Just a few years ago, South Florida was the nation’s pill mill capital.
Floridians and visitors from Ohio, Kentucky and other states came by plane, bus and car. During a six-month period ending in March 2009, 49 of the nation’s top 50 physicians dispensing the addictive painkiller oxycodone worked in Florida, said a grand jury report in Broward County, Fla., where many pill mills were clustered. In less than two years, the number of pain clinics in South Florida had skyrocketed from four to 176.
Customers would line up outside of virtually unregulated clinics that did little more than sell narcotics and other prescription drugs for cash. Houston and Beaumont were experiencing the same problem, after a Louisiana crackdown on pill mills shifted the pill mills west.
As Texas and other states sought solutions to the prescription drug epidemic sweeping the country, Florida officials wondered how they could overcome what seemed like an insurmountable problem.
It was the largest state without a prescription drug monitoring program used to detect “doctor shoppers,” the Broward County grand jury said, despite numerous legislative attempts. Overdose deaths peaked at 2,710 Floridians in 2010, said Broward County Assistant State Attorney Tim Donnelly, who oversees organized crime, gang activity, special prosecutions and public corruption.
Things have changed. Florida passed new laws, put a prescription database in place after much controversy and no longer allows most doctors to dispense — or sell — drugs. Experts said its multipronged approach is making a difference, including the formation of strike forces and other efforts that resulted in more criminal prosecutions of unscrupulous doctors, doctor shoppers and drug dealers.
In Texas, where prescription drug overdose deaths peaked at 577 in 2006, the Legislature acted earlier than many other states, putting more regulations on pain clinics in 2010, including restrictions on who can own and work in them. Authorities busted pill mills in Houston, but overdose fatalities are still 2½ times what they were in 2000, and prescription drug abuse remains a big problem, lawmakers said. They are especially concerned about addicted babies of drug-abusing mothers covered by the state’s Medicaid program.
Neither Texas nor Florida requires doctors to check a statewide database of drugs dispensed to patients before writing prescriptions — a step that national experts say would make a big dent in the problem. Two physician leaders in Texas said such a requirement would be too burdensome.
While increased criminal prosecution of doctors has played a role in Florida’s anti-pill mill efforts, an American-Statesman investigation in December found that Texas, like many other states, focuses more on placing administrative restrictions on doctors, taking licenses from some while allowing many to stay in practice.
The investigation found that fewer than a third of the doctors the Texas Medical Board punished for prescribing violations involving two or more patients faced criminal charges. In most cases, the board acted after the doctor had already been arrested.
Texas legislative leaders charged two committees with assessing the prescription drug abuse epidemic and recommending next steps to the Legislature, which convenes this month.
One of the panels, the Senate Health and Human Services Committee, said in its report that, while Texas ranks 44th nationally in the number of prescription opioid overdose deaths per year, the state ranks 12th in the rate of nonmedical use of narcotic painkillers, called prescription opioids. Neither committee is proposing harsher penalties against doctors who violate prescribing laws.
More Florida prosecutions
Florida Attorney General Pam Bondi, who took office four years ago, championed laws that helped put most of the state’s pill mills out of business.
“We worked tirelessly with the Legislature to pass a comprehensive pill mill bill, toughened criminal penalties and established standards of care for doctors that prescribe narcotics,” Bondi told the Statesman. The medical board, which polices doctors, “was a great partner and they started issuing emergency suspensions (of medical licenses) left and right. We started holding these doctors to a higher standard.”
Florida no longer has any oxycodone-prescribing physicians in the nation’s top 50, Bondi said. The prescription drug overdose death rate dropped 23 percent between 2010 and 2012 and fell 52 percent for oxycodone, according to the Centers for Disease Control and Prevention.
Before Bondi took office in 2011, just four doctors in four years faced criminal prosecution for illegally prescribing drugs, she said. Since then, her office has prosecuted 23 doctors, not counting any who local authorities pursued, she said.
Texas officials said they don’t compile such data.
