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Mark was an up-and-coming attorney in 2001, working long hours in Tampa, when he was involved in a minor traffic accident. The young litigator suffered a neck injury and was prescribed painkillers by the emergency room physician who treated him. Following up with his primary physician, he was prescribed more medication, and referred to a specialist for a surgery consultation to repair the disc in his neck. Problem was, Mark kept long hours. His schedule was filled with depositions and trials, so surgery would have to wait. He chose to deal with the pain, managing it with the medications he had come to depend on.

A year later, his wife went to wake him after a particularly long night spent writing briefs for a case. He was dead. The autopsy showed he died of an overdose of hydrocodone. In the chaotic days that followed, his family discovered evidence of more than a dozen different medications, including hydrocodone, oxycodone, Percocet, Roxicet, Diazepam, and Methadose, prescribed by at least eight different physicians, and from Internet pharmacies. His family doesn’t know why, but for some reason, Mark kept the empty prescription bottles, dozens of them. None of them, not even his wife, had any idea he was taking so much medication, nor how he obtained it all. Two days after Mark’s death, a package arrived via UPS. It contained 100 hydrocodone tablets prescribed by Dr. Jean Dominique, from a clinic in Kissimmee. Dr. Dominique’s name was also on a prescription Mark filled at a Tampa pharmacy.

It was frustrating for Mark’s family to see all the prescriptions he had obtained from these doctors and online Web sites. They wanted to know how he was able to obtain that much medication so easily. They would soon learn just how easy it is and how a staggering number of people are dying of prescription drug overdoses.

The use of opioid painkillers, the class of narcotic drugs including oxycodone, hydrocodone, Vicodin, Fentanyl, Percocet, and Darvocet, now causes more deaths than cocaine and heroin combined. According to the U.S. Drug Enforcement Administration’s (DEA) 2009 report, the number of Americans abusing prescription drugs increased 80 percent between 2000 and 2006, and prescription painkillers have topped marijuana and cocaine as the most used drugs. Overdose deaths from prescription opioids increased by 114 percent in the same period, while deaths from traditional street drugs declined. Florida is a particularly dangerous state for prescription drug deaths. In 2008 alone, over 2,100 Floridians died from prescription drug overdose, compared with 1,169 deaths from alcohol-related automobile accidents. This increase is largely attributed to the high number of pain clinics located primarily in South Florida.

“Pain mills are huge in Florida.” Explains Dr. K., a clinical psychologist, who, because of her work with doctors in recovery, does not want to be identified. “These storefront clinics often work in conjunction with a pharmacy to serve people who are ‘doctor shopping’ for prescriptions.”

Patients are given a quick examination, which often consists of just answering a few questions. Operating on a cash-only basis, these pain mills, or pill mills, attract customers from all over the United States. In fact, one method law-enforcement officials use to find pill mills is by looking for out-of-state license plates in the parking lots.

Why is Florida the pill mill capital? Florida is the largest of the 11 states that has no database for monitoring prescriptions, making it easy to doctor shop in the Sunshine State. People come from Kentucky, West Virginia, Alabama, and other states where prescription- monitoring databases are already in effect. This will change, however. In June 2009, Governor Charlie Crist signed a bill to establish an electronic database allowing physicians and pharmacies to monitor a patient’s prescriptions, thereby reducing a person’s ability to cultivate prescriptions from multiple sources. The program, however, could take a year or more to become active as funds to develop and manage the database are appropriated.

In the meantime, law-enforcement agencies are working to shut down pill mills, as well as illegal Internet pharmacies. Dr. Jean Dominique was arrested in 2006 and pled guilty to one count of conspiracy to possess, with intent to distribute, hydrocodone. According to the DEA database Criminal Cases Against Doctors, after being hired by an Internet pharmacy, Dominique and pharmacy assistants used his DEA registration number to authorize prescriptions and refills. He never spoke to the online patients or confirmed their conditions. He and the assistants received a commission for each prescription filled, often allowing two or three refills per prescription. He was sentenced to five years probation, 300 hours of community service, and fined over $300,000 dollars.

Dr. Juan Antonio Ibanez, a physician affiliated with another Internet pharmacy from which Mark was receiving hydrocodone, was indicted in 2007 on charges he made $85 million selling illegal prescriptions over the Internet and for money laundering. Earlier this year, he was sentenced to 51 months in prison for distributing pain medicine through Internet Web sites. These are just two of more than two dozen Florida doctors who have been arrested for dealing prescription drugs or selling prescriptions since the DEA began tracking cases in 2003.

In October 2008, then-President Bush signed the Ryan Haight Online Pharmacy Consumer Protection Act, named for an 18-year-old California honor student who died in 2001 of an overdose of Vicodin he purchased online with his family computer and his parents’ debit card. Ryan purchased the medication the same way Mark did, through an online pharmacy that employed its own doctor, who would review each patient’s records, and issue a prescription the pharmacy would then fill. The patient records consisted of an online questionnaire, in which Ryan indicated he suffered from back pain. Testifying before Congress, Ryan’s mother later stated, “At a time when we were worried about our children being exposed to pornography and predators, marijuana and alcohol, we did not know that drug dealers were in our own family room.”

