The stimulator helped, reducing the ache with electric shock. But then the battery died. Migliano, 41, was in agony when she saw Dr. Thomas Grade, a pain specialist at the Desert Pain Institute in Mesa.
It turned out she needed only a battery change. But Grade couldn't replace the battery for another six days, so he prescribed painkillers. Although a nurse by profession, Migliano had no idea that Grade's prescribed dosage of methadone — a narcotic usually reserved for heroin addicts trying to kick the habit — could interact with her other painkillers and kill her.
It did.
In his notes, Grade wrote that Migliano should take five to 10 milligrams of methadone. But on her prescription, he wrote 120 milligrams — a fatal dose when combined with her other medications, which Grade never determined before writing the prescription.
Migliano drove to the pharmacy and filled the prescription. Then she went home and drank the pills down with a large glass of water — just as the doctor ordered. She was expecting relief from her lower-back pain.
Instead, her best friend found her dead the next morning.
Accidents happen, even in medicine. Scalpels slip. Drugs interact unexpectedly.
Laws are designed to keep those mistakes at a minimum. But in the case of Laura Migliano and Dr. Thomas Grade, the rules in place weren't strong enough.
Migliano had no way of knowing it, but Dr. Grade was a recovering drug addict — practicing with the Arizona Medical Board's blessing and without drug tests. Even after Migliano's death and multiple patient complaints, the board didn't learn of Grade's relapse into addiction for three years.
That wasn't soon enough to save Laura Migliano. An autopsy confirmed drug interaction as the cause of her death. Last year, Migliano's parents won a confidential legal settlement from Grade, who was still licensed to practice at the time.
Because Grade wasn't being drug-tested, it's impossible to know exactly when he relapsed. What is clear is that he finished the Arizona Medical Board's substance abuse rehab program in 1993 and practiced unmonitored for 14 years. Within 30 days of Migliano's death in 2004, the medical board received two more serious complaints against Grade. Both accused him of the same error that killed Migliano — prescribing narcotics without learning what drugs his patients were taking and failing to document their visits.
As a result of the complaints, the board restricted Grade's prescribing privileges but still didn't test him for drugs. It wasn't until 2007, when Gilbert police arrested Grade on charges of domestic abuse — and found him intoxicated — that the board pulled his license.
Grade isn't alone. Substance abuse was the leading cause of physician license suspension in 2007 in Arizona.
Arizona law requires that the medical board drug-test addicted doctors for only five years after they complete rehab. Then they're on their own. But that may not be adequate regulation. An examination by New Times of the records of 50 addicted doctors over a five-year period reveals that 45 of those doctors relapsed — and 15 of those relapses took place after the board stopped monitoring them.
And those are only the doctors who were caught. The pool is actually larger: If you, as a doctor in Arizona, voluntarily submit to rehab, your addiction is kept confidential. None of those doctors was examined in this investigation.
After the five years of drug tests have passed, addicted physicians are free to practice without monitoring. The board learns of relapse only when a doctor is arrested, self-reports, or is reported by a colleague. Some who completed rehab are caught when nabbed for drunken driving. One Glendale physician was even arrested for running a meth lab. Others avoid trouble with the law and continue seeing patients. In the past 10 years, at least two Arizona residents have died in the care of addicted physicians who relapsed.
In the information age, patients can research their physicians online, including on the Arizona Medical Board's Web site. But when it comes to a physician's addiction, the site can give a false sense of security. New Times found that some cases of addiction don't show up on physicians' profiles.
Arizona's look-the-other way policy for rehab graduates is in line with the national standard, accepted decades ago. But after years of physician relapses, some experts think it's time to examine that standard. Last year, the state of California led the way in questioning its own rehab program for physicians. California's program was strikingly similar to Arizona's, particularly in its no-strings-attached graduation for addicted physicians.
Arizona's program has never been audited. But after California's program was audited, lawmakers forced the California Medical Board to scrap its rehab methods. That board met in January to create a new program, which will be announced in June. Alabama and a handful of other states now require lifelong drug tests of some addicted physicians.
