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The doctor, who devoted her life to treating low-income AIDS patients, had pleaded guilty to a staggering violation of her medical oath. Diana Williamson, 56, admitted she had written prescriptions for tens of thousands of powerful painkillers, which were then sold on the black market by a convicted drug dealer.
In preparation for her sentencing, Williamson's lawyers filed court papers last month containing an unusual defense: They said she had suffered from a multiple personality disorder for 25 years as a result of childhood sexual abuse by a priest. Williamson told her psychiatrists that she had no memory of committing the crimes—that one of her alter egos, a mischievous, immature teenager named Nala, was responsible. Nala "committed these crimes without telling Diana or the other parts of me about them," she wrote in a letter to the presiding judge.
Williamson still awaits sentencing, but the case, unusual as the details are, is hardly an anomaly. It is just one consequence of an epidemic that has spread across the region and continues to thwart government and law-enforcement efforts to stop it.
The prescription-painkiller problem presents itself in myriad ways: fatal drug overdoses, pharmacy robberies, Medicaid fraud, and "doctor shopping" by addicts looking for a friendly physician who will prescribe the painkillers without asking too many questions. And then there are the doctors and medical professionals who dive right into the fray.
Based on a Village Voice review of court records, at least 30 doctors, medical aides, and pharmacists have been indicted since 2010 for illegally prescribing painkillers, OxyContin, and related drugs known as opioids—semisynthetic drugs that act similarly to morphine and heroin. In at least 20 cases, patients of these doctors fatally overdosed on painkillers shortly after receiving prescriptions. Since the source of the pills can be hard to trace, that is probably only a fraction of the total deaths.
Likewise, because it's fairly difficult for law enforcement to make these cases, the actual number of doctors who are illegally prescribing painkillers is probably much higher. The state's medical oversight database shows that this year, dozens of other doctors licensed to practice in New York State have either lost their licenses or were disciplined in some other way for illegally or unethically prescribing painkillers. The most recent statistics show an increase in such disciplinary cases in each year from 2008 through 2010.
Williamson's arrest was unusual in that it involved a doctor working primarily with minority patients. Overall, the painkiller epidemic is considered a white, suburban, middle-class phenomenon. "I've been doing this for 25 years, and I've never seen anything as bad as it is now," says Jeff Reynolds, executive director of the Long Island Council on Alcoholism and Drug Dependence. "It's the perfect storm."
Attorney General Eric Schneiderman calls it "the perfect crime." "Everyone involved is covered by the paperwork," he said in a report on the painkiller problem.
Opioid painkillers have been around for 100 years. About 20 years ago, the medical community began to view pain not as a symptom but as a disease. Eventually the major medical associations ruled that patients must be treated for pain. Pharmaceutical companies saw a vast new market for their drugs, and the use and abuse of opioids exploded.
In the New York metro area, the tipping point for recognition of the epidemic took place about two or three years ago. Since then, law-enforcement authorities have gone to great lengths to address it and have provoked some changes, including a law signed in August by Governor Andrew Cuomo that will eventually allow authorities to track prescriptions more closely. But as Reynolds notes, it's still getting worse, fueled by a range of factors: naked greed, lapses in oversight, loopholes in regulations designed to regulate the drugs, roadblocks from laws designed to protect patient privacy, and carelessness in securing prescription pads and filling prescriptions.
Solutions are out there: improved methods to allow law enforcement to get information on miscreant doctors, mandatory training of medical staff, better labeling, tighter control of prescriptions, and making insurance coverage for drug-addiction treatment as easy to get as the drugs themselves. But the medical community, the pharmaceutical industry, and insurance companies continue to resist many of these changes. Some law-enforcement officials and drug-treatment experts—including the city's special narcotics prosecutor, Bridget Brennan—believe what's needed is a fundamental change in the way doctors treat pain.
Each week seems to bring new reports that yet another medical professional has been caught illegally prescribing painkillers. "As many physicians as we take down, I see more just coming up," a Drug Enforcement Administration agent testified in a Suffolk County grand jury investigation into pill abuse earlier this year.