According to the DEA, the doctors affiliated with these illegal Web sites may have never seen the pharmacies with whom they work. They often are located across the country, working online, and being paid by the number of prescriptions they approve, which could be hundreds per day. The Ryan Haight Act requires that to be a legal prescription, it must originate from a

physician who has conducted at least one physical examination in person with the patient. In addition, online pharmacies must list on their Web site the owner of the Web site, the name of the pharmacist affiliated with the site, and the names of any physicians working with the Web site. Any pharmacy that uses the Internet for distribution of medication must register with the DEA. To identify legitimate online pharmacies, consumers should look for pharmacies that are accredited with the National Association of Boards of Pharmacy as “Verified Internet Pharmacy Practice Sites,” or VIPPS.

After Ryan died, his friend came forward to tell Ryan’s parents how he had ordered Vicodin online. The majority of kids, however, get prescription drugs for free, often straight from their parents’ medicine cabinets. The most commonly used prescription drugs include narcotic painkillers like Vicodin and hydrocodone, depressants for anxiety and sleep disorders, such as Xanax and Valium, and stimulants for treating ADHD like Ritalin and Adderall. The National Institute on Drug Abuse (NIDA) reports that among 10th graders, use of tobacco, alcohol, and amphetamines are down, while use of marijuana, over-the- counter medications, and prescription medications has increased.

There is a perception among young people that these drugs are not as harmful as cocaine, heroin, and methamphetamines, despite the deaths of thousands of teens, and celebrities like Anna Nicole Smith, Heath Ledger, and Michael Jackson. It doesn’t help that some celebrities, like rappers Eminem and Lil’Wyte, glorify drug use in their music. Eminem even sports a Vicodin tattoo.

Parent should never assume their teenagers aren’t candidates for drug abuse. Monitor what is in your house, and keep narcotics locked up. Parents can help by, first and foremost, being good role models.

“A positive example from parents is always the most helpful and effective way to keep a young person on a positive track,” says Carol Wiard, CAP, ICADC, Director of Perspectives Outpatient Treatment Program for Alcohol and Drug Dependency. “A healthy home environment with parents present, both physically and emotionally, provides a solid base.” Wiard says if a parent believes their child is using, he or she probably is, and they should seek professional help. “Excessive punishment, shaming, and chastising will only create an atmosphere for dishonesty and deception.”

Mark started out as a legitimate patient, suffering from real pain. How did he end up as an overdose victim? It’s a cycle that repeats all too frequently throughout the country.

“Most people begin taking prescription painkillers for all the right reasons; to manage pain caused by an accident or injury,” says Dr. K. But when not managed properly, addiction is often the result. A person’s genetic makeup has a lot to with whether they can take narcotic pain medications. If addiction runs in the family, they are more likely to develop a problem. For help in managing pain medications, have your physician refer you to a pain specialist.

“You wouldn’t see a psychologist for a heart problem,” says Dr. K., “Go to a board-certified pain specialist to manage your pain therapy.”

Dr. YiLi Zhou, MD, PhD, board certified in pain medicine, neurology, and psychiatry, and Medical Director of Comprehensive Pain Management of North Florida, says that narcotic pain relievers should be the last resort in pain therapy. While there are people who need narcotics, for example, advanced cancer patients and back surgery patients; people with muscle and joint inflammation should stick to over-the- counter anti-inflammatory medications such as Motrin and Tylenol. Other forms of treatment, such as physical therapy and pain-site injections, need to be explored before trying narcotics.

“Doctors should not let their patients try narcotics ahead of other options because once you are hooked, you’re hooked.” Says Dr. Zhou, “There is only a five percent rehabilitation rate for people addicted to narcotics.” The brain’s chemistry is changed by drug use, making it very difficult to overcome addiction. Dr. Zhou explains the events that happen next. “You lose your family, then your job, and you go to the lowest social status. Your one goal in life is looking for drugs.” His office displays a sign warning people who are doctor shopping or looking for illegal prescriptions that they have come to the wrong place, and will be turned in to the authorities if caught. Dr. Zhou recommends that people “work with your doctor, follow the instructions, and don’t overtake your medications.”

There were signs that Mark was in trouble, but even the people closest to him, his wife and his best friends, didn’t realize how much he was using. If you are worried about someone in your family who is taking prescription painkillers, incorporate a system of checks and balances. Keep a record of the doctors they see and what medications they are taking. Hold the medication for them and administer their doses. Watch for signs that they are taking the medication for reasons other than its prescribed use. The best way to protect your family is to be involved with each other, keep communicating, and act if you see signs of trouble.

Ocala Magazine, November 2009

Winner, Florida Magazine Association Silver Charlie Award, Public Service Writing, 2010