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Don’t Call Them Pill Mills: Palm Coast’s Pain Management Practices Recoil at Bad Rap

| November 22, 2010

The Practice: Drs. Vinod Malik, Kavita Sharma and Tse Lee of Palm Coast's PRC Associates. Their colleague, Youssef Guergues, was at another one of the their five locations. (© FlaglerLive)

Imagine comparing The New York Times to the National Inquirer. Or Lawrence Olivier to Fabio. Or Van Gogh to Thomas Kinkade.

Besides being stunned and not a little bit aggrieved, that’s how the four doctors at PRC Associates, the pain management clinic in Palm Coast (in the greenish building next to Florida Hospital Flagler) and four other locations in Volusia County, felt after Flagler County Sheriff Don Fleming attached the words “pill mill” to their operation.

“The typical pill mill,” says Vinod Malik, a physician with several board certifications and the director of PRC Associates for 11 years, “you walk in, no appointment needed, no evaluation by a physician, you pay cash, you get your prescription, and you go home.”

The PRC practice, as Kavita Sharma, one of its doctors, prefers to identify it (rather than a mere “clinic,” because “no one can walk in and say, I want to be seen today”), couldn’t be further from that. No walk-ins are accepted. It’s a referral-only practice. It’s an elaborate, “interventional” pain management operation staffed by four doctors, each with at least two board certification, each predisposed to shun pills, each dealing directly and exclusively with his or her patients without the intercession of nurse practitioners or physicians’ assistants.  The four doctors have privileges at all Florida Hospital facilities. Pill mill doctors not only would generally be denied such privileges: they’d be segregated from the rest of the medical community, which doesn’t want to be associated with them.

Pill therapy generally goes against the doctors’ principles and medical philosophy: they’re there to cure patients of their pain or their dependence on narcotics, not to feed it. And they do so mostly through “interventional” means such as injections, radiofrequency ablations, and other, equally tongue-twisting procedures that pill mill patrons have no use for.

As for Oxycontin, the pain medication that’s a favorite of pill mills—a single pill sells for $4 at a pharmacy, but for $20 to $30 on the street, and for up to $60 the further north you go—it barely registers on the doctors’ prescription list. Thousands of patients are on the clinic’s roster. Tse Lee, one of the four doctors, has just one on Oxycontin (chances are, it’s a cancer patient), and none of the doctors has any younger person on the pills.  When those younger people come in and list Oxycotin or Oxycodone (its quicker-acting equivalent) on their chart, it’s an immediate red flag.


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The clinic doesn’t take cash payments—cash payments are a pill mill specialty. Patients are required to sign a narcotic agreement and submit to urine tests to ensure that they’re following their prescribed regimen. If any diversion is detected, it’s a sign that the patients are either abusing the drugs or selling them. If, for example, they’ve been prescribed certain pills but their urine doesn’t show that they’ve been using them at the correct dosage, they’re not in compliance with their narcotic agreement. “If they don’t comply with that they get fired,” Sharma says. “You actually discharge the patient if they don’t comply with or fail a narcotics screening.” She adds: “Word on the street is, if you want your pills, don’t go top these doctors. They won’t write prescriptions for it.”

Lou Salvagio, in a small section of his 5,000-square-foot medical and fitness center. (Click on the image for larger view; © FlaglerLive)

Lou Salvagio, a Palm Coast chiropractor whose operation Fleming also categorized, incorrectly, as a pill mill, has referred patients to PRC Associates. Speaking of Vinod Malik, the senior physician in the group, Salvagio said: “Now, Dr. Malik, to get him to prescribe medication when I send him a patient, you might as well pull all wisdom teeth from his mouth.”

Salvagio himself felt maligned by his medical and fitness center’s comparison to a pill mill. Salvagio can’t even prescribe pills as a chiropractor. And since February he hasn’t had a doctor on staff who could prescribe. A physician left his practice at the time because the market could support her fees, and Salvagio’s four-month addiction-recovery program required patients to pay half their charges out of pocket, once insurance ran its course. The center today is a rather large facility on Boulder Rock Drive, opposite Home Depot, where patients can get physical therapy, chiropractic care, “nutritional and spiritual counseling,” aquatic therapy (the only one of its kind in town), and a full-service gym, with a dance studio and two music rooms thrown in for good measure.

