Emergency room doctors at a Santa Barbara hospital saw a disturbing trend for more than a decade _ patient after patient hooked on prescription drugs shared the same physician.
Despite their complaints to state medical authorities and federal law enforcement, Dr. Julio Diaz continued practicing even though 12 patients had died since 2006.
His arrest Wednesday on federal drug trafficking charges came as no surprise to some who knew him. What stunned them is that it took so long.
"I don't really understand what happened there," said Dr. Chris Lambert, an emergency physician at Cottage Health System who was one of the doctors to flag Diaz's prescribing patterns. "Physicians these days get censured for bad record keeping _ the medical board is on them immediately for making an error in a chart. But what happened in this case? How did it slide along?"
Diaz hasn't been charged in connection with the deaths, which remain under investigation. He is accused of illegally prescribing large amounts of painkillers to patients who didn't need the drugs and for accepting sexual favors as payment from some women.
Diaz made his initial court appearance Thursday and was taken into custody without bond. His next court hearing is Tuesday. His attorney Ralph Rios declined comment outside court.
His case comes amid increasing investigations of dirty doctors running so-called pill mills, as deaths from prescription drug abuse have surpassed traffic fatalities in the United States. Diaz is among more than 230 doctors charged since 2003 with federal criminal counts in relation to prescription drug abuse, according to DEA statistics.
Dubbed by some of his patients as the "Candy Man," Diaz supplied OxyContin, Vicodin and Norco and other drugs to addicts with no legitimate need for the powerful narcotics, authorities said.
Some patients diverted the pills to the black market or suffered the fatal overdoses, authorities said, noting that one man who died in November was prescribed 2,087 pills in the six weeks before he died.
In addition, two women taken to a hospital emergency room indicated they were among numerous people who used sex to pay Diaz for narcotics, according to an affidavit filed in the case.
Court records and interviews show authorities had Diaz on their radar but his medical license remained in good standing.
Lambert said the complaints about Diaz date back roughly 15 years, and doctors reached out to the DEA about four years ago. DEA spokeswoman Sarah Pullen said the investigation into Diaz began in mid-2009, but she was unaware of any prior complaints against him.
People traveled hundreds of miles to see Diaz, who specialized in pathology and geriatrics at his Santa Barbara office, authorities said.
Lambert estimated that between 2009 and 2010, the hospital reported more than 400 emergency room visits by patients of Diaz. Two were 96 and 100 and had been provided with significant amounts of narcotics, he said.
In another case, a fellow doctor told authorities that a patient of Diaz had received enough Dilaudid "to kill a horse," according to court documents.
Santa Barbara police interviewed Diaz in late 2007 in connection with the overdose death of a 53-year-old woman, and the physician said he hadn't seen the woman in a month and had been treating her for arthritis and hypertension, according to court documents. The woman's daughter was later interviewed and believed her mother had been overmedicated.
In October 2009, Lambert and other doctors notified the state medical board that the hospital where they worked was admitting at least one of Diaz's patients a month who had been prescribed high doses of narcotics. They never heard back from the board, he said.
Diaz "would always say there was a legitimate reason for them to have high doses of narcotics, which was hard for us to believe," Lambert said.
Dan Wood, a medical board spokesman, said the agency is aware of the allegations against Diaz but couldn't confirm or deny that an investigation was under way. Asked if the board was slow to respond to the Diaz accusations, he declined to comment.
Dr. Herb Malinoff, secretary of the American Society of Addiction Medicine, said doctors generally don't complain about colleagues because they aren't policemen. But if any complaints are voiced to state medical boards or law enforcement by fellow physicians, they should be taken seriously, he said.
Diaz, who could face up to 20 years in prison if convicted, told the Los Angeles Times, "perhaps there were some hints there that I should have known they were going to overdose."
Winning a conviction for causing a drug-related death against a doctor has proven to be difficult, although a jury convicted Dr. Conrad Murray of involuntary manslaughter for the death of Michael Jackson last year.
In 2009, jurors in Los Angeles were unable to decide whether Dr. Masoud Bamdad caused the death of 23-year-old college student Alex Clyburn, who died after overdosing on pills prescribed by the physician. Bamdad was convicted of selling prescriptions to patients and was sentenced to 25 years in prison.
"In these doctor cases it's not like a doctor pulls out a gun and shoots the patient," said Thom Mrozek, a spokesman for the U.S. attorney's office. "The direct connection with the causal effect is difficult to prove."
Diaz said that even in some cases in which he suspected a patient was abusing drugs, he would continue prescribing so that he could manage what they were taking.
"If you don't give them the medications, they are going to go to the street," he told the Times. "That has become an issue of: What is the worse of two evils?"
AP Science Writer Alicia Chang contributed to this report