AMERICAN PAIN (33 page)

In early 2009, the idea finally began to gather steam, though opponents said it could be a threat to patient privacy. A group of top Florida House Republicans sent Governor Charlie Crist a letter saying they believed the database “would be susceptible to cyber terrorists and criminals who would use such information against the citizens of Florida.” Nevertheless, Crist signed the legislation in June 2009, and the database was scheduled to be online within eighteen months.

A
Sun-Sentinel
reporter called Tina Reed to get her reaction.

“I’m thrilled,” she said. “It may not be a perfect bill, but the fact is we have a database established that we can work on.”

Privately, she wished someone would just swoop in and shut the pill mills down. Surely what the doctors were doing wasn’t legal. There had to be some way to stop them.

There were two main ways to take down bad doctors.

One was to charge them with a crime. Like all states, Florida had numerous criminal laws on the books regarding the prescribing and selling and using of controlled substances. It was illegal for patients to doctor-shop—seek prescriptions for narcotics from multiple doctors within the same thirty-day period. It was illegal for patients to lie or deceive a doctor to get controlled substances. It was illegal to forge a signature on a prescription. And of course it was illegal for patients to sell their pills. Local cops spent most of their anti–pill mill efforts harvesting the low-hanging fruit—the doctor shoppers and pill sellers. Those cases were relatively easy to prove. You could catch patients in the act of selling pills, or catch them with a short pill count, or catch them carrying pills without a prescription. It wasn’t as easy as busting someone with a categorically illegal substance like cocaine or heroin, but it could be done.

Going after the doctors was tougher. It typically took more time and money and expertise and luck to prove that a doctor had knowingly supplied pills to drug seekers. By state law, it was illegal for a doctor to fraudulently assist a patient in obtaining a controlled substance, or employ a “trick or scheme” to assist a patient in obtaining a controlled substance. It was illegal to knowingly write a scrip for a person who didn’t exist. It was illegal to write scrips for no medical necessity.

But what was a medical necessity? On that point, state law was vague:
(A) physician may prescribe or administer any controlled substance . . . for the treatment of intractable pain, provided the physician does so in accordance with that level of care, skill, and treatment recognized by a reasonably prudent physician under similar conditions and circumstances.

The problem was, it was hard to determine what was going on behind the closed door of a doctor’s office, especially if the doctor took a few basic precautions, such as requiring some diagnostic tests (MRIs and drug screens) and maintaining some paperwork.

Only the patients knew for sure whether they were in pain, and pill seekers didn’t complain to the cops about doctors who wrote too big.

Despite these challenges, plenty of doctors had been convicted over the years. On its website, the DEA maintains a list of nearly 250 doctors the agency had helped investigate between 2003 and 2009. The charges ranged from distribution of a controlled substance outside the scope of professional practice to conspiracy to launder money. These doctors usually displayed risky behavior. Some had drug problems of their own. Some traded prescriptions for sex. After the investigations, almost all lost their DEA registration that allowed them to prescribe controlled substances, and many also lost their state medical licenses. Their penalties ranged from probation to life sentences.

When investigators turned up dead patients, state or federal prosecutors often threatened to file homicide charges, from first-degree murder to distribution of controlled substances resulting in death. But those cases were tough to win. It was hard to convince a jury that even an egregiously bad doctor should be held responsible for a patient’s death when the patient had violated the instructions on the pill bottle. Juries might convict a doctor of other charges, but the defense could usually make a strong case that the death was the drug-seeking patient’s own fault.

Pain management advocates protested that such cases were making legitimate doctors afraid to prescribe painkillers. They championed the case of Dr. Frank Fisher, a graduate of Harvard Medical School who opened a pain practice in Northern California. Fisher, a top prescriber of Oxy-Contin, was charged with murder after several patients died. As it turned out, one of the victims had died in a car crash and another had stolen the drugs from one of Fisher’s patients. The case fell apart and, four years after Fisher’s arrest in 1999, a state judge dismissed all charges against him. Pain management advocates rallied behind Fisher’s case, and the doctor’s story was told in sympathetic pieces in the
New York Times
and
Reason
magazine. Pain management advocates said there was a hidden epidemic of pain patients committing suicide after their doctors went to prison. Fisher said one of his patients had driven her car in front of a train.

Nevertheless, by 2009, at least eleven US doctors had been convicted on various charges related to the death of patients. One precedent-setting case involved a Florida Panhandle doctor named James Graves. Four patients died after taking OxyContin he had prescribed, all after either crushing and snorting the pills or dissolving and injecting them. The jury heard evidence that Graves ignored pharmacists and family members of drug-seeking patients who pleaded with him to cut back on his prescriptions. In 2002, Graves was convicted of manslaughter and sentenced to more than sixty years in prison.

