The money was good — $500 to $1,000 a day.
The job was easy — ask a question or two and write a prescription. Sometimes, the questioning wasn't even necessary, just the signature.
Sure, these medical providers admitted, they were a bit queasy. After all, none of them knew a thing about pain management and only slightly more about the deadly drugs they were doling out. And, there were plenty of warning signs that the clinic in which they worked was no clinic at all: cash-only payments, gun-toting workers, entire families as patients with identical pain complaints, no medical referrals, no prior testing, no medical equipment, no appointments and a boss with zero medical experience.
But clinics like the one at which these eight medical providers worked were perfectly legal and completely unregulated, so, they say, it was easy to convince themselves they were doing nothing wrong.
"It was good money, an easy job," physician's assistant Don Robert Lewis Jr. testified last week in U.S. District Court. "I had always worked an extra job. I didn't think about it much either way. I was just pretty much going through the motions. It was a kind of willful blindness, I guess."
That willful blindness has put Lewis and his seven medical co-workers at the Breakthrough Pain Therapy Center in Maryville, Tenn., on the road to prison.
Federal authorities raided the clinic in December 2010 and indicted its operators, Sandra and Randy Kincaid, and two family members as drug dealers. That did nothing to stop pill mills or even to stop some of the providers now at issue in the Breakthrough case from going to either work at another pill mill or setting up clinics of their own. So, in 2014, the U.S. Attorney's Office in Knoxville made a bold move. They indicted Breakthrough's medical staff, not for overprescribing or fraud, but for dealing drugs — just like the hustlers on the street peddling crack.
The move comes as authorities and public health officials struggle to contain an opioid abuse epidemic in Tennessee, a state where there are more existing painkiller prescriptions than there are people. Last year alone, a record 1,451 people died from drug overdoses in the Volunteer State.
Federal prosecutors in Nashville also have turned to drug trafficking statutes in criminal cases when it is clear a doctor or medical staff have abandoned their duty and are no longer prescribing drugs for medical purposes, said David Rivera, U.S. attorney for the Middle District of Tennessee.
“You can be subject to the same criminal penalties as a drug trafficker, and we in this office have charged that under the right circumstances and will continue to do so,” he said.
In one prominent case in the Midstate, a Portland doctor and nine others were charged in a conspiracy to distribute drugs from a medical clinic. It was charged just like prosecutors would charge a street drug trafficking ring, Rivera said.
Court records say patients, often from out of state, went to Allen R. Walker’s clinic, paid $300 and left with prescriptions for large amounts of narcotic painkillers and benzodiazepines. Federal court records show Walker pleaded guilty in the conspiracy in 2015 and was sentenced to eight years in federal prison.
In the Knoxville case, Lewis, physician's assistant Walter David Blankenship, nurse practitioners Jamie Chiles Cordes, Sherry Ann Fetzer, Buffy Renee Kirkland and Donna Jeanne Smith, and supervisory doctors James Brian Joyner and Deborah Gayle Thomas have all pleaded guilty to federal drug conspiracy charges.
Each worked at the clinic as a part-time job in 2009-2010, earning anywhere from $500 a day to, for the doctors, $1,000 a day. Their boss, Sandra Kincaid, was an opiate addict who opened the clinic with her husband, Randy Kincaid, as a way to make money and feed her addiction. She not only ran the clinic but paid patients to give her a percentage of the pills they received. In just 17 months, the clinic pulled in $12.5 million — all in cash.
The defendants fought mightily, arguing such an indictment was a federal encroachment on the doctor-patient relationship, an abuse of the government's power and in no way akin to garden-variety drug dealing. They lost.
But even now, with Joyner last week sentenced to 70 months in federal prison and his cohorts awaiting their fates, these medical providers still balk at the label of drug dealer.
"At the time, I never thought anything I was doing was illegal," Blankenship testified last week in a hearing before U.S. District Judge Pamela Reeves.
Their discomfort is understandable. After all, it was doctors who had a large role in starting the opiate epidemic that in Tennessee claimed 1,400 lives in reported overdoses in a single year.
"Patients trust their doctors," Assistant U.S. Attorney Frank Dale said at last week's hearings.
The development of oxycodone and its opiate ilk began in the days of World War II in a search for a non-addictive, pain-relieving powerhouse of a drug. More than 25 years ago, pharmaceutical companies began marketing it to doctors as a wonder drug, able to miraculously treat all manner of pain with little ill effects. Medical providers received little actual schooling on the drug, so they were just as ignorant. But in the 1990s, there were clear warning signs. Prescription fraud, in which patients who had grown addicted to the drug would forge prescriptions to get it, skyrocketed in that decade.
But oxycodone was a money-maker — for the drugmakers, for pharmacies and, through increased patient visits, for doctors. By the early 2000s, a cottage industry sprang up. At pain management clinics those with complaints of chronic pain were supposed to find long-term solutions but instead found legal prescriptions for massive doses of the drug. There were no rules. Anyone could open one. To satisfy what little regulation existed, another industry cropped up — the making and selling of fake MRIs and other "proof" of pain. To avoid scrutiny, clinics cut out insurance entirely, operating as cash businesses.
There was one key ingredient, though. Someone with legal authority to prescribe opiates was required, and that meant doctors, physician's assistants and nurse practitioners were in high demand. Folks like Lewis, who worked full time at the emergency room at Blount Memorial Hospital, could earn big pay for a day's work without a shred of training or expertise in legitimate pain management.
"I had never been in that kind of setting before," Blankenship testified.
He, too, worked in emergency medicine. But there the opiates prescribed were low doses and small quantities and prescription practices were tight.
"You have an assessment of what you think is wrong with a patient and a plan for what you're going to do," he said.
Lewis said it was pretty easy to spot someone in true chronic pain. Claimed injuries also were readily identifiable by swelling, abrasions, broken bones.
But at Breakthrough, like most pill mills, the medical providers didn't bother with a diagnosis. They couldn't have examined a patient if they'd wanted to. There was no medical equipment in the building, not even a stethoscope.
"There were red flags we all should have been aware of," Blankenship testified.