Arizona doesn't. But perhaps it should. Here's a reason why:
Phoenix residents may not recognize the name of Dr. Michael Mahl, but Tucsonans might. In 1997, Mahl, a child psychiatrist, was accused of molesting a number of boys at his Tucson group home for troubled teens.
According to medical board records and news media reports, Mahl's descent into drug and sex addiction started with prescription medication and then eventually included cocaine abuse. Mahl testified before the medical board that using cocaine drove him to sexual compulsion. Despite allegations of abuse from his employees and boys at his group home, Mahl was never criminally charged.
In August 2002, the medical board gave Mahl his license back and placed him on the standard five-year probation for drug use. Mahl moved to Chandler, where he's been working as a psychiatrist for adults. On August 9, 2007, Mahl's five-year probation ended, meaning that if Mahl screws up again, the Arizona Medical Board may be the last to know. Even though he testified that cocaine use launched his cycle of drug and patient abuse, he is free to prescribe drugs and counsel adults behind closed doors, without drug tests or accountability.
Mahl is among dozens of addicted physicians who've graduated from rehab and now practice medicine — including performing surgery and prescribing drugs — unmonitored.
At his office in Chandler, Mahl says he doesn't need drug tests anymore. "Five years is adequate. I couldn't imagine having to do it beyond five years," he says.
Mahl knows a number of physicians who finished the five years and then relapsed while seeing patients, but he's optimistic that he won't join them by relapsing.
Arizona lawmakers are, too. They aren't currently considering changes to physician-relapse laws. But at least one doctor thinks the existing system is broken. Cosmetic surgeon Stephen Locnikar wrote a book about his years in Arizona as an addicted doctor.
"I did the board's addiction program, but I never thought it actually applied to me. I thought, I'm just doing this because they're requiring it," Locnikar says.
He graduated from Arizona's rehab program, only to relapse and practice as an addict for years. He tells stories of snorting cocaine off his private bathroom sink between surgeries.
Locnikar believes addicted physicians should be monitored for the duration of their practice.
"After five years, they take the physicians off probation. It doesn't make sense," he says. "After my probation ended, I started drinking, picked up a few pills on the house. Then within a very short period of time — months — I was deep into addiction again. Whenever that probation period was up, and I had no gun to my head, I would relapse. If the probation had kept going, I don't think I would have relapsed. It's absolutely necessary for addicts."
To be fair, no one's trying to let doctors in Arizona get away with murder. In the past decade, the Arizona Medical Board's rate of physician investigation and discipline has increased, and a number of policies have changed for the better. The board has more investigators and examines complaints twice as quickly as it did. But one practice hasn't changed — the board's Monitored Aftercare Program (MAP) for addicted physicians.
Local addiction experts Dr. David Greenberg and Dr. Michel Sucher run the MAP program. They did not return messages left at their office and declined requests through the board's spokesman, Roger Downey, for interviews. Downey said his agency is too busy to track the relapses of MAP graduates. Greenberg and Sucher report that 80 percent to 90 percent of MAP graduates do not relapse, Downey added.
New Times researched hundreds of medical board and physician records to see whether that success rate was accurate. It's impossible to determine because some doctors enter and exit the program confidentially. But 75 percent of the MAP graduates investigated relapsed after their drug testing ended. And those are just the physicians who were caught.
The investigation included records of 50 physicians who were disciplined for substance abuse between 2002 and 2007. Only 20 of the 50 doctors graduated from MAP. The board revoked the licenses of the 30 who didn't graduate.
But of the 20 addicted physicians who did graduate from MAP, 15 relapsed after the board stopped monitoring them — and while they were practicing medicine.
Many doctors who graduated from MAP in the 1980s and '90s were not caught relapsing until 2002 or later. Because they weren't drug-tested, there's no knowing exactly when they relapsed or how long they practiced under the influence.
