Gene Estes implored his son, Shayn, to go to the emergency room that day, fearful he was having another reaction to his psychiatric medication. Shayn was forgetful, dropping things throughout the day, combative and disoriented during simple conversations.

“I wanted him to see any doctor available,” Estes said.

Gene was worried the dosage was off again. But Shayn, 33, brushed off his father’s concerns as an overreaction. He jumped out of the car after the two argued at the post office and took off walking the six blocks to his Crested Butte apartment
That was the last time the father would see his son alive. He found Shayn the next morning, on Oct. 17, 2020, dead in his bed, lying on the top of the sheets, still clothed.

Nearly six months after Shayn’s death, a psychiatrist at Mind Springs Health, the community mental health center that runs West Springs Hospital, the Grand Junction psychiatric hospital where Shayn sought psychiatric care, filed a complaint with a state oversight contractor alleging potentially fatal prescribing of benzodiazepines at West Springs and potential harm to patients like Shayn.

An investigation into those claims by the state contractor, Rocky Mountain Health Plans, would eventually force the resignation of Dr. Thomas Newton, another psychiatrist at West Springs. Newton resigned in May 2021 after an investigation found he engaged in “aberrant prescribing” of benzodiazepines – the same drug he had prescribed Shayn Estes. It’s a drug the father now suspects caused his son to fatally overdose while sleeping, though he has no definitive answer.

“If Hippocrates could be found, he’s probably rolling around in his grave,” he said, referring to the ancient Greek physician credited with the Hippocratic Oath, which is still voiced today: “First, do no harm.”
‘A broken system’

The heavy reliance on benzodiazepines at Mind Springs has been alarmingly common in Colorado, with state reports identifying thousands of patients as at potential lethal risk because of unsafe prescribing practices, an investigation by The Gazette has found. Known as “benzos,” the anti-anxiety drugs include trade names like Klonopin, Valium, Xanax, Ativan and others, and they are soaring in popularity.

Even as state officials are seeking to rein in the use of benzodiazepines, prescriptions for the drugs nearly doubled over the past two years during a time when the COVID-19 pandemic battered psyches, said Dr. Robert Valuck, executive director of the Colorado Consortium for Prescription Drug Abuse Prevention, housed at the University of Colorado Anschutz Medical Campus.