MANCHESTER, Tenn. -- Adam Loveless recognizes the customers addicted to prescription drugs. Their voices full of gravel, their demeanor edgy and nervous.
They come into Toliver's Pawn and Gun frequently, carrying family items -- a TV, jewelry, games.
They need money.
"They'll say it's for diapers or groceries, but you know what they really do with the money," said Loveless, who works at the pawn shop on the town square in Manchester. "You see a lot of good people that have gone to using painkillers; it's just blown up."
Manchester -- a sprawling town of 10,000 people on the Cumberland Plateau -- has four licensed pain management clinics. Prescription drug abuse is rampant here, many people in the area say.
But it's among many cities in Tennessee battling the problem -- the state ranks among the top in the nation for the number of prescriptions written, oxycodone and hydrocodone sales and drug overdose deaths.
And not much has changed since a law went into effect in January requiring all pain management clinics to be licensed and follow guidelines about who operates them and how much time medical directors -- who must be a licensed medical doctor or osteopathic physician -- spend onsite.
The clinic licensing requirement is the first step in combating the ability for drug abusers to get medication, some local experts say. But they acknowledge the law doesn't have the teeth it needs to adequately address the problem.
"There are loopholes in the law," said Dr. John Blake, a Chattanooga pain management doctor who said he strongly supports the law but thinks more needs to be done. "You have chiropractors and physicians who are using [clinics] as a business franchise for the purpose of profit, not the practice of medicine."
So far, the Tennessee Department of Health has issued licenses to 255 clinics, with about 20 more applications in process. A total of 19 clinics have been denied a license, most because they didn't have the proper paperwork or because a health care provider had past license violations, state officials say.
But an examination of the 255 licensed clinics shows:
• The state has issued licenses to doctors who serve as medical directors to as many as 11 clinics. The state law requires a medical director to be at the clinic at least 20 percent of the weekly time the clinic is open. But some medical directors have clinics in multiple locations across the state, with several hours' drive between the clinics.
• The health department's website also listed at least five clinics with chiropractors listed as medical directors. State officials said the listing resulted from a keying error, and the clinics actually have medical doctors overseeing them.
• There are also vast differences in the distribution of clinics, with the highest concentration located in Northeast Tennessee and the rural counties of the Cumberland Plateau. Some counties -- like Coffee County where Manchester is located -- have one clinic for fewer than 10,000 residents. Hamilton County has 20 clinics approved or in process, about one per 17,000 residents.
State Sen. Andy Berke, D-Chattanooga, a co-sponsor of the law, said it will help the state to gather information about the clinics.
"Once we get our hands around the scope of the problem, it makes it easier to figure out what the next step should be and will make the enforcement much easier," Berke said.
Georgia attempted to pass a similar law this year that would have gone into effect next year, but it failed because of technical issues, state officials said. Lawmakers plan to try again next year.
The Tennessee law that went into effect in January requires each clinic to have a medical director to oversee all pain management services, be on site the required length of time and oversee the quality policies and accuracy of medical records, among other duties. Under the law, clinics are licensed for two years.
Michelle Long, assistant commissioner of Health Licensure and Regulation at the state Department of Health, said they look at each clinic application separately to see if it meets the requirements.
Long said she wasn't aware that the state had issued licenses to 11 clinics with the same medical director. But some clinics are not open five days a week, she said, potentially allowing a medical director to serve numerous clinics.
The 11 clinics are scattered across Middle and West Tennessee, all listed under the name Comprehensive Pain Specialists with Dr. Peter Kroll listed as the medical director.
Calls to more than half the clinics showed most are open an average of 30 to 35 hours a week -- which means a medical director would need to spend about six hours a week at each of the clinics. Driving time between all the clinics is more than six hours.
Kroll did not return a phone message left at Comprehensive Pain Specialists' main number.
Long said doctors are not required to submit documentation of the time they spend at each clinic. However, the state does have access to a doctor's files for inspections whenever it chooses, Long said.
The state is also working on using its drug monitoring database -- which contains doctor-written prescriptions -- and pairing that with licensed clinics to see which ones may be over-prescribing.
The state will investigate any complaints about violations of the law and encourages people to report issues, Long said.
Blake said he doesn't fault the health department for not investigating the clinics because they don't have the funding or resources. He thinks the best way to address the root of the problem -- doctors who don't prescribe pain medication appropriately -- is to limit pain clinics to doctors certified in pain management. Before he earned his certification, he did three years of anesthesiology training and a one-year pain management fellowship, he said.
Allowing any family practice doctor or someone without special training to open a pain clinic is like allowing a general practitioner to open a cardiology practice, he said.
'Handed out way too easy'
A tour of the four clinics in Manchester showed numerous cars parked in both the front and back, many of them with license plates from various Tennessee counties. Some came from Nashville, about an hour away.
One clinic had no sign, unmowed grass along the edges of its low-slung old building. At another, a request to interview a doctor was met with the response that he had gone home for the day.
One man who was waiting outside, who said he had driven down from Murfreesboro, said the clinic was not a "pill mill." He declined to give his name as he sat in his car waiting for his appointment, and said he was not addicted to prescription drugs. He injured his back when he fell out of a tree as a child, he said, and has been going to pain clinics for about four years.
He couldn't talk more because he was afraid of missing his appointment, he said, stubbing out his cigarette and carrying his can of Orange Crush into the clinic.
Loveless, the pawn shop employee, recently graduated college with a degree in criminal justice and said he'd like to work for a drug task force or maybe the Drug Enforcement Administration to fight the problem.
On the streets of Manchester, you can find out where the pills are in 10 minutes, he said. Everyone knows.
And many also know someone who has died from a drug overdose. Coffee County recorded seven such deaths in 2010, the most recent statistics available. Those deaths were among a total of 887 statewide attributed to overdoses, most of them from prescription drugs.
"It's rampant," Loveless said.
In the next county over -- Franklin County -- the story is pretty much the same.
Sgt. Chris Guess, a detective with the Franklin County Sheriff's Department, said it is too early to tell whether the licensing law will do any good. It is almost impossible to police the problem. If they find someone with a bottle of pills on them, even if they got it from a "pill mill," they usually can provide a prescription.
Police try to fight the problem with drug drop boxes where residents can bring old or unwanted prescriptions, ads in the paper to educate about the dangers of prescription drugs, town hall meetings and talking to high school kids. But the clinics keep writing prescriptions.
"In my opinion they are handed out way too easy," Guess said. "The accountability is almost nil. Until the Legislature does something to tighten the regulations, it's probably not going to change a whole lot."