American Pain

by John Temple

  Shelby knew the trip was a failure when she saw Alice coming out only a few minutes after she’d gone back to talk to the doctor.

  The women got back in Lisa’s Suzuki and headed toward the highway, looking for a place to get the tire fixed. Alice cried and told the other women what had happened. How Dr. Cadet just sat there and stared at the floor, no expression. They’d come all this way and hadn’t learned a thing.

  Alice said: It’d be different if the doctor had cried. Or if she’d been upset about what happened to Stacy. But she didn’t care.

  Nobody in Kentucky could do anything about Dr. Cynthia Cadet, and nobody in Florida seemed to care.

  But just a twenty-minute drive away, a woman named Jennifer Turner was zeroing in on American Pain.

  Turner, a special agent of the FBI, was stationed in an unmarked three-story building somewhere in Broward County. The building contained a couple hundred police officers and federal agents of every stripe. The covert multi-agency facility was supposed to provide a physical location where the missions and data and expertise of varied law enforcement organizations could collide and spark. It was a place where a special agent from the Bureau of Alcohol, Tobacco, Firearms and Explosives could easily share coffee with a police detective from Pompano Beach. Where a Broward deputy sheriff could just walk over to the next office suite to pick the brain of an analyst from the Department of Homeland Security.

  Until a few months earlier, Turner had investigated health care fraud. Because of its retiree population, South Florida was the center of the universe for this type of crime. Turner had spent years chasing medical equipment manufacturers who offered free products to seniors in exchange for their Medicare numbers, or surveilling corrupt doctors who billed health insurers for services never rendered.

  Turner was thirty-eight, tall and athletic, with blonde, shoulder-length hair. She loved being an FBI agent, which had been her goal since she was a young girl. She was talkative and ardent, perhaps even idealistic in her devotion to the bureau. She knew the rules and believed in them, but to both her partners and her targets, she came off as someone who could understand opposing points of view, someone who maybe could be counted on to be in their corner, if they did the right thing. She could be harsh in the interrogation room but then follow it up with a compliment or nice gesture, straightening the tie of a government witness about to testify. She was nice. But her eyes—weary and shrewd—kept you guessing.

  Turner had recently transferred from health care fraud to organized crime—Russian organized crime specifically—and she hadn’t quite found her footing in the new assignment. She was helping with a few investigations, but she wanted to find something she could really put her arms around, something that would take advantage of her skills and experience. A case of her own.

  One day in late 2008, Turner was in the break room of the multi-agency building, half-listening to a conversation between police officers from Davie and Hollywood and the Broward Sheriff’s Office. They were standing near a watercooler, talking about pain clinics. New clinics were popping up all over the place, they said, causing lots of problems.

  A police captain said: You know, some of these clinics have Russian doctors in them.

  Russian doctors. Turner turned to the group.

  She said: Excuse me?

  The captain said: I thought that might get your attention.

  Turner pumped him for more information. He said the patients were selling pills, urinating on public property, shoplifting from nearby stores. Many of the patients were from other states. Often, when they got pulled over, the patients had not only pills, but marijuana and cocaine in the car. Local police were trying to crack down on these activities, focusing on the patients, but they weren’t equipped to look into the clinics themselves.

  Local police had talked also to the DEA about the pain clinics, but the drug agency considered legal opioids to be the purview of the DEA’s regulatory branch, the Office of Diversion Control. DEA special agents were primarily focused on cocaine and heroin, not pills manufactured by pharmaceutical companies and prescribed by doctors.

  Turner was intrigued but skeptical. This could be an investigation that would take advantage of her health care experience but still fit into her current assignment. But where was the crime? Oxycodone was legal, and doctors were allowed to prescribe it. At first blush, the whole thing sounded to her like an exaggeration, a problem that had been blown out of proportion. How big could this possibly be? Yes, it was interstate drug trafficking, but was it truly organized crime or just a few individuals? And how many people would really travel from Kentucky or West Virginia just to go to a doctor?

