Book Review: “American Pain,” by John Temple

 

This nonfiction book, published in 2016, describes in amazing detail the rise and fall of one of the biggest of South Florida’s pill mills, named American Pain. The book reads as easily as a novel. It describes the casual criminality and greed that fueled one of our nation’s biggest drug overdose epidemics.

The book starts by describing how a felon, his twin brother, and a body-building buddy decide to open a pain clinic. They hire doctors to work there, but still manage clinic, in appallingly unprofessional ways. These owners and managers show a shocking lack of concern for human life and the suffering they saw daily. For example, they talk derisively of their customers as “druggies” and “zombies,” yet the owners were also drug users. Bribes were taken for all sorts of unethical activities, from advancing a patient through the line more quickly, falsifying drug screen results, or getting the patient seen by a doctor with a reputation for being a generous prescriber.

This pill mill saw mostly people from Appalachia – as the book points out, 43% of the clinic patients lived in Kentucky, 20% in Florida, 18% from Tennessee, and 11% from Ohio.

The methods developed by the addicted patients and their handlers were astounding. Appalachian families who in the past may have distribute moonshine, marijuana, or methamphetamine used the same organizations to distribute these pain pills transported out of Florida. People called “sponsors” would arrange for a group of people to come to American Pain, located in Broward County, Florida, sometimes traveling hundreds in buses or vans or just carloads of people. Each of these people would be given money by the sponsor to be seen by the physician and to buy the pain pills and benzodiazepines dispensed on site. They gave a portion of these pills to their sponsor to be sold through the networks of drug dealers already established, or they could give all the pills to the sponsor in return for a tidy profit.

Some airlines offered cheap flights from the Appalachians to Florida. So many pain patients flew on one flight that it was called the “Oxy Express.”

MRI owners and operators profited because the pain clinic made every patient get an MRI, to maintain a veneer of medical respectability. Patients could bribe their way to the head of this long line, too. Pharmacies profited, as long as they didn’t ask too many questions. Many times, the pain clinics had their own pharmacies and dispensed on site, to make yet more money and to keep legitimate pharmacies from asking uncomfortable questions.

Flea markets in Kentucky sold urine in Mason jars to pain clinic patients who were required to pass a drug test. Dive motels in Florida rented rooms to “oxy-tourists,” and some overdosed and died in these places.

Between 2007 and 2009, Broward County went from having four pain clinics to having one hundred and fifteen. In one area, there were eighteen pain clinics within a two mile radius.

Everyone was happy; the people with addiction got more pain pills to inject or snort, the sponsors made money, the doctors made money, and the clinic owners made staggering amounts of money.

Of course, in the long run, irreparable harm was done. Patients of the clinics died, people who bought pills from American Pain patients died, and families suffered from the deaths of their loved ones. Many people were incarcerated, children were put into foster care, and medical costs of complications from addictions soared. The cost to taxpayers and U.S. social fabric can never be calculated.

Police routinely pulled over cars traveling north on the interstates if they had Kentucky, Tennessee, or West Virginia license plates and were filled with people. Usually, some crime could be detected. If one person had pill bottles from multiple doctors, this was the crime known as doctor shopping. If a pill bottle had too few pills remaining, the owner could be arrested for drug dealing. Many times, there would be drug paraphernalia in the vehicles. The driver could be impaired.

The book is painfully funny in places; the manager of the pain clinic describes what he calls “addict stunts,” like when an RV filled with three generations of a family from Appalachia rolled into their parking lot, spread an outdoor carpet on the asphalt, and set up folding chairs and a grill, planning to make a day of it at the pain clinic. It was a family outing, going to a Florida pain clinic to get pills to fuel one’s addiction.

Pain clinic patients would pee in the hedges, fornicate near other businesses, and shoot up in the parking lot, all of which appalled the owners, who were trying not to attract attention.

The owners even asked themselves, “How could this be legal?” But it was.

Apparently Florida didn’t have any corporate practice of medicine laws, which prevents non-physicians from owning any medical facility. I’ve derided these types of laws in the past, but here’s one situation which cried out for this kind of law.

Florida also had no prescription monitoring program, as I pointed out in my blog of March 8, 2011. Long after Florida’s pain clinic problem exploded, their governor inexplicably blocked development of a PMP. They have one now, but only after Purdue Pharma (manufacturer of OxyContin) offered money to the state to start one.

