First of two parts
Dr. Ty Anderson let assistants use his name to prescribe Vicodin
and other narcotic painkillers for patients three of whom
overdosed and died. Yet Anderson, arrested last year on unrelated
cocaine charges, is still practicing in Largo. Dr. Philip Bagenski
was arrested too, accused of prescribing Roxicodone, a powerful
narcotic, in exchange for cocaine. But he's still practicing in the
same Clearwater building as Dr. Jayam Krishna-Iyer, who authorities
say unlawfully prescribed painkillers to undercover detectives.
Strung-out addicts may be the face of Florida's prescription
drug abuse crisis, but doctors are key figures in a scourge that
now kills seven Floridians a day. While only a small number of
doctors cause problems, one doctor seeing 80 patients a day not
uncommon in some pain clinics can potentially put 20,000 pills a
day in the hands of drug abusers and traffickers.
"It only takes one bad physician in the community to be a
nightmare for the entire community," said Pinellas sheriff's Sgt.
Dan Zsido, a member of the county's drug diversion task force.
Yet it's not easy to take away a doctor's prescription pad. A
St. Petersburg Times investigation found that the system for
identifying and disciplining doctors is plagued with long delays,
light penalties and testy finger-pointing among regulators, law
enforcement and lawmakers over who should be doing what.
The Times reviewed the cases of nearly 200 Florida medical and
osteopathic doctors accused of inappropriately prescribing pain
medications the 159 doctors who have been disciplined by state
health regulators since 2005, plus an additional three dozen who
have come to the attention of regulators and law enforcement but
have not been disciplined. These physicians are linked to at least
99 overdose deaths, yet the review found:
More than a fourth of the disciplined doctors still have clear
and active licenses, meaning they can practice and prescribe
without restriction.
Even a prison sentence is no guarantee a doctor will lose his
license. Some who committed criminal acts are still allowed to
practice.
It takes an average of at least 18 months from the time the
Florida Department of Health starts investigating a doctor to the
time disciplinary action is taken. Some cases have languished for
years without final action.
The Florida Legislature has dragged its feet in enacting
measures to curb prescription drug abuse. Even the highly touted
new laws to regulate pain clinics and monitor prescription drugs
contain gaping loopholes.
The Times also found that the doctors disciplined for illegal or
inappropriate prescribing don't fit the stereotype of shady
back-room practitioners.
Most are veteran physicians, licensed in Florida an average of
22 years. A majority graduated from U.S. medical schools.
Two-thirds have specialty certification, a sign of medical
expertise.
Despite their credentials, their actions have tarnished their
profession.
Some prescribed drugs in exchange for sex. Some were addicts who
took the drugs themselves. But many had no apparent reason for
prescribing other than that it was easy and lucrative.
"There are a lot of unscrupulous people who have seized on this
need for pain medication and have filled that need for financial
gain," said Dr. Allan Escher of Tampa, a pain management
specialist and a member of the Florida board that regulates
osteopaths. "We did not have enough oversight at a time when the
economy was tanking and people were scrambling to find ways to make
money."
Healers or dealers?
From 2005 to 2009, Florida tallied 5,887 deaths from
prescription drugs. That's three times the number of deaths from
heroin, cocaine and other illegal drugs combined.
Though drug abusers can also obtain pills from friends or
pushers, the road to the morgue often winds through a doctor's
office. But red flags can wave for years before a doctor is stopped
from dangerous patterns of prescribing.
Starting in 2002, Dr. Ephraim Aguilar prescribed narcotics to
numerous patients without medical justification, health records
say. One man fatally overdosed in 2003 on methadone, hydrocodone
and Xanax, an anti-anxiety drug all medications that the North
Fort Myers doctor had prescribed just a day before.
Aguilar kept writing prescriptions, sometimes in amounts so
excessive that a local pharmacy and a health insurer questioned
them. In 2005, the Florida Department of Health received three
complaints about Aguilar. But it was only after four patients died
in a single month October 2006 that the department suspended his
license.