So when Fleming attached the word “pill mill” to the operation, Salvagio, who’s known Fleming for a long time, was floored, even if Fleming deemed the operation “legit.” “Can I call a robber legal? Is that not an oxymoron?” Salvagio said. “He needs to really start defining what a pill mill is, not saying we have three pill mills.”

In Palm Coast 16 years, Salvagio said the comparison hurt his business, though he has no quibble with Fleming’s goal. “The purpose of what Don is trying to do,” Salvagio said of the sheriff, “I support 100 percent. He’s trying to get rid of these people who use narcotics either to make money or to feed their addiction.” But, Salvagio said, going by the definition of pill mills, there isn’t a single such operation in the county. There was one a year ago, he said, but he would not name it. Whoever ran it, he said, straightened up and quit operating as such.

Fleming wants Flagler County governments to write ordinances imposing a one-year moratorium on pill mills, which are usually shady operations that do what the name suggests: more than half their operation consists of prescribing narcotics, so they dispense narcotics on the equivalent of a conveyor belt—not for legitimate medical reasons, and without being properly registered with authorities. They’re big in South Florida, where local governments have been aggressively shutting them down and forcing them to migrate north. They’ve moved into Broward and Volusia counties where some have been shut down there, too.

During a town hall meeting earlier this month, Fleming spoke of three pill mills in Flagler County. The three, he said, are “technically legit, but I don’t want to see other ones come in the county.” Speaking to FlaglerLive, he named two of them by name, Salvagio’s practice and that of Robert Fruehan, and referred to the third by its location rather than by name, though the place is familiar to anyone who’s been in the area: PRC Associates. In every case, the doctors at those practices say, Fleming was completely off base. Fleming himself has since retracted the association between those practices and the notion of pill mills. (Fruehan was contacted for this article, but was unable to be interviewed.)

But the association was damaging and confusing at precisely the time when Fleming was aiming to educate the public about the difference between legitimate pain management practices and questionable businesses. So the physicians in those practices took it on themselves to clean up the damage and prevent further confusion.

Fleming wants Malik to serve on an advisory council that would guide local authorities as they develop and monitor a pill mill moratorium, which wouldn’t be without its problems. Such a moratorium, Malik himself cautions, might be unconstitutional if it keeps practices such as his from setting up shop. That debate—who might practice and who might not—is ongoing, though until now it’s taken place in specialized circles. The general public has been made little aware of the challenges posed by pill mills or of the important nuances and differences between pill mills and pain management practices.

As Fleming sees it, the moratorium would mean that new pain management clinics would not be granted certificates of occupancy for a year. That would give a state law design to crack down on pill mills, and that went into effect on Oct. 1, time to sharpen its teeth. One of the law’s components is a drug-dispensing database that has not yet been developed. (Malik, who serves on the Florida Academy of Pain Medicine, says he’s “actively involved in forming those laws.”) A monitoring system is in place, but it doesn’t go beyond patients with insurance. And cash purchases aren’t tracked, so medical practices already predisposed to follow the law are monitored, but operations designed to evade it are not.

So pill mills, for now, continue to thrive, feeding addictions—and damaging the reputation of the legitimate and necessary pain management profession.

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16 Responses for “Don’t Call Them Pill Mills: Palm Coast’s Pain Management Practices Recoil at Bad Rap”

  1. Anonymous says:

    I would call them a pill mill – which is exactly why I don’t go there anymore.

    • Theresa says:

      I went to PRC for pain management for roughly 18 months. First they started me on injections and prescribed Lortab. Then more injections, then oxycodone, then Fentenyl Patch…After they finished giving me every single injection they could think of I was discharged. Sent on my way with a weeks worth of pain medicine and a huge dependence to opiates. Now they preach about pill mills. They are the exact definition!!!!

