American Pain

by John Temple

  No more long hot days at a worksite, covered in sweat and sawdust. Derik was paying every bill and had money left over. This was what all the years of hard work had been for. He couldn’t walk away now. He’d finally made it.

  They’d always figured they’d get shut down sooner or later. Now they were beginning to believe they were in the clear. Either way, for now, they’d grab as much as they could.

  But, four months after South Florida Pain opened: a wake-up call.

  On June 10, a guy came to the clinic, introduced himself as a Florida Department of Health investigator. A smug little sawed-off shit, Derik thought. He spoke street English and generally came off to Derik as more of a Fort Lauderdale city meter reader than a guy with an important state job. Nevertheless, he and Chris were on edge.

  The investigator said it was a routine inspection, something they did for all doctors who dispensed controlled substances on-site. He didn’t ask many questions, but Chris and Derik took the opportunity to ask him a few things they’d been wondering about. After all, he was a state health investigator. If he didn’t know how a pain clinic was supposed to run, nobody did. They asked him if there was a limit on the quantity of prescriptions they should be issuing for a twenty-eight-day period. For instance, what number of 30-milligram oxycodone pills was considered to be OK? The investigator didn’t seem like he wanted to give a number, but eventually conceded that 240 pills could be considered an upper limit, which matched what Dr. Overstreet had told Chris. They asked what they should do when patients came back to the clinic early and said their prescription had been lost or stolen and they needed an early refill. The investigator said the clinic could replace a portion of the prescription if the patient produced a police report that confirmed the theft. For instance, if there were fourteen days left in a twenty-eight-day prescription, they could write a scrip for half the pills. The inspector wasn’t referring to any documents or using any official-sounding words. In fact, his answers just rambled, like he was making up things as he went, pulling rules out of his ass, whatever he thought made sense. He also kept telling them to refer to the DEA website.

  The whole thing felt wrong to Derik, the way the guy seemed reluctant to give solid and specific information. He felt like he was getting set up.

  He thought to himself: You should just walk away. Now. Go back to building houses.

  The inspector looked around the building. He wasn’t pleased when he saw Moe, Dianna’s floppy-eared wiener dog. He said it was considered unsanitary to have a dog around medication, even though Moe wasn’t in the dispensary room. He told Chris he wanted to see receipts for the medication the clinic had ordered. Then he started looking through random patient files, making photocopies as he went. He was particularly interested in prescriptions that had been filled in-house, kept pulling them out of the files and piling up the photocopies. Chris and Derik had a bad feeling about this because the doctors usually didn’t completely fill out scrips that were filled in-house. They weren’t trying to hide anything. It was just a time-saving measure. Why bother writing out the patient’s name and address if the scrip was never even going to leave the building? If the patient wanted to fill the prescription elsewhere, the doctors filled it out completely, and Derik or Dianna photocopied it and put the copy in the file.

  Derik thought the inspector looked pleased with himself as he put the copies in an envelope and sealed it. It was kind of funny. Chris and Derik were a couple of house builders who had only the slightest idea what they were doing in the pain clinic business, and they had found a way to crank tens of thousands of pills a day onto the street. And the state investigator was fine with that fact. Instead, he knocked them for not including the patients’ names or addresses on some prescriptions. And he didn’t like Moe being there.

  The inspector left with his envelope of photocopied prescriptions, and Derik and Chris did what they usually did when they were together: laughed it off. They made fun of the little guy, his street accent and bad grammar. That guy was going to bring them down? No way.

  Chris took the health department inspection more seriously than he let on to Derik. For one thing, he decided he would no longer rely on the doctors to know the rules and regulations around pain management. Other than her brief stint at One Stop Medical, Dr. Gittens was a family practitioner. Dr. Joseph was a gynecologist. They weren’t pain management specialists, and they probably weren’t even very good doctors, or else why would they be working here? Chris needed to figure things out on his own.

  After a local pharmacy began refusing to fill South Florida Pain prescriptions and said it was heeding the advice of the DEA, Chris called the DEA for clarification. He wanted to know, once and for all, what the rules were. He expected to get some kind of runaround, but he got lucky, connected with a woman who was some kind of higher-up in Florida. And then he introduced himself, and the DEA official knew who he was right away. Even knew his address.

  She said: Oh, yes, South Florida Pain Clinic. That’s 500 West Oakland Park Boulevard, right?

  The recognition freaked Chris out. A DEA official had his clinic’s address on the tip of her tongue. He asked her some questions, and she did what the state health investigator had done, told him to consult the DEA website. She couldn’t tell him anything more than what was there.

  Chris consulted the DEA website. It contained a policy, published in 2006, for dispensing pain meds. In the introduction, the policy quoted some statistics, including a national survey from 2004 that found that thirty-one million Americans had used painkillers to get high. But the eye-opening number was the 2.4 million people in the previous year who had tried painkillers non-medically for the first time. That number was higher than the number of new users of cocaine or even marijuana. Among illicit drug users, pharmaceuticals were the biggest growth market.

