ABUSES OF PRESCRIPTION DRUGS 'DEMAND RESPONSE' FROM GOVERNMENT AGENCIES

The victim's skin was cold and had a bluish tinge when Titusville Police
Officer Margaret Vess arrived on May 9, 2001. Geri Futch, 39, was dead of
an overdose of cocaine, diazepam, a sedative, and morphine, a painkiller.

Supplying narcotics that kill someone can be murder under state law, but
Titusville police never found out where the drugs that killed Futch came from.

Vess found three empty diazepam vials and two other pill bottles in the
house and tossed them, police records show.

The handling of Futch's case reflects shortcomings in death investigations
that officials concede they must overcome if they are to stem the abuse of
prescription drugs that has killed at least 2,000 Floridians, most in the
past two years.

Though state law recognizes that others besides the victim may share blame
for these deaths, authorities seldom hold anyone but the victims accountable.

Pain patients and doctor "shoppers" who amass pills and illegally sell some
for quick cash often aren't tracked down and prosecuted.

And some doctors and pharmacists cater to the drug appetites of addicts
with little fear of being arrested or losing their licenses -- no matter
how many of their patients die.

Things won't change unless government agencies rethink their missions,
abandon dated attitudes toward drug abuse and those who knowingly assist
it, and most of all tighten up and modernize record keeping and fraud
detection systems.

"If there were only financial costs, it would be a serious problem," said
state drug czar James McDonough. "But there are also fatal consequences
here. It demands a response."

Among the critical needs:

No standards exist for collecting and preserving evidence in drug deaths.

Not all investigating agencies routinely log the names of doctors taken
from prescription bottles found at death scenes.

There is no way to find out which doctors prescribed the drugs involved in
more than 200 deaths the South Florida Sun-Sentinel looked at in an
eight-month statewide investigation. Nor do most police reports indicate
that detectives tracked down the seller of pills that killed in cases where
the victim purchased them illegally.

Florida's medical examiners could play a key role in helping regulators
weed out bad doctors, but they almost never do.

The newspaper could document only three instances in the past two years in
which a medical examiner reported a doctor with alarming numbers of
overdose deaths, or with a trend for overprescribing drugs, to police or
licensing boards. The three reports came from Dr. Roger Mittleman, whose
medical examiner district covers Martin County and three others.

Even if they have no qualms about turning in problem practitioners, medical
examiners have no systemized or interconnected database that could help
them find doctors with high numbers of patient deaths.

When patients visit a doctor in the jurisdiction of one medical examiner
but die in another, no state agency can pick up the trail. Florida has two
dozen medical examiner districts and each operates independently.

The Sun-Sentinel identified 32 doctors who had patients who died of an
overdose a county or more away. One physician had eight patients die in
five counties in the past two years. Another doctor had 18 patients
overdose and die from Broward County north to the Space Coast. Not until
the newspaper obtained case files from two dozen morgues and computerized
them did the pattern become apparent.

State health officials need a warning system that can identify new drugs
turning up in the bodies of the dead and quickly alert doctors to use
caution in prescribing them.

Methadone, for instance, contributed to more than 350 deaths in Florida
during 2001, mostly because growing numbers of doctors were prescribing the
heroin substitute as a painkiller. But it took state health officials until
mid-December of 2002 to send letters advising doctors of the upsurge in
deaths. Several drugs, including pain patches laced with the narcotic
fentanyl and morphine pills, have not been evaluated in this manner, even
though they are killing people in alarming numbers.

Law enforcement must launch aggressive and coordinated assaults aimed
directly at abuses of drugs and Medicaid fraud.

State officials have siphoned off limited investigative resources as new
drug crises have appeared, most recently: counterfeit drugs, illegal
designer drugs and wayward Internet pharmacies. While each threatens public
health, none has caused anywhere near the carnage of misused legal medicines.

For example, the newspaper could confirm only three cases out of 2,000
overdose deaths examined in which a shady online dealer supplied pills that
caused a death.

The Medicaid Fraud Control Unit of the Florida Attorney General's Office
says it could use more help from the Agency for Health Care Administration,
the operators of Florida's $10 billion-a-year Medicaid program.

The health agency keeps track of tens of thousands of doctors and
pharmacists and their transactions with almost 2 million patients. It is
concerned about keeping enough doctors participating in the program to
provide care for all who need it and tends, like many government units, to
be protective of its contractors.

The fraud unit contends that the health care administration shows little
interest in helping weed out medical professionals who steal from taxpayers
by overbilling.

Casualties Are High

Several Florida counties log two or more pill deaths a week. Middle-aged
people who have slid over years into addiction are struck down at home;
young thrill seekers die on random binges.