  2. Gus Ajram says:

    Thank you DR Salvagio for all you done for me , first your advice against any pills and if not for you when I met you 14 years ago I wouldn’t be walking today. Many thanks from me and my family, may God bless you.

  3. K says:

    My husband went to PRC for pain related to degenerating discs in his neck. On his first visit he was put on 72 hour duragesic patches as well as duragesic pills (duragesic is essentially morphine) and was receiving some kind of biweekly injections .

    Within a month he looked like a full blown drug addict with purple bags under his eyes and pasty white skin yet he was still in pain. I accompanied him to his third appointment to express my concern about the effects of the drugs on him. The response from the Doc (not sure which one as this was a couple years ago) was neither concern nor a desire to work in a consultative manner. I was spoken to as if I were an idiot and basically told that I was wrong for not supporting their efforts to relieve my husbands pain. I felt that they were facilitating drug addiction with no regard for anything else.

    We went home and threw the pills & patches away and when we spoke to our family doctor he told us we were not the first people to have that kind of experience there. I have talked with other people who developed addictions and had similar experiences there but I have also talked with people who found great relief there.

  4. elaygee says:

    Dr. Malik gave me my life back WITHOUT pills. Epidurals and nerve deading removed years of back pain. I think the problem is insurance., My insurance company covered all the expensive non drug treatment. people without or with lousy insurance have to rely on oills if they can’t afford the non drug treatment.

  5. Kevin says:

    And let me add that when one has multiple levels of degenerated, compressed, protruding disks at different levels impinging nerves and such, plus stenosis, and a dose of retrolisthesis covering a range of disks from T7-L5 for good measure, causing back pain and back injury “events” that occur on a regular basis, one is thrilled and thankful to the chemistry gods for allowing man the genius of creating medicines such as oxcycodone and other opiates like it. (Forgive the run-on nature of the sentence) They give a person back their life and reduce or eliminate the suffering they and their loved ones witness and endure. Some may have to sacrifice part of their lives such as once high levels of awareness, wakefulness, alertness, etc…but even that can be managed by not exceeding what is necessary to control the pain.

    It is ONLY when one abuses the medicine that problems arise. It is partially the fault of the physician for not picking up on the patient’s misuse of the drug; there are a lot of druggies no doubt misusing pain medicine for various illicit reasons. Having said that…don’t fucking cast rocks until your life is destroyed by unrelenting, perpetual, debilitating back pain which brings even the strongest willed person to his or her knees. God forbid any of you here who scorn such clinics and their patients, ever have something happen to your backs where it rises to the level of issues I mentioned above—I wouldn’t wish a chronic issue as such even on my worst enemy, nor even Norton Smitty.

  6. Anita says:

    I suffered for years with increasingly severe neck pain and diminishing range of motion all the while being treated unsuccessfully by a local chiropractor and an acupuncturist. Pain killers are disruptive to my digestive system and I couldn’t take any. At my wits end, I sought Dr. Salvagio;s help as a last resort and after a few sessions, realizing he couldn’t help what turned out to be spinal stenosis, he referred me to a orthopedic surgeon. He did not offer, nor did he ever prescribe drugs and so I will clearly and emphatically state that Dr. Salvagio’s practice doesn’t deserve the label, “pill mill”.

  7. tom dooley says:

    ha-ha-ha…it’s about time the law enforcement started cracking down on pain aka pill management and hopefully chiropractors too…what a joke they are…first of all if you have a real problem; i.e. hernaited disks or bulging disks they won’t even touch you and then you go to pill oops sorry pain mangement and all they want to do is give you shots (that are called “steroids”) and pills…used to go to this place and a chiropractor (unfortunately his name is not mentioned; but has “NEVER TAKEN AN ASPRIIN HIS ENTIRE LIFE” and doesn’t think we need “Electrical Impulsuses”; even though our brains send out electrical impulses constantely)…people who get addicted to pills are “LOSERS”…we get addicted to “anything” nowadays…but the point is if you really think pills are gonna “CURE” you than you are a “LOSER WITHOUT A BRAIN”…Thank god for surgery for my back (and NO i still don’t take pill’s) and yes i still walk and no i don’t need a liver transplant…the only reason they give you pills is to keep you coming back and yes i paid “CASH” for my co-pay “EVERY-TIME” so don’t tell me they “don’t take cash”…
    Signed “Tom Dooley” hanging from a tree ha-ha…with no pill’s and i can walk with surgery…thank god and pill free