  Yet doctors hadn’t reached a consensus on painkillers. When the DEA had drafted the policy, many health professionals had provided input, and they split into two groups with different primary concerns: those who felt that pain was undertreated, and those who believed that painkillers were overprescribed. The document quoted one authority who said: “It takes only a few untrained or unscrupulous physicians to create large pockets of addicts.” But the document also said “undertreatment of pain is recognized as a serious public health problem,” and Chris liked the sound of that line, filed it away to use later.

  The document said painkillers like oxycodone could only be prescribed or dispensed for a “legitimate medical purpose.” And there’s where things got really fuzzy. The policy said there were no specific guidelines that determined what was a legitimate medical purpose and what was not. Instead, courts must analyze the evidence surrounding each case individually, and to be found guilty of unlawful prescribing of controlled substances, a physician’s illegal activity must be “glaring.”

  In 1978, a federal appeals court had created a list of actions commonly taken by doctors who were writing illegal prescriptions, and the DEA policy said that list was still relevant. Bad docs, according to the policy, tended to write lots of scrips for large numbers of pills. They gave no physical exams. They warned patients to fill their scrips at multiple drugstores. They wrote scrips too often. They called drugs by their street names and generally acted like drug dealers.

  The policy gave a few examples of bad doctors—Chris paid close attention to this part—but their practices were way more blatant and crooked than anything South Florida Pain was doing. One doctor in the policy had given a patient seven to ten prescriptions in different people’s names every week. Another physician had gone to the pharmacy to help his sixteen-year-old patient fill a prescription. Another had driven off the road after injecting himself with Demerol.

  Chris reasoned that South Florida Pain’s doctors could easily sidestep some of these problems by following a few simple rules. They would fill out diagnostic paperwork for every patient. They would schedule patient appointments no closer than twenty-eight days apart. And hopefu
lly, his doctors would generally not let on to anybody if they knew what the patients were doing with the pills.

  However, if Chris was going to make big money, Dr. Gittens and Dr. Joseph had to keep writing big and servicing big numbers. And one thing the policy made very clear was that the DEA reserved the right to investigate any doctor or clinic it wanted to investigate. So Chris wanted to know if there was a trigger number that would cause the DEA to red-flag South Florida Pain as a possible pill mill. Dr. Overstreet had said 240 pills per prescription was the magic number, and the health department investigator had seemed to confirm it. The DEA policy was vague, saying “what constitutes ‘an inordinately large quantity of controlled substances’ . . . can vary greatly from patient to patient,” and that cases against doctors “typically involve facts that demonstrate blatant criminal conduct.”

  The policy gave only the following specific example: “(I)f a physician were to prescribe 1,600 (sixteen hundred) tablets per day of a schedule II opioid to a single patient, this would certainly warrant investigation as there is no conceivable medical basis for anyone to ingest that quantity of such a powerful narcotic in a single day.”

  Sixteen hundred pills a day to a single patient! That example was so over-the-top that it was useless as a guideline. Chris wondered if the DEA purposely left certain information ambiguous, so clinics wouldn’t know how to avoid getting busted.

  A few weeks after the health department inspection, a man stuck his head in the patient window and said he was Juan Ortega, a reporter from the Sun-Sentinel. Ortega had heard about South Florida Pain from a man who drove past the clinic on the way to work each morning. The commuter had noticed the growing lines of patients and called the newspaper about it. Ortega had spoken to the owner of the bridal headpiece shop next door and a law firm up the block. The neighbors were complaining about the long lines and disruptive patients in the parking lots. The reporter had also tried to speak to patients in line, but they wouldn’t talk.

  Chris agreed to the interview, didn’t think much about it. He brought Ortega back to his office, where he had multiple security camera monitors showing various angles of the clinic property. He agreed to let the reporter record the interview on a handheld video camera. Ortega pointed the little camera at Chris’s face and started asking questions.

  Chris said the clinic was treating patients with medication and exercise. He said his doctors thoroughly examined patients and checked medical records before prescribing. He said they were committed to catching patients who were obtaining prescriptions from multiple doctors. He showed the reporter a filing cabinet in his office. It was filled, he said, with files of patients they’d banned for suspicious activities. At first, Chris refused to identify the names of the doctors, but Ortega had looked up the clinic on the health department website. Dr. Gittens, Dr. Joseph, and a part-time doctor listed the clinic address as their worksite. When the reporter told him the doctors were in good standing with the health department, Chris confirmed that they all worked there.* Ortega asked why there were so many out-of-state vehicles in the parking lot, and Chris sidestepped the question, acted like he didn’t know. Chris also wouldn’t say whether he was advertising the clinic on billboards.

  Chris paraphrased a line from the DEA policy on prescribing painkillers.

  “Pain is a big problem right now, and we’re just doing our part,” Chris said, his mug completely deadpan.

  Chris also told the reporter that he was trying to expand the parking lot in the rear of the building by demolishing the landlady’s back yard. “That’ll solve all of our parking problems here,” he said.