Many death reviews start like the call Titusville Police Officer Vess answered.

Geri Futch's body lay naked on a sofa, with no marks of trauma or foul
play. Vess found prescription bottles for OxyContin, diazepam and
lorazepam, all less than a month old, and she "disposed of " them after the
body was taken to a local hospital. Vess called the medical examiner's
office, which took jurisdiction of the case, according to her sketchy,
one-page report.

Titusville police officials did not respond to repeated requests to
interview Vess.

An autopsy showed that Futch died of intoxication from several drugs,
including cocaine and morphine. The morphine might have been heroin, or it
could have been pills.

But the name of the doctor who prescribed the pills or any indication that
police looked into where she got the drugs that killed her appear nowhere
in police records of the case.

Hundreds of death files the newspaper reviewed lacked basic details,
description and critical information, especially the source of the fatal drugs.

Statewide, in about 1,600 cases, pills were present at the death scene in
pharmacy bottles bearing the name of the medication, its dosage, the name
and address of the pharmacy and the name and identification number of the
prescribing doctor. In about 250 of those cases, available records mention
only the name of the drug.

In Miami-Dade County, with the state's highest concentration of both
doctors and overdose deaths, investigators at the morgue don't keep track
of the names of doctors because county forms contain no space in which to
enter them.

"That might be something we need to start. Somebody ought to be working on
this. There ought to be a professional watchdog on this," said Larry
Cameron, director of operations for the Miami-Dade Medical Examiner's Office.

In Gainesville, "it is not policy to generate" lists of medications found
at death scenes, according to Albert Isaac, the medical examiner's office
operations coordinator.

Staffers at the Hillsborough County Medical Examiner's Office in downtown
Tampa started logging the names of doctors who prescribed drugs found at
death scenes only in late 2002.

"The name of the doctor (who prescribed pills) ought to be there," said Dr.
Stephen Nelson, chairman of the Florida Medical Examiners Commission, a
division of the Florida Department of Law Enforcement set up to oversee the
state's two dozen medical examiners.

"That would be real easy to rectify. That's something the commission could
look at," Nelson said.

Opportunities Missed

Even offices that diligently inventory pills often lack the computer power
to search these records to turn up patterns, so it is possible for one
doctor to prescribe pills in a dozen deaths or more without anybody noticing.

Dr. Mitchell Wick, whose Plantation pain management office police
considered a haven for pill freaks, did just that.

Last year, the Sun-Sentinel conducted a labor-intensive search of thousands
of computer and paper records at the Broward County Medical Examiner's
Office and discovered 16 overdose deaths among Wick's patients dating back
to 1999.

State medical regulators reacted by issuing an emergency order in April
2003 barring the doctor from ordering narcotics. The state Board of
Osteopathic Medicine has not yet scheduled a hearing on his case.

Most of Wick's patients died in Broward County. But doctors whose patients
cross county jurisdictions to obtain pills, which many do, and then die in
their homes are all but invisible to state regulators or law enforcement.

The Sun-Sentinel identified 32 such doctors.

Dr. Bach McComb lost five patients between October and December of last
year, two in the Sarasota area, and two in Broward County, where he also
ran an office, the newspaper found. The fifth victim lived in Palm Beach
County. An autopsy found that Gary Smith, 39, of Boca Raton, died on Oct.
4, 2002, of an accidental overdose of cocaine, hydrocodone and oxycodone.

Four bottles of pills McComb prescribed and Smith filled within three days
of his death, including hydrocodone and OxyContin, which contains
oxycodone, were at the scene.

No doctor has been linked with more pill deaths stretching farther across
Florida than Port St. Lucie pain specialist Asuncion Luyao, one of three
doctors whom medical examiner Mittleman reported to the state for
disciplinary action.

Mittleman said he grew concerned as bodies kept arriving at his morgue with
pills from Luyao in evidence bags. The Florida Department of Health
suspended Luyao's medical license by emergency order in March 2002, citing
a dozen overdose deaths. Prosecutors have charged her with six counts of
manslaughter and she is set to go on trial early next year.

That wasn't all the deaths, however. The newspaper's investigation
documented a total of 18 fatal overdoses among Luyao patients in four
medical examiner's districts from April 2000 to mid-2002. Two people died a
month or more after the state yanked her license, but before pills she
prescribed ran out, autopsy files show.

Mittleman stands alone among his colleagues in turning in any doctors, or
at least he's alone in creating a paper trail.

"I think that as medical examiners we have a responsibility to keep our eye
on the public health," Mittleman said. "I try to do the right thing."

Medical examiners commission chairman Nelson agrees. He said he had "no
hesitancy to drop a dime" on a doctor he suspected of reckless prescribing,
but conceded that not all colleagues share that view.

