by John Temple
“Me and my husband . . .” She couldn’t speak for a moment, then said, simply: “It’s hard on us. And I hope there’s not nary a family that has to go through what I’ve had to go through. I don’t wish it on my worst enemy. I can’t hardly talk about my son without breaking down, and I am so sorry.”
Cadet’s lawyer just wanted this to end. “Ma’am, I’m very, very, very sorry.”
“I know it’s been four years, but to me it’s just like yesterday,” Alice said.
She stumbled climbing down from the witness stand, and Jennifer Turner jumped up to help her. Alice leaned against the tall FBI agent on the way out of the courtroom. Jennifer told Alice she’d done a great job. Alice was glad to get out of there, away from all those people she didn’t know, and go back home.
Paul Schwartz called sixty-four witnesses: ringleaders, staffers, doctors, cops, agents, toxicologists, medical examiners, and pain management experts. By the time the prosecution rested its case, the jury was inundated with details—the important, the trivial, and the lurid—about American Pain and the havoc it had wrought.
The jurors knew a great deal about Cadet’s questionable medical practices. They knew she tended to write higher than the other doctors. They knew she saw an average of seventy-three patients a day toward the end, and spent an average of four minutes and forty seconds with each one.* They knew that the staffers who regularly went into her office couldn’t remember ever seeing her actually examining a patient. They knew that the doctor never questioned the misspellings and dubious statements on the patient forms she used every day.
What they didn’t know for sure was exactly what Cadet knew or believed about what she was doing, whether she was just a bad doctor or a criminal one. The doctor did not testify on her own behalf. And none of the prosecution witnesses offered a smoking gun, a moment when Cadet had said or done something that showed, beyond a reasonable doubt, that she knew she was writing scrips for junkies.
What Cadet did know, according to witnesses, was that American Pain was called out as a pill mill on news reports. She knew that various patients were being investigated for doctor shopping. She knew that patients were ejected on a regular basis for having track marks or dope in their urine. And still she kept seeing more and more patients, pocketing $1,217,125 during her sixteen months at the clinic.
The parts of Derik Nolan’s testimony that had directly concerned Cadet were so tortured and conflicted that, despite the ring of truth in much of the rest of his story, it was unclear what he really thought about the doctor’s culpability.
Detective Sergio Lopez testified about his experiences as an under-cover patient at American Pain—but he’d seen Boshers, not Cadet.
Aruta, Boshers, and Dreszer testified that it hadn’t taken them long to figure out that American Pain was a pill mill. But they also said they’d never had explicit conversations about that subject with Cadet.
The prosecution’s pain management expert, Dr. Rafael Miguel, testified that he studied more than three hundred of Cadet’s patient files and found them to be clearly the work of a pill mill doctor.
The defense’s pain management expert, Dr. Carol Warfield, testified that she’d studied the same randomly selected files, and they looked fine to her.
Paul Schwartz’s closing argument, in a nutshell, was this: The doctor had to have known that her patients were lying. Everyone else at American Pain had known. There’s no way she didn’t know. Her actions had directly led to the deaths of seven people, and she deserved a life sentence.
Cadet’s lawyer told the jury that in 2010, the government was in a fight for the very soul of Florida. They had to get the prescription drug problem under control, by any means necessary, and Dr. Cadet had been swept into a dragnet prosecution. But, he argued, the case was already over. For all intents and purposes, the government had won, and the real criminals were already behind bars.
The jurors spent twenty hours deliberating. They decided they couldn’t see inside the doctor’s brain any more than the doctor could see inside her patients’ brains.
Whether or not she truly believed her patients were in pain, Dr. Cadet chose to accept the stories her patients told.
And the jurors chose to accept Dr. Cadet’s story.
Footnotes
* The charges included racketeering conspiracy, money laundering conspiracy, possession with intent to distribute controlled substances, maintaining drug-involved premises, and wire and mail fraud conspiracy.
* It didn’t work. In June 2012, the firefighters were charged with state racketeering violations related to their involvement with the clinics.
* The crash also killed two passengers, but prosecutors decided it would be too difficult to try Cadet for those deaths.
* At least on February 24, 2010, a day the FBI chose to analyze American Pain security-camera video of the patient flow into Dr. Cadet’s office.
Epilogue
Oakdale, Louisiana May 31, 2014
The visitation room at the Federal Correctional Institution at Oakdale contains about 150 beige plastic chairs lined up in rows, armrest to arm-rest. Vending machines and microwave ovens occupy one concrete-block wall, restroom doors and water fountains another. At peak visiting hours, most of the seats are filled with prisoners and their families, and it’s hard to hear over the din. It’s a self-contained ecosphere, a single room designed to confine inmates for hours at a time. It’s weirdly equivalent to the waiting room at American Pain: a handful of guards overseeing dozens of desperate captives. Except, of course, that Derik Nolan was the head warden at American Pain. At Oakdale, he’s just another prisoner.
