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Feb 8 2012

Are “pill mills” Florida’s newest export?

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In July 2011, Florida enacted sweeping new restrictions that aim to stop or at least dramatically reduce the flow of narcotics from the state’s many “pill mills.” The crackdown has many regulatory and law enforcement agencies concerned that operators of these clinics will attempt to shift their illegal and medically unacceptable practices to other states. The North Carolina Medical Board considers excessive and inappropriate prescribing of controlled substances among its most pressing patient safety and public health concerns. It will not tolerate the patterns of practice typically associated with illegal pill mills and will act swiftly upon any information that such activity is taking place in North Carolina.

This article will provide a brief overview of the problems associated with prescription drug misuse, review the characteristics of pain management clinics often referred to as pill mills and, finally, provide treating practitioners with guidance on spotting “red flags” that may signal drug seeking behavior and/or possible drug abuse/addiction in patients. Prescribers can protect themselves by becoming educated about appropriate standards of care and best practices in pain management.


Each day throughout the US about 75 people die and 2,000 people are treated in an emergency department due to unintentional poisoning. Between 85 and 95 percent of poisoning deaths result from prescription drug misuse. According to the latest data from the NC Center for Health Statistics, unintentional overdoses of prescription medications account for almost three deaths a day in North Carolina. The U.S. Centers for Disease Control and Prevention
(CDC) reports that the increase in deaths from drug overdose is a direct result of increasing abuse and misuse of prescription opioids and other controlled substances.

This increase in some states is directly related to the abundant supply of narcotic medications available due to malicious, illegal and excessive prescribing by individual physicians operating out of what have been termed pill mill pain management clinics. For example, recently a Florida physician was arrested and his medical license summarily suspended. From January through August 2011, this physician reportedly prescribed 250,000 oxycodone pills to his patients. By comparison, in all of California just 300,000 pills were prescribed in the last six months of 2010. The federal government has stepped up law enforcement actions against physicians and others who prescribe excessively and inappropriately. Public policy changes, such as the new law enacted in Florida, are another way of addressing the issue.


Medical regulators in other states know that operators of Florida’s many pill mills won’t simply close their doors. Rather, some are concerned that dangerous and illegal prescribing practices may migrate to other states. A recent article in the Georgia Composite Medical Board’s newsletter, prepared by Adrienne Baker and Jeffrey Lane, outlined certain characteristics associated with these pill mill operations that are not typically found within a legitimate pain management practice. We have shared their list here in order to educate prescribers in North Carolina. Licensees should avoid associating themselves with any practice or clinic with some or all of the following characteristics:

• The physician has minimal to no training in pain management.
• A cursory or no patient exam performed.
• Large volume of patients seen daily (100+).
• Patients drive long distances, often from other states. In many cases patients carpool.
• Clinics place advertisements for pain management physicians in small papers or Employer is a non-physician owned staffing company and work is part time. Clinic owners are not healthcare providers, have no medical training, may be from out of state, and attempt to convince the physician the clinic is operating legally.
• Clinic is run on a cash only basis.
• Similar prescription “cocktail” for each patient.
• Drugs are dispensed onsite (patient pays for office visit then pays for the drugs).
• Security guards are employed by the clinic.
• All patients receive an identical diagnostic work-up or are referred to the same MRI imaging facility.


The NCMB often hears that licensees are hesitant or unwilling to prescribe controlled substances because they fear they will be subject to public action by the Board. It’s important to understand what practices are likely
to bring a prescriber to the NCMB’s attention. Often prescribers who come under Board scrutiny have overlooked red flags that should have indicated the possibility of diversion, abuse or misuse. While the presence of “red flags” does not necessarily mean that the patient is “drug seeking” the presence of some or all of the following circumstances should raise the prescribers index of suspicion:

• The patient is from out of state.
• The patient requests a specific drug and states that alternative medications do not work.
• The patient says his or her previous physician closed their practice.
• Prior treatment records cannot be obtained.
• The patient claims he or she cannot afford indicated or appropriate diagnostic testing.
• The patient presents to the appointappointment
with an MRI.
• The patient presents to the appointment with his or her pharmacy profile showing specific drugs they want prescribed.
• Several patients arrive by carpool.
• The patient tests positive for illegal drugs.
• Drug screen reveals no prescribed medication in the patient’s system.
• The patient recites textbook symptoms.
• The patient pays in cash only and has no insurance.
• The patient calls for early refills and prescriptions or regularly reports that medications are lost or stolen.
• The patient’s pain level remains the same over several subsequent visits.
• The patient is noncompliant with the physician’s treatment plan.


The Board recognizes that quality medical care includes the appropriate, effective treatment of chronic pain and supports patients’ rights to such care. The Board further recognizes that prescribing controlled substances over the long term may be an essential part of an appropriate treatment program. However licensees who inappropriately or excessively prescribe opioids and other controlled substances remain an enduring problem. Once again, North
Carolina will not tolerate illegitimate pain management practice as described in this article.


