Five of Dr. Darrel Rinehart's patients overdosed on his prescriptions in less than a year.

State health officials say Rinehart prescibed huge doses and ignored obvious signs of abuse.

Rinehart's Tennessee medical license is doomed, but he is still practicing medicine in Indiana.

Mathew Blackburn, 27, a Tennessee anxiety patient, had just failed a routine drug test in a small clinic about an hour south of Nashville. The test found two mind-altering drugs that a doctor had prescribed to Blackburn, Xanax and Zoloft, but it also caught a third drug, Valium, for which he had no prescription.

For most medical professionals, this mysterious Valium would have been a red flag suggesting Blackburn may have been abusing pills. But Blackburn's doctor tripled his Xanax dosage — without writing any justification in his medical records.

Two days later, Blackburn was dead.

He overdosed while watching television as a friend slept on the couch nearby. Investigators found a toxic cocktail in his bloodstream and a new prescription bottle of 90 Xanax tablets on his body. Fifty-one pills were already gone.

At first glance, Blackburn’s death, which occurred on March 5, 2015, does not stand out in addiction-ravaged Tennessee, where overdoses have killed more than 7,200 people in the past five years. But state officials say Blackburn’s drug abuse was worsened by Dr. Darrel Rinehart, a longtime Tennessee doctor who moved to Indiana once his prescriptions were questioned. Officials describe Rinehart as a careless prescriber who failed to protect his patients from his own prescriptions, according to public records obtained by The Tennessean and The Indianapolis Star.

Rinehart, officials argue, routinely broke the basic rules of prescribing: He handed out powerful painkillers in unjustifiably large doses; he haphazardly mixed opioids with anxiety drugs; he failed to examine patients before prescribing; he failed to use a prescription database that prevents doctor shopping; and he often ignored obvious signs that patients were abusing or reselling his prescriptions.

And the results, state officials said, were deadly. At least five of Rinehart’s patients suffered fatal overdoses that were partially or wholly caused by drugs he prescribed between March 2015 and January 2016, records state. Health officials are also suspicious of two more deaths of patients who were taking Rinehart’s prescriptions, but they were not autopsied because Rinehart told investigators the patients were killed by natural causes.

Six more patients had nonfatal overdoses between 2014 and 2016, according to an expert's review of Rinehart's medical records. One of those patients, to whom Rinehart prescribed at least 11 different drugs, overdosed three times.

Finally, Rinehart was caught on undercover video increasing a patient’s opioid prescription without any examination and adding an Adderall prescription after the patient casually asked for “something to help me focus.” This video, officials say, offers a firsthand view of how Rinehart failed his patients.

“This is a pattern of negligence and bad practice that extends to anything he tries to do with his license here or anywhere in this country,” Samuel Moore, a government attorney, said while describing Rinehart’s prescriptions to a state licensing board. “This isn’t medicine. This is something else.”

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Rinehart has clean license in Indiana

Rinehart is still a doctor and retains the ability to prescribe addictive drugs.

After agreeing to leave Tennessee to avoid the harshest punishment faced by bad doctors, Rinehart resettled in Indianapolis, where he currently has a clean medical license. Tennessee officials alerted the Indiana government to Rinehart’s prescribing history in December, but the state hasn't taken any disciplinary action against the doctor as of yet.

Julia Camara, a spokeswoman for the Indiana Professional Licensing Agency, said she would neither confirm nor deny if the agency was reviewing Rinehart’s license.

Rinehart said during a medical disciplinary trial in November that he was working at Rush Memorial Hospital in Rushville, Indiana, and in the emergency room at Saint Vincent Health, a hospital chain with numerous locations around Indianapolis. Rinehart maintained he was“upfront” with both hospitals about the investigation into his prescriptions before they hired him.

Rush Memorial said this month that Rinehart no longer works at the hospital but declined further comment. Saint Vincent’s officials said they have no record of Rinehart ever working at its central Indiana hospitals.