Derik reported to prison more than two years ago, and this is his first time in the visitation room. No friends or family have made the long trip to central Louisiana. We sit across from each other, and he drinks cranberry juice, sipping it slowly so he won’t have to ask the CO if he can go to the bathroom. I bought the bottle of juice for him from one of the vending machines. He has no money, of course, so I’ve brought a prison-approved plastic bag of quarters so we can get something for lunch. He’s not allowed to get up and get food for himself, so I buy and heat his double cheeseburger.
Derik has gained weight in prison. The food is crap. Anything decent that comes into the kitchen goes into the inmate black market, and most of what’s left is pure starch. So he eats a lot of rice and beans and works out until he can’t move. And he reads, hours every day. He barely cracked a book in his first thirty-five years, but now he blows through three or four a week. It’s a good way to kill time and stay out of beefs with other inmates. He likes crime stories and historical fiction. It’s the only exercise his brain gets, and that, to him, is the worst thing about prison. Out in the world, he had to use his smarts to get by. In prison, he has a roof over his head and three squares a day, and his brain is starting to shrivel.
He and Chris sometimes exchange letters. He doesn’t hear much from his other co-defendants, and none of them are in Oakdale. Chris is in Georgia, Ethan in Arkansas, Jeff in Maryland. Dianna Pavnick George and Denice Haggerty are already back home.
Cadet is free, for the moment. Derik follows her case through prison-system e-mails from his sister. After the trial last summer, Cadet and Castronuovo were acquitted of the death charges and drug charges. The jury found them guilty only of money laundering. The Palm Beach Post called the verdicts a “stunning defeat” for the prosecutors.
Five months later, the defendants who’d testified or otherwise cooperated in the case against the doctors began to receive their sentence reductions. Paul Schwartz recommended that US District Court judge Kenneth Marra slash sentences by one-third. The defendants asked for more, and the judge cut the sentences roughly in half.
Except for those of two defendants. Chris George got three and a half years off of his seventeen-and-a-half-year sentence, nowhere near half and even less than the one-third that the prosecutors had requested.
And Derik Nolan got nothing. The US At
torney’s Office never requested a reduction for Derik, and Judge Marra didn’t give him one. Derik’s lawyer and sister tried to find out why, but got no answers. Derik figured Paul Schwartz was blaming Cadet’s acquittals on his conflicted performance in the witness box. Schwartz, understandably, will not comment. Derik alternated between rage and depression for a while, then gave up hope and settled in for the long haul. If he can stay out of fights and earn his full allotment of twenty-two months off for good behavior, he could be eligible for release in 2024, two years after Chris’s earliest possible release date.
In April, Judge Marra dropped another surprise when he sentenced Cadet and Castronuovo. The doctors did not expect lengthy prison sentences on the money-laundering convictions, but Castronuovo got eighteen months and Cadet got six and a half years. Marra didn’t buy Cadet’s defense that she had been fooled, and he specifically pointed to the undercover video of Derik yelling at the patients to not shoot up in the parking lot.
“All you have to do is look at (that) and see the chaos, the madness that was going on in that facility,” Marra said. “It’s just not possible to not have known that those people were all drug addicts.”
The doctors’ lawyers appealed. If Cadet wasn’t guilty on the drug charges, her lawyer said, then the money she made was clean. And if the money was clean, how could she have laundered it? The doctors remain free while they pursue appeals, which could take years.
At the FBI, Jennifer Turner and Kurt McKenzie have moved on to other investigations, and neither expects to encounter another case as rewarding or as demanding as American Pain. McKenzie, who led the death probe, says he’s worked only one other investigation that took the same toll on him, and that was the terrorist attacks of September 11, 2001.
Larry Golbom ended the Prescription Addiction Radio show in March 2014. He is proud of his seven-and-a-half-year run and believes the show had a positive impact, but it never took off the way he originally hoped. He continues to work for the same major pharmacy, and notes that many Florida pharmacists now refuse to fill opioid narcotic prescriptions. Golbom fills them when he believes the prescription is legitimate and comes from a qualified doctor. He’s not anti-opioid; he just wants people to understand the drugs.
Meanwhile, many in the medical profession are beginning to recognize that rampant prescribing of addictive narcotics for chronic pain has proven to be a devastating mistake in many cases. Short-term, the drugs make you feel great. Long-term, many legitimate pain patients are taking the drugs as prescribed and finding it harder and harder to get out of bed in the morning. Take these drugs too long and not under the watchful eye of a doctor who understands the subtleties of opioid pain management, and it may be difficult to regain a normal life. Studies have demonstrated that opioids may actually increase pain over the long run and that non-drug treatments are much more effective than opioid therapy. The federal Centers for Disease Control and Prevention has declared that painkiller overdose deaths are an official epidemic.
At the same time, Florida is celebrating having beaten back the pill mill scourge through arrests and legislation. In 2010, ninety of the top one hundred oxycodone-purchasing doctors in the country lived in Florida. By 2014, the DEA said, the state contained only one. The number of oxycodone pills shipped to Florida dropped from 650 million in 2010 to 313 million in 2013. The number of pain clinics dropped from more than one thousand to less than four hundred. Some of the pill mills moved to other states, notably Missouri, home of Mallinckrodt’s US headquarters and the last state in the country that lacks a prescription database. Meanwhile, pills grew more scarce and expensive in Kentucky, and hill-country sheriffs began seeing heroin for the first time ever. The same fix, now cheaper.
