Doctors or dealers?
Although most doctors prescribe medication responsibly, law enforcement officials say it takes only a few who don't to supply a large number of addicts.
By LAURENCE HAMMACK
THE ROANOKE TIMES
Drug addicts often risk the dangers of the streets to make a buy. Todd Williams made his in the safety of a doctor's office.
An OxyContin addict from Lee County, Williams heard last year that, just across the state line, a physician was prescribing the powerful painkiller to almost anyone who asked.
Photo courtesy of Harlan Daily Enterprises
|Dr. Ali Sawaf is led from his office in Harlan, Ky., after being charged with prescribing OxyContin for no legitimate medical purpose. An addict from Lee County says he got the drug from Sawaf.
Williams made an appointment with Dr. Ali Sawaf, drove to his office in Harlan, Ky., and told the doctor his back hurt.
Without so much as a blood pressure test, Williams says he walked out of the office with a prescription for 60 OxyContin tablets.
"I was in there about four minutes," Williams said. "It was like meeting with a lawyer. He stayed on his side of the desk and I stayed on mine."
Since then, Sawaf has been charged with prescribing OxyContin for no legitimate medical purpose. Four Southwest Virginia physicians have been convicted of similar offenses in the past year. Charges are pending against a fifth, and federal officials say other doctors are under investigation.
With police calling OxyContin the most abused drug in Virginia's coalfields, doctors who deliberately put the painkiller in the wrong hands are becoming to the region what South American drug lords are to crack-ravaged communities.
Although the vast majority of doctors prescribe medication responsibly, law enforcement officials say it takes only a few who don't to supply a large number of addicts.
"The word goes out when there's a candy man on the street, and you will have people drive hundreds of miles to find him," said Gregg Wood, a health-care fraud investigator with the U.S. Attorney's Office in Roanoke.
At a bond hearing following his arrest in February, Sawaf said he was seeing between 100 and 120 patients a day. "They'd be lined up, 20 or 30 people standing outside the building at any given time," said Roger Hall, a detective with the Harlan County Sheriff's Office.
Hall said Sawaf's office did not have an examining room. Police seized a plastic bag full of $17,000 in cash and records that indicated patients were coming from Virginia, West Virginia, Tennessee and North Carolina.
Sawaf is charged with three counts of prescribing a controlled substance for no legitimate medical purpose. A federal investigation is ongoing, and authorities say more charges are possible.
An average of one health care professional a week is charged in Virginia with either illegally dispensing a prescription medication or obtaining one by fraud.
That amounts to a physician every 44 days, a pharmacist every 48 days, and a nurse every 10 days, according to 1st Sgt. Landon Gibbs, who oversees health fraud investigations by the Virginia State Police.
Some doctors are motivated by greed, Gibbs said. "There's a lot of money to be made if you have a dishonest physician" billing insurance companies or Medicaid for treatment that is never provided, he said.
Other times, health care professionals become addicted to prescription drugs and find the easy access too tempting to ignore.
And in many cases, well-meaning physicians are duped by "doctor-shopping" addicts who go from office to office, feigning back pain or other ailments, said Richard Stallard of the Southwest Virginia Regional Drug Task Force.
Pain, after all, is not something that shows up on an X-ray, and physicians sometimes must rely on the word of the patient they are sworn to help.
"It is not an exact science," said Hughes Melton, a Russell County physician who believes the risks of OxyContin outweigh the benefits. "If someone wants to beat the system, they can."
Some users do more than fake pain. Tamara Selfe, a recovering OxyContin addict from Abingdon, said she has seen a man bash his kneecap with a hammer to get the drug, and a woman she knows once swallowed gravel to create kidney stone symptoms.
Even when doctors prescribe OxyContin to someone who truly needs it, they have little control over what happens when the patient leaves their office. Authorities suspect that in many cases, patients will skimp on their medication and make fast cash off the extras.
For a $1 co-payment, a Medicaid recipient can get 60 40-milligram OxyContin pills, which at 10 cents a milligram is a $240 value. On the black market, that same amount of OxyContin would go for $2,400, or $40 a pill.
Last year, Virginia's Medicaid program covered $4.5 million in OxyContin prescriptions. There's no way to say how much of that involved fraudulent billings, according to Randy Davis, spokesman for former Attorney General Mark Earley.
Some addicts write their own prescription from pads they steal while at the doctor's office. Purdue Pharma, the Connecticut company that makes OxyContin, warns doctors never to leave their prescription pads unattended.
"Guard them like your credit cards," advised a brochure mailed out to nearly half a million doctors and pharmacists. The company is also distributing tamper-proof prescription pads in states such as Virginia where OxyContin abuse is a problem.