For this investigation by The Tennessean and The Indianapolis Star, journalists reviewed about 900 pages of public records and more than 10 hours of video footage from Rinehart's case before the Tennessee Board of Medical Examiners, which oversees medical licenses. This reporting expands on a yearlong “Bad Medicine” investigation by the USA TODAY Network that discovered hundreds of doctors accused of incompetence or misdeeds have managed to continue to practice medicine by hopping state lines and leaving their troubled pasts behind.

The Tennessee Department of Health tried to stop Rinehart from doing just that. During his medical discipline trial last year, Moore argued that Rinehart had "escaped" to Indiana and the best way to prevent him from hurting someone there was to revoke his medical license in Tennessee.

“Nothing else will protect the people of Tennessee or the people of Indiana or anywhere else this man goes,” Moore said during the trial.

The medical board ultimately stopped short of revocation, choosing instead to suspend the license until it expires May 31 if Rinehart vowed to never attempt to get it back. The impact of the suspension is functionally the same as a revocation in Tennessee, but it makes it easier for Rinehart to practice medicine in another state.

Dr. John Hale, one of the three board members who approved the decision, said the suspension fulfilled the board’s "duty to protect the citizens of Tennessee” but he preferred revocation because it would've sent a stronger message to other states.

Hale advocated for specifically flagging Indiana officials about the doctor’s case.

“If the roles were reversed," Hale said, “I would definitely want them to notify us.”

Rinehart’s suspension also will be reported to the National Practitioner Data Bank, which catalogs doctor discipline information to prevent bad doctors from jumping states. But a suspension does not carry the same weight as a revocation, so it will be less alarming to licensing officials in other states, making it more likely that Rinehart will be licensed elsewhere. The USA TODAY investigation revealed many states rarely check the Data Bank and some don’t do it at all.

Rinehart says he was uninformed, too trusting

At trial, Rinehart’s defense boiled down to two main points: ignorance and naivety.

Rinehart's attorneys said he did not follow Tennessee’s safe prescribing guidelines, which were adopted into law in 2014, because he didn't know they existed. Rinehart added that he was too trusting of his own longstanding patients and "not aware" that some of those patients were dying from overdoses.

“You always want to do what you could to help people,” Rinehart said, describing himself to the medical board. “And, yes, sometimes, people tell you things, you believe them, you trust them, you know them, but you know they’re not always honest. … That certainly has altered the way I practice medicine now.”

Before he moved to Indiana, Rinehart worked for at least two decades at Core Physicians, also known as Family Health Group, a clinic in Columbia, Tennessee. The clinic was purchased by Maury Regional Hospital in 2015, and the new owners were the first to raise issue with Rinehart's prescriptions, he said.

Once alerted, Rinehart familiarized himself with safe prescribing guidelines and began to follow them, said attorney James Looper. Rinehart no longer prescribes medicine to manage pain in Indiana, Looper said, and has faced no discipline issues since leaving Tennessee.

“Once Dr. Rinehart was confronted and told what he was doing incorrectly, he stopped,” Looper argued during the trial. “He fixed it. He got his practice right."

During a brief interview with The Tennessean, Looper insisted that state attorneys failed to actually prove Rinehart's prescriptions caused or contributed to the overdoses of his patients, and the medical board was too "harsh" when it suspended the doctor's license.

Rinehart had grounds for an appeal, Looper said, but the doctor declined to pursue it, at least in part because he was moving on.

“He’s not going to be coming back to Tennessee,” Looper said. “He wants to try and restart life in Indiana."

Rinehart is the subject of an ongoing criminal investigation by the Maury County District Attorney's Office. Law enforcement officials declined to comment, citing the ongoing nature of the investigation.

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Medical records ‘copied and pasted’

Ashley Marie Martin, a 29-year-old mom from Nashville, had back pain, so her doctor prescribed her enough opioids for three football players. She suffered a overdose on July 22, 2015, becoming one of seven Rinehart patients to die before he left the state.

