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.
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.