The NC Controlled Substance Reporting System (CSRS) is a database of all controlled substance prescriptions dispensed in outpatient pharmacies in North Carolina. This resource can help a practitioner avoid prescribing to a patient who may be receiving controlled substances from multiple sources. For more information on the CSRS, or to download an application for access, visit:

 Comments on this article:

All of the above descibe methadone clinics, which according to controlled substance web site don’t have to report their patient’s use.

By drew on Feb 13, 2012 at 12:33pm

In NC the methadone clinics are not required to report their pts usage as the rest of us do.  This is a problem as most of these pts have already had issuse in our prescribing sys.
we always check new and old pts getting narcs at the nc web site for just the reasons stated n the article. It would be helpful if all the clinics were required to report.  as of now there is no way for me to tell if a pt is double dipping without drug testing all.

By D. Michael Mahan MD on Feb 13, 2012 at 12:42pm

Unfortunately the action against pill mills addresses only the tip of the iceberg and then is too late considering all the damage done, lives lost and careers destroyed by addiction.  The Board to take a more proactive stance requiring adherence to quality care standards and doing audits off all high volume prescribers. A small percentage of physicians prescribe more that 80% of the opioids dispensed. The NCMB needs to hold these physicians to a high standard of knowledge and clinical practice consistent with the dangers associated with opioids.

By David Ames MD on Feb 13, 2012 at 3:03pm

the serious problem of abuse and over use of opiods is an iatrogenic problem created mostly by naive or greedy physicians and perpetuated by state medical licensing agencies that have been asleep at the wheel for years. where is the over site of unscrupulous providers and why aren’t they sent directly to jail? hardly a day goes by that I am not impacted in some way be this poor care provided by members of my profession. Our credibility as a profession has been hurt and I am shocked and ashamed.

By james hoffmeister on Feb 13, 2012 at 5:50pm

Completely agree with Dr. Ames. To make any inroads in preventing the misunderstood disease of addiction and reducing the mounting toll of overdoses and death, a proactive, preventative stance is mandatory. This should dictate that opioids for chronic noncancer pain be prescribed very selectively and only for specific clinical indications of severe tissue-generated chronic pain in the absence of a history of substance abuse and concurrent mental health issues, such as depression. There needs to be greater recognition that prescription opioids act upon the brain by displacing the natural endogenous opioids of its own mu-opioid system which controls the intimate inter-relationships between stress, emotions and pain, while controlling these essential functions with prescription opioids can predispose to addiction, especially with long-term use.

By Steve Gelfand, MD on Feb 13, 2012 at 11:33pm

Having gone through the process of investigation and disciplinary action from the NC Medical Board for treatment rendered to patients for chronic pain syndromes and frequently opioid dependence, I have had the opportunity to ponder this problem in great depth. I have concluded that the core problem lies within the failure of the medical community to effectively address the disease of addiction. Patients suffering from this disorder will just find another drug to abuse if one is taken away. In our state chronic pain sufferers are not the problem and neither are the doctors who legitimately try to help them.  Each of these doctors are faced with the challenge of picking up on the red flags for which the remedy is to discharge them back into the evergrowing pool of substance abusers who then seek out another doctor but with more knowledge of how to conceal the red flags. Florida is dealing with fraud and blatant malpractice which is not the issue in North Carolina. It is becoming increasingly evident that a substance abusing individual tends to either exhaust their means or die from accidental overdose at some point. Stopping the behaviors becomes extremely difficult over time. Until we all become more serious about treating this public health nightmare known as addiction the medical profession will see the problems written about here continue to increase. As doctors we have the convenience of washing our hands of addicted patients. That protects our medical license and our reputations but doesn’t have any real effect on the real problem.

By Ken Headen, MD Psychiatrist on Feb 14, 2012 at 7:36pm

“Pill Mills” are but the latest legacy of almost 100 years of drug prohibition, a failed policy based on conservative religious dogma, not medical or social science.
Well, at least 10% of American citizens do not belong to that religion.  Unfortunately, five generations of drug prohibition has caused an horrendous ignorance to safe drug use. Thus the sad overdose deaths that plague us all.  We can make all the rules and laws we want, but the problem will continue until drug prohibition is replaced by realistic regulated sales to adults and real drug education to our youth. Don’t hold your breath.

By James Stewart Campbell, MD. on Feb 17, 2012 at 2:00pm

I am a patient!! After reading each of your comments my problem is I have taken pain medication since 2002 when I was injured in an auto accident. I have never ever requested more prescription or claimed I lost mine. I take my meds as prescribed and this crackdown on pain meds being given by regular physicians is understandable but it is affecting me because my doctor of 24 years is now just completely cutting me off of everything I have been taking for 10 years. I don’t feel like it is fair for the physicians to categorize everyone because of all the idiots out here that use these drugs as a high. I need my meds to function daily without pain and I am horrified at the thought of not having my meds now because of this epidemic. I understand where you are coming from but don’t judge all your patients by whats going on in this world because some of us really do need the pain medication and we use it correctly!!!

By A. Hernandez on Feb 22, 2012 at 1:17am

It’s amazing to me that the pharmaceutical companies manufacturing these drugs take no responsibility. When did we ever need some addictive drugs to stop pain? I think it’s high time the drug companies be held accountable for there role in this epidemic.

By AMKL on Mar 01, 2012 at 6:47pm
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