Dr. Daniel Maynard was the first red flag in Dallas. Called by some a “kindhearted doctor,” he handed out cash to hungry people and pills to chronic pain sufferers. The Associated Press wrote in a June 2003 story that the 57-year-old doctor was “an institution in a part of town where haggard men ask strangers for bus fare and sirens wail incessantly.” It was a neighborhood of South Dallas known for its pain, and Maynard treated it. The neighborhood also has a drug abuse problem.
A doctor of osteopathy and general practitioner since the early ’70s, Maynard ran his clinic for more than two decades. Patients, sometimes hundreds at a time, lined up daily to see him. He wrote more than 54,000 prescriptions in 2002 and wrote more scripts for Valium than any other doctor in Texas. Rebecca Martinez, whose parents were patients, told the AP that Maynard was “the one who keeps my mom and dad alive.”
To law enforcement, Maynard was a drug dealer. Officials claimed he was responsible for 11 patient-related overdose deaths, raided his home and business, and froze his bank account.
“I know there are legitimate reasons to prescribe narcotics for chronic pain,” then-Dallas County District Attorney Bill Hill told the Los Angeles Times in July 2003. “But the allegations against Dr. Maynard leave us to seriously question whether all of these patients had a true medical need for these hard narcotics.”
It's a question prosecutors have been trying to answer for more than 20 years. They've asked it of thousands of doctors from around the country. Some, like Maynard, were eventually cleared of criminal wrongdoing, but Maynard died in 2016. His widow said the stress from trying to clear his name killed him. His name appears along with more than a thousand others on Doctors of Courage, a website created by former Virginia doctor Linda Cheek in an attempt to shed light on other victims of the opioid epidemic: pain doctors.
“It's my mission to expose the attacks,” Cheek says.
The Trump administration is stepping up enforcement with the help of the Department of Justice's new opioid fraud and abuse detection unit. Twelve assistant U.S. attorneys from around the country and a team of analysts will mine data to identify physicians who write too many opioid prescriptions. They'll analyze the average age of patients who receive opioid prescriptions and how many die within 60 days of getting them. They plan to look at pharmacies that dispense disproportionately large amounts of opioids and regional hot spots for opioid abuse.
The unit arrives as most states have been exerting more control over health care and pharmaceutical industries, and counties around Texas and in other states have filed civil lawsuits against Big Pharma. The suits aim to hold drugmakers accountable for allegedly deceptive practices that encouraged doctors to prescribe narcotics for chronic pain patients and contributed to an epidemic of opioid overdoses.
“If you are a doctor illegally prescribing opioids for profit or a pharmacist letting these pills walk out the door and onto our streets under false pretenses, we are coming after you,” U.S. Attorney General Jeff Sessions said.
“Our country is in the midst of a drug abuse crisis, enabled and worsened by rampant drug trafficking and prescription drug diversion,” he said. “This surge of resources ... will help us make more arrests, secure more convictions and reduce the number of diverted or unnecessary prescription drugs causing addiction and overdose.”
Sessions' surge comes as the government is already playing in murky waters when it comes to prosecuting pain doctors. Instead of following clear-cut cases like trading prescriptions for blow jobs or money, officials now look at deviations from standard care. Outspoken pain doctors such as Lynn Webster, a leading researcher in pain management in Salt Lake City, say such deviations are sometimes necessary when dealing with chronic pain.
Some of the increase in prescriptions from pain specialists occurs because most primary care doctors and other specialists are unwilling to take the risk to be targeted by the DEA, Webster told the Observer. “They got to take care of their families and can't afford to be investigated,” he says. Dr. Daniel B. Carr, the president of the American Academy of Pain Medicine, called it a “civil war in the pain community” on how to treat chronic pain. Dr. Sean Mackey of Stanford University’s pain management program told PBS News Hour in January 2017, “There's almost a McCarthyism on this that's silencing so many people who are simply scared.”
The effort to hold someone accountable for the almost 2 million people addicted to opioids and the more than 200,000 overdose deaths since the late ’90s has created an environment of fear among physicians who find themselves forced to choose between their duty as doctors and jail time.