Aguilar voluntarily gave up his right to practice medicine in
2007 almost four years after the first reported death.
Most of the 62 doctors who lost their licenses relinquished them
voluntarily rather than face further board action. Most also faced
criminal charges; two were sentenced to life in federal prison.
"These doctors are dealers. That's all they are. They are
dealers with an MD after their names," said Dr. Steven Rosenberg,
a member of the Florida Board of Medicine.
But some doctors have continued to practice despite facing
serious criminal charges linked to patient deaths.
At least four of Dr. John Mubang's patients had died of
overdoses by the time authorities raided his Seffner clinic in
2008. He was charged with drug trafficking after prescribing drugs
to undercover detectives, allegedly without examining them.
At his trial this month, Mubang testified that he did examine
the agents. Circuit Judge Ronald Ficarrotta declared a mistrial
when the jury was unable to reach a verdict.
But the jury never heard about the deaths. Some of the victims
were addicts who got pills from other doctors, too, so the
prosecution couldn't prove that drugs prescribed by Mubang caused
their deaths. Nor was there any way to prove that cars with
out-of-state tags seen near Mubang's clinic belonged to his
patients.
Mubang, who did not respond to a request for comment for this
story, continued to practice and prescribe in the two years it took
for his case to come to trial. His license remains clear as
prosecutors consider whether to retry him.
"How many people have to die before they take away his license?
How many mothers have to cry themselves to sleep?" asked Victoria
Gabriello, whose 32-year-old son, Michael Tarantola, was one of
Mubang's patients who died.
Sometimes, even a felony conviction isn't enough to revoke a
doctor's license.
Dr. Rene Guerra of Miami was sentenced to 18 months in federal
prison after pleading guilty in 2006 to prescribing controlled
drugs over the Internet. The medical board fined him $10,000, but
his medical license today is clear.
Guerra, who did not respond to a request for comment, is free to
practice.
Prescription for abuse
Starting in the 1990s, the use of legal narcotics grew as the
medical community recognized chronic pain as a significant problem
warranting powerful treatment.
The number of prescriptions for the painkiller OxyContin soared
from fewer than a half-million in 1996 to more than 7ámillion in
2002, a government analysis found. Escher, of the osteopathic
board, recalls drug company representatives aggressively lobbying
doctors to prescribe OxyContin.
At the same time, law enforcement was continuing to crack down
on street drugs.
"There was a war on illicit drugs," Escher said, "and I think
that left the door open for a great expansion of licit drugs."
Many people have been helped by the drugs. But the subjective
nature of pain can make it hard to determine if a patient really
needs a powerful drug like OxyContin or only wants to get high.
"There's no such thing as a pain meter, so doctors basically
have to trust their patients," said Ronald Libby, a University of
North Florida professor and author of The Criminalization of
Medicine: America's War on Doctors.
"They have no control over what these patients do when they
leave the office. They don't know if they mix drugs with alcohol
and tranquilizers or inject them. To blame doctors for that is
absurd."
Still, authorities say some doctors are clearly stretching the
boundaries between appropriate standards of care and dangerous
overprescribing.
"People can't hide behind white coats and medical degrees,"
said Mark Trouville, special agent in charge of the Drug
Enforcement Administration's Miami field office. "If you are doing
the right thing, you are doing the right thing. If you are just
selling dope for profit, then you are not."
Florida is now home to 98 of the top 100 doctors in the United
States who dispense oxycodone right out of their offices. That
practice is a telltale sign of a pill mill, Trouville said, and one
reason Florida is known as the epicenter of the nation's
prescription drug abuse crisis.
Pill mills rising
State health regulators acknowledge they were slow to respond to
the crisis, in part because they were often the last to hear about
problem doctors.
"It was a community and law enforcement problem long before
complaints were being received" by the state health department,
said Lucy Gee, head of the agency's investigatory arm.
It was tips from the public and a former employee that led in
2005 to the first major investigation of a Tampa Bay pain clinic.
