Earlier this month, after an intensive 14-month investigation, officials from the U.S. Drug Enforcement Administration and local police agencies served a search warrant on three dispensing pain clinics[1] in Lake Worth and West Palm Beach, Fla. The clinics, two of which are less than a mile apart, are owned by 29-year-old twin brothers; both brothers have a criminal record and neither has medical training. According to affidavits, one of the clinics netted more than $50,000 in cash daily. Physicians at one clinic earned from $861,550 to over $1.2 million a year.[2] Together, these doctors administered more than 2 million oxycodone pills in one year. Federal authorities contend that the clinics attracted people from Kentucky, Ohio, South Carolina, and Tennessee[3] who would travel to south Florida, often being “sponsored” by a “recruiter”; “patients” paid $5 for a pill that could subsequently be sold for $80 on the street. Charges have not yet been filed in this case.

Unfortunately, however, the practice in these clinics seem to exhibit many of the characteristics of what officials call “pill mills,” clinics where doctors prescribe or dispense opioids with barely a cursory nod to appropriate medical practice. Payments are received in cash; pills are often dispensed at the clinic with no pharmacy visit required. Physicians employed at such clinics often have little or no pain management training or experience and many times have no board certifications in any particular specialty. Many clinics hire security guards to control sometimes unruly “patients” who are seeking an appointment. The parking lots are full of cars and trucks with out-of-state license tags. “Patients” often go from one pain clinic to another and then to another in one day. According to Florida Palm Beach County Sheriff Ric Bradshaw, there are between 200 and 300 of these rogue pill mills now operating in Florida and they are contributing to the drug overdose rate in his county. State records reflect that nine Floridians die of prescription drug overdoses every day.

Last year, the Florida legislature enacted Senate bills 440 and 462 which gave the Florida Board of Medicine rulemaking authority over pain clinics and also authorized the creation of an electronic database to monitor the dispensing of controlled substances. However, the program will not be operational until December. In the meantime, Florida counties have taken their own steps to address the pill mill issue. Last year, Broward County convened a Grand Jury to address the proliferation of pain clinics in south Florida. Its report was issued in November of last year.[4] After a comprehensive review of the pain clinic issue, it recommended several steps that policy makers and legislators could take to regulate pain clinics to ensure that they do not devolve into pill mills. Its first recommendation was that the legislature amend the newly passed legislation by changing the 15-day reporting requirement to a near simultaneous requirement as a way to eliminate doctor shopping. Drug-seekers can see a lot of doctors and garner a lot of pills in 15 days. It also recommended that doctors who work at dispensing pain clinics be required to access and view patients’ prescribing histories in the prescription drug database prior to prescribing and dispensing medication to patients.

The Grand Jury’s report noted that, in less than a two-year period, the number of pain clinics in South Florida expanded from four to 176. It recommended that prescription drugs be prohibited from being dispensed at pain clinics unless there is no dispensing pharmacy within 10 miles or, in the alternative, that the clinics be authorized to only provide a three-day emergency supply instead of a 30-day supply. It also advised that pain clinics should be prohibited from advertising that they sell prescription drugs and that they be required to accept major medical insurance, providing regulators an additional means of regulating them.

On the topic of regulating pain clinics, the Grand Jury asked the legislature to consider whether it is appropriate for non-medical personnel to own pain clinics. It also recommended that the medical director for a pain clinic be board certified in pain medicine and that only doctors who are board certified in pain medicine be allowed to dispense drugs. Owners, doctors, and other employees should have background checks and no pain clinic should be owned by an individual, in whole or in part, who has been convicted or pled to a felony or to a misdemeanor that involved distributing or illegal prescribing of any narcotic. Finally, no doctor who has had his license affected as a result of dependency on drugs or alcohol should be allowed to own or be employed at a pain clinic.

Florida cities and counties have also been active in trying to pass their own ordinances to regulate pain clinics. Boca Raton is considering a law that would adopt one of the Grand Jury’s recommendations. The ordinance would allow a health care provider to dispense only a three-day emergency supply of a drug to a patient. In December, Palm Beach County, West Palm Beach, and Lake Worth passed moratoriums on the opening of new pain clinics. Delray Beach placed limits on where pain clinics can open and prevents them from dispensing medications. More recently, the city attorney is looking into whether the city could require doctors or clinics filling a prescription for a controlled substance to submit the patient’s fingerprint into a database as a method to control doctor shopping.

The Florida legislature is also considering new legislation[5] which would mandate training for all physicians prescribing controlled substances and allow the new prescription monitoring drug program to provide information to law enforcement on possible illegal medical practices. The proposed legislation would also adopt one of the recommendations from the Grand Jury by prohibiting felons and negligent physicians from owning pain clinics.

It is not only Florida that is experiencing a proliferation of pain clinics.[6] Last October, newsman Dan Rather reported on pain clinics that are opening in Houston, Texas. Like the Florida clinics, they accept only cash, not credit cards or insurance. He noted that these clinics attract drug traffickers from Mississippi and Louisiana. On the program, he interviewed a couple whose son, Christopher, died from a prescription drug overdose. Five days before he died, Christopher had walked into a local pain clinic and returned home with nearly 400 pills. Louisiana has passed legislation that required pain management clinics to be licensed.[7] In the last legislative session, Texas passed a bill that now requires pain management clinics to be certified by the Texas Medical Board and provides tools to the Medical Board to investigate and regulate the clinics. It also requires that pain clinics be owned and operated by a licensed physician.[8]

Law enforcement and regulators alike are keenly aware of the delicate balancing act required to address these rogue clinics and doctors. Nonetheless, with the rapidly rising rates in overdoses and overdose deaths from prescription drug medicines, it is incumbent for members of state and local communities â legislators, health care advocates, policy makers, health providers, law enforcement personnel, social welfare agencies, and educators â to come together to hammer out solutions to a problem which has particularly affected young adults. It will take the combined efforts of local communities, states, and the nation as a whole to find effective tools to fight prescription drug diversion and its pervasive effect on our society.

[1] Dispensing clinics are those that are permitted to hand out controlled substances at the clinic with no necessity for a patient to go to a pharmacy to have a prescription filled.

[2] The high monetary compensation may answer the question as to why any doctor would practice in such an environment. Physicians may be being recruited through mechanisms such as Craig’s List. On March 2, the southern Florida Craig’s List posted opportunities for employment for physicians at three pain clinics.

[3] Tennessee legislators are responding to the increase in drugs being trafficked in the state that are coming from Florida by considering S.B. 3027. The bill would increase the penalties for the illegal trafficking of out-of-state drugs from a Class C misdemeanor, which carries only a 30-day jail term and up to $50 in fines, to a Class D felony, which carries a 2 to 12 years prison sentence and up to $5,000 in fines.

[4]The report is available on the web, click here.

[5]See H.B. 225, H.B. 671, H.B. 1449, S.B. 646, S.B. 804, S.B. 2272, and S.B. 2722.

[6] At the Spring Meeting of the National Association of Attorneys General, during a panel discussion on prescription drug diversion, moderated by Montana Attorney General Steve Bullock and Washington Attorney General Rob McKenna, it was noted that California, Florida, Ohio, and Texas were among the states that were particularly concerned about and addressing the issue of pill mills in their states.

[7] La. Rev. Stat. Ann. § 40:2198.12.

[8] S.B. 911. In introducing the bill, Senator Tommy Williams commented that pain clinics in Texas were proliferating because Louisiana’s legislation had been successful in shutting down pill mills.