“Now it is just criminal to practice the best type of medicine possible,” Webster says.
Our country has been in a drug crisis for generations. It started in the late 1800s and early 1900s with opium and alcohol prohibition and intensified in the early ’70s when President Richard Nixon's administration declared a war on drugs. Nixon's top aide, John Ehrlichman, later admitted that Nixon did so because of antiwar liberals and black people who were raising hell about Vietnam and civil rights.
“We knew we couldn't make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities,” Ehrlichman said in a 22-year-old interview published in Harper's Magazine in 2016. “We could arrest their leaders, raid their homes, break up their meetings and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did.”
Drug hysteria hit full throttle in the ’80s with the crack cocaine epidemic. President Ronald Reagan expanded the drug war. The Drug Abuse Resistance Education program appeared in schools, zero-tolerance policies were created and incarceration rates skyrocketed. According to the Sentencing Project, a nonprofit working for a fair and effective criminal justice system, about 41,000 inmates were jailed in 1980 for drug crimes. By 2014, that number grew to more than 488,000, Politifact reported in a July 10, 2016, article.
Reagan’s war disproportionately targeted minority communities, too, but Democratic presidents also implemented harsher drug policies affecting those communities. President Bill Clinton rejected recommendations to eliminate disparity in crack and powder cocaine sentences and end the ban on syringe access programs, according to the Drug Policy Alliance, an advocacy group with a goal of ending the war on drugs.
The ’90s saw the introduction of two more drug epidemics that still haven't ended: methamphetamines and opioids. The latter began ravaging the Dallas area in the early 2000s in the form of “cheese” heroin, a mixture of Mexican black tar heroin and over-the-counter cold medicines. It dominated headlines for a short time when affluent white high school students from DFW suburbs began dying from overdoses.
It hit the Dallas Independent School District around 2006 and spread to other suburban North Texas neighborhoods such as Grapevine and Keller. In 2011, a federal grand jury indicted 17 people, all but one 21 years old or younger, from the affluent community of Flower Mound. They were charged with conspiring to distribute more than 100 grams of heroin.
Heroin wasn’t the only drug fueling the epidemic. Use of prescription opioids like hydrocodone and Oxycontin expanded hugely in the late ’90s after Big Pharma began offering incentives to market opioids for chronic pain treatment.
At the time, opioids were reserved for patients with cancer or recovering from surgery. Then, according to the Texas counties' lawsuits, Big Pharma began sending highly credentialed doctors known as “key opinion leaders” to discuss drugs' benefits and downplay their addictiveness with doctors who treat chronic pain. Writing a prescription for a fairly inexpensive painkiller proven to treat chronic pain was far simpler than trying to get an insurance company's approval for another procedure. It also allowed doctors to see more patients.
The Centers for Disease Control and Prevention reports that between 1999 and 2014, prescriptions for painkillers sold to pharmacies, hospitals and doctors' offices quadrupled. According to the National Safety Council, 4.3 million people were nonmedical users of painkillers.
During roughly that same period, around 183,000 people died from prescription opioid overdoses. In 2015, Texas saw more than 1,100 opioid-related deaths among the 50,000 people in the U.S. who died from drug overdoses that year.
“It is not children reaching in medicine cabinets who have made drug poisoning the No. 1 cause of unintentional death in the United States,” according to the National Safety Council. “Adults have been prescribed opioids by doctors and subsequently become addicted or move from pills to heroin.”
In late 2016, President Trump announced, “No part of our society — not young or old, rich or poor, urban or rural — has been spared this plague of drug addiction and this horrible, horrible situation that's taken place with opioids. The epidemic is a national emergency.”
As Vox news pointed out in a Dec. 21, 2017, report, “If you want to understand how we got here, there's one simple explanation: It's much easier in America to get high than it is to get help.”
Dressed in tactical gear, armed law enforcement agents conducted a SWAT raid on a pain clinic in middle of the afternoon in late January 2015. They quickly dismantled security cameras and seized computers, patient records and other documents as media gathered outside.
A pregnant nursing assistant who was a month away from her delivery date began to cry, as did a chronic pain patient who told one of the local news stations, “All kinds of things go through my head, mainly because it took me a long time to get a pain management doctor, and now I'm going to have to start all over again.”