  8. Palm Coaster2 says:

    Unjustifiable, libel, baseless, distorted, accusatory branding and undermining of at least 3 medical professional local offices by our sheriff will not cover up the lack of proper law enforcement service in our County. Have the sheriff forgotten all the often robberies of our pharmacies around the county that are the one’s that really keep supplying the illegal trade?
    Just to refresh his and his supporters memories read the enclosed link below about the last heist!! Where is our law enforcement meanwhile…parked chatting somewhere or maybe in the empty cruisers stationed around town?
    http://flaglerlive.com/14814/oxycodone-pharmacy-robber

  9. Leslie says:

    In 1997 I had to get a discectomy and lamanectony on my L3-4. Once the doc. was inside operating on my back my L4-5 was found to be just as damaged. My spine could LITERALLY BE lifted out of my spine!! I had two spinal cage fusions put in at both levels and pieces of floating bone in my spinal area put in the fusions for bone growth ( the bone that is put in the spinal cages are usually taken from your hip). My spine had to be rewired back into place. I had gone to the doc. due to numbness in my legs. He took an x-ray and said I wouldn’t be walking w/in a month. I was naturally put on percocet 10/325. I was laid up in bed for 3 months – out every 4 hrs. for 15 minutes. Talk about an ordeal!! After recouperating I was back at work and pain free for 3 yrs. In 2000, I was found to have total nerve damage from L2-3 down. I worked for 3 more years as a bank teller taking every pain pill available from percocets, lortabs, darvocets, roxy’s, and oxy’s. In 2000 I had gone to Dr. Malik and saw him for a total of 4 times and got cortisone shots that helped for a very short time. I left him because he was a very rude and arrogant man and so was his partner at that time. I started seeing a pain mgmt. specialist in St. Augustine around 2002. I was put on htese meds. also by this doc. that my orthopedic surgeon had been keeping me on before my reg. doc kept me on them despite his reservations. The pain specialist I saw in 2002 also gave me spinal shots that were done as outpatient surgery 3 times and these shots were VERY painful and stopped helping. Then I had a nerve stimulator trial done where a nerve stimulator was put in and you controlled the machine. Like a TENS implant. This was like ants crawling up and down your legs and I had it taken out w/in a week. I went back to Dr. Malik and saw him in 2008at my wits end. My tolerance level for EVERY pain med no matter how high the dose would not take the SEVERE crippiling pain I was in. There is only one person I would EVER wish this pain on and that was a child molester I had known!!! The last med. I was on was oxy – 80mg. 2x’s a day. I told Dr. Malik I wanted off all pain pills and to have a morphine pump implant. His reply to me was that I had to take the pills for 6 more months before he would consider this!! I had been on every pain pill for 7 yrs. by then!! I had pill thiefs break into my house and steal them and “so” called friends. I had to buy a safe to lock the pain meds in if they weren’t in my purse w/me at all times! Finally I found a dr. in Jacksonville and told him what I had endured since 1997 and a car accident,also riding horses my whole life hadn’t helped but I had stopped riding by 2000. This dr. put me on morphine while he was waiting for his dr. privilidges to kick in at a Catholic hospital in Jax. I started seeing him in Feb. 2009 and by Sept. 2009 I had the implant put in. Unfortunatly my body and the pump did not mix well and by Jan 2010 I needed a new pump. I had a new one put in April 2010. Before the pump was initially put in I was taking 500mg. daily of morphine – it would have to be taken early morn. because it would knock me out for about 5 hrs. and then I was pain free all day. Between Jan 2010 and April 2010 I was on 12 percocet10/325 a day and could walk a straight line and be sober! By June 2010 the cath. that goes from the pump, which is in my stomache to my L2-3 pain receptor had come completly undone and was bulging out of my own spine. I was then put on 6-8 percocet10/325 a day. These pain pills did absolutley nothing for my pain and I lived with ice packs on my back at night so I could sleep. This Sept 1010 a new pump was put in surrounded by mesh and stiched so tight inside it has not moved yet, which every time it had before. So cross my heart it will stay. But unfortunatly my tolorance level goes up and almost every month the pump dosage has to be raised. The pump puts morphine through the cath tube and insurted into my L2-3 nerve pain receptors and only works on my lower back pain and painful hips. It is times 1000 mg. dosage which you would take by mouth. So Iam taking 6500mgs. of morphine which is equivalant to 650 mg. by mouth. It does not affect my thinking at all and am totally straight 24/7. In fact my tolorance is so high I can’t get high on any drug or drunk or even a buzz on alcohol! Which there is no need for me to be in that state. I have made it very clear to my doc. that I DO NOT want to be put on methodone – which is synthetic heroin. I have never dine street drugs.
    AS far as I am concerned all these thieves that rob pharmacies or used to drive down south to get pain pills and now here, like in South Daytona are nothing but a bunch of drug JUNKIES needing to get high and are making it very miserable for those of us who REALLY need the help to live comfortably and get through life as pain free and as normal as possible!!!! I wish these junkies could walk 20 ft. in my shoes and realize the TRUE physical need for pain meds. for the body and not to get f—– up! My mom hurt her back severly last yr. and said she finally understood the pain I’ve been in since 1997!! Junkies and pill thieves need to understand that to. Just remember — KARMA IS A BITCH!!!!!!!!

