How drug warnings slipped by in the 'Dr. Death' case

Benzodiazepines depress the nervous system. They are used to treat anxiety, prevent seizures and induce sleep, and can produce feelings of euphoria. This class includes alprazolam, sold under the brand name Xanax; diazepam, also sold as Valium; and clonazepam, or Klonopin.

Opioids are derived from natural or synthetic versions of the opium poppy and can be addictive with a single prescription. They are widely recommended as treatments for pain after surgery, an injury or as part of cancer treatment, but are also prescribed for chronic pain. This class of drugs includes oxycodone, sold under the brand name OxyContin; hydrocodone, sold as Vicodin; and methadone.

Prescription stimulants are used to increase focus and concentration and may be prescribed for attention-deficit hyperactivity disorder or depression. These drugs include amphetamine salts, which can be highly addictive and are sold under the brand name Adderall.

Sources: U.S. Centers for Disease Control, U.S. Food and Drug Administration, National Institute on Drug Abuse

Here is a partial list of patients who died while under care of Dr. Narendra Nagareddy:

Cheryl A. Trepanowski, 54, of Conyers. Died Jan. 10, 2014 of acute methadone intoxication.

Audrey Rae Austin, 29, of Forest Park. Died Feb. 23, 2014 of a prescription drug overdose.

Michael Robinson Trimble, 42, of Riverdale. Died March 8, 2014 of actual alcohol, hydrocodone and alprazolam toxicity.

Melissa Haynes, 53, of Douglas County. Died Dec. 25, 2014 of a prescription drug overdose.

David Todd Robinson, 50, of Forest Park. Died Jan. 25, 2015 of acute intoxication of hydrocodone and alprazolam

Ricky Thompson, age not listed, of Henry County. Died Feb. 5, 2015 of oxycodone and alprazolam toxicity.

Source: Search warrant/affadavit

Long before he was dubbed "Dr. Death," Jonesboro psychiatrist Narendra Nagareddy was known across metro Atlanta's southside as the go-to physician for prescription drug addicts.

The users knew it, court records and interviews show. So did law enforcement, pharmacists, other doctors, state regulators and addiction counselors. The mother of one patient complained to authorities in 2012 that he gave her daughter prescriptions she did not need. Years of state and federal data, available to the public, raised red flags showing that Nagareddy was among the state Medicaid program’s top prescribers of one of the most abused prescription drugs.

Patients were arrested for selling their pills. Patients died.

Yet as the death toll mounted, none of the state safeguards designed to protect the public managed to stop Nagareddy, an Atlanta Journal-Constitution investigation found. Inaction, missed signals and state law that blocks regulators from activating an early warning system allowed the doctor for years to prescribe what authorities say were alarming amounts of drugs.

By the time a Drug Enforcement Administration task force arrested Nagareddy Jan. 14, three dozen of his patients had died while he was prescribing them controlled substances, investigators allege. If those deaths prove to be overdoses from scripts he wrote, this could be the deadliest case of over-prescriptions to be prosecuted in the U.S.

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» Chart: Nagareddy doled out more pills than other Georgia psychiatrists

» Map:  Georgia drug deaths by county: 2014

» Document:  Read the search warrant

“While any death is horrible, saying he’s directly responsible for their deaths is wholly inaccurate,” Frey said.

Nagareddy faces one count of illegally distributing or dispensing a controlled substance and was released on $100,000 bond on the condition he does not practice medicine. He is still licensed, according to the website of the Georgia Composite Medical Board, which regulates physicians. A Georgia doctor since 1999, Nagareddy has never been the subject of public sanctions, malpractice settlements or judgments, it shows.

‘Zombied-out’

The patients who squeezed into Nagareddy’s crowded Arrowhead Boulevard office were battling anxiety or depression in addition to addictions, AJC interviews with relatives and an affidavit filed by investigators in Clayton County court show. The psychiatrist was one of the few doctors in south Metro Atlanta certified as a specialist by the American Board of Addiction Medicine, which meant he is considered well qualified to treat them. These specialists are trained on how to monitor patients for signs they are using their medications to get high.

Instead, Nagareddy operated a clinic that bore the signs of a pill mill, according to the affidavit and interviews with people who visited it. Appointments typically cost $75 and barely involved an examination, witnesses told the investigators with the DEA’s Atlanta-based Tactical Diversion Squad. A database search of his patients found that several were on felony probation or parole for sale or distribution of controlled substances.

The waiting room was packed with bleary and dazed patients who’d wait hours to be seen.

“I’d see a lot of zombied-out people. You could tell a lot of them were junkies,” said Rebecca Gray, whose brother Ricky Thompson, 47, died February 2015 of an overdose of oxycodone, a pain-killing opiate, and alprazolam, which treats anxiety.

Because both kinds of drugs are prone to abuse, doctors are reluctant to let their patients take them at the same time. Doctors also keep a close eye on their use. But records show Nagareddy would approve Thompson for months-long supplies in a single visit, which meant the father of two didn’t have to return for a checkup.

Ruth Carr thought her daughter Audrey Rae Austin, 29, had beat her addiction and postpartum depression after finishing rehab at RiverWoods Behavioral Health Treatment Center in February 2014.

“She was 100 percent better. She was 100 percent my daughter again,” Carr recalled.