SWAT raids on pain clinics have been occurring since the early 2000s. Some in the medical community call it “a war on pain doctors,” a “government jihad” or “state-sponsored terrorism.” By the end of President George W. Bush's term, more than 40,000 SWAT raids had been conducted, mostly for nonviolent drug law offenses, according to the Drug Policy Alliance.
“The DEA [Drug Enforcement Administration]'s hardball tactics — storming clinics in SWAT-style gear, ransacking offices and hauling off doctors in handcuffs — have scared physicians nationwide to the extent that legitimate pain sufferers now find it increasingly difficult to get the medicine they need,” the Village Voice reported in November 2003.
The January 2015 raid hit Aria Orthopedics at the corner of 86th Street and Western Avenue in south Oklahoma City. A Harvard-trained spine surgeon, Dr. Harvey Jenkins Jr., 53, had been treating chronic pain patients for nine years. His was one of the few pain management clinics in the state. He also owned and operated a respected medical spa. He was known as an authority on nonsurgical body sculpting and coordinated toy drives for underprivileged kids.
Then the state labeled him a pill mill operator and charged him with 51 felonies. Eight were later dropped. Some of those counts include making or causing false claims under the Oklahoma Medicaid program, illegally practicing and conspiracy to practice medicine without a license, and stealing another doctor's identity. Fourteen involved conspiracy to dispense controlled substances within 2,000 feet of a public park.
“Most pain management doctors adhere to strict standards when caring for their patients, but Jenkins prescribed pills with the sole purpose of making money and illegally allowed his associates to do so as well,” former Oklahoma Attorney General Scott Pruitt said in a prepared statement. “They not only disregarded the law but endangered the health and safety of Oklahomans in doing so. Their dangerous endeavors make them no better than drug dealers with prescription pads.”
The Southern son of an art professor and a math teacher, Jenkins calls his type of practice “basic medical pain management.” He took care of patients who were poor. Some didn't have medical insurance, and most were on Medicaid. Others were older than 65 and on Medicare. A small fraction paid with cash, and 95 percent were referred by other doctors.
“It had become more difficult for primary doctors to take care of their [chronic pain] patients,” Jenkins says. “It became much easier to refer their patients to doctors who were dedicated to only treating these patients.”
Ten days later, he was raided again.
Over the nine years of Jenkins' pain management practice, Oklahoma joined Texas and other states in changing regulations, exerting pressure on pain doctors and scrutinizing patients. Refills of pain medication were no longer allowed unless patients saw the doctor every 30 days, which Jenkins says made it difficult for some of his poorer patients. The state medical board began demanding urine testing to make sure people were taking their pain medications. It was an additional cost that Jenkins says insurance companies didn't want to cover.
The state began investigating him in 2012 and charged him in March 2017. Assistant Deputy Attorney General Abby Dillsaver told Oklahoma City station KFOR-TV that most doctors see about 20 patients on a good day with a highly qualified staff, but Jenkins was handling 85-90 patients each day with a staff lacking medical licenses. Instead, two staffers used pre-signed prescription pads with Jenkins' signature.
When Jenkins took a medical leave, another doctor stepped in to help out. The staff electronically saved her signature without her permission and began using it, too. Five staffers were charged alongside Jenkins. Two have accepted plea bargains.
“For someone they were representing to the media as a major threat, it makes no sense and defies reason why they took so long to survey and file charges for something they believed as illegal and dangerous,” Jenkins says.
At the time of the raids, he was on a two-year probation with the state medical board after he allowed unlicensed practitioners to practice on patients without him present. He was arrested on the day of his appeal in district court to get his medical license back.
Jenkins says that he saw all of his patients initially, as state law requires, and that no one under his care received more dosages than the law allows or overdosed on medications, which the state isn't claiming. As for the identity theft, he says he was hospitalized during that time period, in intensive care and on life support for complications from pneumonia, sepsis and respiratory distress syndrome.
Now Jenkins works as a ride-share driver, trying to earn the means to fund his defense and beat the 11 life sentences he faces. It's a difficult task since the government took all his cash, froze his bank accounts and confiscated his property, which it might not return even if he's acquitted.