  She decided to look into it. She talked to some local police departments for background and began doing surveillance of the biggest problem clinics. She saw long lines outside the buildings, zombie-like patients wandering around the neighborhoods. She watched Carmel Cafiero’s reports on a place called South Florida Pain and was surprised by the guys who seemed to be running the place. They were so young. She saw billboards advertising pain clinics, notices in the free weekly newspapers.

  Turner took her information to an assistant US attorney. Like Turner, the prosecutor wasn’t sure whether a federal case could be built around pill mills, but he encouraged her anyway.

  He said: Someone’s making a ton of money here. Let’s keep digging.

  6

  By early 2009, Chris George was worried. His secret was out. American Pain was still the top dog, but the pack was now a herd.

  That was the problem with legitimate business, Chris realized—it was transparent. Everyone could see what you were doing and just copy it. There’d always been individual candymen in Florida, the doctors who’d built a reputation for being loose with the prescription pad. But American Pain had helped turn a handful of clinics into a major growth industry, inspiring shady entrepreneurs and basically handing them a template for the pain-pill business. Some of the new pain-clinic owners had started out as sponsors at American Pain. They’d bring dozens of people to the clinic every month, funding their visits and then collecting half the pills. Making a nice profit, but it was never enough. Pretty soon, they’d start thinking about opening their own places.

  The new clinics borrowed Chris’s aggressive marketing techniques: search engine optimization, out-of-state Yellow Pages promotions, advertisements in the New Times and City Link. Before long, every other billboard seemed to be plugging pain management, as if an epidemic of agony had swept across the state.

  The pain clinics kept an eye on each other. One would start promoting half-off specials on certain days of the week, and then a slew of them would do the same in the following week’s New Times. Some clinics paid patients $25 for bringing in a new patient; others rewarded new patients directly with $25 gasoline cards. For a while, Chris offered free initial visits to attract new patients, but when others started doing it, patients began simply moving around from clinic to clinic, taking advantage of the special offers on initial visits. So Chris started offering a free second visit.

  A new clinic was opening every three days, on average, and Chris spent a lot of time driving around, checking out the new guys, trying to figure out who was behind each clinic and whether it was a real threat. Most of the offices were tiny, with a single doctor. Others were strictly small-time, the doctor fearful to hand out narcotics in quantities that would keep patients coming back. Many didn’t have strong wholesaler connections, and couldn’t dispense pills themselves.

  Chris wanted American Pain to appear more legitimate than the horde of upstarts. He gave Baumhoff a new title—“compliance officer”—and sent him to Florida Board of Medicine meetings, so they could monitor the latest policies and laws about pain management.

  By 2009, the American Pain doctors were regularly receiving letters of inquiry from the health department about overprescribing, usually triggered by complaints from patients’ relatives. Chris didn’t want the doctors worrying about legal problems. He
kept an attorney on retainer, and when the doctors received letters, they’d turn them over to Ethan, who would forward them to the lawyer. The doctors would pull the file of the patient in question and write a report about the patient’s treatment.

  They joined the American Academy of Pain Management, which involved paying a small fee and getting a membership certificate. Chris displayed the certificate in the clinic. They also paid a law firm $10,000 to write a standard operating procedure manual. Ethan gave copies of the manual to every employee and doctor and told them to read it and sign it and return it to him, so he’d have something to show the DEA if they came back. Everyone ignored his instructions. No one returned the manuals.

  Ethan also told the doctors that the DEA targeted clinics that ordered nothing but controlled substances. He asked the physicians to send him lists of medications that he could order so the clinic wouldn’t look like a pill mill. Again, no one followed through.

  Chris backed Ethan’s new dress policy, and despite Derik’s opposition, the staff began to follow it: no jeans Monday through Thursday, and collared shirts and medical scrubs were acceptable, as long as they were clean and had no holes.

  When patients e-mailed American Pain to inquire about treatment, Ethan responded cautiously: “I cannot and will not guarantee you will be prescribed medication. What I can tell you is that you will have a quality examination done by a qualified physician. If you are interested we take walk-ins from 9–5 Monday through Friday.”

