Broward County has become the painkiller capital of the United States, the notorious home to a cottage industry of storefront pain clinics selling alarming numbers of narcotics and feeding a brazen black market sprawling through the South and New England.
In the last six months of 2008, doctors at Broward's pain clinics handed out more than 6.5 million pills of the potent painkiller oxycodone -- almost four pills for every Broward resident, according to federal data compiled by the Broward Sheriff's Office.
Pills flow by the thousands every day through an ever growing number of clinics offering drugs and prescriptions to walk-in patients at strip malls and nondescript office parks -- some with armed guards stationed by the clinic doors. One Fort Lauderdale clinic has taken over a defunct drive-through fast-food restaurant.
Many clinics lure patients with the promise of drugs sold on site, and with coupons and discounts advertised in the back pages of alternative weekly newspapers, or on bus benches and billboards.
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"Out of State Patients Welcome, " blares a recent ad for A1 Pain in Fort Lauderdale. "No Wait for Walk-Ins, " another clinic's ad says. One doctor offers a $25 gasoline coupon to the weary, pain-afflicted traveler.
And the travelers come -- by the thousands, narcotics investigators say, from Kentucky, Ohio, West Virginia, Massachusetts and other states. Prospective pill buyers sometimes camp outside clinics overnight, waiting for the doors to open, said Hollywood police Capt. Allen Siegel, director of a South Broward narcotics task force.
"Broward County has become the Colombia for pharmaceutically diverted drugs, " Siegel said. "We're supplying everywhere."
The number of pain clinics in South Florida has ballooned from 60 to 150 in just the past year, the U.S. Drug Enforcement Administration estimates. Broward alone has 89 clinics, Siegel said.
Pain management with narcotics is recognized as a legitimate medical practice to quell chronic pain for those with injuries or conditions like arthritis. But investigators and health advocates say many of these clinics are merely pill mills where doctors feed narcotics to 65 patients a day or more.
"This medicine is about profit-making, " said Mark Trouville, special agent in charge of the DEA's Miami office. "I hate to call them doctors. These people are just out to make money."
A single physician can dispense hundreds of thousands of pills. In the last six months of 2008, Trouville said, just 45 South Florida doctors dispensed nearly nine million pills of oxycodone -- a favorite among drug addicts and traffickers.
Experts blame these clinics for a startling rise in prescription-drug overdose deaths in Florida, including a 107 percent jump in oxycodone deaths in two years.
"The rate [of overdoses] is just incredible, " said George Hime, assistant director of toxicology for the Miami-Dade County Medical Examiner's Office. "It is the new epidemic of drug abuse."
Yet, regulators and police can't control the problem -- handcuffed, they say, by tepid Florida laws that allow these clinics to open in-house pharmacies and sell drugs directly to clients walking in off the street, even from far-away states.
"We are source-supplying many other states. This is literally embarrassing, " Sgt. Lisa McElhaney of the Broward Sheriff's Office told a recent meeting of a county drug task force. "The system has enabled this."
Indeed, Florida's laws regulating clinics and pain doctors ignore the red flags that would alarm any drug counselor or narcotics detective. Consider:
* No state agency regularly monitors many pain clinics where narcotics are dispensed. The state Department of Health regulates healthcare professionals -- not facilities. The Agency for Health Care Administration oversees only the clinics that accept insurance, and many pain clinics take only cash.
* Many Florida pain doctors can dispense narcotics directly to patients without a pharmacist -- even doctors with disciplinary or criminal records. One Fort Lauderdale doctor can still dispense pills despite his arrest last year on charges that he gave a bogus prescription to an undercover detective. Another doctor is dispensing drugs at a pain clinic although his license is on probation after a criminal conviction in an insurance-fraud scheme.
A Miami Herald review found more than a dozen South Florida doctors with criminal or disciplinary records who are dispensing pills.
* Many clinics are not owned by doctors; rather, the doctors work as contractors for owners who may have little or no medical background.
