executive Director is authorized to terminate Dr. Bulette’s probation and close this matter or refer it to a special conference committee for review.
- Any violation of the foregoing terms and conditions of this Order or any statute or regulation governing the practice of medicine and surgery shall constitute grounds for further disciplinary action.
Pursuant to Virginia Code §§ 2.2-4023 and 54.1-2400.2, the signed original of this Order shall remain in the custody of the Department of Health Professions as a public record, and shall be made available for public inspection and copying upon request.