Based on a five-year records review, at least 200 addicted physicians have enrolled in Arizona's MAP program. Downey reports that an additional eight to 10 doctors self-report into confidential rehab each year.
Several legislators were contacted about the laws governing MAP. None was aware that legislation passed in the 1980s requires drug testing of addicted physicians for only five years.
Bob Stump, a Republican who chairs the state's House Health Committee, was surprised to learn Arizona's MAP program has never been audited. "I would certainly be curious to know, myself, what the relapse rate is," he says.
Stump says he has long supported malpractice reform and other physicians' rights but adds that public safety remains his highest priority.
"We can't allow physicians who are relapsed to be taking patients," he says. "If an audit of the board's Monitored Aftercare Program would be helpful to that end, then I would certainly be in support of that."
Sitting in a north Scottsdale Starbucks, Dr. Steven Locnikar looks like he walked straight off the set of Scrubs, House, or ER. At 40, he still looks the part of a suave, sophisticated young physician. But Locnikar has had his license revoked twice because of his drug addiction.
Locnikar wears a tight blue T-shirt that covers his well-built upper body and matches his eyes. He talks with the intelligence of a med school whiz. His voice is calm and engaging as he candidly discusses his years as a drug addict and cosmetic surgeon in Scottsdale, detailed in his self-published book Doctor Hyde, released last year. The book gives a glimpse into the denial of an addicted physician.
In the early '90s, Locnikar was fresh out of his residency, and his cosmetic surgery practice was thriving. Cosmopolitan magazine even named him Bachelor of the Year.
And he was descending into his first bout with addiction.
"I started using casually, like anyone else, on the weekends," he says. "That went on for months. Then the weekends began on Thursday or lasted until Monday. You go to work tired and hung-over. To me, that is the absolute most impaired you'll ever be. Even if you didn't use on the way to work, you're cloudy, tired, impaired. You don't want to make decisions. Soon, I was using during work. There was a time where I'd run into the bathroom, nasal snort, and finish up the day."
In 1995, Scottsdale police arrested Locnikar for drunken driving. They found cocaine in his car and in his bloodstream. Locnikar, a D.O., was responsible to the Osteopathic Medical Board, the cousin of the larger Allopathic Medical Board, which licenses M.D.s. The D.O. and M.D. boards share the same five-year rehab program.
The osteopathic board forced Locnikar into inpatient rehab and then onto the MAP probation, with its random drug tests. But Locnikar remained in denial.
"I played the game, went through the 'recovery,' but I didn't really get it. They wanted me to do it, and I did it. I still didn't think I was an addict," Locnikar says.
During his five years of MAP probation, Locnikar built another successful cosmetic surgery practice. At its height of success, he was making $5 million a year. He got married and bought a 10,000-square-foot home.
Five years later, he graduated. And the drug tests ended.
"At the end of my probationary period, once again, I'd achieved all this financial reward. But I never really felt fulfilled or happy or content. I casually started drinking, picked up a few pills on the house. Addiction progresses, even if you aren't using. You'll pick right up where you left off. I soon got to the point where pills or cocaine snorted didn't work. I started shooting, injecting heroin, Demerol, anything I could get my hands on."
Locnikar then practiced as an addict for three years.
"Even at that point, people were still hesitant to confront me because I was a doctor," Locnikar says. "We were in a $3- or $4-million house in Paradise Valley, with all the toys. When you see that on the outside, you think that somebody has it together."
At 3 in the morning on November 9, 2004, Locnikar was desperate for a fix as he sped downtown to buy cocaine. On the way, he totaled his Mercedes. Officers found syringes, vials of Versed, and other drug paraphernalia in his car, according to osteopathic board records.
The police notified the osteopathic board, which suspended Locnikar's license.
"Once I signed power of attorney, my wife sold the house and kept all the proceeds. I literally went from Paradise Valley to penniless," Locnikar says. "Within a very short period of time, I was homeless on the streets, pushing a shopping cart on Van Buren."
