Cracking Down on Pill Mills Is Painstaking Work (Part 2)

The cases I worked on during my time at both the Cincinnati Police Department and later at the Warren County Drug Task Force were ultimately very rewarding. The prescribers we went after were not the true friends of patients with chronic pain. Some patients thought highly of the prescribers, but little legitimate medical work was being performed on their behalf.

In the beginning, before diet regulations were amended, the practice of treating patients under the guise of losing weight dominated much of our work. Pain clinics had not fully developed, so most of our time was spent on these bogus operations. The typical scenario was for the prescriber to document hypothyroidism for the patient because this was a legitimate medical condition paid for by insurance. Weight loss, unless it truly involved a treatment needed to save the patient’s life, was not covered.

The prescriber would usually dispense phentermine to patients with a hypothyroidism diagnosis, thus getting the insurance payment and making patients happy. This operation also kept the criminal operation away from local pharmacies by dispensing out of the doctor’s office.

These cases, like those of the bogus pain clinics, usually led to undercover visits by several officers from our department or insurance or regulatory investigators. A significant amount of information was gleaned from the undercover visits, including discovery of bogus insurance cards to track the billings. Some prescribers did not care whether patients lost weight or gained it, as long as the money kept flowing.

Pain clinic investigations were similar, but those clinicians sometimes prescribed the drugs to patients who then had to fill them at local pharmacies. In some cases, the pharmacies were also involved, willing to fill hundreds of scripts a day from certain prescribers when other pharmacies refused to fill any of the unnecessary prescriptions. Often, these prescriptions were a cocktail of drugs that included pain medications and 1 benzodiazepine. During undercover visits or surveillance outside the offices, we often witnessed lines or people loitering who were either themselves addicted or picking up drugs for traffickers.

It is impossible to detail all the scenarios at these operations, but some were involved in selling sample-controlled substances to patients, which was

illegal, especially when the prescriber had paid nothing for the drugs. Prescriber operations that dispensed large amounts of controlled substances out of their offices, whether diet or pain clinics, were almost always involved in illegal behavior.

Health insurance was often being grossly abused as part of both operations. Working with these insurers was a great way to add charges onto the criminal drug statutes and money laundering that were also a part of the indictments. Filing false insurance claims was easy and often continued for months or even years undetected. Greed in all these cases was many times the Achilles’ heel of the operations. The time for one operation’s billings many times exceeded 20 hours in 1 day for an operation that was open for business for only 6 hours.

Over the years, many agencies got involved in pursuing criminal medical practices. I saw some great investigations and knew about others that had not done the kind of background and preparation that our office and others did. In some of those cases, a 2-to-3-year effort resulted in no civil or criminal charges, even though intimidation and threats were part of the plan to remove prescribers from their practice. Innocent prescribers could face bankruptcy while trying to fight these kinds of tactics.

Legitimate patients with pain were some of the patients at the criminal enterprises. I felt sorry for these folks, as they were getting all the drugs they wanted but not receiving good health care. Some would be visibly upset with our work, claiming that the doctor was a saint and that we were just shy of being Nazis. They were happy with their care and did not want to find another prescriber, but their knowledge of what the prescriber was doing was very limited. Legitimate prescribers in the area would also voice their unhappiness with these cases, but they, too, were in the dark about the day-to-day operations of their criminal colleagues. Sometimes they knew these prescribers socially and could not believe that their friends were criminals.

Cases that were investigated properly by experienced officers and supervisors who received sound legal advice from prosecutors usually ended in the shutdown of drug traffickers posing as legitimate health care professionals. This process ultimately benefits legitimate patients with pain, though they may not immediately understand the benefit.

Cmdr. John Burke is a 40-year veteran of law enforcement, the past president of the National Association of Drug Diversion Investigators, and the president and cofounder of the International Health Facility Diversion Association.