Rinehart had written Martin a prescription for 30 milligrams of oxycodone to be taken three times a day, then later upped the dosage to four times a day. A proper starting dose would have been 5 milligrams, according to a pain management expert.

“If it were a very large linebacker-shaped male who’s very healthy, maybe 7½ to 10 milligrams,” Dr. William Clay Jackson saidat Rinehart’s trial. “But I don’t know of any of my colleagues who would start with 30 milligrams three times a day.”

This was a common refrain at Rinehart’s trial, at which Jackson, a West Tennessee pain specialist, became the backbone of the state’s case. During hours of testimony, Jackson said he reviewed medical records from 32 Rinehart patients, finding them all to be “below the standard of care.”

In many of those cases, Jackson said, it appears that Rinehart “copied and pasted” symptoms and examination notes from one patient’s file to another, creating medical records that were contradictory and nearly impossible to follow. Jackson also testified that Rinehart’s patients repeatedly failed routine drug tests — revealing they were taking drugs outside of their prescriptions — then Rinehart responded by increasing dosages instead of cutting them off.

In the rare cases in which patients did face consequences, they didn’t stick.

That was what occurred to J.S., a young man who first came to Rinehart’s clinic complaining of back pain in 2014. He was prescribed Norco, an opioid painkiller.

Red flags arose the next year when multiple urine tests found no painkillers in his system, suggesting that J.S. may have been selling the Norco instead. Rinehart responded by sending J.S. a letter saying he was dismissed from treatment at the clinic.

But, for some reason, that just didn’t happen. Medical discipline records show J.S. returned to the clinic several times after the dismissal letter was sent. Rinehart continued to see the patient and prescribe him painkillers.

What Rinehart didn't realize, however, was that the patient had a secret.

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Opioids, Adderall and an undercover camera

It was Feb. 9, 2016, when J.S. returned to Rinehart’s clinic with a hidden camera, secretly collecting evidence for the ongoing investigation by Maury County law enforcement.

This video footage, obtained through a public records request, shows Rinehart increase J.S.’ Norco dosage from two pills a day to three after the patient says he has been taking the pills faster than prescribed.

J.S. then asks if there is anything Rinehart can prescribe to help him “focus.” Rinehart offers him a prescription of Adderall, an addictive stimulant used to treat attention deficit disorder.

The video, which appears to capture the entire doctor's visit, lasts only 2½ minutes. It does not show the patient receive a diagnosis to justify the Adderall.

When questioned about this video footage by the Tennessee Board of Medical Examiners, Rinehart could not explain why he was so quick to prescribe powerful medications or why he wrote in medical records that he physically examined the patient when the video made it clear no such exam occurred.

Rinehart also could not explain why he still prescribed the patient drugs even after banning him from the clinic. Rinehart blamed his nurses, who he said should have stopped J.S. at the front door.

“I would never dismiss somebody knowingly, bring them back and then prescribe them the same medicine I dismissed them for not being in their system,” Rinehart said. “I just wouldn’t do that.”

“But you did,” said Robert Ellis, a board member.

“I did, unknowingly,” Rinehart responded. “You are absolutely right.”

Admissions like this one are no comfort to parents like Bonnie Blackburn, the mother of Mathew Blackburn, who had a fatal overdose.

In an interview, Bonnie Blackburn said her son had long struggled with medication abuse, so he needed a doctor who would protect him from addiction, not enable him.

When told that Rinehart had tripled her son’s Xanax prescription only two days before he died, her voice quivered. Then she smiled wide, trying to mask her rage.

"I'd like to wring his neck," she said. “I hope, when this story comes out, that in Indiana they look into his records, so it doesn’t happen to somebody else.”

Indianapolis Star reporter Shari Rudavsky contributed to this story.

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Brett Kelman is the health care reporter for The Tennessean. He can be reached at 615-259-8287 or at brett.kelman@tennessean.com. Follow him on Twitter at @brettkelman.