LEWISBURG, TN (RNN) - Shortly after Dr. Mark A. Murphy, a top opioid prescriber in the U.S., started practicing here three days a week last year, the clinic owners asked a police detective to meet for dinner.
Lewisburg Police Lt. Tom Miller thought the request seemed like a preemptive strike to keep the cops away from the Specialty Associates clinic.
"They … wanted to stress with me they weren't doing anything wrong," said Miller, who served as a drug task force commander for 18 years before joining the Lewisburg force.
But Miller's suspicions of the doctor were already amplified. He knew Murphy had been the No. 1 opioid prescriber in the federal Medicare program for years; that he closed his practices in Alabama when that state's medical board accused him of writing excessive opioid prescriptions.
He also knew that many of Murphy's patients were driving far distances to see him: Alabama, Florida, Georgia, Louisiana, and Mississippi.
The parking lot at the Specialty Associates clinic in Lewisburg, Tennessee is crowded with cars shortly after the doors open. Dr. Mark A. Murphy, a pain specialist at the office, sees patients only three days a week. (Photo credit: Jacob Hughey, JCB Media)
That led Miller and Lewisburg Police Chief David L. Henley to conclude Murphy's practice had all tell-tale signs of a pill mill.
"That clinic, with that many license tags from out of state, is not right," said Henley. "That type of activity, I don't want in my town."
Murphy declined repeated requests for an interview. A woman on his staff shooed a reporter out of the clinic parking lot, stating: "We don't need any TV (expletive) going on."
Despite law enforcement crackdowns and new federal guidelines and state laws to limit the number of opioids given to patients, some of the highest prescribers have avoided scrutiny, a Raycom Media national investigation found.
The top 1,000 highest prescribers in the Medicare Part D program, which provides drug benefits to the elderly and disabled, collectively wrote 14.6 million prescriptions between 2013 and 2015, public records show.
Some wrote prescriptions for so many opioids that the patients' daily supply of the pain-killing medication exceeded, on average, the number of days in a year.
Murphy gave 1,100 of his Medicare patients opioids that, if taken as prescribed, would have lasted each of them 497 days in 2015.
Medicare covers at least one out of every four prescriptions written in the U.S.
But some medical and law enforcement experts say: being a top prescriber in the Medicare program should raise red flags. Murphy wrote more prescriptions between 2013 and 2015 than anyone else in the U.S., the Medicare data shows.
"The doctors who top the list… one has to question whether they are drug dealers in white coats," said Andrew Kolodny, co-director of the Opioid Policy Research Collaborative at Brandeis University. "If you're prescribing that aggressively, you are killing patients."
Dr. Andrew Kolodny is co-director of the Opioid Policy Research Collaborative at Brandeis University. He's critical of doctors who played a role in the opioid crisis. "This is without a doubt the worst drug-addiction epidemic in U.S. history." (Photo credit: Andy Miller, Raycom Media)
It's been well documented that doctors were deceived by the pharmaceutical industry about the addictive nature of opioids - and began changing their prescribing habits about a decade ago. Overall, last year they wrote 17 percent fewer opioid prescriptions than in 2012, according to the American Medical Society.
Yet 70 percent of Medicare's top 1,000 prescribers increased the number of opioid prescriptions they wrote between 2013 and 2015.
Raycom Media sent letters to each of the top 1,000 prescribers; 44 responded as of Feb. 14. Many said that they are prescribing appropriately to patients who need opioids because of severe medical problems. Others threatened legal action if their names were made public. A few said that they now prescribe fewer opioids because of new federal guidelines that, among other things, push for alternatives to painkillers.
And, the problem is huge.
"Four million people are addicted to prescription drugs," said Stephen G. Azzam (left), special agent in charge of U.S. Drug Enforcement Agency operations in Alabama, Arkansas, Louisiana, and Mississippi. "The doctor needs to open his eyes. Why do you still need that prescription?"
As opioid drug makers and distributors have found themselves in the crosshairs of cities and states ravished by the opioid epidemic, doctors and other prescribers largely avoid scrutiny by state and federal regulators, Raycom's investigation found.
A deep dive into the backgrounds of Medicare's top 1,000 opioid prescribers found that few have faced discipline for prescribing drugs that the Centers for Disease Control and Prevention says should be restricted to cancer patients, those who had surgery or were involved in a serious accident and some with chronic pain.