It all began with heroin. At one time, heroin was legal and believed safer than morphine. Folks soon figured out the drug's recreational benefits, and the ensuing epidemic ended its sale in the commercial marketplace. In 1970, heroin was declared a Schedule I controlled substance. Related versions of the drug, known as opioids, arrived on the market.
Opioids are known generically as oxycodone or hydrocodone, and by trade names such as OxyContin, Percocet, and Vicodin. The strength of the drugs varies based on the amount of the active ingredient in each pill. Somewhat like antidepressants, each drug can have different effects on a given patient.
In the mid 1980s, the World Health Organization began encouraging doctors to use opioids to treat cancer patients for pain. In 1995, national medical advocacy groups, many of which took money from the pharmaceutical companies, began advising doctors to use the drugs for non-cancer patients as well.
In 2001, the recommendation was codified by the Joint Commission on Accreditation of Healthcare Organizations "to ensure that patients receive appropriate pain treatment." Doctors were required to treat pain as a disease rather than as a signal of another condition. In addition, the government approved use of these drugs for "moderate to severe pain," which vastly broadened the potential market. Those two changes had enormous consequences. "Pain was no longer considered a symptom but a condition requiring treatment," according to the grand jury report, which was released by Suffolk County District Attorney Thomas Spota in April.
Meanwhile, the drug companies began aggressively marketing pain pills as less addictive. They also claimed the pills made pain sufferers more functional. Spota's report described this as a "disgraceful history of careless marketing of opioids."
The DEA approved issuing 25,000 kilos of hydrocodone in 2002. In 2012, the number climbed to 59,000 kilos. Similarly, the amount of oxycodone pills increased from 34,000 kilos in 2002 to 98,000 in 2012. (While the two drugs are chemically similar—both are semisynthetic opioids—oxycodone is generally considered the more powerful.)
As sales of the drug shot up, the number of unintentional overdoses per 100,000 people tripled. Eventually, opioids replaced Tylenol and aspirin as commonly prescribed pain relievers by doctors. Doctors became afraid of "under-prescribing" pain medication. The fact that the drug was so widely prescribed gave people a false sense of security about the likelihood of addiction. A range of celebrities became enraptured with the drugs, leading to reports of addiction and health problems: the late singer Michael Jackson, radio host Rush Limbaugh, Friends star Matthew Perry, singer Courtney Love, and the late actor Heath Ledger.
"The convergence of these factors became the foundation for the rapid increase in opioid abuse," the Spota report says. "Thus was created the epidemic."
Concerns surrounding use of these drugs actually started years ago. Back in 2007, for example, then state Attorney General Andrew Cuomo won $7 million from Purdue Pharma, the makers of OxyContin, as part of a $160 million settlement with the feds on allegations that the company misrepresented the dangers of the drug.
But things didn't get any better. In Suffolk County from 1996 to 2011, the number of people in drug court programs for heroin rose 425 percent, but those in programs for opioid abuse rose 1,100 percent. People in treatment for cocaine use declined by 13 percent. Drug overdose became the leading cause of accidental death in New York State, with prescription-pill overdoses a big part of that.
Although the pain-management community touted the benefits of opioids, other experts told the grand jury that there was no agreement that the use of these opioid painkillers is effective for the treatment of chronic non-cancer pain. Some studies suggest that the drugs actually hurt the patient's ability to function.
In cities and towns across the state, pill abuse has driven up crime. For example, Massena, New York, a town of 13,000 souls near the Canadian border, saw pill abuse triple the rate of violent crime, according to the town's police chief. As with the crack epidemic, babies born addicted to drugs have once again increased.
Over 10 years, pill-related DWI arrests quadrupled. In 2011, half of those arrests involved not alcohol, but painkillers. Last year, 174 people fatally overdosed on pills in Suffolk County. Arrests for the sale of painkillers went up by a factor of eight, while treatment for painkiller addiction in New York State grew by 300 percent.