Florida also allowed physicians to sell pain pills and other medication directly, without involving a pharmacy. This allowed much of the mis-prescribing to go unnoticed.

Of course, things finally ended badly. The FBI got involved, and did investigations, undercover work, and eventually got wire taps to prove RICO indictments of all the main people. After they were arrested, the owners and operators, who talked big about how they would never turn on each other, all ratted on each other to get favorable plea deals.

The main owner got 14 years in prison for his part in the scheme that earned him 40 million dollars, and his twin was sentenced to 17 years in prison. Their friend, the manager of American Pain, was sentenced to 14 years.

All but two of the physicians took plea deals, and most lost their medical licenses and had various criminal penalties.

The two doctors who refused to take plea deals were both charged in the deaths of patients who had overdosed on medications these doctors prescribed. Both doctors said they had no idea they were working for a pill mill, and the juries acquitted both of them

However, they were both convicted of money laundering, under the premise that they would have to be willfully blind not to know the operations of this place weren’t legitimate medical care. Prosecutors said the doctors had to have known they were prescribing to people with addiction or people who intended to sell their pills. In one doctor’s case, she would see in excess of sixty patients per day, and was the largest prescriber in the nation for certain drugs.

She also made 1.2 million dollars in just the sixteen months she worked there. That last fact alone is so far out of line for what legitimate physicians make in that same time period that she had to have known she was committing crimes. She was sentenced to 6.5 years in prison.

The only other physician not to take a plea deal made around $160,000 for working at the pill mill, and was sentenced to 18 months in prison.

This is a fascinating book, about an incredible time in Florida’s history. Of course, as the book illustrates, Florida’s problem bled into other states, and poured gasoline of the raging fire of opioid use disorder that already existed in Appalachia.

The book illustrated the mindset of people who operate such pill mills, their derision towards the people who are making them all this money, and their disregard to the human misery caused by addiction.

One of the most poignant scenes in the book is when the mother of a young man who dies of an opioid and benzodiazepine overdose goes to talk to the doctor who prescribed him the pills. This mother left the hills of Kentucky and drove to Florida for the confrontation. But the doctor said nothing, only looked downward to the floor. For what could she say? Under the best light, she was guilty of willful blindness, and under the worst, something much more sinister.

The events in this book took place not even ten years ago, and we were about ten years into the opioid epidemic when American Pain opened its first clinic. The owners and operators and doctors weren’t the only ones at fault. Why did it take Florida so long to get an operational prescription monitoring program? Why did their governor, Rick Scott, block efforts to establish this important program? Where was the state’s medical board, and why didn’t they investigate the doctors’ actions at American Pain?

I highly recommend this book to anyone interested in the opioid use disorder situation in the U.S., to get better insight into how it started and how it was perpetuated

 

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5 responses to this post.

  1. Posted by Bess Stanton on July 30, 2017 at 1:11 pm

    Really sad book to read! Poignantly describes the misery of drug addiction and the greed of the pill mill owners and Doctors. Also the admin staff were very cruel and very inappropriate in working with patients. Where was the DHSR( dept of health and safety) who had to license this medical facility and which allows the opening of health clinics?
    I also have read a number of books on this topic. My favorites are “Chasing the Scream”, by Johann Hari and “Dreamland ” by Sam Quinones”. Y
    Thanks for the interesting and spot on review,Jana.
    Bess Stanton

    Reply

  2. Posted by MarkEssex2016rbl on July 30, 2017 at 4:30 pm

    Great review – I read the book a few months ago and found it unbelievable that it was legal at the time. Crazy stuff. The other books in the previous comment were also a good read. Narconomics is also interesting to understand some of the economics behind drug trade. Thanks for the summary.

    Reply

  3. You are a fantastic reviewer, Doctor Burson. I don’t at all feel I need to read the book. I told the doctor I see monthly here in Napa Valley who prescribes me buprenorphine and treats me like a real human being about your blog. He did come here and likes it.

    Anyway, the name they chose seems very fitting and nice and creepy too. “American Pain.” Just effing wow. Seems more like a prediction to me.

    Nothing surprises me with regard to greed anymore. It’s scary. I live close to off-grid to try and avoid these type of people. People.

    Reply

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