In the past two decades, 98 prescribers have been sanctioned for inappropriately prescribing medicine; 22 are facing criminal charges or have been convicted.
But 49 of the prescribers with checkered pasts - including Murphy - have licenses that allow them to practice as of Feb. 14.
The Medicare data, state medical board records, and court documents show that:
- Rogue prescribers keep practicing for years as regulators build investigations.
- State medical boards have given some doctors second chances.
- Some boards also dropped investigations into doctors’ conduct, allowing them to move their practices to other states.
The data also shows the highest volume prescribers are practicing in the south - and not in the states typically associated with the opioid crisis such as Kentucky, Ohio and West Virginia.
More than half of the highest prescribers are practicing in nine southern states: Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina and Tennessee.
Alabama had more than twice as many health-care providers on the list than Ohio, a state with nearly three times as many residents.
In Mississippi, there were enough opioid prescriptions filled last year to give everyone in the state a bottle of 70 pills, said John Dowdy (left), director of the Mississippi Bureau of Narcotics and a former assistant U.S. Attorney General.
"We have an addicted state because of over-prescribing," Dowdy said. "I knew that with us having that kind of prescribing rates, we were going down the same paths as Ohio, Kentucky and West Virginia."
Nearly 12 percent of everyone in the U.S. recorded as having died of prescription opioid overdoses between 2013 and 2015 came from those three states, according to Kaiser Family Foundation.
The highest opioid-prescribing volumes shifted into southeastern states in recent years.
"You have legal drugs coming from doctors," Dowdy said. "The vast majority of our medical doctors are good doctors. I wish there was an easier way for us to identify the bad doctors."
Basing conclusions on prescription data can be dangerous because it overlooks the histories of chronic-pain sufferers who truly may need the drugs, said Dr. Stefan Kertesz (left), a professor of medicine at the University of Alabama at Birmingham School of Medicine and specialist in addiction and opioid safety.
Even so, he said, doctors bear a great deal of responsibility for the opioid crisis.
"Physicians flooded the market with opioid prescriptions in ways that proved unhelpful," he said. "There was a conspicuous lack of caution, care and a great deal of optimistic feelings by physicians."
Terah Holley's family called the U.S. Drug and Enforcement Agency after her death in 2014 with one request: put Dr. Howard Diamond out of business.
The family's call triggered a lengthy investigation that ended with Diamond's arrest last summer on 18 counts of health-care fraud, conspiracy and distributing controlled drugs. Diamond's downfall came nearly three years to the day since Holley died.
During that time, Diamond continued to practice medicine at his two clinics in small towns in northern Texas and prescribed so many opioids that he was among the top 25 Medicare prescribers in the country.
At least 19 of his patients died as investigators built their criminal case, according to federal court records.
Health insurance companies sent some 100 letters to Diamond expressing concerns he was prescribing excessive doses and toxic combinations of opioids. But those companies did not alert the Texas Medical Board.
In 2015, a pharmacist complained to the board about the prescriptions Diamond was writing. The medical board ordered him to take an 8-hour class on medical record- keeping, state records show.
Diamond kept on practicing.
Investigating a doctor is difficult and can take a long time because they have the medical expertise that investigators lack, said Miller, the former Tennessee drug task force commander.
"They know they can do the bare minimum - touch your wrist, ask you a few questions and make their assumption on how to treat you," he said. "It's hard to challenge a doctor."
By 2012, the Florida medical board had initiated four investigations into Dr. Brian James' prescription writing. Two patients under his care had died of opioid overdoses. Yet the board did not permanently suspend the pain management doctor's license until the conclusion of its investigation five years later, records show.
Kolodny is critical of state medical boards' passive role in scrutinizing doctors' prescribing habits. Many rely on complaints to begin an inquiry.
State medical boards "should be proactively mining data," Kolodny said. "They shouldn't wait for these doctors to kill people."
As far as her family was concerned, Terah Holley died long before she ingested a deadly amount of morphine on July 25, 2014.
"She didn't function at all. She was a living zombie," her daughter Allyson said.
Holley was involved in a car crash in 2001 that left her with nerve damage. She lived with constant pain for more than a decade, holding down three physically demanding jobs as a waitress, maid, and cosmetologist.
After a sleep study in 2012, a doctor referred her to Diamond, who immediately prescribed opioids. Over the three years that Diamond treated Holley, she received prescriptions for hydrocodone, oxycodone, Zantac, Lortab and morphine, Allyson said.