The head of the New York State Board of Pharmacy told the grand jury: "Improper prescribing is not a defense for what we are seeing. The numbers are just too staggeringly high. There is not that much chronic pain."
A Suffolk County nurse practitioner who'd been arrested for three counts of possession of forged prescriptions told the grand jury that she started with a mild prescription for Percocet to help her get over a childbirth. Her tolerance increased, and she started taking more. Her doctor sent her to a "pain-management specialist," who radically increased her dosage. She got pregnant again and used the drug through her term. After the birth, her doctor prescribed oxycodone again for pain. She soon increased the dosage, and when she ran out, she started writing her own prescriptions, using the names of relatives.
As she told the grand jury, she "already had a prescription pad with the hospital name on it and a stamper with my DEA number. So, basically, I would just write the prescription under somebody else's name, and then I would bring it to the pharmacy and fill it."
Her husband found her pills, and that led her to attempt suicide. But even though she had two young children and a husband and had surrendered her DEA license, she continued to write false prescriptions.
"At first, I thought that I would go there and they would tell me, 'I'm sorry, we cannot fill this prescription; you do not have a DEA number,'" she told investigators. "Surprisingly enough, my number was still in the system. . . . So they filled it. . . . No one ever said a word. . . . I don't know if they trusted me or just didn't care."
The grand jury investigation was triggered when painkiller addict David Laffer shot and killed four people in a Medford, Long Island, pharmacy during a robbery in June 2011. Laffer was sentenced to life for the first-degree murder, and his wife got prison time for robbery.
One of Laffer's doctors was Stan Xuhui Li, a Flushing anesthesiologist running a pain-management clinic. Li had written Laffer scripts for 2,500 pills in the month before the robbery. In all, prosecutors say, Li saw 90 patients a day and wrote 17,000 prescriptions over two years. His patients then actually sold the drugs on the street in front of his clinic. Investigators linked 16 overdose deaths to Li's practice, including drug victim Michael Cornetta , 40, who overdosed twice before pills finally killed him in November 2010. (Li has not been charged in any of those deaths.)
In June, police raided the Woodmere home of Shaikh Monirul Hasan, a 57-year-old Bangladesh-born doctor practicing in Sunset Park. The raid recovered $150,000 in cash and gold bars. Hasan, court papers show, prescribed 3,480 oxycodone pills over two years using the name of a woman who was unaware her name was being used. He also allegedly prescribed drugs to people whom he had never treated or even met.
Hasan was a family doctor, but he was writing 100 painkiller prescriptions a day. The police sent an undercover into his office and watched him write the woman's name on a prescription in exchange for $80 in cash from a client. Pharmacists then filled the prescriptions without even asking for proof of identity. Of Hasan's conduct, Special Narcotics Prosecutor Brennan said, "There was not even a pretense of delivering medical care."
In July, Rohan Wijetilaka, a 63-year-old cardiologist living in Manhattan but practicing in Yonkers, was accused of illegally prescribing oxycodone, Percocet, and other painkillers over a six-year period. During that span, pharmacists complained more than 30 times that he was issuing too many prescriptions. Some of his patients told police that he sold them prescription drugs if they allowed him to bill their insurance companies for unnecessary tests. In June, his license to practice here was suspended, but someone kept using his registration number to write prescriptions.
That month, authorities across the region put together a series of investigations that led to 100 arrests, including two doctors, a nurse, the owner of a pharmacy and corporation, the manager of a doctor's office, and a phlebotomist (someone who takes blood samples).
One of the doctors swept up in the operation, Eric Jacobson, kept a pain-management practice in Great Neck, Long Island, and was one of the largest oxycodone prescribers in the state. Three of his employees had quit because they believed Jacobson was illegally prescribing the drugs in exchange for cash payments. One of those, a psychiatrist, sent him a text, saying, "You are running an illegal practice, and I don't want any part of it, so I am not returning to work."
Jacobson would see such patients on Tuesdays and Thursdays and often take home between $12,000 and $20,000 in cash. In 2011, one of Jacobson's patients died of a cocaine overdose, one day after receiving a prescription for 240 pills from Jacobson's office. The cause of death was chronic substance abuse.
