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Florida system often fails to catch Medicaid abuse at source

 FORT LAUDERDALE, Fla. - (KRT) - 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, Fla., 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.

_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.

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.

_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.

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.

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.

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, Fla., 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.

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.

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.

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.

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."

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