A Miami Herald review found a handful of clinic owners with criminal records, including a Sunrise man who served two prison terms for racketeering and fraud, and a 28-year-old Palm Beach County man with convictions for auto theft and possession of steroids with intent to sell.
Building contractors, a real-estate broker and a mortgage broker have all recently joined the pain-clinic business, records show. The Miami Herald found several clinics owned by chiropractors, and others owned by an X-ray technician, a massage therapist and an acupuncturist.
While most states allow police and doctors to track patients receiving large quantities of prescription drugs, Florida is one of only 12 states without a prescription monitoring system, making the Sunshine State a magnet for the black-market pill trade and "doctor-shopping."
"Shame on us for letting it get this far, " said Rep. Kelly Skidmore of Boca Raton, who is pushing in the Legislature for stricter pain clinic regulations. "We don't want every other state to view Florida as the pharmacy for illegal pain medications."
Police in Kentucky, Tennessee, West Virginia, Ohio and other states routinely arrest drug suspects who have oxycodone bought or prescribed in Florida, often using bogus medical records to justify the medication.
"Ninety-eight percent of it is coming out of Florida, " said Capt. David Hall, a narcotics detective in Scioto County, Ohio, outside Cincinnati.
More oxycodone is distributed in Florida than in any other state -- 40 percent more than in second-ranked California in 2006, according to DEA data.
Driving this trend are Florida's "dispensing practitioners" -- doctors who have special approval to sell drugs directly from their offices. In 2006, they handed out 85 percent of all the oxycodone distributed by doctors nationally.
Broward County is home to 33 of the 50 doctors who dispense the most oxycodone in the United States, according to the DEA. The 17 other doctors on that list are also from Florida.
"Totally suspicious, " said Dr. Charles Grudem, a board member of the Florida Society of Interventional Pain Physicians and a vocal critic of storefront pain clinics. He questions the need for doctors to dispense narcotics from their offices.
"It creates an automatic incentive to dispense medicines that are profitable, " Grudem said.
Many patients go to pain clinics with genuine medical complaints, Grudem said, but the suspect clinics offer only one remedy: powerful drugs. Drugs that can make addicts out of patients.
"They get turned into criminals, " he said.
As oxycodone has spread, so have overdoses. The number of oxycodone deaths in Florida more than doubled from 2005 to 2007, to more than 700, according to the Florida Medical Examiners Commission. Some traces of oxycodone were found in 1,253 overdoses in 2007. Oxycodone-related overdoses continued to climb in the first half of 2008.
Oxycodone is only one factor in the overdose epidemic, experts say. Often, users combine the narcotic with other potentially dangerous drugs, such as methadone, and sedatives such as Xanax and Valium -- all drugs commonly sold at pain clinics.
It was a similar cocktail that killed 41-year-old Jonathan McLaughlin at his Plantation apartment last July 23.
Police found four different prescriptions at McLaughlin's bedside, all filled the day before his death. The most potent: a prescription for 240 oxycodone pills. When police found McLaughlin's body, only 121 of the painkillers remained.
McLaughlin also had anti-depressants, sedatives, and a stimulant typically used to treat children for hyperactivity, records show. All four prescriptions were written by Dr. Amy Seinfeld, an osteopathic physician in North Miami Beach, the police report says.
Messages left for Seinfeld were not returned.
McLaughlin's girlfriend told police he had been a heroin addict; only two weeks earlier, he had stopped taking a medication to quiet his addiction. The autopsy, which ruled McLaughlin's death an accident, revealed traces of cocaine in his system.
McLaughlin used illegal drugs for years, bouncing from jail to rehab and back again before turning to prescription pills, said his sister, Alex Amos. She said he found lenient doctors -- "voodoo doctors, " her brother called them -- by word of mouth, or in ads in the back of alternative newspapers.
"He couldn't get away from the temptation that surrounded him, " Amos said. "He wanted so much to be better."
