The Medical Board of California put Dr. L. Scott Stoney on probation for 10 years for excessive prescribing, falsifying records and other offenses.
It was a stiff sanction by the agency's standards. But when a judge recommended that Stoney's probation be lifted three years early, the board did not object.
The Newport Beach pain specialist said he had turned his practice around and had grown wise to the tricks some patients used to obtain prescription painkillers.
A doctor who had monitored his practice vouched for Stoney's assertions that he had better-trained staff and had begun requiring patients to sign contracts agreeing not to abuse the drugs he prescribed.
"He has taken the opportunity in the last seven years and truly turned the bitter taste of lemons into the lemonade of a new and different person and physician," state Administrative Law Judge Stephen E. Hjelt wrote in August 2009.
"Perhaps the best word to describe the change in respondent's practice is vigilance," the judge wrote.
The board approved the judge's recommendation six weeks later, cutting short Stoney's probation.
Unmentioned in the judge's ruling, and apparently unknown to him or the board, two of Stoney's patients had fatally overdosed on medications he prescribed while he was on probation, according to coroner's records.
One was addicted to pain medications and had overdosed previously, the records state.
Four more of Stoney's patients -- all known drug abusers -- have died of overdoses since his probation was lifted, according to coroner's records.
One of those patients had a crack habit and liked to take "a handful of pills" when she became upset, coroner's records state.
Another had taken to smoking his pain medications or dissolving them in cocktails.
A third was hospitalized after mixing alcohol and pain drugs, then suffered a fatal overdose a week later, coroner's records say.
Medical board officials declined to discuss Stoney's case. Stoney, 51, a graduate of Robert Wood Johnson Medical School in New Jersey, did not respond to requests for an interview.
In a promotional video on the doctor's website, several people identified as Stoney's patients deliver glowing testimonials to him.
"Because of your work, your patients have described you as a miracle worker," an interviewer says.
"When they talk about you, tears come to their eyes. You've saved some lives. Is that what your favorite part of your job would be?"
Stoney replies: "When I am able to help them and I can take them from their situation to a better quality of life, that's the most rewarding and most joyful experience I've ever had in my whole life."