The guy who claims he has severe abdominal pain doesn't grimace when sitting up. A woman who recently moved to the area fails to disclose she sees a doctor elsewhere. An ambulance patient complaining of a sore leg and back doesn't reveal she was turned away by another hospital.
There was a time Khushigian's hunches took weeks to confirm and required phoning or faxing the attorney general's office to obtain a patient's prescription drug information. Nowadays, a computer helps him catch cheaters. But it can only reach so far.
While a state online drug database went into effect last year to thwart addicts who bounce from doctor to doctor to feed a habit or make a small fortune peddling meds, there's now a push to extend it beyond state lines to snare so-called doctor shoppers and curb drug abuse.
"The whole purpose of this is to have states communicating with one another," said Dr. Laxmaiah Manchikanti, chief executive officer of the American Society of Interventional Pain Physicians. "If you know a patient is abusing, a doctor isn't going to give that patient a prescription anymore."
Doctors can be hamstrung in making critical decisions about prescribing painkillers if they aren't able to find out if patients filled prescriptions elsewhere.
A nationwide network might have helped Michael Jackson's doctor better monitor the medication he was receiving from multiple doctors.
Dr. Conrad Murray, who was recently charged with involuntary manslaughter in the singer's death, told police Jackson gave few details when Murray repeatedly asked about Jackson's medications, according to an affidavit. The Los Angeles County coroner said Jackson was killed by a mix of a powerful anesthetic and a sedative.
Police have searched for information in three states to see if Jackson's medical history played a role in his June death.
Jackson's death and those of other celebrities such as former Playboy Playmate Anna Nicole Smith and actor Corey Haim highlight the dangers of prescription drug abuse. More U.S. teens used prescription drugs over any other illicit drug except marijuana, the Office of National Drug Control Policy reported.
Forty states have passed legislation to allow prescription drug monitoring programs, but only 34 are operating.
Under the National All Schedules Prescription Electronic Reporting Act signed by President Bush in 2005, more than $50 million has been appropriated to states for programs where doctors and other authorized users, such as police in some cases, can access patient records.
The law aims to have a coordinated national system, but there are no estimates what that would cost and a majority of the federal money hasn't been allocated.
Joanee Quirk, who runs Nevada's prescription monitoring program, said having access to other state databases would help stop those from Southern California or Hawaii who come to Las Vegas or Reno to score Vicodin or OxyContin.
Nevada's four-year-old program has grown to more than 225,000 patient requests in 2009 from about 155,000 in 2008.
Most prescription monitoring programs are voluntary, but Nevada requires doctors to check a patient's drug history during a first visit.
"If we took it away the practitioners would have a revolution," Quirk said. "It's almost like getting a lab test, where the doctors are trying to figure out what is wrong with this person and whether they are trying to get drugs legally."
Some privacy groups are concerned databases could invade patients' privacy. Virginia's database was hacked into in April 2009 and millions of electronic records were stolen by a thief still at large.
"There is a significant intrusion into the lives of individuals who are taking these medications legitimately," said Pam Dixon of World Privacy Forum, a nonprofit public interest research group. "There needs to be more restrictions about who can access this information."
The response to having secure, online access to patient records has been overwhelming so far in California. More than 2,300 doctors, pharmacists, physician assistants and registered nurses have used the website since September to access more than 134,000 patient reports. The state had averaged about 60,000 requests annually when they received requests by phone or fax.
Katherine Ellis, who runs the database of about 100 million prescriptions, said emergency room doctors would benefit most from a multistate system.
"If there was a way for ER doctors to sign on as they are triaging that patient and see if that person has been doctor shopping, then they may not elect to give them the controlled substances," she said.
Khushigian, 52, who works at Kaweah Delta District Hospital in Visalia in the Central Valley, is glad he no longer has to rely solely on his gut every night. He uses the database two or three times a night to shut down potential abusers.
"When they get caught, there isn't much they can say," he said.