Amos found pharmacy records showing that her brother had received painkillers from a half-dozen doctors. She said she knew of no injury or ailment that would justify the medications prescribed to him.
The State Board of Medicine has backed proposals for stricter regulation of pain clinics and reforms to prevent doctor-shopping. But the agency says any reforms must not inhibit doctors who are treating people with legitimate ailments.
One of the difficulties for doctors treating pain -- and for police and health officials investigating fraudulent prescriptions -- is that a patient's pain is often impossible to measure objectively, making fraud that much easier.
The Florida Department of Health disciplined 119 doctors for prescription abuse from 2003 to 2007. But police and health advocates say many complaints don't make it to the medical board, and the pain clinics largely escape scrutiny.
"There are significant black holes of information, " said McElhaney, the Broward sheriff's detective.
In Florida -- as in most states -- doctors who dispense pills from their offices need no special training or certification. They need only pay the state a $100 fee, and agree to submit to the same annual inspections required of pharmacists.
Some states are stricter. Montana doesn't allow doctors to dispense pills. Doctors in New Jersey can provide no more than a seven-day supply of drugs. In Maryland, doctors can dispense drugs only when a pharmacy is unavailable.
Several Florida doctors continue to dispense drugs despite past citations by the Department of Health -- or even criminal charges.
Last July, Dr. Robert F. Hunt, a Fort Lauderdale family practitioner, was charged with providing illegal prescriptions, after allegedly giving steroids and the painkiller hydrocodone to an undercover Broward sheriff's detective without a medical exam, court records show.
"Just to cover my ass, I'm going to put down that you've got a history of osteoporosis, " Hunt told the detective, according to the arrest report.
Yet, Hunt -- who has pleaded not guilty and is awaiting trial -- still has the power to dispense pills directly from his office.
It was unclear last week whether the state Health Department was aware of Hunt's arrest. Hunt declined to comment for this report.
Regulators have suspended the rights of some doctors to dispense drugs on their own, said Eulinda Smith, a spokeswoman for the state Department of Health. But details about those cases were not available late last week.
But in some cases, doctors on probation with the Department of Health have still been allowed to dispense drugs from their offices.
Dr. Enrique Gonzalez-Pujol's license was placed on probation after he pleaded guilty to a criminal charge of filing false medical records for clinics involved in a $7 million insurance-fraud ring.
Under the probation, the 60-year-old doctor is barred from drinking alcohol, and he can't take any medications without a prescription from another doctor, records show. Now he is dispensing drugs to patients at the Affordahealth Pain Relief Center in Davie.
Gonzalez-Pujol has been in trouble before: In 1992, the medical board placed him on five years' probation for his failure to provide patient records to justify Medicaid claims. He also had to repay Medicaid $14,500, records show.
The doctor said his probation does not reflect on his medical practice because the citations were not health-related.
"My probation has never had anything to do with dispensing or how I took care of patients, " he said.
Gonzalez-Pujol said he screens his patients for drugs and does criminal background checks to weed out potential doctor-shoppers. He has called the police on some prospective patients.
"After you've seen the patient two or three times, you can tell whether the patient is faking it or not, " the doctor said. But "you can never tell for sure."
Gonzalez-Pujol does not own the clinic where he works. Indeed, many doctors work as contractors at pain clinics, rather than own the clinics themselves. Because of this, many clinics fall through the cracks between the state agencies that monitor doctors and healthcare facilities.
The Department of Health can monitor a doctor's practice, but it doesn't oversee clinics. That's the job of the Agency for Health Care Administration. But under state law, the AHCA monitors only clinics that accept insurance -- and many pain clinics are cash-only.
Clinic owners also escape the scrutiny of state health officials. And several of those clinic owners have a criminal past as well.
Michael Zoyes' past includes convictions for racketeering in 1987 in a boiler-room scam, and in 2001 for fraud in a telemarketing scheme involving diet supplements, court records show.
