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Sunday, Nov 18, 2018
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Florida heals from pill mill epidemic

— The “patients” used to pour into Florida from across the country.

Just four years ago, Florida was the unofficial pill mill capital of the country with 93 of the top 100 oxycodone-dispensing doctors in the United States.

Oxycodone, a powerful narcotic intended to treat intense, short-term pain, was being passed out like candy as part of a prescription cocktail that was popular with addicts. It was being abused in all corners of Florida, which had become a destination for pill users from states with tougher regulations.

In 2010 alone, manufacturers shipped more than 650 million oxycodone pills to Florida — more than 34 pills for every resident of the state.

In 2011, Florida had 856 pain clinics. Hillsborough County alone had 107.

And people were dying.

In 2010, oxycodone caused 1,516 overdose deaths in Florida — more than four a day, more than any other drug. The number of fatal oxycodone overdoses was increasing every year.

For a time, law enforcement didn’t know what to do. And lawmakers in Tallahassee were frozen, unable to act because of strenuous objections in some quarters, including the governor’s office, that increased government regulation of prescription drugs would cost money and invade patients’ privacy.

But things began to change.

In August of 2010, Purdue Pharma, the primary maker of oxycodone, reformulated the drug to make it tamper resistant and tougher to abuse. No longer could the pills be crushed and snorted or injected.

In early 2011, law enforcement began aggressively cracking down, using laws against street drugs to prosecute doctors. Pain clinics were investigated and raided. Drug-dealing doctors were put on trial and sent to prison. Among the actions was “Operation Pill Nation,” led by the Drug Enforcement Administration and targeting rogue pain clinics in Florida.

Then, with a push from Attorney General Pam Bondi, the state Legislature passed several measures directed at the problem, and Gov. Rick Scott signed the bills into law, although he insisted on some limits.

Under the new laws, doctors were no longer allowed to dispense the most abused pills; penalties were stiffened for doctors who over prescribed. Pharmacists had to log them in a statewide database controlled by the Department of Health.

Although there have been struggles to fund it, authorities cite the implementation of the prescription drug monitoring database as the most significant development in helping to get the pain pill epidemic under control.

The effects of the changes were immediate.

The number of oxycodone pills shipped to Florida dropped to under 527 million in 2011 and continued to drop each year. Last year, the number was 313 million, less than half the pills sent to the state just three years before, according to data from the DEA.

There are now 367 pain clinics statewide, less than half the number in 2011. In Hillsborough County, there are 61, according to the Florida Department of Law Enforcement.

And oxycodone — still lethal — is no longer the leading overdose killer in the state. In 2012, 735 people died of oxycodone deaths in Florida, less than half the number just two years before, according to numbers from the Florida Medical Examiners Commission.

The decrease in deaths is continuing. In the first six months of 2013, 279 deaths in the state were attributed to overdoses of oxycodone, now fourth on the list of overdose drugs behind benzodiazepines, alcohol and cocaine.

“The pill mill problem has gotten dramatically better in our state, dramatically better,” Bondi said. “Of course, we still have pain management clinics. We need good pain management clinics.”

Bruce Goldberger, chief of forensic medicine at the University of Florida, is part of a group that studied the drop in oxycodone deaths in Florida and has submitted its findings to a major medical journal in hopes of having the study published. Goldberger said the key finding was the actions taken by the drug manufacturer, law enforcement and state government in 2010 and 2011 reduced the number of deaths. “Those are lives saved,” he said.

“Unfortunately, we can’t just stop it completely,” Goldberger said. “I wish we could because we have too many people who die in the state of Florida as the result of misusing prescription drugs. The number of prescription drug overdoses in the state of Florida far exceeds the number of overdoses from ingestion of illicit drugs.”

Four years ago, Tampa Police Sgt. Rich Mills said, there were about 50 pain clinics in the city, about half of which he estimates were not legitimate. Now, he said there are about 23, the majority of which he says are legitimate. The department, he said, is investigating a handful.

“We’ve definitely made it much harder for them,” he said. A few years ago, “it was basically nothing more than an open air drug market.”

Then, he said, “It was very, very frustrating … We got kind of blindsided because all these northern states had seen the influx and increase in pain clinics and they were addressing it, but that wasn’t shared to the southern states … We were kind of caught off guard because they were now flocking to Florida because we didn’t have any of the laws in place yet.

“It was crazy,” Mills said. “It was absolutely crazy.”

“In the first part of the 21st century, Florida was ground zero for pill mills,” said Assistant U.S. Attorney Simon Gaugush, who prosecutes pill mill doctors. “It was the equivalent to the ‘cocaine cowboys’ era of the 1980s in Miami, only people were dealing with oxycodone and hydrocodone.”

Gaugush said pain clinics and mom-and-pop pharmacies were flooded with business.

“There were lines of drug-seeking customers, not patients, who would snake out the door like some hungry serpent seeking prey. Back then, we saw rogue doctors and crooked pharmacists basically turning people into zombies like the walking dead, and instead of feeding on people, they fed on oxycodone.”