  Ortega’s story came out a day or two later—NEIGHBORS CALLING CLINIC A PAIN—underneath a big color photo of the front of the clinic, shot with a long lens from across Oakland Park Boulevard. The photo showed a couple dozen people loitering beneath the big red-lettered sign on the clinic’s low roof, a mix of men and women who looked to be in their thirties and forties, mostly. One young guy leaned on a walking cane.

  The story wasn’t too bad, Derik thought. It focused mostly on the neighboring businesses’ complaints, one saying, “It’s been horrendous. The people hang out all day.” Ortega had checked police records and reported that local cops had been called to the clinic six times, including one time in May because someone had stolen a patient’s pills. The story dropped a few hints about what was going on—the out-of-state patients, the pill thief, the fact that city leaders were looking into whether the clinic was complying with all municipal requirements. But it never mentioned pain-killers or narcotics. An uninformed reader or someone giving the story a quick scan might come away thinking it was a minor dispute between a couple of local businesses over parking.

  Chris and Derik enjoyed the video that accompanied the story on the newspaper website, especially the part where Chris said, with a straight face: “Pain is a big problem right now, and we’re just doing our part.” Derik loved that statement, especially since there was a random balloon bobbing in the background of the shot, like Chris was at some kid’s birthday party. Derik couldn’t remember where the balloon had come from, but somehow it made the whole thing even sillier. They played the video over and over, laughing. Chris had played the part well, Derik thought. He was solemn and earnest, just a well-meaning health care professional trying to solve the difficult problem of pain.

  A week after the Sun-Sentinel article came out, Derik was having a bad thirty-first birthday. He came to work hung over from the night before. Then, two neighborhood thugs attacked two elderly patients in the parking lot, grabbed their meds, and took off. Derik chased them down some back streets, past the quiet ranch houses. They splashed across a canal and got away, and Derik slogged back to the clinic, soaking wet and in a foul mood.

  It was Friday, a payday. After Dr. Gittens got her check, she told Derik that this would be her last day at the clinic. Derik was shocked. Dr. Gittens had always showed more interest than the other doctors in how the pain clinic was run. She was the one who said every patient needed to have an MRI. She was always asking questions about how they kept the books, how much the various medications cost, which MRI services were best. She was a nice woman, and she’d seemed invested in the clinic’s future.

  On the other hand, she’d been acting a little different lately. Before, she’d been friendly, meeting Derik and his roommate out for drinks. Her brother, who’d helped her move to Florida three months earlier, had showed up again, asking questions about licensing and how they ran the office. Derik had thought it was odd when he saw her studying the price lists they’d made for medications. Still, Derik couldn’t understand why she was leaving so suddenly. He asked her to stay on for a week or two, give a reasonable notice so he could find another full-time doctor. Otherwise, they’d have to go back to servicing clients until midnight. But Gittens said no, she had made up her mind. She tried to give him a hug as she left, but Derik just walked away.

  A few days later, Derik was riding in to work with his roommate, as usual. When they pulled off I-95 and headed east on Oakland Park Boulevard, a new sign caught Derik’s eye, off to the right. A place called Oakland Plaza Medical Center. The sign said it offered pain management. Same side of the busy boulevard as South Florida Pain, just off the interstate, a half-mile closer to the exit than South Florida Pain.

  He got into work and talked it over with Chris, who’d also seen the sign on his way in with Dianna. They were worried. What if patients coming off the interstate saw the other clinic’s sign and started pulling in there? They believed whoever had put up this clinic was trying to steal their business.

  So Derik paid a visit to the new clinic. It was in a building that looked like a warehouse, tucked between a window-tinting shop and a decorative concrete showroom. But the interior had been renovated, with nice stone countertops.

  And that’s when Derik saw Dr. Gittens’s brother, working at the new clinic. No sign of Dr. Gittens herself, but her strange recent behavior suddenly made sense, the su
dden interest in the inner workings of the clinic, her quitting without notice. She’d obviously decided to go into the business by herself, siphoning off the patient traffic from I-95.

  Chris and Derik knew that if Gittens could piggyback on the success of South Florida Pain, nothing was stopping anybody from doing the same thing. The word was out, that there was money to be made in pain management. To stay on top, South Florida Pain needed to grow. It needed a bigger space, more doctors. More pain clinics were popping up every day, and Chris wanted to be the biggest and the best.

  That was how Chris was. He’d wrestled back in high school, and he’d win lopsided matches, taking down a weaker opponent over and over. Afterward, his dad would ask why he didn’t just pin the guy, take the quicker victory? But Chris didn’t just want to win. He wanted to dominate the other guy, control him, mash his face into the mat. The more patients the clinic got, the more Chris wanted. He wanted every hillbilly streaming into Florida to know about South Florida Pain.

  He began scouting new locations.

  The local cops turned up the heat. The clinic sat just within the border of Wilton Manors, but the boulevard was patrolled by Oakland Park cops. They’d park their cruisers just to the east and west of the clinic and roll up on patients as they left the clinic. Patients said the cops would search the cars, question them, arrest them, take their pills. Other times, they’d cruise by the parking lot and scope out the patients’ tags, run them, and then come into the clinic to get them if their insurance or registration wasn’t up to date. Sometimes they’d tow cars right out of the lot.