American Pain

by John Temple

  Every once in a while, though, they’d see something they couldn’t ignore. One day, a guy came in, maybe thirty years old: dreadlocks, sagging black shorts, and a wife-beater. Derik took his $200 and made a copy of his MRI report, sent the guy back to Dr. Joseph.

  A little while later, Dr. Joseph called Derik to the examination room, pointed to the MRI report. He looked upset.

  Dr. Joseph said: Please read the conclusions, Derik.

  Derik read the report aloud, all the way to the part where it noted a tear in the uterine wall. Dr. Joseph pointed at the patient.

  Dr. Joseph: Does he look like he has a uterus?

  Derik looked closer at the report and could tell the patient had duplicated his name over whoever’s report it actually was. The birth date on the report didn’t match the guy’s ID. Worse, on the gender line the guy had just left the “F.”

  Derik apologized to Dr. Joseph and kicked the patient out. The guy had the nerve to argue with him over his $200 fee, which Derik refused to give back, on principle. He didn’t want word getting out that if you got ejected from South Florida Pain they’d just give your money back. Derik threatened to call the cops, have the guy arrested for prescription fraud. The guy left, then came back later with some friends. Dr. Joseph heard the commotion, came out and told Derik to give the guy his $200 back. So Derik did, and that was that.

  Hey, Derik thought, I’m not the one who went to medical school. I’m learning as I go here.

  And it was hard work. At any moment in a typical day, a million things were happening. Patients waiting in a long line out the door. Multiple phone lines ringing. A toilet overflowing because a patient had tried to flush a bottle of Mountain Dew. The patients were desperate and strung out, eagerly peppering Derik with flecks of spit when they finally reached the customer window. Or just standing there in a stupid opiate haze, drawling in that distinctive guttural oxycodone register, as if the drug had dulled their voice boxes along with everything else.

  Derik called them zombies. Dumb and slow, but you had to watch your back around them. If one crushed a pill and nodded off, another would try to steal his meds. Or they’d start making side deals with each other and a fight would break out. They would lie to each other or rip each other off, if they thought they could get more pills. Or a guy would see someone he knew from back home in Kentucky and flare up over some old beef. One day, Derik saw two guys staring each other down and intervened: turned out, both were carrying guns.

  And the parking lot! Everything you could imagine took place in that little lot, steps away from the cars on Oakland Park Boulevard. Pill-sick patients sweating, trembling, vomiting, peeing on the palm tree, trading pills for cash. A couple months in, Derik caught a guy shooting up around the side of the bungalow. The guy ran off, dropping an insulin needle. After that, patients shooting up became a regular occurrence. Chris bought a vending machine and a forty-two-inch flat-screen TV for the waiting room, trying to keep the patients from going outside and causing havoc, but it didn’t really work.

  Derik also began paying a homeless guy who hung around the clinic, to keep an eye on the parking lot, and to call him when necessary. Everyone on Oakland Park Boulevard knew the vagrant, who slept at a nearby coin laundry, a gaunt and sickly-looking guy who was also funny and game in his cowboy hat and boots. One of those people whose age you couldn’t tell—could have been thirty, could have been fifty. Derik and Chris liked their new parking-lot sentry, kept him around like a stray dog, feeding him and paying him to run errands. The homeless man wasn’t really able to handle parking-lot problems himself, because no one took him seriously, but he could at least report them to Derik.

  Derik was learning that even crafty and experienced addicts could be counted on to screw up. Derik gave these incidents a name: “junkie stunts.” Some would take prescriptions from multiple doctors to the same legit pharmacy and get busted for doctor shopping. Others would slam a pill right before their appointments and nod out in the waiting room, and Gittens would kick them out for being high. And they’d all come to Derik, begging for a second chance. He’d give an offender a stern talking-to, and then suggest a solution: Come back tomorrow, see the other doctor. He reasoned that since the drugs were all they cared about, they’d clean up their acts to preserve their access to the clinic.

