Doctors and the opioid crisis: An AJC National Investigation

The nation struggles to rein in doctors

After Dr. Hasan Babaturk was fired from a medical practice for his erratic behavior, he took his prescription pad and came up with a new business model. He met patients in parking lots, shopping malls and motels, where they paid him $250 to $350 in cash. Babaturk then gave them what they wanted: prescriptions for high doses of oxycodone.

“It’s easy money,” the doctor said, explaining his mobile medical practice to the Maryland medical board.

Earlier this year, a Las Vegas jury convicted 93-year-old Dr. Henri Wetselaar of conspiracy to distribute controlled substances, money laundering and other charges. Then in August he was sentenced to 10 years in prison. (Las Vegas Review-Journal photo)

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In Georgia, prosecutors say Dr. George Mack Bird pre-signed prescriptions that his employees filled out and stocked his office with hydrocodone and other drugs for one-stop service. He stuffed proceeds — nearly $1 million in cash — in boxes and bags in his medical offices, home and vehicle.

Dr. Naga Raja Thota, a California pain management specialist, gave out hundreds of pain pills in exchange for sex. Dr. Henri Wetselaar, a 93-year-old World War II veteran who made house calls, prescribed potentially deadly combinations of opioids, Xanax and muscle relaxants to Nevada patients who had no medical need for the pills. Dr. Howard Gregg Diamond doled out hydrocodone, as well as fentanyl, even as patients kept dying of overdoses, prosecutors allege.

His Texas staff told one patient not to worry about obtaining prescriptions. “Legal drug dealing is easy,” the patient was told, according to testimony.

Drug enforcement agents trying to halt the opioid epidemic are overwhelmed by cartels that smuggle heroin from Mexico and sneak fentanyl in from China. But they also haven't stopped some of the largest suppliers of narcotics: America's doctors.

Years after drug companies admitted that opioids were highly addictive, years after overdoses started decimating rural communities, and years after the Drug Enforcement Administration started cuffing doctors in pill mill raids, physicians continue to flood the nation with opioids.

"What I have been saying for years is these are dangerous medicines," said Dr. Tom Frieden, the former director of the Centers for Disease Control and Prevention. "If you take just a few doses, you can become addicted for life, and if you take just a few too many pills, you can die."

Well-meaning doctors who want to help patients in pain are part of the problem. But far too many licensed doctors across the nation have become drug dealers enabled by their DEA certificates.

A 50-state investigation by The Atlanta Journal-Constitution found that, since 2016, more than 1,000 doctors have been brought before medical boards for improperly prescribing opioids to patients. In that same time, nearly 150 have been in federal court on opioid drug charges. Every month, authorities bust another round of doctors gone rogue. Some doctors do it for cash, some for sex, some to keep their struggling practices afloat, the AJC found. Many leave a trail of dead patients connected to their prescription pads.

"We're still inundated with prescription drugs," said Vanita Hullander, the coroner in Catoosa County, a rural area of Georgia on the Tennessee state line that stands out for high rates of opioid prescribing. Hullander sees the crisis up close in the overdose deaths she must investigate and the grieving families left behind.

“There are a lot of doctors that are still writing left and right,” Hullander said, “and have no scruples and no morals about it.”

‘Doctors know best’ attitude

An opioid problem that once seemed confined to struggling corners of West Virginia and Ohio now is taking lives everywhere. Across the country, all types of drug overdoses kill more than 175 people daily, with opioid-related deaths now far outpacing overdoses from cocaine and methamphetamine.

“If a terrorist organization was killing 175 Americans a day on American soil, what would we do to stop them? We would do anything and everything,” New Jersey Gov. Chris Christie, chairman of the national opioid commission, wrote to President Trump last month when presenting the commission’s report. “We must do the same to stop the dying caused from within.”

But how? When doctors with the legal authority to prescribe medications act more like dealers than healers, how can they quickly be stopped?

U.S. Attorney General Jeff Sessions speaks during a press conference about combatting the opioid crisis at JFK International Airport on October 27, 2017 in New York City. U.S. President Donald Trump announced that the federal government will fight the opioid crisis as a public health emergency, which has claimed more than 59,000 lives in 2016.