Other forms of fraud range from something as simple as adding a zero to increase the doctor's dosage on a prescription to a sophisticated system in which authentic-looking prescriptions are produced on a home computer.
Some say the best way to catch "doctor shoppers" is with a statewide database that tracks all prescriptions, allowing doctors and pharmacists to check out a questionable patient. Eighteen states have such a system; Virginia is not one of them.
A state task force is considering such a system, and Purdue Pharma has pledged $100,000 to the effort. Just last week, Virginia and four other states were chosen for a pilot program on prescription monitoring set up by the federal Drug Enforcement Administration.
State police have made 1,401 prescription fraud arrests since 1988. Authorities say the number would be much higher if they did not have to spend weeks investigating a single suspect, driving from pharmacy to pharmacy to examine records that could be checked electronically from a central database.
The law classifies both cocaine and OxyContin as Schedule II controlled substances.
But charging a doctor with distributing OxyContin is far more complicated than busting a crack dealer on a street corner.
Prosecutors must show that a physician prescribed drugs for no legitimate medical purpose, which can be a difficult call for a judge or jury to make when a patient may suffer from both real pain and addiction to painkillers.
"To charge a physician, you have to have all your ducks in a row," said Randy Ramseyer, an assistant U.S. attorney in Abingdon who has been involved in several recent prosecutions.
"They have a good standing in the community, and they're going to come in and say they gave these drugs to people because they needed them." That was the case with Franklin Sutherland, who was convicted last month of illegally prescribing more than 3,000 OxyContin pills.
Sutherland's attorney, Thomas Dillard of Knoxville, Tenn., said a courtroom is the wrong place to examine a doctor's pain treatment philosophy. Professionals with the state Board of Medicine and other regulatory agencies are better able to judge doctors than a jury of average citizens, he said.
If criminal charges become commonplace, "we're not going to have any more doctors," Dillard said. "They're going to be too scared to practice medicine."
Even without the threat of prosecution, many doctors already have stopped prescribing OxyContin.
"It's not because they're doing anything wrong," said Dr. J.K. Lilly, co-chair of the Appalachian Pain Foundation, an organization that advocates pain management in an eight-state region. "They just don't want to be caught up in the whirlpool."
Addiction is the common bond between doctor and patient in some cases of prescription fraud.
Dr. Denny Lambert, for example, ran a pill mill out of the backseat of his car. Federal prosecutors said that to satisfy his own addiction, Lambert wrote prescriptions to friends and acquaintances who promised to return half the drugs to him. Last year, Lambert was sentenced to 52 months in prison for illegally distributing OxyContin, Ritalin and Dilaudid.
When he wasn't practicing medicine in Tennessee, Lambert would roam the highways of his native coalfields, recruiting "patients" like Dallas Thomas.
Thomas, who became addicted to the painkiller Dilaudid after his back was crushed in a coal-mining accident, said Lambert would come around with his briefcase and prescription pad.
"He knew I was a junkie," said Thomas, also in prison on drug-related charges. "They thrive on people like that."
But Thomas had a hard time saying no to Lambert.
"Somebody like me, I ain't even got a high school education," the 48-year-old said. Being in the company of a doctor "was sort of a privilege," he said.
In a letter to The Roanoke Times written from a federal prison in Florida, Lambert likened the federal government's war on drugs to another failed war - the one fought in Vietnam.
"I am afraid their call for more federal prisons and money for law enforcement is much like their call for more bombs and soldiers of the 60s and '70s," he wrote. Instead of locking up first-time drug offenders, he said, the system should provide more treatment to addicts.
"In my own case, what might have happened had I been allowed to speak to groups at risk or become part of a diagnostic/treatment team?" he wrote. "Specifically, I wonder if some of those who died from OxyContin or similar substances might be alive today?"
By the time Todd Williams found Dr. Sawaf's office, he already had developed an appetite for pain pills.
He started popping Lortabs, Percocet and Tylox as a 15-year-old, mixing the drugs with alcohol and teen-age exuberance.
Despite the fact his uncle is the county sheriff, Williams didn't see much harm in a habit he figured he could kick any time.
When a friend received a $12,000 insurance settlement from an accident, they started to spend more money on drugs. "I couldn't let him outdo me. If he would buy 15, I would buy 20," Williams said.
One day when Williams needed more pills, someone mentioned Dr. Sawaf. "Everybody and their brother was going over there," he said.
Sawaf is being held in lieu of a $650,000 cash bond. His lawyer recently declined to talk about the case.
When Sawaf was arrested at his office next to a shopping mall, a crowd of people who work in adjacent businesses gathered to watch, Hall said. They applauded when the doctor was led away in handcuffs.
Williams, meanwhile, still is struggling with his addiction.