  Chris believed American Pain was the biggest pain clinic in Florida, which almost by default meant it was the biggest in the United States and maybe the world. Chris wanted to be even bigger. He wanted clinics across the country, in every state that would allow him to own one. That way, if Florida ever got its act together and successfully banned him from owning one, the money flow would barely be interrupted.

  Meanwhile, he kept hiring until he had five full-time doctors, plus a number of part-timers and a staff of about twenty. Parking-lot security guards, who were paid in cash. Inside, more security, cashiers, pharmacy techs, and receptionists, all on the payroll. And the cleaning woman, an independent contractor.

  Fort Lauderdale code enforcement officers began to pressure the clinic, and in March, Chris moved for the third time, this time to Boca Raton, where they stayed for the rest of 2009, the longest the clinic had ever remained in one place. They took over the lion’s share of a strip mall, about ten thousand square feet, with a huge waiting room that could seat 150 patients. The Boca location looked great, not like the seedy little clinics popping up everywhere. Boca had artwork and big flat-screen TVs on the walls, potted palms, high ceilings with exposed trusses and beams, and nice off-white carpeting they had to switch out every few months after the zombies had ruined it with spilled Mountain Dew and smuggled urine.

  More patients meant more problems. In Boca Raton, seizures became a weekly occurrence. If the patient looked really bad, Derik called one of the doctors to help. The rest of the time, he just called 911. The parking lot became a sex-for-drugs zone, patients trading pills for back-seat blow jobs. Derik heard about these encounters regularly from his security team, and he witnessed them himself a few times. He couldn’t bear to interrupt another guy’s moment; he just walked away. Next door to the clinic was an Italian restaurant called the Basil Garden. Shortly after the clinic moved in, the restaurant stopped offering lunch, and Derik believed it was because they preferred to wait until American Pain was closed to start serving patrons so they wouldn’t have to deal with the pain clinic clientele. Some neighborhood residents took advantage of the situation and began charging $20 to park in their yards.

  The same month that American Pain moved to Boca Raton, Chris opened a second, smaller clinic in Dianna’s name. Their breakup had lasted only a couple of months. But Chris had begged her to come back, and eventually she had. She believed she had nowhere else to go, and she was ready to fully embrace Chris’s pain clinic venture.* The clinic in her name was called Executive Pain. It was in an office plaza in West Palm Beach, sandwiched between another medical clinic and a dental office. Starting out, the staff was just two part-time doctors and two non-medical employees, Dianna and Ethan Baumhoff’s wife.

  At first, Chris saw Executive Pain as a backup location, in case American Pain got chased out of Boca. He also wanted to keep Dianna busy and happy running her own place away from American Pain. He knew it was smart to stake a claim in West Palm Beach. Broward County was overrun with pain clinics, and the commerce was moving north into Palm Beach County.

  As time passed, Chris gradually figured out how best to utilize the second clinic. As American Pain had become more stringent with its patients, maybe one in ten patients walked out the door without a prescription. Derik and his staff rejected patients for failing drug tests, and the doctors kicked them out for having track marks, for openly jonesing, for begging the doctor for drugs, whatever happened to make that doctor uncomfortable. But Chris hated to lose a patient. So Executive Pain became a second chance for the patients he called “dirtbags”—the 10 percent who didn’t pass muster at American Pain.

  Over time, they developed a cover story for these referrals. When they bounced an American Pain patient for track marks, the official rationale was that they were sending the patient to Executive for treatment. The clinic paid for a doctor to take an online class in drug detoxification. They bought some Suboxone, an opiate-detox drug, and put lettering on the door that said DETOX AVAILABLE. Only one patient ever asked for it. The rest of the patients referred from American to Executive simply asked for pain meds when they got to the new clinic.

  By the end of 2009, Executive Pain had hired several more doctors and was servicing eighty patients or more a day, pulling in between $15,000 and $40,000 a day: much less than American Pain, but still one of the bigger clinics around.

