STORY BY CHRISTINE DAVIS & MICHAEL CROOK
WEEK OF JANUARY 13, 2011, Palm2Jupiter
It’s a fairly typical day at North Palm Pain Management.
A burly security guard in black, armed with a nightstick, ushers visitors in and out of the clinic door. His name is Larry, and he is there for the safety of the staff, because sometimes a pain patient “has waited too long to get their refill and gets out of hand” from the urgency of withdrawal symptoms, says a receptionist named Beth.
In the parking lot, there are cars and trucks with Kentucky, Tennessee, Georgia and North Carolina plates. Customers drive a long way to get prescriptions for addictive pain killers, testosterone and human growth hormone here.
The clinic doesn’t accept health insurance. What is required is $250 cash – VISA and Mastercard are accepted, too — for an appointment, along with a photo I.D., an MRI report, and a printout of the customer’s prescription history from their pharmacy of choice, Beth said.
She would not name the doctor a patient would see, when a P2J reporter called.
“We have several different doctors working for us,” she said.
Presently, licensed by the Florida Department of Health, there are eight pain clinics in Palm Beach Gardens, one in North Palm Beach and three in Jupiter. Ten pain clinics closed county wide in 2010.
Meanwhile, a short drive south, a Palm Beach Gardens man is on trial for murder, accused of stabbing his roommate to death and dismembering his body. Over a handful of opiate pain pills.
South Florida’s struggle with addictive prescription drugs, with unorthodox “clinics” like North Palm Pain Management — as much a convenience store as a medical practice – and with the wreckage of human lives, is not finished.
Prescription drugs kill seven Floridians every day. And that dwarfs the death rate caused by illegal drugs, said past director of the Office of Drug Control, Bruce Grant.
“That’s a tremendously high number. Florida has had a serious problem with the diversion and abuse of prescription drugs for some time.”
The availability of drugs drives their use, he said, and there is currently nothing in place that will mitigate the problem.
“Florida Medical Examiners Commission Report on Drugs Identified in Deceased Persons,” January through June 2010, notes that out of 89,800 deaths in Florida, 4,150 people were found to have died with one or more drugs in their bodies.
The top four that caused the most deaths were Oxycodone (715), all Benzodiazepines (597), Methadone, Ethyl Alcohol and Cocaine.
Note that the top two of these are prescription drugs…
In Palm Beach County, Oxycodone caused 68 deaths. While deaths caused by Methadone and Cocaine declined by 1.2 percent and 11.3 percent, respectively (and Heroine, the most lethal, decreased 40.5 percent) deaths caused by Oxycodone increased 10.9 percent over the last six months in 2009.
“The Medical Examiners Report continues to show the lethal consequences of the diversion and abuse of prescription drugs,” Grant said. “This new drug crisis rivals the crack cocaine epidemic of the 1980s. We must get agencies at all levels of government, along with our communities and our medical professionals to step up and take action.”
The growth of pain clinics, often called “pill mills,” has made Florida a source state for other states along the East Coast and Appalachia, Grant said. “They operate on a cash only basis. You can get the drug right there, if the doctor has a dispensing license, and if not, you can go and get your prescription filled elsewhere.”
Drugs for cash, with no valid medical reason, foster addiction, he added. “Some purchase the drugs to sell them, some to use them, and, for others, it’s a combination of the two. And if you talk to pain seekers from other states, and ask them why they come to Florida, they’ll tell you it’s because they can’t get these drugs in their own home state.”
“I know for a fact, an individual will go for a doctor’s appointment and walk out with 100 to 200 pills. They’ll sell half of them at a great markup to pay for the doctor’s appointment. That’s standard medical procedure,” said Stephen Gumley, the addiction-treatment manager of Recover Resources, a drug- and alcohol-treatment center in North Palm Beach.
More than 75 percent of his center’s current clients and 90 percent of those in residential treatment, came because they are addicted to prescribed opiate or narcotic medications, he said.
“If a person takes five 150-milligrams of Oxycodone a day for a month, he or she is addicted.”
And then what? “We are shaking our heads. Our jobs, as counselors in addiction treatment, is to get our clients off those drugs.
“My big contention is, what do those doctors think they are doing?”
Pill mills are a booming business, he noted. “If a doctor sees ten pain management patients a day, he makes a lot of money, $2,500 to $5,000 just on those ten people.”
Pain clinic doctors say they administer these drugs as their duty having taken the Hippocratic Oath, he said. “They say they don’t want their patients to suffer, but I would like to know how they plan to address the fact that once they get the patient on that regiment, how are they going to get them off of it?
“They are demonstrating a lack of understanding of the addictive nature of narcotic pain medication or they have a laissez-faire attitude.”
Board-certified pain-management doctor, Louis J. Raso responds similarly and asks the same question. He owns and runs a licensed pain-management clinic in Jupiter. He is also on staff at Palm Beach Gardens Medical Center and practices at Jupiter Medical Center.
“Prescription mills are a big problem,” he said. “People who are addicts have found out that if they went to one of those clinics and paid an amount of money, they would get a prescription where the drug was pure.
“These clinics operate on a strictly cash basis, and are owned by people who aren’t physicians. The physicians who work there couldn’t make a living in private practice and all they do is write prescriptions. They have pharmacies within their offices, so now they are making cash money for the office visit, and for handing out the prescriptions themselves.
“People are driving here from other states because we have so many clinics, and they can get more drugs cheaper, go back and sell them, and make money to pay for the trip.
“It’s all driven by the almighty dollar,” he said.
