Tampa anesthesiologist Dr. Rafael Miguel helped lead the fight against a surging prescription drug abuse crisis in Florida.
As vice chair of the state's Board of Medicine, Miguel called for legislative change to stem the flow of drugs that led to thousands of overdose deaths each year.
Eventually, people listened.
Laws tightened. Police stepped up enforcement. And deaths declined by 23 percent from 2010 to 2012.
Miguel now is in a different drug battle — one for more access to narcotics, not less.
The obstacle, Miguel and other doctors report, are pharmacies that are increasingly second-guessing them, asking to see medical records or refusing service.
"They call us sometimes and ask if (a prescription) is medically necessary," said Miguel, 59, who has a Brandon clinic and teaches pain medicine at the University of South Florida. "Well, if I write a prescription and it's got my DEA number and my signature on it, what do you think, I'm joking around?"
The tightening by drugstores comes after the Drug Enforcement Administration imposed record fines on pharmacies based on allegations they weren't scrutinizing questionable prescriptions. Some companies that supply the drugs have been fined, too.
That has exacerbated the tension between doctors and pharmacists — a schism that is occurring across the country.
In June 2013, the American Medical Association adopted a policy saying that "a pharmacist who makes inappropriate queries on a physician's rationale behind a prescription, diagnosis or treatment plan is interfering with the practice of medicine."
The AMA warned that if it could not resolve the impasse with pharmacists, they would try to change the laws to "prohibit pharmacies from denying medically necessary treatments."
Representatives of Walgreens, CVS and Walmart responded to inquiries from the Tampa Bay Times, all emphasizing a pharmacist's duty to exercise care.
"As health care providers on the front lines of health care delivery, our pharmacists use their professional judgment and consider a variety of factors when determining whether a prescription for a controlled substance was issued for a legitimate purpose, which is part of their professional responsibility under state and federal law," said CVS Caremark spokesman Michael DeAngelis.
Some Florida doctors are hoping they can work out the differences face to face. Three associations — the Florida Society of Interventional Pain Physicians, the Florida Academy of Pain Medicine and the Florida Society of Physical Medicine and Rehabilitation — are trying to organize a meeting with pharmacy associations, the DEA and state Attorney General Pam Bondi.
Patients who can't get their medicine say the experience has made them miserable.
"For a while, 75 percent of the time they could not get it to me," said Karen Westover, 49, of New Port Richey, who has had one kneecap removed, suffers from fibromyalgia and uses a service dog to help her walk. "They'd tell me I had to go to another pharmacy. When I did, they said I was drug shopping."
The past couple of years, pharmacies' reasons for denying her prescriptions have multiplied, Westover said.
One Walgreens initially refused because she didn't live within 5 miles of the store. When Westover insisted she did, a store manager checked a computer and confirmed Westover lived less than 3 miles away.
The store still refused.
Her osteopathic physician, Dr. Lynne Columbus, helped draft a Pinellas County ordinance aimed at curbing pill mills. Now, she said, patients with cancerous tumors or spinal stenosis bounce from pharmacy to pharmacy without success.
"It's crazy," said Columbus, 49, whose practice is in Clearwater. "It's gone way too far to the other side."
Columbus said she is fielding many more calls from drugstores lately. "We've had pharmacists ask us to send up copies of a patient's MRI," she said. "They don't know how to read it."
In 2013, the DEA rocked Walgreens with an $80 million fine for allowing addictive drugs such as oxycodone to reach the black market, sending shock waves through the industry. In 2012, the DEA revoked the controlled substances licenses of two CVS pharmacies in Sanford. The DEA also slapped Cardinal Health, which supplies CVS, with a $34 million fine for failing to monitor their own sales for suspicious activity.
Consequently, patients frequently hear that pharmacies do not have their requested medication on the shelves.
"My feeling, and I can't prove it, is that they do have the medications but they don't want to dispense it," said Miguel, whose patients have sometimes returned to his office in tears after hours of unsuccessful trips to pharmacies.
In Florida, pharmacists do not need to justify refusing to fill a prescription, said Larry Golbom, 61, a Clearwater pharmacist who hosts a radio show about addiction.
"The pharmacist has been the unheralded silent partner in the reduction of deaths," Golbom said in an email.
"Pharmacists did not go to school for at least six years to be drug dealers for the highly suspect 'profession' called 'pain management,' " he said. "The ruse on pain management is fully understood by the majority of pharmacists, especially at the chain establishments."
Other pharmacists say they don't always have that choice because the pharmacy's suppliers only send a fixed number of controlled substance medications each month.
"It's sad when you see a patient who has cancer and is in pain," said Devan Patel, 36, a pharmacist and chief operating officer of Trinity Medical Pharmacy in Trinity. "They are getting the runaround. They have been to five different pharmacies and you can't get it."
One late-stage lung cancer patient who was unable to obtain prescribed medications from pharmacies elected to enter a hospice instead.
"If she underwent chemotherapy, she may actually have been able to extend her life by a year," said Christopher Wittmann, 47, a physician's assistant who owns Trinity Pain Center. "But the option of having a year and being in miserable pain or living two to three months but having her pain controlled was her choice, because there was no guarantee that we could control her pain."
In Clearwater, Arlene Hoffer, a 52-year-old retiree, had undergone spinal injections and nerve blocks to control pain. It was, however, "impossible for her to get pain medications," according to her sister, Cheri Hoffer, 56.
On Jan. 16, 2012, Arlene Hoffer parked her Mini Cooper at the top of the Sunshine Skyway Bridge and jumped.
"My sister was terrified of pain and suffering and certainly took her life to stem that rising tide," her sister said.
Other patients end up delaying refills, according to Heather Papp, 30, of St. Petersburg, who has been diagnosed with multiple autoimmune diseases since childhood, including lupus and rheumatoid arthritis. She takes Percocet to manage pain.
To fill a prescription, she once traveled to eight pharmacies over two days, her 3-year-old alongside her in a child safety seat.
New patients she sees while volunteering for the Lupus Foundation of America often don't want to talk about their pain, she said, due to the specter of being "made to feel as if you are a drug-seeking degenerate."
"It's like this secret, like they're taking drugs they shouldn't be taking," she said. "It makes you feel defensive for why you're taking it."
Researcher Carolyn Edds contributed to this report. Contact Andrew Meacham at firstname.lastname@example.org or (727) 892-2248. Follow @torch437.