But Graves’s case was unusual. More typically, prosecutors used overdose deaths as leverage, eventually discarding them in exchange for a guilty plea to a lesser charge.

The other way to stop pill mill doctors was to suspend or terminate their licenses through the Florida Department of Health.

The health department enforced the Florida Administrative Code, which spelled out how doctors should prescribe opioids. The code said doctors should conduct a complete medical history and physical examination, documenting the nature and intensity of the pain and the patient’s history of substance abuse. Doctors should write treatment plans and adjust drug therapy according to individual medical needs of the patient. Doctors should tell patients that the drugs are highly addictive. Doctors should periodically review patients’ courses of treatment. Doctors should refer the patient to specialists, if appropriate. Doctors should keep thorough medical records.

In other words, doctors who prescribed addictive narcotics should diligently and continuously assess the effects of the drugs on the patients, tweaking the treatments as needed and seeking alternative solutions whenever possible. Mechanically stamping out prescription after prescription for high doses of oxycodone wasn’t practicing medicine.

Investigations were usually triggered by complaints, typically from distraught relatives of pill seekers. Compared to many criminal defendants, doctors often had the money to fight or stall cases against them. The Board of Medicine—a panel of physicians that could discipline or suspend medical licenses—was designed to deal with the occasional bad doctor, not a slew of them.

Reporters at the
St. Petersburg Times
reviewed almost two hundred cases of doctors accused by the health department of inappropriately prescribing pain medications. Ninety-nine overdose deaths were linked to the accused doctors. More than a fourth of the doctors who had been disciplined still possessed clear and active licenses, the newspaper discovered, even some who had spent time in prison. Sixty-two doctors had lost their licenses, and usually they had relinquished them voluntarily in exchange for not having to face further board action.

Cases tended to plod through the system, taking eighteen months on average. Larry Golbom, the Clearwater pharmacist/radio host, discovered just how slow the system could be when he complained to the health department about the doctor who’d prescribed drugs that ended up in his son’s hands. That case took twenty-seven months and might have gone longer if the doctor had not settled, paying a $12,500 fine and doing some community service. That doctor kept his medical license.

At that time, in 2006, such doctors were still rare. But two years later, a wealthy young felon met a steroid-dealing physician, and through trial and error, created a template for a new industry.

Chris George’s personal history and characteristics made him perfectly suited to conquer the oxycodone game. He was capable of straddling two worlds. He looked plausible in a business suit, was good at making calls about zoning bylaws and small-business loans. But he also had none of the straight businessman’s qualms about breaking the law when necessary. He possessed both the lubricating influence of money and the reckless aggression of youth. He was an entrepreneur who had few misgivings about selling a deadly product.

Chris George had stumbled into the business, skeptical at first that it would prove lucrative, but over time he learned to exploit three loopholes in Florida law and regulations. The first was the state’s lack of a prescription database. Pill seekers and their doctors found it easy to operate in Florida because cops and pharmacists had no way to track the flow of prescription narcotics. Meanwhile, Kentucky and other Appalachian states had developed databases and cracked down on their own pill mills. Drug-running clans began trekking to Florida for pills.

The second loophole: Florida didn’t license pain clinics or their owners. The state issued licenses to electrolysis clinics, massage establishments, and optician offices, but anybody who could register a business with the Florida Secretary of State office could own a pain clinic, meaning, basically, anybody. Including Kent A. Murry, a convicted marijuana smuggler who opened Delray Pain Management in February 2009. And Anthony V. Laterza, who opened North Palm Pain Management not long after finishing a five-year stint in federal prison on drug charges. Both clinics modeled their business practices after the George clinics, which had been in operation for a year by that time.

Even if the state possessed the resources to crack down on a thousand new self-proclaimed pain doctors, the clinic owners themselves were largely untouchable, as long as they weren’t doctors. Nobody had considered the question: What if a bunch of quick-buck artists and con men and felons decided to hire doctors and open their own pain clinics?

Chris George had discovered the implications of this second loophole early, when Dr. Overstreet died in Panama three weeks after they’d opened South Florida Pain. Yes, sure, he needed a doctor, but any doctor would do. Chris George himself was the hub of the business. This concept was reinforced when Dr. Gittens quit the clinic and again when Dr. Joseph surrendered his DEA registration.
^*
Dr. Joseph lost his livelihood; Chris George hired
more
doctors, expanding American Pain’s full-time physician staff to five.

And doctors who needed work were plentiful in Florida, especially after the stock market crashed in 2008, leaving thousands of retired physicians looking for ways to make some extra money. Some small percentage of them began writing oxy scrips, along with young doctors who needed to pay off crippling student loans and MDs from Caribbean medical schools who couldn’t find jobs or earn board certification. And some doctors who simply wanted an easy job and easy money.