Dr. Gary A. Shearer continued to prescribe painkillers, even as 14 of his patients died of drug overdoses, according to Kentucky investigators.

Maryland psychiatrist Patricia A. Newton kept prescribing to a struggling addict, according to a judge’s account in a dispute over her license, until that patient turned up, unconscious, in a Maryland hospital bathroom with a syringe and 545 pills.

Physician Michael B. Rosen was prescribing nearly 1,000 highly addictive pills per month to a patient who told a Pennsylvania detective that he “did not have any serious pain,” but could get “whatever he wanted” from “Dr. Feel Good,” according to a police affidavit.

Now law enforcement is searching through prescribing records of doctors in Minnesota and California in relation to the April 21 death of the musician Prince.

Warned time and again that pain pills can addict and kill, hundreds of doctors throughout seven narcotic-plagued states wantonly prescribed painkillers, setting the stage for the worst drug epidemic in U.S. history as brand-name opioids joined with cheap heroin.

From 2011 through 2015, across Pennsylvania, Ohio, West Virginia, Maryland, Virginia, Kentucky and Tennessee -- which include the bulk of addiction-ravaged Appalachia -- 608 doctors have been disciplined by state medical boards for overprescribing narcotics, according to a six-month Pittsburgh Post-Gazette investigation.

Some wrote thousands of prescriptions for OxyContin, even though, in 2007, Purdue Pharma agreed to pay $600 million to settle criminal charges that it lied when it called that opioid “less addictive.” They prescribed powerful narcotics for everything from migraines to sunburn, according to the state medical board documents, ignoring the White House’s 2011 declaration of a “prescription drug abuse crisis.”

Doctors dismissed red flags that patients were selling their pills to street customers who paid a dollar per milligram.

When insurers or pharmacists balked at the quantities of drugs patients were getting, many shrugged it off.

Physicians looked the other way when their patients’ spouses or parents pleaded with them to turn off the spigot of addiction.

Some vigorously defend their decisions, telling the Post-Gazette that they were doing more good than harm. Their stories will be published over the coming days.

Others, though, have traded the Hippocratic Oath’s call -- “that warmth, sympathy, and understanding may outweigh … the chemist's drug” -- for million-dollar windfalls, sex with the addicts they supplied, or drugs to feed their own cravings.

“In Appalachia, there was definitely a pill culture that overtook the whole region,” said Van Ingram, who directs Kentucky's Office of Drug Control Policy. “We’ve lost a generation, really, to this disease.”

In states like Kentucky that disciplined or jailed rogue doctors and curbed the actions of others, painkiller prescribing has ebbed. In states slow to respond, including Pennsylvania, the flow of narcotics has barely budged. In six of the seven states studied by the Post-Gazette, fatal overdoses have climbed as heroin moved into areas that developed a taste for narcotics at the hands of healers.

U.S. Attorney David Hickton, Western Pennsylvania’s top prosecutor and a co-chair of the National Heroin Task Force, placed some of the blame for “an epidemic of related problems of heroin and opioid pill abuse” on “the small percentage of doctors who we call drug dealers with white coats.”

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Pills and needles

Gary A. Shearer, of Florence, Ky., had patients who claimed that they had lost their prescriptions. He’d write new ones.

Urine tests would reveal that patients weren’t taking their prescribed pills. One patient had five irregular tests and admitted that “the father of her children may be getting her medication,” according to Kentucky Board of Medical Licensure reports. Dr. Shearer kept prescribing.

Coroners started counting the corpses that came in saturated with drugs that he’d prescribed. They totalled 14 over two years. The state’s drug database revealed that he was a top-five source of oxycodone prescriptions in Kentucky’s Appalachian east. Federal agents searching his office found 313 blank, pre-signed prescriptions -- a practice which would enable staff, or a patient who snatched the blanks, to prescribe drugs.

Investigators found one patient who "met the [doctor] through her brother, who sold cocaine to the [doctor]," and brought him her 17-year-old daughter. The daughter then "began receiving Vicodin" and the doctor "asked [the daughter] out on dates," according to the board reports.

The board suspended Dr. Shearer’s license in 2012. He died in 2014. Though he’s an extreme example, none of Dr. Shearer’s practices were unique. A medical establishment that had, since the 1990s, prioritized pain management is now debating whether the opioid epidemic stems from a few bad apples or a cultural shift.

"Clearly, there are physicians and others who abdicate their professional responsibility and act outside of what is best practice and standards of care," said Patrice A. Harris, chairwoman-elect at the American Medical Association and leader of its Task Force to Reduce Opioid Abuse. She said that the scarcity of insurance coverage for alternative treatments likely ranks above doctor misconduct among the causes of the painkiller epidemic.