Months later, Locnikar's friends found him homeless, with no shoes or ID, in Tijuana, Mexico. "I don't even remember a lot of it. I was in a perpetual state of psychosis. I was finding spent needles on the ground, didn't eat for weeks at a time. Just shot up drugs."
Back in the States, Locnikar learned that his wife had divorced him. "At that point, no clothes, no shoes, as a homeless guy ready to die, I realized for the first time that I had a problem. I lost tens of millions of dollars, my family, every tangible thing in life. I watched all of it go away without even realizing what happened."
In January 2006, the osteopathic board revoked Locnikar's license for the second time because of his substance abuse. Under Arizona law, he was allowed to re-apply in January. He did.
Locnikar expects to have his license back soon. If that happens, the MAP program will stop testing him for drugs five years from now. Locnikar knows his propensity to relapse again and claims he'll continue paying $65 a day for random drug tests, even after the board stops requiring them.
"There's something about the thought of the random test that motivates somebody," Locnikar says.
Gary Blass was a successful emergency room doctor. He and his wife, Carlee, a ballet teacher, moved to Arizona in 1994, shortly after Blass finished his residency at Episcopal Hospital in Philadelphia.
On June 29, 2005, Glendale police raided Blass' Arrowhead home and uncovered, of all things, a meth lab. Blass and his wife were arrested for making and selling crystal meth. The Arizona Medical Board revoked Blass' license one month later.
But if the board had monitored Blass sooner, it might have saved the life of one of his patients.
Blass had graduated from his third MAP probation eight years earlier, in 1997.
When Colleen Lomax saw Blass' face on the front page of a newspaper after his arrest, she wasn't surprised. The Phoenix attorney knew the name Blass well, having represented the family of a man who died in his care. Doug Morton Jr.'s family won an undisclosed settlement in 2002, and that was without any proof that Blass had been impaired when he diagnosed Morton's heart attack as a sports injury.
"The nature of the malpractice was so egregious we thought all along, at some level, he had to be impaired," Lomax says.
Because the board wasn't drug-testing Blass, it's impossible to know when he began practicing under the influence, or whether, in fact, he was using when he saw Morton on the night of May 19, 1998.
That night, Morton, 36, felt a sharp pain in his left shoulder. Morton was a tough Midwesterner, a construction materials salesman who didn't much care for hospitals. After prodding from his fiancée and parents, he finally drove to the emergency room at Chandler Regional Hospital.
According to court records, Blass diagnosed Morton's pain as tennis shoulder — even though Morton had a full range of motion in the joint.
Lomax says Morton actually exhibited five of the seven classic signs of heart attack.
Morton tried to sleep that night, sitting upright in a recliner because of the throbbing. He assured his worried fiancée it was only a sore shoulder. That's what the doctor said. By sunrise, Morton had died a slow death from cardiac failure.
His son found him early the next morning, dead in his La-Z-Boy.
A heart attack killed Morton, less than 24 hours after his ER visit. Despite that grave error and four more errors in the ensuing years, the medical board still didn't submit Blass — an addict with a 20-year history of relapses — to drug tests.
The medical board instead mailed Blass a handful of disciplinary warnings for practicing sloppy medicine and keeping poor records. Then they allowed him to continue practicing, even after he unlawfully prescribed the narcotic OxyContin.
After the board stripped Blass' prescribing privileges, he apparently grew more desperate to secure drugs.
In 2006, Blass pleaded guilty in court to making meth at his house and was sentenced to probation. Two months into his probation, Blass allegedly pulled a gun on three Mesa police officers. According to court records, the officers subdued him without firing shots and then found marijuana on him.
On March 17, Blass' third drug-related criminal trial is scheduled to begin in Maricopa County Superior Court.
The deaths of Laura Migliano and Doug Morton Jr. have not been enough to get the attention of the Arizona Legislature, perhaps because of the lobbying power of the Arizona Medical Association.