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Attorney General Jeff Sessions, whose home state of Alabama tops the charts nationally for opioid prescribing, created a new unit in August to spot and prosecute more dealer doctors. Some states have imposed legal limits on opioid prescribing, after being convinced that doctors on their own wouldn't stop doling out too many opioids. States also use databases to track every prescription, which some mine to flag and investigate high-volume prescribers.

But no state has solved the prescribing problem, including Georgia, where Attorney General Chris Carr created an opioid task force in September.

"When you see that there are 541 million opioid doses legally prescribed — 54 for every man, woman and child in the state of Georgia — it raises eyebrows," Carr said. "There are counties in Georgia where the number of doses prescribed doubles — or in some rare cases, triples — the population for that county. We need to get solid data points that indicate why this is happening."

One reason: Some doctors blatantly disregard medical standards for prescribing. Other doctors think they know best and keep prescribing even after family members beg them to stop feeding the addiction of a daughter or son. Then there are doctors who get involved in blatant drug trafficking organizations.

Take Dr. Robert Gene Rand. The Nevada doctor pleaded guilty in July to involuntary manslaughter of a patient and unlawful distribution of narcotics. He was sentenced last monthto 10 years in prison. He wrote prescriptions for employees of a Ford dealership, who then sold the drugs, sometimes out of the dealership's parking lot. Rand was also accused of seeing patients after hours to give them prescriptions for $150 cash.

From March 2011 to April 2016, Rand prescribed one patient more than 23,000 oxycodone 30 mg pills. Despite warnings and questions about the high volume of pills he gave another patient, the prescribing didn’t stop. That patient died of an overdose. Investigators in 2016 said they were looking into the deaths of 60 other patients who received narcotics from Rand.

Is it murder?

Defense attorney Tracy Green, left, comforts Dr. Hsiu-Ying "Lisa" Tseng, in 2015 as she is sentenced 30 years to life in prison. The California physician was convicted of second-degree murder in the overdose deaths of her patients.

Credit: Tribune News Service

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Credit: Tribune News Service

In the worst cases, a doctor who blatantly overprescribes is actually a killer.

That’s the conclusion John Niedermann reached when he started working the case of Dr. Hsiu-Ying “Lisa” Tseng.

A special assistant in the Los Angeles County District Attorney’s Office, Niedermann has built a high-profile record of going after doctors who deal. He convinced a jury in 2015 to convict Tseng of murder in the deaths of three patients who overdosed as a result of rampant over-prescribing.

While the criminal case revolved around the three deaths, many more overdosed. A general practitioner, Tseng authorized pain pills without proper evaluations or to patients who had admitted addictions. After being told repeatedly by authorities that patients overdosed, she kept prescribing.

That’s what made it murder and not just malpractice or a drug case. “In Tseng’s case, the fact that kids were dropping like once a month, I thought there has got to be something bigger here, because there has to be more liability for having so many people die, as well as being told about it and not changing your habits,” Niedermann said.

Since Tseng’s conviction, other prosecutors have connected the dots between prescribing and deaths and upped the charges to murder.

In metro Atlanta, Dr. Narendra Nagareddy, a psychiatrist, is facing felony murder charges in the deaths of six patients, who overdosed between 2011 and 2015. Nagareddy's attorneys are putting up a vigorous defense, saying medical records will show he wasn't dealing drugs. "There is not a doubt in my mind that Dr. Nagareddy was attempting to prescribe these medications for a legitimate medical purpose," said David Wolfe, one of the doctor's attorneys. A jury is expected to hear the evidence sometime next year.

Greed is often a factor in the cases of blatant over-prescribing. Doctors can easily get cash from “patients” who want prescriptions to feed their own addictions or to supply their drug-dealing businesses. Some quickly get rich. Two Alabama doctors convicted in a pill mill case pumped up their bank accounts, bought beach condos and acquired 23 luxury cars, including multiple Bentleys, Lamborghinis, Mercedes and Ferraris.

But Niedermann said it’s not just greed. He noticed that hubris was also a common trait among doctors he has prosecuted.

“They feel they are above the law,” Niedermann said. “They have always been so highly respected and deferred to. I can say that, of the dozen or so doctors that I have convicted, whenever a jury returns a verdict of guilty they look absolutely stunned. I look at them and I’m like, you sat through this month-long trial. You heard all the testimony. How are you surprised by this? But they honestly, honestly think they are doing nothing wrong.”