The woman who had been a free spirit willing to try or do anything suddenly was falling asleep in her food at dinner, her family said. She also lost her jobs.
Allyson once accompanied her mother to an appointment with Diamond. After a 10-minute visit, she left with new opioid prescriptions.
"I feel like the doctor took her life away," Allyson said.
She was just 16 when her mom died. "I quit school for a little while. It took a toll on me," she said. "I shouldn't have to go through that at 16. Sometimes I want to pick up the phone and call my mom."
Diamond, meanwhile, remains in jail awaiting trial.
Allyson Holley visits her mother's grave after she graduated from high school. After her mother's death, Allyson took a break from school to deal with her loss. (Family photo on Facebook)
The family-practice doctor owned two clinics in small towns about 90 minutes northwest of Philadelphia. He was a local school board member, who once caused a stir when he was arrested for drunken driving.
In 2012, Kraynak and the medical board came to an agreement to settle the case against him: he would pay a fine and take a course on "controlled substances management."
Soon after, oxycodone became Kraynak's drug of choice, writing prescriptions for more than 3.6 million pills in less than three years.
At least five of his patients have since died of a prescription opioid overdose.
Among Medicare's top prescribers, at least 19 had at least one brush with their state licensing boards for prescribing-related problems and were given second and third chances.
George Loucas, a Cleveland lawyer who also is a pharmacist, said state medical boards haven't done enough to stop doctors.
"I have no idea where they have been the past 10 years," Loucas said. "I'm aware of more than one doctor who killed seven or eight patients and they are still practicing today."
Among Medicare's highest prescribers who have been disciplined for wrongdoing by state medical boards for prescribing-related issues, 53 still have licenses that allow them to practice.
A dozen of them, including Kraynak, eventually faced additional allegations of over-prescribing that led to suspensions or revocations of their licenses.
Days before Christmas, federal agents arrested Kraynak and charged him in the overdose deaths of five patients as well as other drug-related violations.
The doctor's prescribing habits shocked investigators.
"The sheer number of pills prescribed in this case is staggering," U.S. Attorney David J. Freed said on Dec. 21, the day Kraynak was arrested at his office in Mount Carmel, PA. "Death or serious injury was the inevitable result of this...conduct."
Before he left Alabama for Lewisburg, Tennessee, Dr. Mark Murphy's ability to practice medicine was in jeopardy. The Alabama Board of Medical Examiners had levied an 8-count complaint against him in August 2016 for:
- Acting unprofessionally.
- Endangering patients.
- Prescribing not for legitimate medical purposes.
- Performing unnecessary tests.
- Lacking basic medical knowledge and competency.
The 33-page complaint detailed Murphy's questionable care of 15 patients. One was a 58-year-old man who overdosed on a dangerous combination of opioids and other drugs prescribed by Murphy. Several other patients said they received opioids even though they had documented substance abuse issues. In some cases, Murphy increased the doses.
But that didn't happen.
Instead, the board allowed his license to practice in Alabama expire at the end of 2016 and dismissed the case two months later. That left Murphy's reputation unscathed by formal disciplinary actions.
Other top opioid prescribers in the Medicare Part D program also have been allowed to leave a state under a cloud of suspicion.
The board considered suspending his medical license but then backed off after Ahmad agreed in 2015 to pay a $20,000 fine.
Soon after, he was practicing near Anchorage, AK, and almost immediately under investigation there.
State medical officials launched an investigation, which resulted in formal, administrative charges against him 14 months after he opened his clinic in a strip shopping center.
Though he worked in the state only one weekend a month, one pharmacist told investigations that she turned away 18 of his patients in a single morning. Each arrived with prescriptions for such high-dose opioids that Costco didn't even stock it.
Within 17 months of arriving in Alaska, the state medical board revoked his license. That action prompted Arkansas to act, too. It revoked Ahmad's license two months later - four years after it first looked into his prescribing practices.
Ahmad could not be reached for comment and is believed to now be living in Pakistan, said a lawyer who has filed a civil suit against him.
Murphy had long held a license to practice medicine in Tennessee, where he lives.
The Tennessee state medical board hasn't filed an administrative complaint against him, the only public way to know if a doctor is under investigation.
But the Tennessee Bureau of Investigations knows of Murphy.
Lewisburg police Lt. Tom Miller made sure of it.
Other stories in the series:
If you want to share your experiences with opioids or any doctors, send us an email to firstname.lastname@example.org