  At the end of a day of dealing with the zombies, Derik went home more exhausted than he had been after pouring concrete for a house foundation. He needed help. He just couldn’t handle it by himself anymore. In most situations, Derik was a friendly guy, but it didn’t take much to make him twitchy. A patient would irritate him, and he’d start flinging his big arms around, eyebrows jumping, voice getting unnaturally loud. He couldn’t quell it.

  So he hired his roommate, who’d helped him with the office renovation, to cover the front window. They’d known each other since kindergarten up north. Derik had told him stories about South Florida Pain, but his roommate didn’t believe them, scoffed at the description of the hillbillies who drove fourteen hours for oxycodone, the doctors who wrote scrip after scrip all day, the lines out the door. It was a sweet feeling when his friend started working there and told Derik: I can’t believe you were telling the truth.

  It hadn’t taken Chris long to realize that South Florida Pain had more potential than his other business, South Beach Rejuvenation. More people wanted painkillers than steroids, and the buying power of addicts was greater than Chris had ever imagined.

  Jeff was paying attention to Chris’s success too. He hadn’t managed to open his own clinic in West Palm yet, and after South Florida Pain started making buckets of money, Chris and Derik knew he was going to cause trouble. Jeff and Chris argued about it a few times, and then Jeff brought a couple of his pals to South Florida Pain one day, barged in past Derik and into Chris’s office. There was lots of yelling, and at one point Jeff grabbed a pair of needle-nose pliers and waved them at Chris. When Jeff and his buddies left, things were different between the twins. A couple of months later, Jeff sued Chris over the ownership of the pain clinic.

  Jeff and Chris had clashed plenty of times growing up, of course, but they’d never had a serious falling out. This time felt different. Chris stopped speaking to Jeff altogether, and Derik followed Chris’s lead out of loyalty.

  Meanwhile, Chris and Derik grew closer. Chris started introducing Derik as his brother.

  Chris took what he knew from the home-building trade and applied it to pain management, starting with marketing. Chris believed he was the first pain clinic to advertise by billboard, and it was the single best return on investment he made. He bought billboards for southbound drivers on I-95 and the Turnpike, all the way from the Georgia/Florida line to Fort Lauderdale. The billboards were straightforward; just huge block-letter words—PAIN CLINIC—a phone number, a half mile east off exit 31. Later, he added one of the doctor’s names.

  He wasn’t the first to advertise in the local free weeklies, the New Times and City Link. Those publications called him, asking if he wanted to place ads in their back pages, which was where people went to find strip clubs and escorts. There were already a sprinkling of pain clinic ads. Chris bought advertising in both papers and on the Internet and offered promotions in print and online Yellow Pages, up and down the eastern half of the United States. He hired a search engine optimization expert to make sure that South Florida Pain’s website popped up early in pain clinic searches. When people searched keywords like “pain medication,” “oxycodone,” or “pain clinic,” a link to South Florida Pain’s website came up on the first page, often within the top five links.

  The clinic website contained stock photos of doctors in white jackets who appeared to be conducting experiments. The doctors in the pictures were in sleek laboratories, not a crumbling yellow bungalow in a sketchy stretch of South Florida. The text and format of the website was cut-and-pasted from other pain clinic sites, and Chris had inadvertently neglected to remove a different clinic’s name from one section of text.
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  Derik looked at the website only once and thought it was over-the-top and not quite believable, like something a kid would put together, trying to pass himself off as a businessman. It mentioned a bunch of official-sounding organizations—the International Association for the Study of Pain, the National Institute of Health, the American Medical Association, the American Pain Society—and said that millions of Americans suffered from chronic pain and couldn’t get help. One confusing line: “The majority of people suffering with chronic pain have been living with their pain for over 5 years, almost 6 days a week.” No explanation of what was going on on the seventh day of the week. The “Education” page had a lot of words that sounded made-up, like “radiculopathy” and “herpetic” and “splanching,” stuff Chris and Derik knew nothing about.