  10. Determined says:

    Pill Mills are just that. Easy access to perscription drugs and plenty of them. They need to be shut down.

    Unlike what Leslie says “all these thieves that rob pharmacies or used to drive down south to get pain pills and now here, like in South Daytona are nothing but a bunch of drug JUNKIES” She doesn’t want to acknowledge that there is NO DIFFERENCE between her version of a junky and a Perscription Drug Addict. They are one and the same!
    They only think of themselves, no one else they may hurt. Like innocent babies that are born to women that take Oxies and Roxies, or innocent people hurt in car accidents because the driver was addicted to perscription drugs.
    There has been a huge uptick in drug addicted babies who will suffer their entire lives because of the ease at which perscription drugs can be bought.
    It is time to shut off the easy access to perscription drugs!

  11. Loriel says:

    My mother has excruciating leg wounds caused from her cancer treatment that cause her such ongoing intense pain that some days she just stays in bed and moans. She has been through treatment after treatment and nothing has helped. She relies on a carefully registered dose of pain medication to survive from one day to the next. To say that they are all “pill mills” is such an unbelievably uninformed and ignorant statement I am flabbergasted. Yes, I know there is abuse out there but you cannot lose sight of the people who need effective pain medication to get by from day to day. She receives her prescriptions from a very reputable would care center that is not in Flagler County. There will always be doctors who dole out pills to more than will patients who pay well.

  12. ignorancecosts says:

    I am afraid that it is just an attempt, to micro-manage a problem by over-regulation, and in the process infringe on the rights of people who actually need the medicines some abuse. The law abiding citizens are being hurt by big government trying to regulate every aspect of our lives. My mother-in-law just spent her last weeks in hospice dying with a Dr. who was scared she would become ‘addicted’ when she only had a few weeks to live, in terrible pain! It has to stop. If people abuse drugs and die, it is what it is. Stop suing the Dr.’s, stop law-suit abuse and enact loser-pay, stop the blame game..and let the Dr’s practice, ie…PRACTICE medicine. You do not make law that infringes on the rights of the law abiding citizen, period. It defies logic and common sense, and leads all of the ‘czar mentality’ that we are suffering from now. Look how the left-leaning Government just took control of the Internet traffic yesterday…when it is a serious overstepping and over-reach into the private sector.