  The atmosphere at Executive Pain was loose. Some of the doctors called the patients “pillbillies” and joked about the ones with lots of track marks. They came up with a nickname for the flow of patients from American to Executive: “The Pain Train.” Two employees snapped pictures of themselves rolling in piles of cash in Dianna’s office.

  A few months in, Chris offered his mother, Denice Haggerty, a clerical position at Executive Pain. Previously, she’d worked at a large property management firm for twelve years, working her way from bookkeeper to vice president of administrative services, and then she’d worked for the twins’ father at Majestic Homes, but she left when her ex-husband’s company was facing bankruptcy. Since then, she’d been bored at home, so she took the job at Executive. Friends later speculated that it was because she was trying to get closer to Chris.

  Derik almost never went to Executive, but he had a hard time picturing Denice there, a pleasant middle-aged Wellington housewife type among all the dirtbags. Derik knew he didn’t have the most normal family, but he thought of Denice as the classic mom figure. Nicest lady in the world, even if she drank a few too many glasses of wine at night. After her divorce from John George, she’d married a firefighter, but she and Chris’s dad seemed to get along. Sometimes John came to the big family get-togethers Denice hosted regularly at her house, up to thirty-five people at a time. She also donated to animal shelters and hospices and crocheted afghans for a homeless shelter in Youngstown, Ohio. How on earth she’d ever brought Chris and Jeff into the world and ended up working at Executive, Derik would never understand.

  Chris had his full-time doctors sign a power of attorney so Ethan could use their DEA registrations to order pills. Ethan bought pills as fast as he could, but it was never enough for Chris. American Pain had a year’s head start on most of the new clinics, and he and Ethan had developed relationships with a dozen or so wholesalers. Chris had realized his access to pills was his key advantage over other pain clinics, and he told Ethan to protect his relationships with the wholesalers and keep them to himself.

  In early 2009, the wholesalers were saying their supplies of oxycodone were
running low due to the glut of new pain clinics in South Florida. Which meant that American Pain’s dispensary was “dry” more often. When that happened, Chris took it out on Ethan, shouting: You’re costing me $5,000 a day!

  When they did have to send patients to outside pharmacies, they tried to direct them to ones that wouldn’t cause problems. Pharmacists, especially those in other states, constantly called the clinic to make sure the prescriptions were from a legitimate doctor and not a stolen prescription pad. Derik believed he usually could tell by their tone of voice whether they were just calling to cover their asses—so they could say they did their due diligence—or if they were really trying to verify whether the scrip was legitimate. Over time, Chris and Derik learned which pharmacies to avoid. Large chain pharmacies tended not to carry large enough quantities of controlled substances to meet the demands of hundreds of patients a day. They would also eventually red-flag American Pain patients. Independent mom-and-pop pharmacies were hit and miss, so Derik was always keeping an ear out for the ones that stocked a lot of oxy and would fill painkiller scrips without asking questions. Derik put up signs in the clinic ordering patients not to fill scrips at Walgreens and CVS. He went down through the listings in the phone book, calling pharmacy after pharmacy and asking if they stocked oxycodone and accepted patients from other states. If those questions didn’t seem to raise a red flag with the pharmacist, it was a safe bet that patients wouldn’t run into problems there.

  But it was a lot of work, and Chris began thinking about investing in a larger chunk of the pharmaceutical supply chain. Sending patients to outside pharmacies was not only a pain in the ass, it was lost revenue. Also, he assumed Florida would eventually outlaw the dispensing of drugs from pain clinics. All of these factors led him to a conclusion: He wanted his own pharmacy.

  He found one for sale in Orlando, a place called QuickPharm. The pharmacy had a DEA license and a staff pharmacist who wanted to stay on. Best of all was the location. Patients driving back home to Kentucky, Tennessee, and West Virginia passed through Orlando on the Florida Turnpike, so it was a convenient place to send them to get their scrips filled. The pharmacy wasn’t making much money, but Chris wasn’t worried. American Pain would supply the patients.