State regulators stripped Dr. Michael I. Rose's power to write prescriptions two months ago, after health officials found that the pain-clinic doctor had prescribed enough painkillers to put one patient "at risk of death from overdose."
The health department findings are all the more alarming given the North Miami physician's other specialty: drug-addiction treatment.
Rose is one of at least 41 South Florida doctors who straddle the fence between two seemingly opposite disciplines: They treat drug addicts while at the same time giving pain patients addictive drugs that have been blamed for a spike in overdose deaths statewide. Rose declined to comment for this article.
Some of the same clinics offering addiction treatment are often targeted by out-of-state drug couriers seeking painkillers for an illicit black market stretching from South Florida to Appalachia and the northeastern United States.
Many of these doctors who serve as both pain and addiction specialists have been disciplined by state health officials for improper prescribing of drugs -- and some have been convicted of crimes, a Miami Herald review found.
Yet these doctors retain approval from the federal government to prescribe a narcotic called buprenorphine -- a drug used to help wean people addicted to opiates such as oxycodone.
Addiction experts say this mixing of two delicate medical fields has potentially dangerous consequences: Instead of receiving the therapy they need, addicts seeking to get off drugs may simply end up alongside users and drug peddlers who frequently skip from clinic to clinic seeking narcotics to be sold illegally. 'ADDED RISK'
"If you have an environment where you have drug access and availability, then you have an added risk, " said Dr. Ihsan Salloum, an addiction psychiatrist with the University of Miami's Miller School of Medicine.
"Offering services of this kind is a slap in the face, " said Dr. Bernd Wollschlaeger, an addiction specialist and past president of the Dade County Medical Association. He suspects many pain clinics are seeking not to help addicts but to boost profits by selling drugs used to curb dependency -- in addition to selling large amounts of potent painkillers.
"It's just a fig leaf to conceal their true nature, " Wollschlaeger said. "These pain clinics are pure and simple pill mills. Their goals are pushing huge volumes of prescription pills."
Clinics offering both pain medications and addiction treatment can also present difficulties for police investigating pill trafficking. Under federal law, doctors approved to provide addiction drugs are afforded special protection from narcotics investigators. Agents need a court order from a federal judge before pursuing undercover investigations of these doctors.
Over the past two years, South Florida has emerged as the pill-mill capital of the United States, the chief supplier of black-market painkillers that spawned an epidemic of overdose deaths in Kentucky, Ohio, West Virginia, Tennessee and other states.
The pills have flowed by the millions through storefront pain clinics that open up almost daily from Miami to Palm Beach County. Broward County alone has at least 115 pain clinics, and is home to 33 of the 50 doctors who dispense the most oxycodone in the country, according to U.S. Drug Enforcement Administration data.
Dozens of clinics entice patients with blaring advertisements in alternative newspapers, offering coupons and discounts and not-too-subtle appeals to out-of-state clients.
In the same ads, many clinics also promote treatment for drug addicts with Suboxone, whose primary ingredient, buprenorphine, is designed to help blunt the affects of heroin, oxycodone or other opiates.
Suboxone and similar drugs are considered highly effective for treating dependency and addiction. It's also proven safer than methadone, once commonly used to treat heroin addicts.
To encourage more addicts to seek treatment, federal regulators in 2002 began allowing doctors to dispense Suboxone from their offices -- unlike methadone, which must be administered in hospital or clinic settings.
But a doctor does not need to be a board-certified addiction specialist to distribute Suboxone. A doctor can receive approval simply by completing an eight-hour online course. About 17,000 doctors nationwide are approved to administer Suboxone, including almost 1,200 in Florida. TREATMENT METHODS
Addiction experts and federal health officials warn that Suboxone should be given to patients along with counseling and other treatment methods -- methods rarely employed at many pain clinics, where pills are often the only remedy, critics say.
"Use of the medication in and of itself is not a substitute for full addiction treatment, " said Dr. Louis Baxter, president of the American Society of Addiction Medicine. "Some of these people that are advertising their services may not be certified, and may not be experienced to do what they say they can do."
But some doctors say it can be difficult to get many addicts to attend counseling or psychological therapy, which is often more costly than Suboxone treatment.
"The No. 1 reason for someone coming in to do detox is that they can't afford their addiction, " said Dr. James Milne, who offers both pain management and addiction treatment as part of his general family practice in Fort Lauderdale.
Milne said he believes the need for addiction treatment has increased with the explosion of pain clinics in South Florida. As many as half of his new patients come to him first seeking painkillers -- and many end up as addiction patients, he said.
"Some of these people convert there on the spot. They burst into tears and beg for help, " he said.
At the Fort Lauderdale Pain Relief Center, the staff emphasizes its detoxification program to its pain patients who may feel they are becoming dependent on pills, said clinic attorney Sandy Topkin.
"They want people to get off these medications more than they want them on them, " Topkin said.
Though buprenorphine is less dangerous than methadone, a patient could overdose or die if it is mixed with other drugs, Baxter said. The drug is sometimes sold illegally on the street as well, although it doesn't produce the highs of other drugs.
"You want to have it prescribed in legitimate settings, and these pain clinics are not legitimate settings. There is a high probability that they are using this medication inappropriately, " Wollschlaeger said.
Records show many of the doctors working for South Florida pain clinics have no special certification in either addiction or pain management. And many of the doctors offering both services have troubling professional records. 53 DISCIPLINED
A Miami Herald review of 353 Suboxone-approved doctors in Miami-Dade, Broward and Palm Beach counties found at least 53 of them have been disciplined by state health officials or have been charged with a crime -- about one of every seven doctors.
Among those allowed to dispense drug-treatment narcotics are doctors disciplined for recklessly prescribing addictive drugs, including:
* Dr. Rachael Gittens of Wilton Manors. She was suspended for 90 days and fined $10,000 earlier this year after investigators found 33 blank prescriptions given to patients without including their names or addresses. At the time, Gittens was working at a pain clinic identified by Kentucky investigators as a prime source of illegal pills in that state.
* Dr. Robert Lentz of Lake Worth. He was fined $30,000 and placed on two years' probation earlier this month for prescribing "very high dosages" of painkillers to a patient without documenting the medical need. The health department found that Lentz increased the dosage of oxycodone when the patient should have been sent to addiction counseling, records show.
* Dr. Ricardo Sabates of Delray Beach. State health officials suspended his medical license in October for over-prescribing painkillers and anti-anxiety drugs to 10 patients, records show.
Federal officials say the law allows any doctor to prescribe Suboxone, regardless of any disciplinary history, as long as the physician has completed an eight-hour training course, and the doctor has a valid medical license and approval from the DEA to prescribe medications.
"If the physician has a license to practice medicine, we don't have the right to prevent them from prescribing Suboxone, " said Nick Reuter, a senior policy analyst with the Substance Abuse and Mental Health Services Administration, a branch of the U.S. Department of Health and Human Services that oversees the Suboxone certification program.
The American Society of Addiction Medicine has pushed for greater scrutiny for doctors prescribing medications to drug addicts, and for doctors offering narcotics for pain management, Baxter said. For example, he said, some states like New Jersey require doctors to be board certified in pain management before they can dispense painkillers. Florida has no such requirement.
"There are some renegade physicians that are doing the medication harm by doing unregulated and unorthodox pain and addiction treatment, " Baxter said.