Doctors push back

Before he became the chief of Mississippi’s Bureau of Narcotics last year, John Dowdy spent a career prosecuting federal criminal cases.

But he was shocked when he found out how many opioids the state’s doctors were prescribing. When Dowdy started, Mississippi ranked fifth nationally for its rate of opioid prescriptions. In the latest rankings, it is fourth.

Mississippi isn’t near the top of the charts for overdose deaths, but Dowdy could see what the excessive prescribing could lead to. He is all for going after the bad apples. But he concluded that focusing only on the dealers in white coats wouldn’t be enough to fix Mississippi’s problem.

He started talking to as many Mississippi doctors as possible, to convince them that many had to immediately change the way they are treating pain.

Dowdy believes opioid prescribing climbed so high because pharmaceutical companies convinced plenty of Mississippi doctors that their painkillers were safe and effective. “The bottom line is, big pharmacy in this country, they are nothing more than legalized drug cartels” he said.

Doctors became “unknowing pawns” whose prescriptions pumped up pharmaceutical profits, Dowdy said.

In August, a governor’s task force Dowdy chaired recommended sweeping changes for doctors, dentists and even coroners who investigate overdose deaths. It’s up to the state’s medical licensing board to adopt the recommended rules for physicians, including a seven-day limit on opioids for most patients dealing with short-term pain.

But as in other states that have passed or considered similar measures, many in Mississippi’s medical community are objecting. After hearing hours of complaints at a November hearing, the all-doctor board appears likely to back down and pass less-strict rules than those recommended.

"We're getting some pushback from a lot of different groups, physician groups and different organizations from around the state, some even nationally," said Dr. Randy Easterling, a medical board member who was co-chair of the task force. "The overriding thing, quite frankly, is just some state agency or some state group – even though it's made up of physicians — coming in and telling people how to practice medicine. Doctors always push back on that."

Almost every state is in the same quandary. Lawmakers and regulators want doctors to have the discretion they need, but they are tired of doctors abusing the discretion they have.

“We now have an addicted society,” Dowdy said. “And the addicted state that Mississippi finds itself in — and you can start rattling off Louisiana, Alabama, Tennessee, Arkansas and Georgia, too — is because of the prescribing habits that have been going on for the last five, six or 10 years.”

Some doctors forgiven

Going after a doctor abusing that discretion isn’t an easy task for law enforcement.

It’s not like finding a drug dealer with a bag of pills. Doctors have a legal right to prescribe narcotics, so prosecutors often have to prove that prescriptions were given for no legitimate medical purpose. That can require months of investigation, including undercover work, to prove a case beyond a reasonable doubt.

In some states, there are additional challenges.

This past July, an Alabama prosecutor had to drop criminal charges pending against a Tuscaloosa doctor arrested after complaints that he prescribed massive amounts of pain medication. Alabama court rulings say that the state drug laws used to arrest the doctor don’t apply to a licensed physician writing prescriptions for patients.

Criminal prosecution shouldn’t be the first response when questions arise over a doctor’s approach to treating patients for pain, said Rob McLendon, a Georgia attorney who is representing Dr. Bird.

"Unfortunately, too often when law enforcement disagrees with how a doctor is treating his or her patients, rather than simply referring the issue to a medical board that has the ability and expertise to deal with any particular situation, they want to call it criminal conduct, " McLendon said.

Medical licensing boards are charged with protecting the public from dangerous doctors. While some have begun taking a hard line, others give doctors a pass.

New Jersey, for example, in the past 18 months has suspended or revoked numerous doctors after finding their prescribing habits were putting patients at risk, the AJC found. Michigan also has cracked down. In the past two years, Michigan has immediately suspended doctors it believes are overprescribing opioids and has put doctors on notice that it’s monitoring their prescribing habits.

Other licensing boards, most of which are dominated by practicing physicians, take a forgiving attitude, the AJC found. A doctor’s arrest on drug charges doesn’t necessarily prompt any board action in some states. Even in cases of blatant over-prescribing, doctors may only be required to pass a prescribing course before being allowed to see patients again.

