How did Florida shut down its pill mills?

Florida is the best-documented case because CDC investigators evaluated it directly. The sequence there ran: a 2010 requirement that pain clinics prescribing controlled substances register with the state; a joint DEA and state law-enforcement operation beginning February 2010; expanded pain-clinic regulation later that year; statewide raids in February 2011; a July 2011 statutory prohibition on physicians dispensing schedule II or III drugs from their offices, alongside a public health emergency declaration and regional strike forces; mandatory dispenser reporting to a new prescription drug monitoring program from September 2011; and in 2012, expanded regulation of wholesale distributors.

Around the same time, a reformulated, harder-to-tamper-with version of extended-release oxycodone replaced the original on the market.

Did the pill mill crackdown reduce overdose deaths?

In Florida between 2010 and 2012, drug overdose deaths fell 16.7% (3,201 to 2,666) and the rate fell 17.7%. Prescription drug overdose death rates fell 23.2%. Oxycodone overdose deaths fell 52.1% and oxycodone prescribing fell 24.0%. CDC described these as possibly the first substantial decline in drug overdose mortality in any state in a decade.

Nothing on this site disputes that. Pill mills were a real harm, closing them was right, and it saved lives in Florida in those years.

Did closing pill mills push people to heroin and fentanyl?

In the same state over the same period, heroin overdose deaths rose from 48 to 108 — a 122.4% increase in rate, from 0.3 to 0.6 per 100,000. CDC’s own framing was cautious: the absolute substitution effect was limited in that window (668 fewer opioid analgesic deaths against 60 more heroin deaths), heroin deaths had fluctuated widely for years, and other states without prescription declines also saw heroin increases.

The larger displacement was not visible yet. Purified, cheap heroin and then illicitly manufactured fentanyl entered a market of people whose supply had been cut off and whose underlying condition — in many cases an opioid use disorder — had not been treated. Within a few years the fentanyl supply would make the pill-mill era look small.

The limitation the report named itself

The data sources available for this investigation did not permit any assessment of potential unintended consequences of these policy changes, such as reduction of access to pain medication for legitimate prescribing indications.

Johnson et al., MMWR, 2014 — stated limitations

That sentence is the hinge of this entire argument. The evaluation that established the crackdown worked explicitly could not measure the harm to legitimate patients, because the data to measure it did not exist. It still largely does not. Supplying it is part of what this program is for.

Frequently asked questions

When was the Florida pill mill crackdown?

Florida’s crackdown ran from 2010 through 2012, within the wider 2010–2013 pill mill crackdown. Florida made pain clinics that prescribed controlled substances register with the state in 2010, joined the DEA in an enforcement operation that February, and ran statewide raids in February 2011. In July 2011 it banned physicians from dispensing schedule II or III drugs from their offices, and from September 2011 dispensers reported to a new prescription drug monitoring program. In 2012 it expanded regulation of wholesale distributors.

Did the pill mill crackdown hurt legitimate pain patients?

Nobody measured it. The CDC evaluation that showed the crackdown worked stated that its data could not assess unintended consequences, including reduced access to pain medication for legitimate prescribing. The data to measure that harm did not exist then, and it still largely does not. Supplying it is part of what the IntellaRx program is for.

Was shutting down pill mills the right decision?

Yes. Pill mills were a real harm, closing them was right, and it saved lives in Florida. Between 2010 and 2012, drug overdose deaths in the state fell from 3,201 to 2,666, and oxycodone overdose deaths fell 52.1%. The failure was what the crackdown left unmeasured, and the demand it pushed toward heroin and then fentanyl.