Julie Fellmeth, a public interest attorney and law professor at the University of San Diego, says physician trade associations have been successful in limiting oversight on drug use among physicians. Fellmeth has been studying physician-addiction programs for more than 20 years. She was influential in the California Legislature's demand that the California Medical Board scrap its equivalent to Arizona's MAP program.
"Physician-rehab programs were all created years ago at the behest of physician trade associations. These are trade groups that want to protect physician licenses. Public protection is not their role," Fellmeth says.
David Landrith has been the Arizona Medical Association's chief lobbyist and policy expert for 17 years. Landrith wasn't a lobbyist 20 years ago, but he remembers the legislation from the 1980s that created today's MAP program.
And he is familiar with another bill he fought to make law 10 years ago. Dubbed the "Drunk Doctor Bill," it created confidential rehab for physicians who self-report their addictions. That law is the reason why certain cases of physician addiction don't surface on the medical board's Web site today.
"We're very supportive of the current program, and we do believe it falls within the effective standards in place around the country. We think it's great that the board would take the opportunity to mediate and return a valuable community resource back to the community," Landrith says.
But Jon Hinz of the Arizona Trial Lawyers Association says current laws favor the few physicians who are responsible for the majority of malpractice.
"Two percent of doctors are responsible for 75 percent of malpractice," Hinz says. "But if they keep passing these broad laws that protect all doctors, they're protecting the bad ones along with the good ones. By helping the very worst, they're lowering the level of the whole profession. They're literally opening the door for every quack who can't practice in another state to come here to Arizona."
Hinz says the laws can be traced beyond physician trade groups to malpractice insurance companies.
"There are countless measures to keep physician addiction as private as possible," he says. "They don't want monitoring because that protects them from civil liability. If the doctor was monitored and then hurt somebody while proven to be an addict, they would get sued."
Landrith disagrees. He says drug-testing physicians for more than five years would be cumbersome and unfair.
"We don't have any information to the fact that there's something wrong with the status quo. Lifelong monitoring would probably be unfair. We'd say, show us the data. Show us the studies that say it's appropriate. If you can show us the studies, then we'll talk," Landrith adds.
Dr. Greg Skipper, a national expert on physician addiction, heads Alabama's equivalent to the MAP program. He has studied thousands of addicted physicians and thinks lifelong monitoring would better protect not only the public, but also physicians.
"I think lifelong [monitoring] is a good idea," Skipper says. He adds that more state boards, such as Alabama's, are requiring some physicians to agree to lifelong monitoring. Arizona's is not among them. In fact, the Arizona Medical Board could not name a single physician who has opted into lifelong drug testing.
"The medical board can say you have to do this indefinitely," Skipper says. "Sometimes malpractice companies will require it. Actually, that's becoming more and more of a trend, where some third-party requires lifelong monitoring."
In California, that third party is the Legislature. After California's physician rehab failed its fourth audit, state lawmakers there forced the board to scrap its MAP program and present something more effective by June 2008.
Audits of the California program revealed many of the same holes found in Arizona's: physicians practicing unmonitored and killing or injuring patients, and MAP graduates relapsing into career-ending addiction.
A full-fledged audit could dig much deeper than New Times did, simply because more information is available to auditors. A committee of state lawmakers can order the Arizona Auditor General to perform such an audit. Fellmeth says that's the only way to evaluate the program's success or failure.
"An external audit is invaluable. Unfortunately, you cannot believe the medical board because most members of the medical board have no idea how that program works or how it's supposed to work. You can't trust the staff of the program to be straight with you. They never want to self-report, 'Oh, we're doing a bad job,'" Fellmeth says.
"We've had 27 years of spin about this program, of essentially lying with this false success rate, and every state program does it. I've seen it. Our program doesn't monitor any participant after they've left the program. They have no idea if this program is effective in the long term. To make any conclusions, you have to continue tracking them."
Downey, the medical board spokesman, says the board isn't cutting breaks for addicted physicians. "The Arizona Medical Board always keeps its mission in mind: Protect public health and safety. It investigates these cases completely, thoroughly, and fairly in a standard way with a formal process."