“I didn't see this coming,” he says. “I followed the rules the way I was trained. I thought I was the one being careful and the doctors who were being arrested were doing bad things, but realized it's not the case.”
Law enforcement agents first swarmed New River Medical Associates pain clinic in Virginia in 2006, but the former doctor, Linda Cheek, says they couldn't find any occurrences of illegal prescribing. Instead, she pleaded guilty to Medicare fraud in federal court in 2008. Her medical license was reinstated in February 2009 (but suspended again in 2011). Cheek's DEA certificate of registration to prescribe pain medications was not reinstated. (It was denied in October 2011.)
Cheek, now 69, began her medical practice when she was 45. She marketed herself as an alternative medicine and pain specialist. She practiced acupuncture, homeopathy and the seven steps of healing on the poor population of rural Virginia. The federal government later called her “a drug dealer wearing a white coat,” according to an Oct. 22, 2013, report by The Roanoke.
Cheek says because she couldn't get the DEA to issue her a certificate in 2009 or 2010, she brought another doctor, who was 78 at the time, to the clinic to write prescriptions. The government later claimed in court that Cheek was still writing prescriptions under her expired certificate number. Then, two of her patients died of acute prescription drug poisoning. Law enforcement returned, and a jury convicted Cheek of 172 felony drug charges in 2013 for prescribing painkillers without a federal permit. She was acquitted of maintaining a pill mill.
“The jury found me innocent of committing a crime out of the office, which goes to show that they don't know what they're doing,” she says.
After being convicted of illegally distributing controlled substances, Cheek served more than two years in prison and lost her medical license. She created the Doctors of Courage website upon her release to highlight the plight of other pain doctors. She calls them ambassadors, as defined by Alen Salerian, who was once considered Washington, D.C.'s favorite psychiatrist.
“It is 'a physician who, at the expense of his personal harm, has courageously practiced medicine consistent with the Hippocratic oath and made the medical needs of an individual the predominant priority of care,'” Cheek says.
Only a few doctors are listed on Cheek's website because, she says, pain doctors worry about sharing their stories. Besides Jenkins' plight in Oklahoma, she also highlights another Oklahoma doctor, the Rev. Ronald Myers, whom The New York Times profiled in February 1990 as “a rural doctor struggling to care for the poorest.” At the time, the 33-year-old Milwaukeean, who founded the American Pain Institute, was a “jazz-playing, Baptist-preaching family practitioner whose dream has always been to practice medicine in the kind of place most other doctors wouldn't even stop for a tank of gas.”
The Oklahoma Bureau of Narcotics and Dangerous Drugs portrayed Myers as a drug dealer and revoked his medical license in 2015 for prescribing 4.6 million dosage units of pain medication over a year at his rural clinic in Roland. Richard Brittingham, a Lawton physician hired by law enforcement to review Myers' records, testified that Myers and other doctors at his clinic were “practicing substandard medicine and were using the term 'pain clinic' as their title, but 'pill mill' would be more appropriate.”
At pill mills, patients drive usually long distances to see doctors and flock outside like moviegoers on opening night. Pill mills prefer cash, fail to keep accurate records and issue a high rate of prescriptions of similar drug combinations, like Lortab, an opioid, and Xanax, a tranquilizer. A telltale sign of a pill mill, according to the government, is an on-duty security guard.
Like Myers, Jenkins was also accused of operating a pill mill. He had hired three off-duty law enforcement officers to keep the peace and divert illegitimate patients. He argues that the term "pill mill" is highly stigmatized, has no legal definition and doesn't apply to him, because he almost never prescribed deadly combinations and his prescription numbers were not high for a pain clinic. He also took forms of payment besides cash.
“The reputation damage from the negative publicity campaign that the attorney general’s office waged and continues to wage through local media was designed to make sure I would not be employable, to manipulate public opinion and to poison the potential jury pool,” he says.
Billy Earley looks like a poorly dressed undercover cop in his profile photo on Doctors of Courage. His disguise is left over from his days as an indie artist known as "Papi Chula," or "Cute Daddy." He is a former physician assistant, a board member of the American Pain Institute and Black Doctors Matter, and a blogger for Cheek's website.