Five years after completing his second prison sentence, Zoyes, 54, opened Davie Pain Management in a strip mall on West State Road 84. He placed help-wanted ads on the Internet, seeking a doctor to help open a pharmacy at the clinic, and promising as much as $12,000 a month in pay.
"No adjunct therapy, " one ad reads. "Monitoring and prescribing of meds only."
Zoyes did not return messages seeking comment.
In some cases, pain doctors are paid on an escalating scale based on how many patients they see in a day, said Siegel, the Hollywood police captain. Patients typically pay $300 to $500 in cash, covering the cost of the visit and the prescriptions -- and then come back 28 days later for more.
Among police in Appalachia, one Fort Lauderdale clinic has earned a notorious reputation for selling pills that end up on the black market: South Florida Pain.
Police in Kentucky, Tennessee and Ohio say they have made separate arrests of drug suspects carrying pills prescribed by doctors at that clinic, owned by 28-year-old Christopher George of Royal Palm Beach, records show.
George has no formal medical training -- although he does claim a financial stake in an "anti-aging" clinic founded by his twin brother, Jeffrey George, court records show.
Christopher George, a former draftsman with a home builder, pleaded guilty in 2002 to possession of steroids with intent to sell, after postal inspectors tracked a package of pills he ordered on the Internet, court records show. He also pleaded guilty to grand theft for stealing a motorcycle, records show. He served concurrent sentences of five months in jail and three years' probation.
George did not respond to messages left at his home and with his attorney.
George's brother Jeffrey -- who has a criminal record of grand theft and resisting arrest -- owns two other South Florida pain clinics, records show. The brothers are now tangled in a court dispute over the profits from South Florida Pain.
The DEA has devoted two new special units to South Florida pain clinics, said Trouville, the Miami special agent. But many detectives and health officials say that what Florida needs is a prescription-drug database, to allow doctors and police to monitor for doctor-shopping.
Thirty-eight states have such a program -- and Florida is the largest state without one. "The 38 states that have a program like this -- they don't have this problem, " Trouville said.
Efforts to create a monitoring program in Florida have been defeated repeatedly over the past seven years by lawmakers concerned that such a database would infringe on patients' privacy. Two new prescription-monitoring proposals are now gaining momentum in the Legislature, passing through key House and Senate committees last week.
Police and doctors say such a database would protect prescribing physicians, so they could check on whether a patient is getting pills from multiple doctors.
"It liberates the legitimate pain patients and legitimate pain doctors, " Dr. Grudem said.
And while investigators say a prescription database would help them detect prescription fraud, they warn that it would not end it.
"It's simply a tool to help address the problem, " said McElhaney, the Broward sheriff's detective. "It's not going to solve the problem."
What The Herald found
45 South Florida doctors sold nearly nine million oxycodone pills in the last six months of 2008.
33 of the top 50 oxycodone-dispensing doctors in the United States practice in Broward County.
The number of pain clinics in South Florida grew from 60 to 150 in the past year, the DEA estimates.
Overdose deaths in Florida caused by oxycodone rose from 340 in 2005 to 705 in 2007.
Florida: No. 1 in oxycodone
In 2006, Florida led all other states in the retail sale of the potent narcotic oxycodone -- selling more than 10 percent of all the oxycodone in the country, and outselling the most populous state, California, by 40 percent.
2006 retail drug distribution by state (in grams) Florida California Texas Oxycodone 3,958,798 2,816,273 922,209 Hydrocodone 2,288,824 3,550,674 3,064,044 Morphine 1,242,494 2,156,640 765,759
Broward: Pill central
Broward County is at the center of Florida's pill epidemic. In the second half of 2008, Broward doctors dispensed more than 6.5 million oxycodone pills -- 3½ times the number Palm Beach County doctors distributed, and 14 times more than Miami-Dade doctors dispensed.
Oxycodone units dispensed by county, July-December 2008:
Palm Beach: 1,809,400
SOURCE: Broward Sheriff's Office, via U.S. Drug Enforcement Administration