The DEA raided his office, and Jacobson agreed to give up his license on December 1, 2011. But he continued to operate, allegedly finding another doctor and a nurse to prescribe the drugs to his customers. The new doctor came to believe that Jacobson was purposely serving addicts and people who were reselling the pills. He tried to institute better controls, but Jacobson resisted. The nurse, however, was more cooperative with Jacobson's demands.
Another Long Island doctor caught in the net, William Conway, was charged in Nassau County with illegally prescribing oxycodone between 2009 and 2011. In all, Conway prescribed 782,000 pills in less than two years. His "examinations" involved little more than taking the patient's height, weight, and blood pressure.
When he learned he might be under scrutiny, Conway told a patient he wanted "to review and alter his treatment records to ensure all the treatment dates fit," the indictment alleges.
Two of Conway's patients, Giovanni Manzella and Christopher Basmas, fatally overdosed in 2011, shortly after Conway gave them prescriptions for hundreds of pills. Their patient records showed that Conway had prescribed more than 1,800 pills total for the two men in just a few months.
Conway told investigators that he prescribed the drug to people he knew were addicted without examining them. Conway also admitted he "pre-signed" prescriptions to allow his office aide to dispense the pills as soon as patients entered the office. That aide, Robert Hachemeister, told investigators that a number of pharmacies had questioned the amount of prescriptions emanating from Conway's office, but the doctor ignored them.
Brentwood, Long Island–based nurse practitioner Rools Deslouches, a "pain-management specialist," was also accused of dispensing the drug without performing examinations or asking questions. In all, he wrote 4,300 prescriptions for 422,000 pills between August 2009 and October 2011. Half of his clients were people with criminal records. He typically charged about $200 per five-minute visit in which he wrote a prescription for oxycodone. In one visit, he actually suggested an ailment the patient could claim to have.
Lutful Chowdhury, 62, a Baldwin, Long Island, pharmacist indicted in February on conspiracy to distribute oxycodone and fentanyl (a drug for post-surgery pain), allegedly told his customers not to use the same name on their prescriptions. Chowdhury had been prescribing drugs to Kayla Gerdes, 20, of Freeport, Long Island, who was sentenced earlier this year to nine years in prison for killing a Hempstead doctor in 2010 while high on oxycodone and Xanax.
If you think doctors are carefully securing their prescription pads, consider this: In the June raid, authorities caught 11 people throughout Long Island using forged prescriptions from 11 different doctors. In September, Suffolk police arrested a man who was so rabidly obsessed with obtaining the drugs, he hung around emergency rooms and doctors' offices trying to steal their ID card so he could use them to buy pills.
In January 2010, police arrested Arnaldo Gonzalez for possession of forged prescriptions. He told police that on visits to Long Island doctors, he just lifted them. "I noticed a prescription pad on the desk and took a bunch of prescriptions when no one was looking," Gonzalez said.
While the oversight of painkillers might appear to be highly regulated, it is riddled with loopholes, information gaps, delays, and poor monitoring. State public health law blocks law-enforcement agencies from obtaining patient information. The state Bureau of Narcotic Enforcement, which is supposed to oversee these issues, might have information about illegal prescribing, but it is barred from sharing it. The bureau can't initiate that process—the police have to know something first.
Another problem is the lag of up to 45 days between the time pills are sold and when the sale is reported to state authorities. That makes tracking illegal prescribing more difficult.
Pharmacies and doctors can check a free state database of patient prescription histories, but only about 2 percent of them actually do it. If a pharmacy assistant is fired for stealing drugs, no record is kept. That employee can get the same work again.
Even though medical professionals have to get a DEA license to write prescriptions, there's no requirement for initial training, board certification, or ongoing education in federal or state law in prescribing painkillers.
On the plus side, last August, Cuomo signed the so-called I-Stop legislation, which creates a prescription monitoring registry and mandatory electronic prescribing (making prescriptions easier to track in real time). The teeth of the law won't go into effect until the end of 2014.