The California Medical Board revoked Earley's license because of his prescribing habits and record keeping. He says it was because he stood up against racism and discrimination. He shut down his clinic in 2016.
In an April 11, 2014, Facebook post, he wrote that CVS Pharmacy and Walgreens were calling him and his patients “Negritos” (or “Little Blackies”) and the “N-word.” He says CVS told his customers that he was under DEA investigation, which he was for several years but was never charged.
Earley filed a lawsuit against CVS and Walgreens in August 2013 in the Superior Court of California. He gave about $144,000 to an attorney who failed to represent him, according to court documents. The case was dismissed in August 2014. He says he's now suing the medical board, the physician assistant board and the office of administrative hearing in California.
Earley started a petition to the U.S. House of Representatives on Change.org called Stop Government Police Misconduct Against Doctors and Nurses, which has a litany of accusations about “medical police” making false statements, bullying and retaliating against doctors and nurses, concealing evidence and using paid informants to entrap doctors.
Earley says pain doctors are not at fault for the opioid epidemic and that China and other countries are fueling the problem.
“China ships enough illegal drugs to kill 32 million U.S. citizens weekly,” according to his Change.org petition, where he links to a Sept. 18 report about fentanyl by NBC News. He calls the government crackdown on pain doctors "social engineering" and wonders why no one blames the real culprit of the overdose deaths: fentanyl.
"This is not even from the doctors," he says. "Overdose deaths [are] the result of multiple substances."
According to Doctors of Courage, most of the people it calls “medical political prisoners” are minorities; are independent physicians competing “with hospital-owned, government supported physicians in the area”; and accept Medicare and Medicaid patients. Like most people, they lack the financial resources to fight the government.
Lynn Webster, the Salt Lake City pain doctor, knows all too well the cost of defense. He spent tens of thousands of dollars on his legal team to prepare for the DEA to file charges against him after it spent three years investigating his Lifetree Pain Clinic because of overdose deaths.
“Since [indicted doctors] don't have the resources, they have to plea bargain to save their family,” he says. “There is not a fairness in the system and not justice. Many physicians are being targeted. There are some pill mills — not trying to say there haven't been bad doctors — but most are well intended and, unfortunately, they are being caught in the web of the anti-opioid movement.”
The U.S. attorney for the District of Utah declined to pursue charges against him in 2013.
But others aren't so lucky, and legitimate chronic pain patients are the ones left suffering. Webster chronicled his pain patients' experiences in his 2015 book, The Painful Truth: What Chronic Pain Is Really Like and Why It Matters to Each of Us.
“There are millions of Americans and Canadians who are being abandoned and forgotten and discarded,” he says. “The suicide rate has escalated, and people with pain are unable to get their pain treated. That is a travesty.”
After the Observer wrote about Texas counties suing pharmaceutical companies, chronic pain patients sent dozens of emails reiterating Webster's claims. One wrote, “In my journey, I have seen many doctors and nurses scared to write a script for what they know is the only thing that will help. I have seen many end their lives because they saw no hope of help. My own brother-in-law ended his life because of this, and I have considered this option myself.”
Clarence Verdell spent decades working as psychiatrist in hard-pressed Philadelphia neighborhoods, treating people with mental illness and addiction. A few years ago, he got permission from the DEA to prescribe Suboxone, a relatively safe opioid used to counteract the craving for heroin. It's sold on the streets to keep addicts from getting dope sick when they can't find their fix. He didn't know he was under investigation until the DEA showed up on his doorstep in August 2014.
Verdell, who is in his late 60s, says he knew something was wrong when CVS and Walgreens began refusing to accept his prescriptions. He started his own investigation and thought about firing his entire staff because he knew something wasn't right. He didn't realize that the agency had sent in an informant and two undercover officers who obtained prescriptions without physical examinations. He was sleeping on his couch when agents banged on his front door. A few years passed before he was indicted.