Raso, who has been called as an expert witness in malpractice cases, recalled a lawsuit concerning the death of a 24-year-old man.
“He had gone to one of those places because he had knee surgery ten years ago. They did not do an MRI and they gave him Methadone, Roxicodone and Xanax.
“The young man’s family settled for the limits of the insurance policy and we brought the physician to the state, who is taking his license away.
“Any physician, not board certified in pain management should cease and desist practicing pain management. Prescription mills should be shut down and dispensing out of the office should be stopped.”
Raso, as part of his practice, drug screens his patients to make sure they are taking only what is prescribed and at the prescribed dosage. He also insists that a new patient submit records and has an MRI.
“I’ve had people walk into my office, clammy and shaking, clearly going through withdrawal. I don’t see them. I can’t contribute to that. I tell them to go to the emergency room.”
Raso draws a distinction between being drug dependant and drug addicted.
“Addiction is a behavioral problem. Those people have a craving. But if a person with a bad chronic illness takes a pain drug as it is prescribed, they’ll do well and are less likely to develop a tolerance to the drug.
“We have to be very careful whenever we prescribe any of these medicines. These drugs don’t work over the long term. The Number One job of a pain management physician is to find out what part of the body is generating the pain and find the best way to treat that. It’s not just about medication.”
Not all pain management doctors are willing to talk about their practices. The receptionist who took our call to North Palm Pain Management on 10th Street in Lake Park, for example, said that the supervising physician listed on its license no longer worked there, refused to name the clinic’s doctors and hung up when we requested a call back.
Starting in March 2010, Palm Beach County and some of the county’s cities have either put a moratorium in place for a year on the licensing of pain clinics or have added stricter regulations in their city ordinances.
They did that because pain clinics were opening at the rate of one new clinic every three days from August 2008 to November 2009, in Broward and Palm Beach Counties and doctors in Palm Beach County had dispensed the second highest volume of Oxycodone pills in the United States in 2008.
Presently, the county has extended its moratorium, said Barbara Alterman, Palm Beach County’s director of planning and zoning. “And we are working with the cities for a more universal approach.
“IPARC (Intergovernmental Plan Amendment Review Committee) came up with recommendations, but they asked the county to draft an ordinance,” she said. “At this point, probably starting in January or February, the county will draft a model ordinance picking and choosing from the IPARC menu and bring that back so the cities can see what we have done.”
Apart from these local actions, Florida’s Senate Bill 462 was passed during the 2009 Legislative Session. It requires the registration and inspection of pain management clinics by the Department of Health.
Also, Senate Bill 2272 was signed into law in June 2010 and its provisions became effective October 1, 2010.
It stipulates the following:
The clinic must designate a physician to register the clinic and the designated physician must practice at the clinic. The clinic must be owned by an MD, DO, or group that has MD and DO licenses, unless it is licensed as a health care clinic with the Agency for Health Care Administration under Part X Chapter 400.
Annual inspections, with medical records review, must be conducted annually.
Sections 458.3265(2)(c) and 459.0137(2)(c), Florida Statutes, provides that if a physician prescribes or dispenses more than a 72-hour dose of controlled substances for the treatment of chronic non-malignant pain, the physician must document in the medical record the reason for prescribing or dispensing that quantity.
Further, Section 465.0276, Florida Statutes, provides that a practitioner registered under this section (pharmacist or a dispensing practitioner) may not dispense more than a 72-hour supply of a controlled substance listed in Schedule II, III, IV, or V of s. 893. 03 for any patient who pays for the medication by cash, check, or credit card in a clinic registered under 458.3265 or 459.0137 except in certain instances as set forth in that section.
Sections 458.327 (1)(e) and 459.013(1)(e) are amended to provide that knowingly operating, owning, or managing a non-registered pain management clinic that is required to be registered with the Department of Health pursuant to Sections 458.3265(1) and 459.0137(1) is a third degree felony.
Following 458.3331 (1)(pp), and 459.013(1)(rr), a physician or osteopathic physician can be disciplined for failing to timely notify the department of the theft of prescription blanks from a pain-management clinic or a breach of other methods for prescribing within 24 hours, as required by Sections 458.3265(2) and 459.0137(2).
Problems continue to crop up, though. For example, authorities believe some pain clinic owners and investors are getting around the new restrictions by opening pharmacies away from the clinics, so that they can continue making money off the pills. In addition, a group of physicians has filed a lawsuit in federal court with an injunction against the Department of Health regarding SB 2272.
And the Prescription Drug Monitoring Program (PDMP), supposed to have gone into effect December 2010 has been slowed down by House Bill 1565 due to a bid protest.
Currently, 34 states have operational programs and five states (including Florida) have enacted legislation to establish a prescription drug monitoring program. The purpose of this database is to track prescriptions, reducing the chances for patients to doctor and pharmacy shop and to repeatedly and illegally divert prescription drugs.
“Prescription drug abuse is a tough area to police,” said Laurence Poston, sergeant at Palm Beach County Sheriff’s Office, assigned to the narcotics unit.
“They go in and say they have pain and the doctor gives them an examination. The doctor has a medical degree and is licensed, writes a prescription that the patient takes to Walgreens and has it filled. A lot of people are getting these drugs who don’t need them.”
There is no one solution, he said, noting that education, enforcement and regulation combined are helpful. “This is just another form of drug abuse. It just happens to come from a pharmacy and not a jungle in Colombia. It’s no different, though, and people get hooked. It’s a savage cycle they get involved in.”