Cars clogged the streets near Doctors Urgent Care, a St.
Petersburg walk-in clinic that advertised easy access to Vicodin,
Percocet and other drugs. Detectives watched people limp in with
braces and canes, than race out a few minutes later waving
prescriptions.
"Going by it was like a lunchtime at Publix," said Zsido of
the Pinellas drug task force. "You couldn't get by because of the
gridlock. Any legitimate clinic would not be able to see that many
patients in that period of time."
Dr. Ty Anderson, the clinic's medical director, was rarely
there, according to detectives. Instead, he signed stacks of blank
prescriptions and sent them by courier from his main office in
Seminole.
Among the patients: Todd Brazis, a 28-year-old cook from
Charlotte County. On March 10, 2006, he paid the clinic $249 and
got three prescriptions all with Anderson's initial for a total
of 330 Xanax, Roxicodone and methadone pills.
Two days later, Brazis' girlfriend found him dead of an
overdose.
In May 2006, the Pinellas Sheriff's Office raided the clinic and
arrested Dr. Mary Jane Eicher, then 71, who had lost her own
prescribing privileges and had written prescriptions on forms
Anderson signed. Also arrested were the clinic's owner and two
physician assistants.
But Anderson wasn't charged. Though detectives said he had
signed "boxes and boxes" of blank prescription forms used by
others, that's a civil violation, not a crime.
The state health department suspended Anderson's license and
fined him $12,500, but he was back at work within two months. He
has an active license and a family practice in Largo even though he
is awaiting trial on a felony charge of possessing cocaine.
Anderson did not respond to calls or a certified letter seeking
comment.
Pinellas detectives say they're frustrated that Anderson and the
physician assistants didn't lose their licenses.
"The problem," said Detective Phillip Mansfield, "is not with
law enforcement."
Disciplinary pipeline
State Sen. Mike Fasano, who sponsored legislation to curb
prescription drug abuse, says he has been frustrated by what he
calls the "professional courtesy" extended to doctors by the
boards that discipline them.
"They would just get a slap on the wrist and go back to work,"
said Fasano, a New Port Richey Republican.
But board members say state law does not give them authority to
hunt for those who may be misprescribing.
"The biggest problem is we can't discipline anybody unless a
complaint is filed," said Rosenberg, a West Palm Beach
dermatologist on the Board of Medicine. "And drug addicts aren't
about to complain about their drug dealer."
He and others acknowledged, though, that the state disciplinary
process can take too long.
The Times found that an average of at least 18 months elapses
between the time a complaint is received and when regulators take
action.
Though a long delay means an accused doctor can continue to
prescribe, physicians have the same right as others to maintain
their innocence until proven guilty.
"On the one hand, we want to stop all bad medicine," said
Escher of the osteopathic board. "On the other hand, we have to
(protect) physicians from wrongful prosecution."
After the health department receives a complaint sometimes from
parents who lost a child to an overdose authorities must find
"probable cause" to proceed. Investigators say it can take months
to obtain patient records from doctors that would prove a pattern
of excessive prescribing.
The department also must have a medical expert review the
records. It's a time-intensive effort that doesn't always hold up.
Consider the case of Dr. De Nguyen.
Patients from as far away as Pensacola flocked to the Kissimmee
clinic where Nguyen worked. Pharmacists complained to the health
department about the large quantities of oxycodone and other drugs
Nguyen prescribed. Six of his patients died of overdoses.
In 2005, the health department called Nguyen an "immediate
serious danger" to the public and issued an emergency order that
barred him from prescribing controlled drugs.
But the state dropped the case after Nguyen and his attorney
showed that the department's expert had made several errors in his
report.
"I was falsely accused," Nguyen, 68, told the Times. He said
he retired when the state began investigating him but his license
is clear, meaning he could resume practicing if he chose.
Other cases drag on for years.