State regulators, however, are “seeing a lot of physicians who were being educated and licensed when everyone was focused on treating pain,” said Cameron McNamee, director of policy and communications at the Ohio Board of Pharmacy. They were taught “that pain is the fifth vital sign,” added to the traditional four: blood pressure, breathing, pulse and temperature.

Medicine, he said, needs to “course correct. … Because what concerns us the most is that everyone is focused on heroin, but the heroin problem wouldn't be one-tenth as bad if we hadn't primed the pump with prescription opioids and all the controlled substances."

The Post-Gazette reviewed more than 4,200 actions taken during the years 2011 through 2015 by medical boards in the seven states that constitute most of Appalachia. Those boards are charged with ensuring that medical doctors and osteopaths aren't acting contrary to their oaths to heal the sick, and can reprimand physicians, demand education, impose probation, suspend or revoke licenses.

Some of the boards have been inundated with tales of tragedy -- like the fortysomething woman found unconscious in the bathroom of a Baltimore hospital in 2014. She had a needle in her arm, but not a speck of heroin. Instead, police found 63 pills of oxycodone, 31 OxyContins, 30 hydromorphones, 4 methadones, 9 methylphenidates, 60 alprazolams, 161 dextroamphetamines, and 187 other pills.

The woman had come to Baltimore psychiatrist Patricia A. Newton in 2012 for depression, anxiety and chronic pain, and was on Suboxone, which staves off opioid withdrawal, a Maryland administrative law judge wrote last year. Dr. Newton weaned her off of Suboxone -- but put her back on oxycodone. The doctor later added more drugs and prescribed early refills when the patient claimed she'd lost her pills.

Confronted by investigators, Dr. Newton said that it is "inhumane not to treat a patient if they have a legitimate chronic pain condition, whether or not they've had a substance abuse disorder," wrote the executive director of the Maryland Board of Physicians, in an order suspending the psychiatrist's license.

The judge detailed Dr. Newton's prescribing to nine other patients in a decision finding "misconduct" and "professional incompetence." Dr. Newton, who could not be reached for comment, is still licensed to practice, though barred from pain management.

“The most trusted people”

Opioids and opiates are narcotic drugs that attach to nervous system receptors, often reducing pain and, as the dose increases, bringing a sense of well-being, drowsiness, confusion, nausea, constipation and slowed -- or stopped -- breathing.

Opiates are extracted from opium, as is heroin. Opioids are synthetic -- but equally effective -- imitations. Benzodiazepines, including Xanax and Valium, magnify the effects of narcotics.

The U.S., with 4.4 percent of the world’s population, consumes around 70 percent of the world's output of powerful pain medicines, according to the American Society of Interventional Pain Physicians, which analyzed International Narcotics Control Board data.

From the early 1900s to 1995, narcotics were used mainly for severe pain, especially from cancer. OxyContin, a time-released oxycodone product, changed that after its approval by the Food and Drug Administration, and release by Purdue Pharma, in 1995. The drug boasted a time-released formula meant to make abuse unlikely, if not impossible. To some, that meant the opioid could be used safely for chronic pain.

“The pharmaceutical company, a legal corporation, here they go down this road,” said West Virginia Sen. Joe Manchin, who, as a leader from a state rife with addiction, has become Capitol Hill’s most vocal critic of the medical industry’s role in this epidemic.

“And the Food and Drug Administration, who we think is supposed to be protecting us, says ‘No problem at all.’ Doctors, who are the most trusted people we have in America, legally saying, ‘This is what you need. This will help you.’ It exploded from there, and now we’re trying to put the genie back in the bottle, and it just got bigger and bigger and bigger.”

The genie didn’t get out on its own.

In the 1980s and '90s, physicians faced complaints that they were undertreating pain, said the AMA’s Dr. Harris, an Atlanta psychiatrist who grew up in Bluefield, W.V.

In 2001, California doctor Wing Chin was sued by a patient’s three children for not prescribing their father enough pain medication. The patient, 85-year-old William Bergman, had been treated by Dr. Chin for stress fractures in his back. He would later die of lung cancer. A jury found Dr. Chin guilty of recklessness and abuse and ordered him to pay the Bergman family $1.5 million for their father’s pain and suffering.

Dr. Franklin Demint of Kingston, Ohio, remembers a sea change occurring soon after Dr. Chin’s case. It sounded an alarm to the medical community that treating pain with more potency should become a priority. It was no coincidence that Dr. Demint began his own pain management practice in 2002.

Ten years later, in 2012, the State of Ohio Board of Medicine cited Dr. Demint for improper prescribing practices in his care of 14 patients. His medical license was suspended for 180 days. He now regrets ever getting involved in the booming pain treatment industry and considers himself a victim of a politically-driven “witch hunt” meant to put the blame on doctors and paint them as pill pushers.