In Virginia, the medical board did a thorough investigation of Dr. Jeffrey Bryan Conklin and found he violated prescribing rules for nine patients. He gave one an early refill when the patient said his dog destroyed his pain meds, and authorized another patient’s refill when she said cops took her drugs during a raid. He kept prescribing when pharmacists and an insurer questioned his practices, and after one patient overdosed, survived and came back to him for more.

The father of one patient told the doctor his daughter had a “serious, crippling” addiction and “implored” him to stop writing prescriptions for her, the board’s order shows. He did not.

The Virginia medical board reprimanded the doctor, prohibited him from treating chronic pain patients and placed him on probation. But the board allowed him to keep practicing.

He declined to comment.

Given the national crisis, many experts say it’s time for every medical board to step up and fulfill its mission.

“This will never stop until some more physicians get their licenses revoked and state medical boards start taking seriously the responsibility to ‘protect the health, safety and welfare’ of the constituents,” said Dr. John Hall, the former executive director of the Mississippi board who had urged the board to do more to punish doctors who improperly prescribed or who engaged in sexual misconduct.

New tactics coming

As everyone tries to figure out what to do to stop the opioid crisis, broad new rules are being imposed on doctors.

Retraining is one emphasis. Georgia is one of many states now requiring doctors to take classes on proper opioid prescribing.

The most aggressive states are taking a less-trusting approach with physicians.

At least 17 states now limit opioid prescribing. Massachusetts got the ball rolling with a seven-day limit for first-time adult prescriptions. Kentucky passed a three-day limit this year for short-term pain, mirroring CDC guidelines. Some states have special limits for children and teens, who are especially vulnerable to future addiction if they are exposed to opioids.

“I think legislating clinical practice is generally a bad idea. But, if the medical profession doesn’t greatly improve, it may be the least-bad alternative,” said Frieden, the former CDC director.

Individual doctors are also facing increased surveillance. Tennessee and Kentucky authorities, for example, use their prescription-tracking databases — set up to identify patients getting too many pills — to flag doctors who are high prescribers. That allows the states to spot doctors who might be a problem without waiting for complaints to come in to the medical boards.

In Atlanta, the newly appointed U.S. Attorney Byung J. “BJay” Pak said his office is all about mining the data on prescriptions. If a doctor’s numbers make him an outlier, “that’s a clear sign that something interesting is going on,” Pak said.

Pak said his office will try to bring more civil actions, in addition to criminal cases, so it can more quickly shut down doctors whose prescriptions feed addicts.

"Doctors are given a great amount of power and discretion," Pak said. "But if we find they are abusing their discretion with the intent or recklessness of flooding the market with opioids, we are going to use all the tools we have in this office and under federal law to bring them to justice."

When Sessions announced his opioid unit, he pledged a data-driven effort to spot the doctors who use their prescription pads to traffick drugs. It’s an effort that’s bringing extra resources to a dozen regions. The unit’s first indictment came in October.

Dr. Andrzej Kazimierz Zielke, 62, was charged with conspiracy and unlawful distribution of controlled substances for his actions in western Pennsylvania. The region has some of the nation’s highest rates of overdose deaths.

Zielke advertised his “Medical Frontiers” office as a holistic pain management practice. Tipped to Zielke’s high prescribing of oxycodone, investigators found the doctor charged $250 in cash for visits and gave out powerful narcotics to patients for no legitimate medical purpose.

It didn’t happen in a back alley or a parking lot. But the government says it was a drug deal, not a medical appointment.

The Atlanta Journal-Constitution series on Doctors & Sex Abuse is a finalist for the Goldsmith Award for Investigative Reporting.

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» Read the AJC's award-winning investigation, Doctors & Sex Abuse: A 50-state investigation

About this story

To examine the role the nation’s doctors play in the deadly opioid epidemic, The Atlanta Journal-Constitution reviewed medical board disciplinary documents issued in all 50 states and the District of Columbia from Jan. 1, 2016 through June 30, 2017. The AJC also examined federal criminal cases nationwide, as well as some state criminal cases that involved the prosecution of doctors accused of improperly prescribing opioids.

The newspaper then interviewed doctors, law enforcement officials, advocates and policymakers about the system that still struggles to quickly stop errant prescribers from fueling the epidemic. The AJC sought interviews with the doctors identified in this report. Some did not respond to messages. Others could not be reached for comment, including some who are currently in prison or jail.