Mazhar Nawaz, a surgeon in Kissimmee, already had been fined
$20,000 for signing blank prescription forms when the health
department received a new complaint against him in 2004. It alleged
that Nawaz had inappropriately prescribed pain medications to
several patients, including one who came in complaining of back
pain and toenail fungus and walked out with a prescription for 150
pain pills.
But the department did not file a formal complaint against Nawaz
until 2009, and it has yet to take any action. So Nawaz, who did
not respond to the Times' request for comment, can continue to
practice at several Orlando-area hospitals where he has staff
privileges.
Spreading the blame
Some doctors escape health department scrutiny altogether.
Though they often work closely with each other, police aren't
required to tell the health department when a doctor is arrested.
Though Florida medical examiners inventory prescription drugs
found with overdose victims, they aren't required to tell the
health department who prescribed them.
"We're not the doctor police," said Dr. Vernard Adams, chief
medical examiner for Hillsborough County.
And though the DEA can revoke a doctor's registration to
prescribe controlled drugs, it doesn't have to tell the health
department when it does so.
In 2000, Dr. Jayam Krishna-Iyer of Clearwater was arrested on a
federal charge after prescribing painkillers to three undercover
agents even though they told her they were not in pain. The
investigation stemmed from numerous complaints about Iyer.
The charges were dropped when Iyer completed a pretrial
diversion program. Nonetheless, the DEA revoked her registration in
2006, saying she had violated federal law.
An appeals court set aside the DEA order in 2007, enabling Iyer
to resume prescribing. Last year, the agency renewed Iyer's DEA
registration on the condition she file monthly reports with the
agency for a year.
Today, anyone checking Iyer's record on the health department's
website would find no evidence the department knew of her arrest.
Did it? The agency won't say.
Iyer, who did not respond to a request for comment, runs the
Creative Health Center in Clearwater. Its website says it is
dedicated to making patients "feel young and vibrant" with Botox
and other treatments. Listed last among its services is "pain
management."
Iyer is fighting a lawsuit that accuses her of negligence in
prescribing drugs to a 44-year-old woman who fatally overdosed six
years ago.
Laws and loopholes
Regulatory boards say they are cracking down on doctors who
misprescribe. Among them: Ricardo Sabates, a Delray Beach physician
accused of prescribing excessive amounts of narcotics.
Sabates, a doctor for 33 years, defended his actions even though
he conceded that "the pill mill problem," as he called it, had
given him pause.
"I think that medical pain management is a very necessary
specialty," Sabates told the Board of Medicine in August. "I
think I am very highly qualified. I stayed up on all the
information. I treat my patients very well. I have had no
complaints from my patients."
The health department proposed a $60,000 fine. But after
questioning Sabates about his specialty certification in pain
management (none) and whether his practice was all cash (yes),
board members voted to revoke his license. They noted he had been
fined $10,000 three years ago for sloppy record-keeping and other
violations, yet was back before them again.
"The doctor just cannot follow the rules," Dr. Lisa Tucker, a
Pensacola ob/gyn, said as she made a motion for revocation, which
Sabates is appealing. "We've not gotten his attention yet."
Board members say they have long begged the Florida Legislature
for more safeguards against prescription drug abuse.
"I'm sometimes frustrated that we haven't gotten more credit
for really trying to bring this issue out to the public's
attention," Rosenberg said.
Finally, seven years after it was introduced, state lawmakers
passed a bill last year that creates a prescription drug monitoring
system. Florida is the largest of about a dozen states without such
a system, designed to catch patients who doctor-shop for drugs.
"There were many members in the House who didn't believe we
should care about the prescriptions people were taking," said
Fasano, who introduced the bill in the Senate.
But because of delays, the monitoring system is not expected to
start operating until early next year. And the Legislature failed
to provide money for the program, which is relying on a federal
grant and donations for start-up funding.
The system has a major loophole doctors aren't required to
check it. So patients might still be able to score thousands of
pills in the 15-day lag time between when the drugs are dispensed
and must be logged into the system.
Nor will medical examiners be required to log in the names of
doctors who prescribe drugs contributing to fatal overdoses.