Nelson said he would support legislation to broaden use of medical examiner
data in medical disciplinary proceedings and to require that all districts
report these cases to state health officials.

"I think if there is legislative action it would happen, and I support
that," Nelson said. "We should try to make a difference."

Slow Recognition

Florida's medical examiners could make a difference just by getting an
accurate count of the drugs that kill.

Twice a year, the state's morgues submit reports on drugs found during
autopsies to the Florida Department of Law Enforcement, but in recent years
the list has been heavily weighted toward such illegal drugs as heroin,
cocaine and marijuana.

As a result, the system was slow to recognize the speed with which
prescription medicines overtook street drugs as killers in most parts of
the state.

The state started logging deaths involving the painkillers fentanyl,
propoxyphene and morphine only this year, for example, thus missing a surge
in deaths connected to these drugs that started as early as 2000. Had they
been alerted, health officials might have been able to warn doctors.

In most parts of Florida, patterns of pill abuse jump out at anyone who
sits down and reviews medical examiner case files.

For instance, in Leesburg, seven of 27 deaths during 2002 involved
propoxyphene, three of them the same month. And bodies brought in with
fentanyl-laced patches stuck on them are becoming far more common.

State officials hope to cut the death toll by setting up a computer system
that would track all narcotics prescriptions in real time. A doctor or
pharmacist could tap into the computer and verify on the spot whether a
patient was receiving drugs from more than one doctor.

In the last two sessions, however, the Florida Legislature has failed to
act on a measure to establish the system, for which Purdue Pharma, the
maker of OxyContin, pledged $2 million.

In theory, the database could save lives by cracking down on "doctor
shopping," as in the case of a Broward County man who died in March with
prescriptions in his home for the sedative alprazolam from six doctors.
Pills that "shoppers" then sell to others also have been implicated in deaths.

In Broward County on Aug. 20 of last year, police found Geraldine Kifner, a
26-year-old waitress, dead on the living room floor of a Hollywood mobile
home owned by Marilyn Georges. At the time, Georges was on probation for a
drug conviction. She told police she supplemented her $600- a-month
disability check by selling pills that her doctors prescribed for her. In
about a month and a half, she secured 1,639 tablets of morphine, OxyContin,
methadone and the sedative Xanax from five area doctors.

Georges admitted selling Xanax to Kifner. The two met at a drug rehab
center two years before Kifner's death of what autopsy records show was an
overdose of Xanax, methadone and morphine.

In a plea deal, Georges was sentenced in December 2002 to four years in
prison for obtaining drugs through fraud. Kifner's mother, Carol, didn't
like the deal and thought Georges should have been charged with causing the
death.

Police are most likely to find pills when people die at home. But even
then, relatives or friends sometimes get rid of drug paraphernalia and
clean up incriminating evidence before authorities arrive.

Much of the time, records show, what's left are pills that the victim
obtained legally with a prescription from one or two doctors.

Police often must wait three months or more for autopsy results because of
delays in receiving lab toxicology studies. Sky-high drug levels or the
presence of undissolved pills in the stomach, a note left behind or
testimony from friends and family that the person was seriously depressed
or had previously tried suicide may lead the medical examiner to rule that
the victim intended self-destruction.

But most of the time, lab tests show several drugs present in the body at
ranges beyond so-called "therapeutic" levels, leading medical examiners to
conclude that the mix accidentally caused death.

Even if police were inclined to ask questions about the source of drugs,
that long delay before test results come back and the fact that several
substances are implicated make prosecution difficult.

People don't usually incriminate themselves by telling police they gave or
sold the victim drugs. In other cases, people often die alone with no
witnesses to say what happened, or in the presence of fellow drug users
whose testimony is not reliable.

Still, police and prosecutors are taking a harder look at accomplices, even
accusing some doctors of crossing the line from healer to drug dealer.

In the past two years, authorities have arrested at least six Florida
physicians on narcotics trafficking charges and served search warrants on
others.

Florida officials say the number of drug deaths gives them no choice but to
step up investigations, both by focusing on Medicaid fraud that spills
prescription medicines into the black market and by paying more attention
to patterns of patient deaths.

Attorney General Charlie Crist said he strongly supports these efforts as a
step toward identifying the tiny group of doctors who recklessly prescribe
pills to addicts.

"That just seems to be a reasonable thing to do," Crist said. "If you can
attach deaths in any medical practice to an overprescribing of a powerful
narcotic drug and you see that it is happening repeatedly, there has to be
some consequence for that."

Crist said that doctors must take steps to treat pain effectively but also
need to guard against abuse.

"A legitimate doctor should not be enabling someone who is obviously an
abuser," he said. "That's wrong. It's irresponsible."