Authorities found Kelly Bell lying face down in bed, wearing a red robe, a towel wrapped around her strawberry blond hair.
On the bed next to her they found a nearly-empty pill bottle containing carisoprodol, a potent muscle relaxer also known as Soma. Elsewhere in Bell’s Okmulgee home they found partially-full bottles of morphine, oxycodone and clonazepam, all powerful narcotic drugs.
All of the prescriptions had been written by Dr. Joshua Livingston, proprietor of the South Pointe Pain Management Clinic and Transformation Weight Loss Clinic in Tulsa. The Medical Examiner’s office attributed her death to an overdose.
The Okmulgee County Sheriff’s Office recorded Livingston’s name, but noted that it hadn’t tried to contact the doctor to let him know his patient had died.
Bell, 50, who suffered from chronic joint pain, anxiety and panic, died on Oct. 9, 2011. Four months went by before the Office of the Chief Medical Examiner in Oklahoma City finished its report on Bell’s death and forwarded it to the Bureau of Narcotics and Dangerous Drugs.
By that time, another one of Livingston’s patients had succumbed to an apparent overdose. A 32-year-old chronic pain sufferer in Pawhuska died en route to the hospital on Jan. 13, 2012. His blood tested positive for oxycodone and alprazolam, both of which had been prescribed to him by Livingston. The medical examiner’s report on his death was not completed for another four months.
By then, a third patient had died. Mary Doak, 61, was found dead on the living room couch in her Tulsa home on May 5, 2012. On her last office visit, Livingston had written her prescriptions for morphine, oxycodone, alprazolam and carisoprodol. Her blood tested positive for morphine and alprazolam. It also tested positive for tramadol, another narcotic she apparently obtained from a different source. Her death was ruled an overdose by the medical examiner.
It only took the medical examiner’s office two months to finish Doak’s report. Yet by then, a fourth Livingston patient had died.
Regina Ogunlana, 64, was found on the floor of her Tulsa bedroom on May 30, 2012. A chronic pain sufferer, Ogunlana died from an overdose of oxycodone that Livingston had prescribed along with two other narcotics, alprazolam and zolpidem. Her death, like the others, was recorded as an accidental overdose by the medical examiner.
Two of Ogulana’s siblings said they had no idea their sister had died from an overdose until they were called by a reporter last week. They had thought her death was caused by congestive heart failure.
“Wow. That is something,” said Donald Turner, her brother.
Learning the cause of death “won’t change anything for her,” he said. “But it’s good to know. If you write something, maybe it will help somebody later … I appreciate it, and I appreciate you calling. We would have never known.”
It was another three months before the Oklahoma Board of Osteopathic Examiners began investigating Livingston after another patient’s relative complained that Livingston was prescribing too many drugs.
Nobody had told the board about the four patient deaths.
According to newly-released data, Livingston was the state’s No.2 prescriber of oxycodone to Medicaid patients in 2012. He ranked eighth among alprazolam prescribers and 15th among hydrocodone prescribers. The figures were provided by the Oklahoma Health Care Authority last week in response to a data request by The Oklahoman and Oklahoma Watch.
At one point, Livingston’s website ran a new patient promotional offer:
“Tell your friends about the Tulsa Pain Management doctor you already love, Dr. Joshua Livingston, and start earning today. Refer 1-5 new patients and get a $10 gift card for each one. Refer 6-9 new patients and get movie-passes-for-two per patient. Refer 10 or more? You’ll get a Kindle…Easy money for talking to people who come in for a first visit!”
When the osteopathic board ran its check on Livingston’s prescribing practices in 2012, it determined that he was dispensing narcotics at a rate of 24,588 prescriptions – or 2.3 million doses – per year.
He was seeing 60 to 100 patients each workday. His clinics wrote or authorized an average of 186 prescriptions per day. About a third of the prescriptions were for powerful Schedule II narcotics such as morphine and oxycodone.
Patients were filling his prescriptions at 201 pharmacies in 40 cities, including Tulsa, Oklahoma City, Moore, Norman, Lawton, Perry and as far away as Elk City.
Livingston’s clinics had no dispensing logs, the osteopathic board discovered. The patient files for the four overdose victims contained no psychological assessments, no prior medical records, no hospital records, no imaging results, no alternative treatment plans and no mention of the risks of CDS (controlled dangerous substance) use, drug abuse, alcohol consumption or suicide.
The board reviewed a total of 30 patient medical records and 11 patient charts. None complied with its rules on prescribing narcotics to treat intractable pain.
Livingston acknowledged to investigators that he did not require his patients to provide prior medical records. He said he checked his patients’ 12-month prescribing history on the state’s online Prescription Monitoring Program and asked them to submit to a urine test before prescribing narcotics.
It is not known whether Livingston ever declined to write prescriptions to patients with a history of doctor shopping. Bell’s PMP records showed that she had been obtaining narcotic prescriptions from three doctors at the same time.
On Mar. 21, 2013, the board placed Livingston on probation for five years and suspended his authority to write narcotic prescriptions during that time. It ordered him to take a course in proper prescribing of controlled substances.
By that time, 17 months had passed since Bell’s death.
Livingston has moved to a different clinic, Restorative Pain To Wellness Center in Broken Arrow. He practices primary care medicine and does not write prescriptions for narcotic drugs. His partner, Dr. Jim Meehan, writes prescriptions to patients who need them.
The clinic’s website contains no mention of the disciplinary case against Livingston.
Contacted by a reporter last week, Livingston declined to comment on the deaths of his four patients. But he noted that an autopsy was performed in only one of the four cases, and disputed whether cause of death can be adequately determined in any death without an autopsy, even if a toxicology report detects narcotics in the dead person’s blood.
“You can’t just do toxicology and assume that’s the cause of death,” Livingston said. “That’s the only real comment I’d have, not specific about those cases, but about all cases. That’s an inadequate determination of the cause of death… I know it’s expensive to do an autopsy, and I know they’re backlogged and all of those other things, but it’s just not fair to the families.”
Livingston also declined to comment on the osteopathic board’s criticism of his prescribing and record-keeping practices.
“The board made their determination. My determination is kind of irrelevant,” he said.
“I obviously would not feel like I was doing anything out of the scope of standard practice. However, the board decided I was.”
Warren Vieth can be reached at firstname.lastname@example.org