by John Temple
Tina said: Are you snorting coke?
Her son moved his hands away, revealing a tiny pile of blue powder. It was his pain pills, he said. He’d crushed them to make them work faster.
The next five months, Tina watched her son spiral. She confronted his doctor, who refused to stop writing him prescriptions. Her son was caught snorting oxycodone again, and the family staged an intervention. He agreed to go to detox, but didn’t follow through. High at work, he accidentally cut off part of two fingers, which made it even easier for him to get oxycodone. Tina researched oxycodone and wrote letters about his doctor to the state board of medicine. Her son went to a detox program, then relapsed a few weeks into it. He disappeared for stretches. He nodded off in front of her. He was arrested for shoplifting cigarettes.
Tina began writing down everything that happened, as well as her frantic thoughts: “Heroin addicts, crack addicts, cocaine addicts, oxy addicts? What? What? Why? What is this drug/poison/curse?”
In April 2008, terrified that her son was going to overdose, she went to his probation officer and begged him to have her son arrested. The probation officer met with her son, who failed his drug test. Her son was arrested and put in a rehab program, and Tina felt some small relief. He was safe for the moment.
When she got her son’s car back, Tina found pill bottles in his name from a different doctor—a Dr. Enock Joseph from South Florida Pain on Oakland Park Boulevard. Tina filed complaints with the local police and with the Florida Department of Health, but she didn’t expect much would come of it.
In July 2008, a week before Tina’s son was to get out of rehab, the Sun-Sentinel ran a big story and photo about the South Florida Pain Clinic. The article filled Tina with energy and hope. She wasn’t alone. Others were upset too. She began calling people named in the article, and, over the next year and a half, Tina Reed became a leading voice against the pill mills. She testified in front of the Broward grand jury investigating pill mills. She called in to Larry Golbom’s radio show in Tampa, and Carmel Cafiero featured her on Channel 7. She talked to the White House’s drug czar when he came to Broward to learn about the oxycodone trade.
Tina pushed state lawmakers to create a drug database that would prevent patients from doctor shopping. Thirty-two states had databases that tracked prescriptions for controlled substances, and six more states were launching databases soon. Some Florida lawmakers had been trying to create a prescription database since 2002, but pain-management advocates and doctor’s groups had repeatedly blocked the legislation, raising concerns about privacy and funding. By 2009, Florida was the largest of the dwindling number of states that lacked a database, which meant that addicts and dealers could seek drugs from multiple doctors with relative ease. No one knew where the pills were going once they got to the pharmacist or doctor’s office.
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 aft
er 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.
The third loophole that led to the oxycodone rush was that Florida law allowed doctors to sell narcotics themselves, no pharmacist needed. Pain clinics that charged for appointments and drugs could make a lot of money, and the one-stop shopping concept lured drug-seeking patients who didn’t want to pay for prescriptions that might be hard to get filled. Some states allowed this setup; others did not. Some states banned doctors from charging dispensing fees for the drugs. By the height of the state’s pill mill rush, Florida doctors were purchasing nine times more oxycodone than doctors in other states. That’s nine times more than the other forty-nine states combined. In one six-month period, according to DEA records, Florida doctors bought 41.2 million doses while every other physician in the country collectively purchased 4.8 million doses.
Ohio was the second-ranked state in this category of physician purchasers. Its doctors bought about a million doses of oxycodone in 2009. The same year, through his doctors, Chris George bought more than twice as much oxy as every single doctor in Ohio. Four of American Pain’s full-time doctors ranked among the top nine physician purchasers of oxycodone in the country.
When Jennifer Turner saw those numbers, she knew she’d found her target.
In the early going, the federal task force had set its sights on ten of the biggest new pain clinics in South Florida. But the DEA numbers made it clear that Florida’s oxycodone racket was dominated by a single entity: American Pain. Other agents agreed with Turner that bringing down the biggest, boldest pill mill of them all would be a statement that might do more than any law to deter shady operators from the pain clinic business.
Which is why the task force wanted to take down the entire operation, including Chris George, his staff, doctors and major sponsors, as well as any affiliated pharmacies and key drug wholesalers. Simply arresting doctors or taking their licenses wouldn’t erase the problem. Chris George had shown that he would just hire more.
But it was hard enough to build cases against doctors. To take the next step and federally prosecute Chris George and his entire org
anization would require the use of a tool originally devised as a way to bring down Mafia organizations. RICO—the Racketeer Influenced Corrupt Organizations Act—could allow the government to bring Chris George to trial on the grounds that he operated and managed a criminal enterprise. Chris George’s operation had begun with a couple of employees in a single clinic in a shabby bungalow on Oakland Park Boulevard, but it had metastasized to include multiple clinics, pharmacies, dozens of employees, tens of thousands of patients. Throw in his twin brother’s two clinics and other illicit activities and you had a sprawling, potentially criminal, organization. Chris George didn’t write the prescriptions for controlled substances without a legitimate medical purpose, but he directed the organization that did.
To make its case, the task force needed evidence that Chris George was running the show, and the best evidence would be recordings of his day-to-day phone calls.
To convince a judge to let them wiretap Chris George’s cell phone, the task force had to gather evidence of criminal activity. But not so much evidence that the judge would deem a wiretap an unwarranted invasion of privacy. Walking this line wasn’t too difficult: 1,891 federal and state wiretap authorizations had been requested in 2008, and 1,891 had been granted. Nevertheless, to avoid having the recordings thrown out in court, the task force had to demonstrate that it had attempted normal investigative techniques, such as surveillance, interrogating participants, and infiltration by undercover agents and informants.
So Turner stationed a surveillance vehicle in the American Pain parking lot. The vehicle contained video cameras, microphones, recording devices, and a Hollywood Police Department detective who knew how to use the equipment. The detective shot video of cars with out-of-state license plates and a trio getting out of one car, one man handing cash to the other two before going inside. The black-tinted windows of the vehicle eventually caught the eye of a security guard, who called Chris George and Derik Nolan to the parking lot to take a look. The detective sat still as George and Nolan tried the doors, speculated about whether it was a news vehicle, and talked about trying to tip it over. Eventually they left.