  Chris spent a lot of time in his office on the phone, looking for drugs. Keeping the clinic flush with oxycodone meant additional profits. Wholesalers charged between 33 cents and $1.25 per 30-milligram oxycodone pill, prices that fluctuated with supply and demand. Chris usually charged about $2 per pill.

  The clinic grew more popular as word got around that South Florida Pain almost always had Mallinckrodt-made “blues” in stock. For patients, this meant one-stop shopping and no hassling with pharmacists who might question the flood of oxycodone scrips pouring out of South Florida Pain.

  But as the number of patients grew, it became harder to keep the dispensary stocked all the time. Usually, the maximum amount an individual drug wholesaler would allow Chris to order was five thousand pills per doctor per week. Occasionally, one would agree to send ten thousand pills at one time, or to send five hundred every day, which Chris assumed they did to avoid large individual shipments. But the standard weekly shipment was five thousand per doctor. If the doctors prescribed two hundred pills per patient on average, one order would meet the needs of approximately twenty-five customers, which would get them through maybe half a day. So Chris needed multiple wholesalers.

  First he looked into major wholesalers, national suppliers like Cardinal Health and McKesson and AmerisourceBergen. But the big guys had too many regulations, including a requirement that individual drug orders had to include at least 50 percent non-controlled substances. So Chris began looking at smaller wholesalers. He researched the companies on the Internet and called one after another, filling out application forms for credit lines. Over the next few months, Chris developed a roster of half a dozen wholesalers that he used regularly.

  One day that spring of 2008, Derik was smoking a cigarette in the clinic parking lot, when a car pulled in. Blue Nissan Sentra, late 90s model. Windows rolled down, rap music pulsing. Good old-school stuff. The guy behind the wheel was black, which put Derik on alert. There were plenty of black guys on Oakland Park Boulevard, but they weren’t customers of South Florida Pain Clinic. Most of their customers were white hillbillies. What was this guy doing here?

  The guy got out, baseball cap tilted to the left, gold chain around his neck, friendly as he could be.

  He said: What’s up, man? I got this package for you.

  The guy said he was from a local company that sold drugs wholesale. Derik knew Chris had placed a big order the previous day, but he still didn’t quite believe this guy worked for a drug wholesaler. Most of the drug shipments came by UPS or another delivery service. What company would trust this dude to deliver a load of narcotics? Drugs worth about $20,000 retail, maybe $200,000 on the street? Pulling up in his ten-year-old blue Sentra, blaring his Tupac?

  But there were the boxes, two of them, sitting there on the Sentra’s front passenger seat. Derik thought they should have been in some kind of bulletproof briefcase, chained to the guy’s wrist.

  Derik told the guy to follow him. The guy grabbed the boxes, headed inside, through the waiting room, patients watching. Walking with a little swagger, thousands of pills inside the box shaking along with his rhythmic stride: chica-CHICA, chica-CHICA.

  And that’s when it really hit home for Derik, what they had here. They had a license to deal drugs. No one was watching. He’d thought the pain clinic was a short-term gig, a way to get back on his feet after his jail stretch, but he’d been wrong. This was where he was meant to be. He and Chris were going to be rich.

  It couldn’t be this easy, could it?

  2

  On the west coast of Florida, a pharmacist named Larry Golbom was pondering the same question as Derik Nolan: How had it become so easy to obtain and prescribe heavy-duty narcotics in the United States?

  On a balmy Sunday in early May 2008, Golbom left his home in Clearwater, Florida, and drove over the long Courtney Campbell Causeway. The skies were blue and cloudless, and Old Tampa Bay glittered in the sun, but Golbom’s stomach was in knots. He was always nervous before going on the air, and this had been an especially discouraging week at the major-chain drugstore where he worked. In the past few days, he’d refused to fill huge narcotic prescriptions from three doctors he’d never heard of. One customer was nineteen years old and could barely speak. He had a prescription for 240 oxycodone 30s from a pain clinic in Tampa. Another was in his twenties, and looked fit enough to run in a track meet. He wanted oxycodone and muscle relaxant. Golbom had reported the doctors to the state board of pharmacy, but he wasn’t holding his breath for a response.