Florida is one of just three states imposing tough new
requirements on pain clinics, defined as those that advertise pain
management or employ a doctor who primarily prescribes painkillers.
Since January, pain clinics have been required to register with
the state health department and submit to annual inspections.
Starting Friday, clinics must be owned by doctors licensed to
practice in Florida. They soon will have to adhere to clinical
guidelines developed by the state medical boards.
"Unfortunately, in any business, there are criminals," said
Dr. Fred Bearison, a Valrico internist on the Board of Medicine.
"Hopefully, one of the biggest impacts that will help to clean
this thing up a little bit is the clinic inspections."
Skirting the rules
But here's the biggest catch of all: The new rules target
doctors working in pain clinics, but many who prescribe narcotics
work in other settings.
The Times found that all types of doctors have been disciplined
for inappropriately prescribing painkillers internists, family
physicians, gynecologists and urologists. There's even a
pediatrician from South Florida, Sergio Rodriguez, who faces
first-degree murder charges for prescribing painkillers that killed
three adults.
And one chain of pain clinics has already notified the state
that it now runs "injury clinics."
"I'll bet you're going to see an explosion in injury clinics,"
said Escher of the osteopathic board. "You'll see a lot of
unscrupulous people rebrand enterprises as injury clinics and
they're not going to advertise Vicodin and OxyContin. But people
who doctor shop all talk to each other. They know where to go and
when one place shuts down they go to another."
Dr. Rafael Miguel, a Tampa pain medicine specialist and former
member of the Board of Medicine, says he thinks the new regulations
will give law enforcement better ammunition. That will help the
medical boards take action.
"A lot of the legwork will be done now by law enforcement
because they will have specific laws to point to and say, 'This is
being violated.' " he said.
But some law enforcement officials say the medical boards need
to better control doctors who practice outside the bounds of
accepted medicine, not just those who break criminal laws.
"Professional self-regulation needs to be much more part of the
answer because it has historically been more part of the problem,"
said Palm Beach County State Attorney Michael McAuliffe, whose
office has been aggressive in filing charges against doctors.
"Some of the misconduct may very well fall short of trafficking
and criminal activity, but nonetheless is outside the scope of what
a physician should be doing, McAuliffe said.
"That's why there is an opportunity for self-policing to be
part of the answer."
Starting Friday, the Board of Medicine will take up the cases of
several doctors accused of prescription drug improprieties. Among
those on the agenda: Bagenski, the Clearwater doctor accused of
prescribing Roxicodone in exchange for cocaine.
In 2008, he pleaded no contest to a felony charge of possessing
cocaine and was put on probation for three years.
But the medical board allowed Bagenski to keep practicing under
the supervision of another doctor.
He now wants an early end even to that restriction.
Times researchers Carolyn Edds, John Martin and Natalie Watson
contributed to this report. Letitia Stein can be contacted at
lsteinsptimes.com. Susan Taylor Martin can be contacted at
susansptimes.com.
About this story
These stories are based on documents obtained from the Florida
Department of Health, which was asked for records on every doctor
disciplined for prescription drug violations since 2005, plus
pending complaints. The Times also reviewed actions taken by the
federal Drug Enforcement Administration, federal and state courts
and law enforcement. The Times interviewed members of the state
medical boards, health regulators, law enforcement officials and
sought interviews, by certified letter, with the doctors whose
cases are cited.
Coming Monday
The prescription drug superhighway: How doctors helped make
Florida a standout in the world of Internet prescription drug
abuse. About this story
These stories are based on documents obtained from the Florida
Department of Health, which was asked for records on every doctor
disciplined for prescription drug violations since 2005, plus
pending complaints. The Times also reviewed actions taken by the
federal Drug Enforcement Administration, federal and state courts
and law enforcement. The Times interviewed members of the state
medical boards, health regulators, law enforcement officials and
sought interviews, by certified letter, with the doctors whose
cases are cited.
c.2010 St. Petersburg Times