Downey admits that it's a tricky business to balance the doctor's right to practice with the patient's right to safety.
"We're trying to preserve the physicians we have. If we can rehab a physician and get him to take care of his problem, we don't lose a physician," Downey says. "The problem is, when you revoke a physician's license, you impact the lives of about 2,000 patients who are looking for a physician. That's not so easy these days. That doesn't mean we cut the doctor any deal. It's just, we're trying to balance public safety with the doctor's career here."
Laura Migliano's story ended with her death after Dr. Thomas Grade over-prescribed methadone. But Grade's story continued.
After Migliano's death, Grade's partners voted him out of the practice and the office building he'd constructed. But Grade still held his license to practice, with a restriction only on the drugs he could prescribe.
Two years later, on March 4, 2006, Kathryn Curtis Campbell nearly died during a routine cervical epidural performed by Grade. According to a lawsuit and a medical board complaint, Campbell's heart stopped; she was legally dead. She was revived and rushed to a hospital. The lawsuit has since settled out of court for an undisclosed amount.
Grade continued to practice. Another complaint was filed, but because the board dismissed it in April 2007, the details remain secret.
Two weeks after that complaint was dismissed, Grade's wife, Emily, a radiation oncologist, arranged an addiction intervention.
On a Wednesday afternoon, Grade drove his black Mercedes SUV into the upscale Circle G Ranches neighborhood in Gilbert and parked next to his restored 1969 Camaro in his three-car garage.
At his home, Grade's family and friends, along with a professional interventionist, tried to convince Grade that he needed help for his addiction. The intervention didn't work.
According to a Gilbert police report, "Thomas became very angry and ordered everyone out of the house. When they all refused to leave, Thomas started screaming and yelling obscenities."
Grade shoved his wife, shouted at the interventionist, and retreated to the basement, yelling. Gilbert police arrived at the home to find Grade inebriated and barricaded in the closet of a basement bedroom.
Officers beat down the bedroom door and tried to arrest Grade. When he resisted, they used a Taser on him.
Grade was booked at the county jail. His wife soon dropped all charges.
In a phone interview from his home in Gilbert, where he still lives with his wife and four children, Grade is difficult to understand. He sounds like a fine-tuned machine that's been fed the wrong fuel, his complex vocabulary packed with four-syllable medical terms.
Grade says that after he was released from jail, he hopped a flight to the Ukraine to find a new wife.
"After Ukraine, I was paralyzed in Kiev, it turns out. I'm thinking that's what I might title my book, Paralyzed in Kiev. Well, I was looking for a woman to have another family with because my wife, also a doctor, is in the middle of a divorce with me," Grade slurs.
"It's a meaty story. I became so ill through the course of this. Post-traumatic stress probably instigated from a sporting injury in 1984. I started to get ill [at] the time when the medical board came after me. It's one of the worst boards in the country. I've been doing these hyperbaric treatments."
After Grade's arrest, the board ordered him back into addiction treatment, but Grade didn't show up for treatment or the required drug tests.
In September, the medical board met to vote on Grade's license. Physicians usually bring an attorney to such votes and defend their right to make a living. But Grade didn't show.
On September 14, 2007, the board voted to revoke Grade's license, citing an evident relapse. It had been four months since Grade's arrest, one year since Kathryn Curtis Campbell went "code blue" during a routine epidural, three years since Laura Migliano died of a prescribed overdose, and 16 years since Grade graduated from rehab.
Grade still doesn't seem to understand that his license was stripped because of his addiction relapse.
Contacted by New Times, Dr. Emily Grade says her husband didn't practice under the influence.
"As physicians, we don't always get our records perfect," she says of the discrepancy between Grade's office notes and the actual prescription he wrote for Migliano. She thinks the medical board's strict discipline after Migliano's death drove him back into addiction.
"He had an amazing life until they took it away," Emily Grade says. "It's also a good lesson. Addiction is a lifelong risk."
For more stories from this series, check our special reports page: Prescription for Disaster.