“As time went on, I started to realize that I was in hot water, and these fools are looking at you like you are a drug dealer,” he recalls. “I started searching on the internet and started to realize that it was not personal, but I'm caught up with something going on everywhere. I got hooked up with Doctors of Courage and started getting a better understanding that I walked into a minefield.”
Some of the website's most recent posts are titled “Doctor Shows Up in Medical Board Investigation in his Underwear,” “Republican Secret Attack on DOJ” and “The Pain News Network Shields Forest Tennant, Calling DEA's Expert Dr. Timothy Munzing Unaware and Ignorant.”
Tennant is kind of a messiah figure in the pain doctor community. A member of the American Academy of Pain Medicine, the Academy of Integrative Pain Management, the American Pain Society and American Society of Addiction Medicine, he began treating pain in the ’70s at his clinic in West Covina, California, and served as an expert witness for pain doctors and prosecutors. He also helped to draft California's Pain Patient Bill of Rights, which states, “a patient who suffers from severe chronic intractable pain has the option to choose opiate medication for treatment.”
When the Department of Justice began cracking down on pain doctors, Tennant was one of the few willing to continue treating chronic pain patients. They traveled across state lines to see him.
“Millions of chronic pain patients now take opioids responsibly and constructively,” Tennant wrote in an April 2016 guest column on Pain News Network. “While opioids aren't for everybody, many pain patients who are taking high-dose opioids have enhanced their overall health, achieved a decent quality of life and have likely extended their life span.”
Despite being a well-known expert who's published more than 300 scientific articles and books, Tennant joined the ranks of other pain doctors whom the DEA claimed were drug traffickers participating in health care fraud. Federal agents raided his offices in November.
Cheek argues on her website that the government is misusing 1970's Controlled Substances Act, which exempted doctors from criminal charges. The government took the phrase “medical purpose” and used it to attack pain doctors, “saying their treatment was 'not for a justifiable purpose' and jurors bought it: hook, line and sinker,” she writes. “Once one court found a doctor guilty, it opened the door for more doctors to be charged.”
Although the act offers an exception for medical professionals, the Department of Justice issued an additional guideline: Physicians must write each prescription for a “legitimate medical purpose” and act in their “usual course of professional practice,” according to the website of Washington, D.C., law firm Burnham & Gorokhov. “The fact that these two terms are not clearly defined creates confusion and, in some cases, it can place even well-meaning doctors at risk for prosecution.”
Verdell says he knew he didn't stand a chance against the federal government's 98-percent conviction rate, especially since the government seized the money he needed to pay for his defense. The U.S. Attorney's Office Eastern District of Pennsylvania announced in an Aug. 17, 2016, press release that he had been charged with conspiracy to distribute controlled substances, distribution of controlled substances, health care fraud and money laundering.
Verdell denies doing anything wrong, but he accepted a plea bargain and spent a few hours in jail and several months under house arrest. He also lost his license to practice after 28 years.
“Unfortunately, the DEA wants to be the doctors and want us to police,” he says. “They have the authority to determine what is medical necessity, and that is very strange when you think about it.”
Law enforcement's raid on another pain doctor took place on a Tuesday morning in early March at his home in Greensboro, North Carolina, and his office in Martinsville, Virginia. This time, it involved Joel Smithers, a native Texan from the small town of Atlanta.
Smithers says his wife and four children were put in the front room as law enforcement officers went through all their vehicles, froze his bank accounts and seized $70,000 from his business and personal accounts.
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“They have the most perfect system to rape you and steal from you and all your ability to fight in court,” he says. “Whether you're talking about capital murder, drug dealer or terrorism, there is a set formula for how they go about it. They take all your assets and totally deprive you as much as possible.”
Smithers was arrested and charged with possessing with intent to distribute schedule II controlled substances. He'd been practicing since 2015 and taking patient referrals from other doctors. He says because it's hard for patients to find a good pain management doctor to treat them, he received patients from as far away as Ohio.
Smithers says federal prosecutors offered him a plea deal with a 15-year prison term but that he refuses to sign a document that isn't true although they plan to add 717 more charges.
“It is a theatrics to put in the jury's head that I am guilty until proven innocent,” he says. “It is purely circumstantial and based on their interpretation on facts. None of these people are doctors and have not gone to medical school.”