Bondi said she was inspired to take up the cause on the campaign trail when she learned how many Floridians were dying of overdoses. “Parents would give me beautiful high school graduation photos … of their children who are now dead,” she said. “I carried those with me. … I could not fathom we did not have laws to stop this.”
Florida’s strategy “required getting the medical community, law enforcement and prosecutors, all working together,” Donnelly said. “Legitimate pain specialists were outraged over these doctors.”
National experts cite Florida as being among the states making strides, although officials said funding those efforts without state aid is an ongoing problem.
Experts also give high marks to New York, Kentucky and Tennessee, which require doctors to check an online database of patients’ prescriptions before prescribing a controlled substance. Nineteen other states require prescribers to check the database at least sometimes, depending on the circumstances, according to Heather Gray, legislative director of the National Alliance for Model State Drug Laws.
Only Missouri doesn’t operate such a database.
Bondi called a mandatory system in Florida doubtful.
Texas mulls next steps
Texas’ two legislative committees are recommending that prescribers be encouraged, but not required, to check the state’s database before prescribing controlled substances. Legal drugs are ranked from Schedule II to V based on their addictive potential, with Schedule II being the most addictive. Schedule I drugs are considered the most dangerous and have no accepted medical use; they include heroin.
In October, the U.S. Drug Enforcement Administration enhanced restrictions on prescribing hydrocodone combination products from Schedule III to Schedule II — a change that experts expect to make doctors more cautious prescribers.
“I think that will have an enormous impact,” said Dr. Andrew Kolodny, director of Physicians for Responsible Opioid Prescribing and chief medical officer of Phoenix House, which offers addiction treatment services in various states and in Austin.
Shutting down pill mills and arresting the small percentage of law-breaking doctors who have played a big role in fueling the crisis will save lives, he said. But “even if you close down every pill mill in the country, it doesn’t end this epidemic. It’s the well-meaning doctors and dentists who inadvertently create new addicts.”
States need to expand treatment services for drug addicts, he and other experts said.
New York’s prescription drug database has treatment information on the site to make it easier for doctors to refer patients, Gray said.
“As patients we assume our doctors know everything, and if we need referral to an addiction specialist they’ll know what to do,” she said. “Having that link on the page is awesome.”
A draft recommendation on tackling the problem in Texas by the House Public Health Committee proposes that treatment programs and outreach be expanded. Both the House and Senate committees also want the state to move the prescription database from the Department of Public Safety to the State Board of Pharmacy — to improve monitoring — and for such information to be shared interactively across state lines.
Gray and Kolodny said Florida could make more progress if it required doctors to check the state database and share information with other states. Some physician leaders in Texas, including Texas Medical Association President Austin King of Abilene, said putting more demands on doctors’ time is not the answer.
Leaving it to the doctor’s discretion doesn’t work, either, Kolodny said. “For the most part, primary care doctors are not using it,” he said. “They think they can tell by looking at a patient whether they are drug dealer or not.”
Medical boards should step in by actively mining data to identify risky prescribing practices and “doctor shopping” patients, Kolodny said.
“Across the board, medical boards are failing to do their jobs well,” he said. “If the doctor is a drug dealer, it’s a law enforcement issue. If a doctor is prescribing very aggressively, the state should be able to figure that out and say, ‘Cut it out, or we will take your license.’ Often the fear of losing one’s license will get the doctor out of the narcotic business.”
Educating physicians on proper prescribing and identifying drug-seeking behavior is important, Gray said. So is equipping paramedics with naloxone, a medication that reverses an opioid overdose and saves lives.
Draft recommendations by the House committee include better education and expanding the use of naloxone.
CORRECTION: This story has been updated to correct that cocaine is not a Schedule I drug.
What we reported
An American-Statesman investigation found that fewer than a third of the doctors who misprescribe powerful prescription drugs to more than one patient are criminally prosecuted, four years after new laws were passed to crack down on pill mills. Local law enforcement agencies and prosecutors say they often don’t get word of doctors who are disciplined by the Texas Medical Board for violating prescribing laws. Authorities also point to difficulties in proving cases against doctors and to vague laws that make prosecution problematic.