“We were trying to do the best we could with the knowledge we had,” said Dr. Demint, whose license was reinstated by the board in 2015. “The problem is, we still don’t have a very good knowledge of pain. … We’re winging it, trial and error. It’s the way it is. The medical community, we don’t know everything. We’re not God. Doctors don’t like to admit that.”

Physicians fell under the spell of persistent pharmaceutical drug company representatives, who bombarded them with free lunches and provocative pitches for their products. Another doctor disciplined by the Ohio board for poor prescribing, Paul Wilson, recalled a day in 2007 when reps from three different drug companies brought lunch to his Cleveland area office.

“Psychologically,” said Dr. Wilson, who surrendered his medical license in April, “when somebody brings you lunch, and they’re real nice and everything, you want to write their drugs, at least a little bit.”

Some doctors decided to try the drugs themselves. In 2011, Kentucky doctor Anthony B. Karam started down the road to treatment for opioid abuse when a nurse raised questions about his handling of two vials of fentanyl.

A hospital nurse at the Pattie A. Clay Regional Medical Center in Richmond, Ky., noticed that the vials were missing from her patient's bedside cabinet. Moments later, Dr. Karam rounded the corner from the bathroom with the vials and a syringe in his pocket, the nurse reported, according to a Kentucky Board of Medical Licensure order co-signed by the doctor. Whatever the doctor had put into the syringe, and then injected into the patient, “did not appear to have an effect,” the nurse reported, according to the order.

Dr. Karam admitted taking part of the 2,500 doses of drugs that he had prescribed for his fiancee and her two daughters over five months. A consultant spotted a dozen violations in Dr. Karam's prescribing practices, although the doctor insisted that the treatments matched patient needs.

Dr. Karam declined comment through his attorney. In 2013 he resigned from his practice, then entered addiction treatment in Mississippi after the board suspended his Kentucky medical license.

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Feeding the epidemic

While two studies have showed no overall change in the amount of pain Americans report to hospitals, the quantity of opioids consumed quadrupled from 1999 to 2014, the Centers for Disease Control has found. In three of the states studied by the Post-Gazette -- West Virginia, Tennessee and Kentucky -- the number of opioid prescriptions written annually by doctors exceeded the population.

The CDC tallied 47,055 drug overdose deaths nationally in 2014 -- a record -- and found that 28,647 involved opioids, heroin or both. Celebrity deaths from Philip Seymour Hoffman's (blamed partly on benzodiazepines) in 2014 to Prince's (reportedly connected to opioids) in April increased the issue's public profile.

Gary Tuggle -- now the Drug Enforcement Administration’s special agent in charge for Pennsylvania and Delaware -- has seen three epidemics. Soldiers returning from Vietnam brought a heroin surge in the 1970s. Crack cocaine singed cities beginning in the mid-1980s. Now it’s pills and heroin.

“It dwarfs those [earlier] two epidemics,” said Mr. Tuggle, to a January gathering of concerned citizens in Monroeville. “This particular heroin epidemic has a feeder system, and that feeder system is the misuse and abuse of opioids.”

In April 2011, the White House report, “Epidemic: Responding to America’s Prescription Drug Abuse Crisis,” labeled pills, especially opioids, as “the Nation’s fastest-growing drug problem.”

From 2011 to 2015, federal prosecutors in the seven states charged at least 66 physicians as narcotics dealers. “To me, they’re no better than the guy or the girl selling heroin on the corner,” said Mr. Tuggle. “To me, they’re worse, because they took an oath to do no harm.”

The CDC says that 2 million Americans are now addicted to, or abuse, opioids.

“Scared to death”

Towns throughout Appalachia, already strangled by depressed economies, have become easy targets for heroin drug lords. Demand is highest in places with faint horizons, and the supply must follow.

Last August in Pennsylvania’s Washington County, where Interstates 70 and 79 intersect near the county seat of Washington, Pa., a community of more than 200,000 saw a frightening display of what can happen at the end of the tragic road of opioid addiction.

Stamp bags of heroin marked “Made in Colombia” hit the streets, and addicts were soon buzzing about a high that shouldn’t be missed. Only the suppliers and their distributors knew what was driving that little something extra -- the batch had been cut with fentanyl, an opiate 100 times more powerful than morphine.

On August 16, as the county fair began in Washington on a hot, sunny day, 16 overdoses were called in to 911 dispatchers. From 7:33 p.m. to 8:42 p.m., there were eight calls in 70 minutes. The next day, 11 more. By the end of the week, there would be 38 total -- including five deaths.

The victims would be filed in the books as heroin overdoses. That label may have been accurate, but it failed to tell the full story.