But on her first two days home, she had filled prescriptions from Nagareddy for alprazolam, methadone, and amphetamines, according to investigators. The mother of two overdosed and was put on life support on the third day. Less than a week after getting out of rehab she was dead.

“I’m just glad he’s not writing prescriptions for everybody (anymore),” Carr said of Nagareddy.

“She was a healthy … woman at the time but he wrote her prescriptions for large quantities of Xanax and methadone and something called amphetamine salts,” Carr said. “He just overwrote prescriptions for my daughter that weren’t necessary. It’s the medicine that he gave her that led to her death.”

Other psychiatrists at Southern Regional Medical Center didn’t come close to prescribing as many pain medications, according to an investigator’s comparison of prescriptions signed by Nagareddy and three other psychiatrists. In an 11-month period ending in July 2015, Nagareddy signed off on nearly 500 times the amount of oxycodone prescribed by his closest peer there. He also wrote prescriptions for methadone and fentanyl, while they prescribed none.

Patients “can get anything they want from Dr. Nagareddy,” the medical director of a methadone clinic told investigators, law enforcement records state.

‘Black hole’

The years before Nagareddy’s arrest were filled with chances to spot signs of trouble.

During her son’s repeat emergency room visits for bleeding stomach ulcers and other problems, the mother of Ricky Thompson complained to other doctors that Nagareddy was giving him too many prescriptions, Gray said, but nothing came of it.

Carr said she filed a written complaint with regulators in 2012 — two years before her daughter’s death. Their reply said that “they’d look into it and I’d hear if any action was taken. I never heard back from them,” she said.

After Michael Trimble was found dead on the sofa of his parents’ Riverdale house in 2014, his father was told an autopsy showed he died of a heart attack. But a GBI autopsy concluded the 42-year-old died of “acute alcohol, hydrocodone and alprazolam toxicity,” according to the Nagareddy search warrant and affidavit. It noted that in just three months, he had filled prescriptions for 270 alprazolam pills.

Pharmacists in Stockbridge and Conyers told investigators they refused to fill Nagareddy’s prescriptions, an investigator’s affidavit states. An addiction counselor said she warned the doctor in writing that it was too dangerous to prescribe alprazolam to the clients of her methadone clinic, but received no response.

Former probation officer Craig Ogilvie is convinced he saved lives by banning his probationers from seeing Nagareddy.

“You develop this theme and recognition of the players who are out there feeding your addicts,” said Ogilvie, now director of Henry County Accountability Courts, which includes the local drug court. “His name was at the top of the list very prominently.”

Whistleblowers must often navigate a maze of bureaucracies to find an investigator willing to take on these complicated cases, said Rick Allen, director of the Georgia Drugs and Narcotics Agency. And pharmacists for major drug store chains can be reluctant to sound the alarm because their employers threaten to write them up, Allen said.

“The bigger the chain, the bigger the black hole,” Allen said.

Georgia’s Prescription Drug Monitoring Program, a statewide database of all controlled substances dispensed by pharmacies in this state, could fill this gap because its software is programmed to alert law enforcement of suspicious activity automatically. State officials created it in 2012 to slow prescription drug abuse by allowing doctors and pharmacists to spot suspicious trends. But because of privacy concerns from legislators, state law makes it illegal for investigators to use its automatic alert function and it erases data after one year.

State laws passed to halt the growth of pill mills earlier this decade can do little when it comes to doctors like Nagareddy. Their legislation places restrictions on pain clinics, not other types of medical practices.

Georgia Composite Medical Board spokesman Daniel Dorsey declined to answer questions about Nagareddy, saying only that the board is aware of recent media reports. By law, board complaints and investigations are confidential.

It was left to Henry County Community Supervision Officer Sonja Worth to put the pieces together. As she supervised her caseload of 80 or so probationers, the 12-year veteran noticed that Nagareddy’s name kept appearing on prescriptions that she reviewed as part of the hundreds of drug tests she oversees each year.

After three of her probationers died, Worth noticed they all were Nagareddy’s patients and told her agency’s DEA task force member, said Bert Flewellen, a spokesman for the Georgia Department of Community Supervision.

“To be able to identify a pattern of three deaths spanning years is an incredible testament to the depth of her care for the people she supervises and her attention to the details that matter,” Flewellen said. Worth declined a request for an interview placed with Flewellen’s office.

‘I knew it was him’

The DEA raided Nagareddy’s office more than one year later, . Conyers resident John Trepanowski watched him on TV being led away in handcuffs.

“As soon as I saw the building on TV I knew it was him,” Trepanowski said.

His wife, Cheryl, who suffered from severe, chronic lung disease, was referred by another doctor to Nagareddy for depression. But she only grew more listless during the brief months that she was under the psychiatrist’s care, Trepanowski said.

On the morning of Jan. 10, 2014, he woke to find his 54-year-old wife dead in bed beside him.

“I went to nudge her a little bit and she was gone,” he said. They had been married for 32 years.

While an autopsy for the grandmother of six listed her cause of death as “acute methadone intoxication,” three anti-anxiety medications – all controlled substances – were also in her bloodstream. The prescription drug database held no information on where she obtained methadone, but two of the anti-anxiety drugs had been prescribed by Nagareddy.

“It’s sad. You go to a doctor for help and they dole out poison,” he said.