Fourteen of Doanh Nguyen's patients have died of prescription drug overdoses since 2005, coroner's records show.
But he's not to blame for any of them, he said.
His practice in Orange County's Little Saigon caters to pain sufferers of all kinds. Nguyen says he instructs patients on the safe use of the narcotics he prescribes. If they misuse them, he says, it's not his fault.
"I cannot control that, so I don't allow myself to feel responsible," he said in an interview.
Nguyen said some patients fake pain and even injure themselves to ply him for prescriptions. Some come in for early refills — a sign they are taking too many pills, selling them on the street, or both.
"I can't last," said a woman with a weathered face and bad teeth, pleading for another prescription late one Friday afternoon. "I can't be like this until Monday."
The woman had caught Nguyen in a hallway of his office in Westminster, within earshot of Times reporters. Nguyen refused her request, saying he already had given her too many early refills.
But he doesn't always turn down such requests. The first time a patient asks for an early refill, he said, he writes the prescription — and charges "a fine." The second time, he said, he charges more.
After that, he said, they're out of luck.
Nguyen, 48, a native of Vietnam, earned a degree from USC's Keck School of Medicine. He is board-certified in anesthesiology and taught at the UC Irvine medical school. Nguyen said he opened a pain management practice because he wanted more interaction with patients.
Most of his patients who fatally overdosed had a history of substance abuse before they began seeing him or showed signs of abuse after they began taking medications he prescribed, according to coroners' records. They ranged in age from 28 to 65 and included people struggling with workplace injuries and with histories of mental illness and suicide attempts.
Asked about his management of high-risk patients, Nguyen replied: "You can't hold their past against them and say, 'You're here because you are a drug addict ... and now that you have pain, you have to suck it up. You have to be in pain for the rest of your life.'"
He says his goal is to help those with chronic pain function better. If he sees signs they are abusing medications, he said, he reduces the dose or weans them altogether.
Theresa Jones went to Nguyen because of pain in her arthritic knees that was aggravated by waiting on tables at Disneyland. She became addicted to the pills Nguyen prescribed, said her husband, Jim Jones.
Jones said she overdosed at least seven times in recent years, including twice in the weeks before her death. Jones said he brought the incidents to Nguyen's attention, but the doctor kept giving her prescriptions. Nguyen said Theresa could have lost consciousness because of her diabetes, not from an overdose.
Theresa died April 1, 2010, of an overdose of six drugs, including two prescribed by Nguyen, records show. She was 51. At least 10 different medications prescribed by Nguyen were found at the scene, coroner's records show.
Nguyen said it was frustrating that some patients don't heed his warnings or learn from their mistakes, even after surviving an overdose.
"They don't care," he said.
John Dimowo's father was a folk healer who treated people's ailments with herbs.
"There was no Vicodin," recalled Dimowo, a native of Nigeria. "If you [had] Tylenol, you were very lucky."
As a result, Dimowo said, he developed a high tolerance for pain — something most Americans lack, in his opinion.
Today, he prescribes powerful medications to patients complaining of pain. A vanity plate on his BMW reads: "PAYN DOC." A sign in the lobby of his Anaheim clinic informs pain patients that they will be seen on a "cash only" basis.
Dimowo, 54, attended medical school in Nigeria. After practicing there for six years, he moved to the U.S. and was trained in anesthesiology and pain management. He is board-certified in both specialties. For three years, he said, he served as chief of anesthesia at Anaheim Regional Medical Center. In 2007, he opened a pain management practice.
He is also medical director of a spa he runs with his wife, where he performs liposuction, Botox injections and other cosmetic procedures. He is part owner of a nutritional supplement company and markets himself as a prescriber of medical marijuana.
Dimowo said he became a pain specialist because he finds satisfaction in spending time with patients and helping to ease their suffering.
He said it can be hard to tell whether someone genuinely needs narcotic painkillers or is simply looking for a high.
"Pain is a difficult thing to define. You can't say, 'No. You don't have pain.… You're just seeking drugs.' It's very difficult to tell anybody that," he said. But if he believes a patient is abusing drugs, he said, "they are out of my clinic. I would send them to a psychiatrist, because that's where they belong."
Five of Dimowo's patients died of prescription drug overdoses over 18 months in 2009 and 2010, coroner's records show.
They included Renee Salot, 37, who passed out on her living room floor after overdosing on painkillers and sleeping pills. Her 14-year-old son found her the next morning when she failed to wake him for school.
Chaz La Bry, 26, was an aspiring rapper who used to drive more than 50 miles from San Clemente to see Dimowo. He died of an overdose of prescription painkillers and methamphetamine in 2010, coroner's records show.
La Bry's father, who was also a patient of Dimowo, told authorities that Chaz had a history of abusing pills and that the doctor had overprescribed to his son, according to coroner's records.
Dimowo said he was unaware that La Bry had been misusing the drugs he prescribed. Informed of the fatal overdoses identified by The Times, he said the patients and their family members shared responsibility.
"We all need to be vigilant," he said.
Dr. Naga Thota says he welcomes the challenge of caring for patients in chronic pain, even those who have become addicted to the drugs that give them relief.
"Somebody has to take care of these people," he said in an interview. "And I am the chosen one."
Since 2005, at least 15 people have died of overdoses after Thota prescribed drugs for them, according to a Times review of coroners' records.
Confronted with the findings, Thota was not surprised. He said the death toll was probably even higher because he suspects some of his patients sell the drugs he prescribes on the streets of San Diego. Federal agents, he said, routinely visit his office to review files of patients they suspect of dealing drugs.
"There are so many deaths in the city with my prescriptions sold on the street that you don't know and I don't know," he said.
He said he requires patients on narcotics to submit to regular urine tests — and he kicks out those whose exams come back negative, a sign that they are selling the drugs. He dismisses a patient several times a week for that reason, he said.
When he learns that a patient died of an overdose, he and his staff review the case to see if they could have done something differently, he said. Thota said prescribing painkillers is like "playing with fire," and said he is blunt in informing patients of the risks. "This medication might kill you one day," he said he tells them. "Be careful."
Thota, 58, grew up in a thatched-roof home in eastern India. He went to medical school and trained to become a neurosurgeon. He later immigrated to the U.S. and completed a fellowship in pain management at the Cleveland Clinic, he said. He is board-certified in anesthesiology.
He said he was inspired to go into pain management in part by watching his grandfather writhe in pain in a hospital bed in India after fracturing a hip. Doctors would not give the elderly man morphine for fear he would become addicted.
Thota said he once made $1 million a year from his practice and lived in a spacious home in La Jolla. Then insurers began reducing the amounts they would pay doctors to treat patients. The sort of monitoring needed to prevent patients from abusing their drugs was no longer feasible, Thota said.
He said he once saw high-risk patients two or three times a month, but insurance cutbacks have made that "almost impossible." He once worked closely with a psychologist, an addictionologist and a physical therapist, he said, but no longer does. He also sold his La Jolla home and moved to a smaller house inland.
Thota said he has been reduced to providing a "third world" level of care. He compared health insurers' cutbacks to removing air bags and seat belts from cars.
"What do you expect?" he said. "The deaths are going to go up."