When Valerie Mack found her brother, Sammy, 50, dead on the floor of his bedroom, she knew that he likely wouldn’t have found his way to heroin if he hadn’t been injured months earlier in a motorcycle accident and been prescribed painkillers.

Those who were fortunate enough to have been revived on the scene by first-responders armed with Narcan -- an opioid antagonist now used as a nasal spray antidote -- were given a second chance at life. Some of them told the Post-Gazette their stories, which will be published in the coming weeks. The victims who survived share a common theme: They never imagined they would be the person sticking their arm with a needle.

Today, Jessica Neal, 27, is nine months clean after eight years spent in the throes of addiction. Around Washington, it will be hard for her to escape the stigma of being the woman who overdosed in a Walgreen’s bathroom stall with her 2-year-old daughter in a stroller.

A decade ago, as a student at Washington High School, Ms. Neal played basketball for four years and was headed to Waynesburg University. But a boyfriend introduced her to OxyContin, which led to heroin abuse.

So many times throughout those eight years, Ms. Neal went to rehab and tried to get back on track. But medical issues kept coming up -- hernia surgeries, a miscarriage, abscesses, a hand infection, gallstones -- and each time, she said, she was prescribed opioids by a doctor without any questions about her addictive tendencies.

“He was just willing to give them to me,” Ms. Neal said. “There are other ways to manage pain, and you know, no one ever cared to explain that to me. I shouldn’t have gotten them. I knew that if I wanted to get pills, or pills to sell for money, I can go to the hospital. I can go to the doctor and say, ‘Oh, this is hurting me.’ You learn how to manipulate the system.”

In February 2015, Ms. Neal was in detox. In March, a gallstones surgery and the corresponding prescription pills sent her reeling again. In August, she heard about the strong batch of heroin and had to have two bags, even though she’d been advised that one was enough. Her overdose woke her up, and now she’s working her way through Washington County’s drug court program and attending daily Narcotics Anonymous meetings.

She is starting to feel like Jessica Neal again, but she still carries with her one big fear about the future.

“I’m scared to death,” Ms. Neal said, “that I might have to get surgery again, and they’re going to have to give me pain pills. I just pray all the time that nothing happens again. I don’t have the obsession anymore, and I don’t want it brought back into my life.”

Uneven response

The cures offered for the opioid epidemic have ranged from new drugs to expanded rehab. The data assembled by the Post-Gazette suggests that changing the behavior of doctors is crucial.

Some states, like Kentucky and Tennessee, have made prescribing guidelines official, meaning doctors can be disciplined or sued if they stray. Pennsylvania's medical boards haven't yet voted to endorse guidelines, but the state's physician general plans to suggest that step this summer.

In Kentucky, where addiction sank deep roots, doctors are now required to check a patient's drug history before prescribing narcotics, and must take 4.5 hours of prescribing classes every two years or risk a license suspension. Over five years, Kentucky disciplined 12 out of every 1,000 doctors for overprescribing narcotics. Opioid prescribing there dropped by 12.5 percent from 2012 to 2014, and fatal overdoses edged downward.

By contrast, Pennsylvania’s boards can’t readily tap prescribing data, and have disciplined just over 1 out of every 1,000 in-state doctors for their narcotics practices. Opioid prescribing inched downward by 2.3 percent, and overdoses climbed.

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The CDC's new prescribing guidelines, finalized in March, tell doctors to try other options before turning to opioids. They say that if opioids are needed, doctors should disclose the risks of addiction, check databases to find out if patients are getting painkillers elsewhere, start with low dosages and increase them only slowly, avoid mixing opioids and benzodiazepines, and refer addicted patients to treatment.

Dr. Harris said the AMA worries about unintended consequences of "one-size-fits-all approaches" to pain medication, preferring an individualized approach to treatment. The AMA resists universal opioid training for doctors and mandatory checks of prescription-drug databases. Some databases are poorly funded and error-prone, while any one doctor's education needs can vary widely, Dr. Harris said.

"I think it's critical, if we really get to solutions, that we talk about the other issues" in addition to physician misconduct, Dr. Harris said. She said non-drug alternatives for managing pain such as physical therapy "are not always accessible to our patients, even our patients who have insurance."

Passionate critics of the medical field like Mr. Manchin are tiring of excuses for keeping the status quo.

“If the [Veterans Administration], Medicare and Medicaid basically said, ‘We’re not going to allow prescriptions to be the first line of defense for pain. We’re going to try every alternative first,’ you can change the culture again,” Mr. Manchin said.

Medical boards can choose to change that culture, one doctor at a time.

Michael B. Rosen, of Elkins Park, Pa., was charged with two state crimes, agreed to pay $14,442 in restitution and do 140 hours of community service, but can ask for the return of his surrendered physician's license this year.