State Sen. Jimmy Higdon used to think Eastern Kentucky was the only part of the state that had a problem with cash-only clinics where doctors churned out prescriptions for drug abusers.
Then a pain clinic opened last year in his hometown of Lebanon, 60 miles southwest of Lexington. Neighbors began complaining about vans full of people waiting in the parking lot, but as police prepared to investigate, the clinic closed abruptly, local officials said.
But Najam Azmat, identified by local media as the doctor at the clinic, is back in business this year in Lexington, working at a pain clinic owned by a Florida man convicted of running an office there that prescribed pain pills without a license.
State medical board authorities recently opened an investigation into whether drugs have been prescribed improperly at the North Broadway clinic, called Lexington Algiatry. No charges have been filed, and Azmat has declined to comment.
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His attorney, Kent Masterson Brown, said such investigations are not unusual at pain-management facilities, but he declined further comment.
Many pain clinics are legitimate and meet the treatment needs of people suffering a range of conditions.
But there has been a resurgence during the past couple of years of suspected "pill mills" that help feed the state's epidemic of prescription-drug abuse, and the facilities are not just in Eastern Kentucky, where the problem was once most prominent, police say.
Clinics that raise concern have popped up in Central and Western Kentucky and Louisville, and there are active investigations around the state, authorities said.
Faced with a growing problem, calls are mounting for increased regulation of pain clinics.
Several state lawmakers, including Higdon, plan to push measures next year requiring licensing and other controls for such clinics.
"Legislation is needed to put a sign up on Kentucky borders that we're closed to pill mills," said Higdon, a Republican.
A decade ago, Eastern Kentucky had several notorious pill mills, where unscrupulous doctors gave people prescriptions for powerful painkillers and anti-anxiety narcotics after cursory examinations — or no exams at all — in return for piles of cash.
At one office in Paintsville, for instance, Frederick Cohn of Albuquerque, N.M., and Yakov Drabovskiy, a Russian national, wrote prescriptions for 6.9 million pills in one year, a federal prosecutor said.
The two sometimes spent as little as three minutes with patients. Police found files on 10,000 people when they raided the office in August 2001.
And at a Lewis County clinic he opened in 2000, Fortune Williams of Baltimore prescribed more than 2.3 million pills to 4,000 people in 101 days, according to state medical-board records.
Authorities cracked down, sending those doctors and others to prison.
That enforcement, and the state's model prescription-monitoring system, which started in 1999, tamped down the problem with wide-open pill mills.
Drug abusers turned to shady Internet pharmacies for pills after that, but the state legislature largely shut off that avenue with new rules in 2005.
Then, people started traveling by the carload from Kentucky to other states to get pills. South Florida, with hundreds of storefront pain clinics and lax regulation, was a key destination.
Police found files on 1,400 people, most of them from Eastern Kentucky, when they raided a South Florida doctor in May 2010, according to a court document.
There is still a major problem with pills coming into Kentucky from Florida, Georgia, Michigan and elsewhere, but police say they're seeing a comeback for pill mills in Kentucky.
Police think efforts to crack down on problem clinics elsewhere have played a role in that trend.
Police have stepped up enforcement efforts in Florida, for instance, and lawmakers there have approved measures such as limits on pill prescriptions to out-of-state residents and a prescription-monitoring system.
In the past year, more than 400 Florida pain clinics have closed or been shut down, and the amount of the painkiller oxycodone that Florida doctors bought in the first six months of 2011 was down 97 percent from a year earlier, The New York Times reported in August.
Dan Smoot, deputy director of Operation UNITE, said he thinks the growth in suspect clinics in Kentucky relates directly to Florida's effort to shed the state's image as the pill supplier to the Eastern United States.
"When you could take 10 people to Florida and get all you needed, there was no need for them here," he said of pill mills in Kentucky.
Lt. Todd Dalton, assistant commander of the state police drug-enforcement unit for the eastern half of the state, which includes Lexington and much of Central Kentucky, said that when Florida authorities started discussing legislation aimed at curbing pill mills, clinic owners started looking to move into Kentucky.