Drug abusers came here from all over — from Kentucky, West Virginia, Ohio and Tennessee and elsewhere.

Word had spread on the streets that Florida was the place to get what they craved.

Their pockets were stuffed with cash, and they lined up at clinics along Dale Mabry Highway, Hillsborough Avenue and Dr. Martin Luther King Boulevard. They stood beside addicts and people working for dealers from across Florida.

The doses that were being prescribed, experts say, were unusually high, even for a cancer patient or someone in extreme, short-term pain. They were routinely being given for people who reported chronic — and little documented — issues with back or knee pain.

Gaugush said he talked to a drug addict who testified at one of his trials. That person had previously been addicted to a variety of drugs, including crack cocaine. Gaugush said the witness told him that withdrawal from crack was “a walk in the park” compared to withdrawal from oxycodone.

The clinics were cash-only businesses. At one clinic, first-time “patients” were charged $300 for an audience with a doctor who saw scores of people a day, giving them all the same potent prescriptions. The clinics had security guards, and at least one gave deli-style tickets to patients, who were sent away and called when their number was about to be served.

Some drug dealers rounded up homeless people and paid their clinic fees. They would take them from the clinic to pharmacies and then pay them for the pills.

Business was so brisk, pharmacies sometimes ran out of oxycodone.

One doctor told police she was paid $2,000 in cash, given to her in an envelope at the end of each day. She told investigators she didn’t normally perform medical exams before doling out prescriptions on pre-stamped pads at what she described as the “high volume” clinic. Although the operators of that clinic were prosecuted, the doctor died of a drug overdose before the case went to trial.

Investigators calculated that at that one clinic alone, between Jan. 1, 2010, and July 23, 2010, 1,906 patients from 23 states and across Florida made 4,715 visits, according to a police report. They estimated the patients paid the clinic more than $850,000 in fees during that period in which the patients were given prescriptions for more than 1 million oxycodone pills.

Another clinic had a “staging area” at another site, where clients were held and brought over in groups of five so as not to have too many people hanging around outside.

Pain clinic proprietors drove around in expensive cars and kept hundreds of thousands of dollars in cash in suitcases and plastic bags in their homes and vehicles.

Legitimate pain management doctors found it challenging to operate in such a corrupt environment.

One, Steve Barna, moved to Tampa from Boston three years ago and says he was shocked at the climate. “A few bad apples ruined it for a lot of people,” he said.

“Florida is a whole other world compared to the rest of the country,” Barna said. Pain management had such a stigma, Barna said, he changed what he called himself.

“I think the problem in Florida is you had all kind of doctors who may have had a medical degree, (but they) really had no specific training and were calling themselves pain management doctors … They really kind of hijacked what it means to be a truly credentialed and trained well-meaning doctor.”

So Barna, who is board certified and has fellowship training in pain management, described himself as specializing in interventional spine or interventional pain.

Barna said treating pain does not have to involve prescribing narcotics. Opiods, such as oxycodone, have not been proven effective for long-term, non-cancer pain management, he said.

Hillsborough Assistant State Attorney Darrell Dirks said the changes in state law and stepped-up law enforcement have made a difference in an area that is usually difficult to prosecute. Unscrupulous doctors, he said, often create documentation to make it look like their prescribing practices are legitimate. And they appeal to jurors, who don’t want to second-guess medical professionals.

Dirks said he thinks the law should be even stricter, requiring physicians who prescribe high doses of potent pain pills to be required to more stringently document why they’re needed.

He also said he’s concerned about a change in the law enacted in the last legislative session. Lawmakers, he said, were trying to address an issue relating to varying punishments based on the amount of a drug that is illegally distributed. The problem comes in the difference between oxycodone, which has concentrated amounts of narcotics in small doses, and hydrocodone, which has much smaller levels of controlled substances in larger pills.

Dirks said lawmakers increased the number of both oxycodone and hydrocodone pills that trigger mandatory minimum sentences, in other words, requiring convictions for higher amounts of drugs before higher sentences are imposed. “That, to me, is working in the wrong direction,” he said.

Bondi said she would be looking into how to address the issue in the next legislative session.

Although experts say the situation has vastly improved, no one is ready to say the prescription drug problem has been solved.

“I would not declare victory just yet,” Gaugush said. “In my opinion, the pill mill epidemic has not ended. Its just shifted into a different phase.”

Gaugush said illegitimate doctors are adapting and finding other ways to operate.

Experts also say that with less access to prescription drugs, some addicts are turning to heroin. Across the state, the rate of heroin overdose deaths is on the rise, although not to the extent that oxycodone deaths decreased.

In Hillsborough County, Chief Forensic Toxicologist Julia Pearson said in recent years, there have been three or fewer fatal heroin overdoses annually. “So far this year we’ve had eight, which is probably the most number of heroin overdoses we’ve had in at least five years,” she said.

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Twitter: @ElaineTBO

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