  13. NortonSmitty says:

    A question for you Mr. Ignorancecosts: Has there ever been a problem in the history of mankind you couldn’t explain away with one of your simplistic Republican talking point bromides?

  14. Anonymous says:

    in the case of Dr Sharma and his partner, I have been a user of pain control drugs for over 40 years.
    when my Doctor refused to issue anymore scripts, he set up a meeting with Dr. Sharma. first thing
    he told me was I was not a addict but a person dependent upon controled drugs.
    he gave me options to wean me off oxycodone, and he suggested a way to deal with the pain.

    he showed me information on nerve unit that redirects the pain signals. I tried it by going thru a long
    process of trial test of the unit and had to wait for that information to be processed.
    I did great, my pain level was reduced by ninty five percent. I am now with my permenant unit and I am walking and doing things I have not for years. in short–Thank You Dr. Sharma.

    PS
    unless you have been in pain for years or a very long time, please keep your opinions to yourself.
    we have reduced people who are need pain drugs to criminals. put the phony pain clinics out of business and the people who run them in jail.

  15. ROSEMARY MCNALLY says:

    3 YEARS PLUS I BROKE OUT WITH A VERY SEVERE CASE OF SHINGLES, THE LEFT SIDE OF MY BACK AND FRONT BREAST WAS COVERED I NEVER WOULD HAVE BELIEVED ONE COULD SUFFER THE INTENSE PAIN THAT RANGES FROM STABBING TWISTING BURNING SOMETIMES ALL AT ONCE
    I AM NEVER WITHOUT PAIN DAY AND NIGHT IT HAS CONSUMED MY LIFE I AM NO LONGER THE HAPPY VIBRANT PERSON I USED TO BE I HAVE BEEN TO SEVERAL DRS NOW ON 3RD PAIN SPECIALIST YES I AM ON PAIN MEDICATIONS TRAMODOL IT TAKES THE EDGE OFF ONLY
    I COULD AND SHOULD TAKE UP TO 4 PERDAY BUT TRY TO STAY ON 2 SOMETIMES AT NIGHT I PACE THE FLOOR CRYING OUT IN PAIN NOTHING HELPS I HAVE HAD SEVERAL OUT BREAKS OF SHINGLES THE PAIN DURING THE BREAKOUTS BECOME MORE INTENSE AND I FEEL LIKE I HAVE THE FLUE
    I HAVE TRIED ACUPUNTURE NERVE BLOCKS AND EVERTHING ELSE INCLUDING ALL THE MEDS TO NUMEROUS TO STATE, THERE ARE TO TRY
    DR MALAK HAS BEEN THERE FOR ME HE LISTENS TO MY STORIES AND IS KIND

    ONE HAS TO UNDERSTAND THE INTENSE FEELING OF PAIN TO BE WILLING TO NOW TRY AT LEAST FOR ME THE LAST OF TREATMENTS TO TRY RADIO FREQUENCY ABLATION
    I AM ASKING FOR ALL YOUR PRAYERS FOR A POSITIVE OUT COME
    THOSE THAT HAVE NOT EXPERENCED PAIN DONT BE SO QUICK TO BLAME PAIN DRS. NOR THEIR PATIENTS
    I WORKED IN THE FEILD OF ADDICTIONS FOR 20 YEARS AND NEVER REALLY UNDERSTOOD UNTIL NOW OF COURSE I ALSO UNDERSTAND THE OTHER SIDE OF ADDICTION AND THOSE THAT ARE INVOLVED FOR THE WRONG REASONS
    AFTER BEING WITH DR. MALAK FOR THE PAST FEW MONTHS IT WAS DESIDED I WOULD BE A CANDIDATE FOR RADIO FREQUENCY ABLATION WHICH BURNS THE NERVES FROM SENDING SIGNALS

    BETWEEN THE SPINE AND BRAIN IF IT WORKS I WILL BE PAIN FREE OR BETTER THAN I AM NOW AND WILL NO LONGER HAVE A NEED FOR PAIN MEDICATION
    TO ANY ONE OVER 50 GET THE SHINGLES VACCINE OR YOU COULD BE ME GOD BLESS

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