  After reaching Tampa, Golbom pulled into a nondescript office park just off Tampa International Airport, long tresses of Spanish moss trailing from the pin oaks that surrounded it. The building was the home of WGUL-AM, a local talk-radio station owned by Salem Broadcasting. Once a week, Golbom paid Salem $125 so he could talk about legal narcotics on the air. He’d been doing the one-hour show—called Prescription Addiction Radio—for a year and a half, since the fall of 2006. Golbom had no idea how many people were listening.

  Inside, Golbom entered a beige studio, just four walls and a desk, a few computer monitors and microphones. No personal items adorned the studio, no workspace toys or ornaments. The studio was nobody’s permanent home, just space rented by the hour.

  Tonight, Golbom pulled on bulky headphones and kicked off the show by playing a few lines of a 2002 rap song that described the pleasures of OxyContin, Lortabs, and Percocets. Then the sound engineer faded the song away, and Golbom spoke close into the microphone, his insistent nasal drone in distinct contrast with the Memphis rapper’s drawl.

  “Again, folks, in case you missed it, that’s the lyrics of the song, ‘Oxy-Cotton’ by Lil Wyte. That song’s actually been around for a little while. There’s no question that since the introduction of OxyContin, our country’s been experiencing what I refer to as the new opium epidemic of the twenty-first century. The active ingredient of oxycodone is interchangeable with heroin, and I think more and more people are beginning to understand that we have a huge medical hoax going on.”

  Golbom believed he’d been an unwitting part of the hoax until the day, five years earlier, when he’d discovered that his teenage son had bought oxycodone pills from a local woman. Golbom had reported the woman’s doctor to the Florida Board of Medicine. The subsequent investigation revealed that the patient was a textbook drug seeker. She’d altered prescriptions. She’d been charged with possession of a controlled substance. She’d claimed more than once that her medications had been stolen. She’d claimed to need drugs early so she could go on trips. Despite all these red flags, the doctor had continued to prescribe the woman high doses of opioids.

  In 2006, the doctor settled his case. He was fined $12,500, plus administrative costs, and was ordered to do seventy-five hours of community service and complete two courses. He retained his medical license, continued practicing.

  To Golbom, it felt like nothing had been accomplished.

  But in the meantime, he’d educated himself about opioids. In fact, the drugs had become his obsession. He’d founded the radio show and talked on-air to hundreds of people about the resurgence of opium in America—public officials, experts, addicts and their relatives. He’d read medic
al texts and histories of past temperance movements. He’d delved deep into obscure corners of the Federal Register to find statistics about oxycodone production. He’d searched newspaper archives for information about pharmaceutical companies.

  He couldn’t believe he hadn’t figured out sooner what was going on. He’d spent more than twenty-five years as a pharmacist, meaning he had lived through an entire sea change in narcotics prescribing practices and never questioned it. Or even realized it.

  It embarrassed Golbom, and it made him angry. If he’d been fooled, along with most other pharmacists and doctors, what chance did the average person have?

  Through his research, Golbom discovered that humans have known about the wondrous substance inside opium poppies since before the dawn of recorded time. It’s not hard to extract. Just before the plant’s seed pod ripens, scratch its smooth, blue-green skin and catch the tears of whitish milk that leak out. Dried until it’s a sticky yellow residue, opium contains the elemental ingredients for the vast array of illegal and legal opioid narcotics made today, from heroin to oxycodone.

  Opioids subdue pain. They work beautifully, blocking electrical and chemical signals before they can leap the synapse from one nerve cell to the next. In six thousand years, we’ve never found another painkiller that works as well. They don’t cure anything; they simply mute sensations. They also change the way the brain perceives the nerve signals. Suddenly, pain doesn’t cause as much panic or stress. It becomes tolerable.

  But opioids produce a number of additional effects. They slow the pump of heart and lungs. Bowels grow sluggish too, causing constipation. They galvanize the brain’s pleasure centers, causing joy.