So the pill mills left Florida, to great fanfare . . . but, unabated and under the radar, the country’s appetite for pills has only continued to grow. That much is clear because the manufacturing companies keep asking the DEA for permission to make more pills, and the DEA keeps granting it. All those pills are going somewhere. In 2014, even as supplies shipped to Florida were shrinking, the total number of kilograms of oxycodone manufactured took another big leap, from 131,500 to 149,375—almost three times the amount produced a decade earlier, and forty-two times the amount made in 1993.
Any narco cop will tell you, when you kill off one secondary source of narcotics, two more tend to pop up elsewhere. You have to choke off the source, strangulate the fountainhead.
Or, as Derik puts it, junkies gonna get them pills, somehow, someway.
Derik doesn’t know what he’ll do if he makes it out of prison. Chris’s mom sent him magazines not long ago, and the pictures of Ireland made him want to go there. When old friends e-mail him, which is infrequently, he thinks about returning to South Florida. When he hears it’s snowing up north, he remembers growing up on the farm near Binghamton, New York, and he longs to go back home.
I’ve been communicating with Derik almost daily over the phone and e-mail for months, and he shows little remorse about his role in supplying millions of pills and fueling a gigantic wave of addictions up and down the East Coast. He mainly feels sorry for himself.
But he does feel bad about certain things. He feels bad when he thinks about the kids he saw at American Pain. He feels bad when he thinks about how he fired the homeless guy who watched over the parking lot. He feels bad about testifying against Cadet, though he believes she knew what she was doing.
And that’s the thing. He wasn’t alone. For a few years, in plain view, hard drugs were for sale in Florida, and it seemed to Derik that almost everyone was on the take. He and Chris turned doctors into drug dealers. They turned an ex-cop into a bag man. They turned pharmaceutical wholesalers into accomplices. Politicians and realtors and lawyers and landlords and medical associations and the New Times weekly newspaper helped them pull off the scam. And in the end, it was the big boys—Actavis and Mallinckrodt—who made the big money in Florida.
He and Chris were bad guys, no doubt about it. Felons. Violent men. So why did everyone make it so easy for them?
No doubt, this line of thinking is a way for Derik to blame the whole thing on somebody else.
But that doesn’t mean it’s not true.
“The fucked-up thing isn’t that we did this,” Derik says. “Of course we did it. The fucked-up thing is that we were allowed to do it. That they let us do it. Why were two guys like me and Chris allowed to set up a business like this? When we said we wanted to set up a pain clinic, they shoulda been like, ‘Umm . . . No.’ Or, ‘Let’s see your criminal record.’ When we said we wanted to order $100,000 worth of pain medication, they shoulda said no.”
He pauses, raising his eyebrows high to emphasize his point.
“They shoulda said, ‘ Fuck, no.’ ”
SOURCES
This book is a work of reported nonfiction. I changed no names or details. All information in the book was either told to me, observed by me, or found in public records or in journalistic and academic venues.
To report the book, I traveled to Kentucky and Florida numerous times and conducted hundreds of interviews. I researched and visited most of the sites described in the book. I also read numerous books and hundreds of newspaper and magazine articles, as well as dozens upon dozens of scholarly articles and government reports. I attended the 2013 National RX Drug Abuse Summit in Orlando, Florida, where I met many people on the front lines of the prescription opioid epidemic and heard numerous experts speak. I spent two weeks in West Palm Beach observing the federal trial of Dr. Cynthia Cadet. I also reviewed hundreds of court transcripts, pleadings, and investigative documents.
While I did not use a great deal of specific data from the following books and articles, they were key sources nonetheless:
•Barry Meier’s books—Pain Killer: A “Wonder” Drug’s Trail of Addiction and Death from 2003 and A World of Hurt: Fixing Pain Medicine’s Biggest Mistake from 2013—and his years of coverage in the New York Times provided a foundational un
derstanding of the resurgence of opioid narcotics.
•The article “How Florida Brothers’ ‘Pill Mill’ Operation Fueled Painkiller Abuse Epidemic,” by Thomas Francis, published on msnbc.com on May 7, 2012, introduced me to the story of American Pain.
•The article “American Pain: The Largest U.S. Pill Mill’s Rise and Fall,” by Felix Gillette, published in Businessweek in June 2012, helped me understand the pharmaceutical opioid manufacturing and sales process.
I read numerous academic journal articles about the opioid epidemic. The following were particularly useful to me:
•“The Prescription Drug Epidemic in the United States: A Perfect Storm,” by J. C. Maxwell, Drug and Alcohol Review, 2011.
•“Black Beauties, Gorilla Pills, Footballs, and Hillbilly Heroin: Some Reflections on Prescription Drug Abuse and Diversion Research Over the Past 40 Years,” by James A. Inciardi and Theodore J. Cicero, Journal of Drug Issues, 2009.
•“The OxyContin Epidemic and Crime Panic in Rural Kentucky,” by Kenneth D. Tunnell, Contemporary Drug Problems, Summer 2005.