"We see a bunch of them, and they're growing," he said of the clinics.
Just a few years ago, he said, cocaine, crack cocaine and marijuana were the most common drugs police bought in undercover cases in Central Kentucky.
Now, pain-pill cases are the most prevalent.
"We're buying a whole lot more pills," Dalton said.
Nancy Horn Barker, owner of Corner Drug Winchester, told a legislative committee last month that as Florida authorities have tried to close the pill pipeline, she has had more requests to fill pain-pill prescriptions originating from clinics in Central Kentucky.
Barker said she gets 30 calls a week from potential customers about filling such prescriptions, but she does not fill them because the requests are not from her established customers.
Van Ingram, executive director of the state Office of Drug Control Policy, said Ohio also has moved to regulate pain clinics. Because many out-of-state clinics were fueled by Kentucky customers, it makes sense some clinic owners would relocate here, he said.
"Why not move closer to your customers?" Ingram said.
Kentucky has supplied plenty of pill-seeking customers through the years.
Poverty and other factors result in a higher rate of prescription-drug abuse in the state than in many other areas of the country.
For instance, one federal agency estimated that in 2007-08, Kentucky tied for the second-highest percentage of people 12 and older who had used pain relievers for non-medical purposes.
Kentucky's rate was 6.58 percent. The national level was 4.89 percent.
Abuse of prescription drugs has helped drive up overdose deaths in the state, with more people in Kentucky now dying of overdoses than in car crashes.
Overdose deaths in the state rose from 403 in 2000 to 978 in 2009, according to the Cabinet for Health and Family Services.
State officials are responding to the rise in suspect pain clinics with calls for tougher regulation of such facilities.
Higdon is sponsoring one bill. Among other things, it would require a pain-management facility to get a state license, require that at least one doctor have an ownership interest in a pain clinic, set up criminal background checks for owners, and bar anyone convicted of a felony from owning a clinic.
The bill would bar clinic ownership by doctors who have had certain problems related to their authority to prescribe drugs.
Higdon is a convert on the issue. In 2009, he did not back a colleague's bill to regulate pain clinics.
"I just didn't figure it affected me or my district," he said. "When it happened to me in 2010, I felt bad that I hadn't paid any attention."
The clinic that opened in Lebanon last year was an eye-opener for him.
Local officials said the clinic came in with no fanfare, but neighboring businesses soon were complaining about vanloads of people from counties more than 150 miles away waiting in the parking lot for hours for the clinic to open each day.
Investigations by Higdon's son Jim Higdon III, who runs a blog called the Marion County Line, and the weekly Lebanon Enterprise revealed that the address listed on the clinic's local business license was a vacant house and that one of the clinic's owners reportedly also was involved with clinics in Ohio that had been raided by authorities in a drug investigation.
Several other lawmakers, including Senate Majority Leader Robert Stivers, a Manchester Republican, and House Speaker Greg Stumbo, D-Prestonsburg, also are working on proposals aimed at curbing problem pain clinics that are feeding the state's epidemic of prescription-drug abuse.
Lawmakers said they would work together during the 2012 legislative session to mesh the proposals.
"I think there will be a very significant piece of legislation next year that will deal with this problem," Stumbo said.
The measures are aimed at dealing with what authorities see as potential problems with pain clinics: many are owned by businesspeople seeking profit, not doctors; they sometimes hire physicians with blemishes on their records; and there is no state licensing requirement.
Mike Rodman, an administrator with the Kentucky Board of Medical Licensure, said most pain-management clinics are owned by someone other than the doctor, and most don't stay in one spot very long.
"That can make them pretty hard to track," he said.
Doctors at legitimate pain-management clinics consider various approaches, such as physical therapy, to help their patients; doctors at suspect clinics just write prescriptions, Stivers said.
"They are bringing in doctors from out of state ... that are coming in fly-by-night, locating and moving on, not doing good medical techniques," Stivers said. "What I want to do is to stop that."