The bill was introduced by State Senator Andrew Lanza, from Staten Island, an epicenter of the epidemic.
Last June, Lanza described the problem as a "medicinal Trojan horse."
"On the outside," he said, it was "a medicine born legitimately, something we're all accustomed to seeing in our society as something that helps us. And meanwhile, on the inside, there's a killer lurking."
The Medical Society of the State of New York and seven other doctors' associations had qualms with the legislation, however, saying doctors didn't have time to check a database every time they wrote a prescription.
A much deeper problem is the medical community's philosophy about the treatment of pain. Brennan points out that hospitals commonly prescribe 30-day supplies of multiple pain drugs even to patients who were admitted for fairly routine injuries. Because they believe insurers won't pay for a second visit, doctors often prescribe a much larger amount than might be necessary. They are also afraid of being sued or receiving a lower rating on claims for not fully treating pain. But the practice floods the market with unneeded, incredibly addictive drugs.
"The medical community has to take a hard look at its prescribing practices," Brennan says. "There are doctors who were trained to liberally prescribe opioid drugs without a lot of thought about their addictive properties. The solution has become worse than the problem."
Brennan supports mandatory training for medical staff as well as relabeling the drugs from "for moderate to severe pain" to variants of "for severe pain" or "for severe pain and to ease terminal cases," so they aren't applied to such a wide variety of pain. She believes these steps will sharply reduce the black-market supply. "You would see the number of prescriptions written go way down," she says.
Reynolds of the Long Island Council on Alcoholism says a lot more needs to be done, including increasing the penalties against doctors. He is also urging health officials to do a better job of monitoring doctors who are prescribing a lot of painkillers. "I-Stop was a great step in the right direction, but if you cut off supply without addressing demand, it will get worse," he says. "That demand goes somewhere. It's like squeezing a balloon."
Reynolds now wants the state legislature to focus on the responsibility of insurance companies for the epidemic. Insurers, he says, are quick to pay millions for medication, but they balk at treatment. "They say the patient has to fail at outpatient treatment before they'll pay for inpatient," he says. "A chronic addict needs 30 days. But the insurers will only pay for three to five days. That's just not enough time, and, of course, the patient relapses. Then we ask the insurer to send them again, and they say no, it didn't work the first time. It's akin to using a Band-Aid to treat a severed arm."
Similarly, Andrew Kolodny, chair of the psychiatry department at Maimonides Medical Center and member of a group called Physicians for Responsible Opioid Prescribing, says cracking down on drug-dealing doctors and addicts who manipulate the system is necessary, but it doesn't get at the core problem.
"There has to be effective treatment," he says, pointing out that doctors are well-reimbursed for prescribing the pills but not so well-reimbursed for providing treatment for addiction. "What's more urgent is preventing new people from becoming addicted. The real problem is the well-meaning doctor who has been told for a decade that he needs to treat pain with opioids if he is going to be a compassionate doctor."
Kolodny's group joined several dozen doctors, researchers, and public health officials, including city health commissioner Thomas Farley, in petitioning the FDA to change the wording on opioid labels to make it harder for the drug to be marketed to patients with chronic pain not caused by cancer. They argue the labels allowing use for moderate to severe pain are too broad and leave a massive gray area that leads to overprescribing and abuse. "The labeling gives drug companies a license to promote opioids as safe and effective," he says.
A Purdue Pharma spokesman signaled that the company would resist a labeling change. He said the FDA believes current labels are "appropriate."
Organizations such as the American Academy of Pain Medicine and the American Pain Society also object to the label change. "We have serious concerns about the petition and believe the rationale is seriously flawed, potentially harmful to patients, and without substantive scientific foundation," AAPM president Martin Grabois wrote the FDA in August.
The FDA has yet to respond. In July, it overrode the proposals of an expert panel and opted not to require doctors to take special training before they would be allowed to prescribe painkillers. The American Medical Association also objected to mandatory training.Meanwhile, the pharmaceutical companies are said to be developing even more potent painkillers.