web only rx16 presummit pillmills-mon_200_investigating and prosecuting pill mills

Investigating andProsecuting Pill Mills

Presenters:

•Jennifer Doll, Special Agent, California Department of Justice

•John Niedermann, JD, Deputy District Attorney, Los Angeles County District Attorney’s Office

Pre-Summit Workshop

Moderator: Karen L. Kelly, District Director, Congressman Harold “Hal” Rogers (KY-5th District), and Member, Rx and Heroin Summit National Advisory Board

Disclosures

Jennifer Doll; John Niedermann, JD; and Karen L. Kelly have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.

Disclosures• All planners/managers hereby state that they or their

spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.

• The following planners/managers have the following to disclose:– John J. Dreyzehner, MD, MPH, FACOEM – Ownership

interest: Starfish Health (spouse)– Robert DuPont – Employment: Bensinger, DuPont &

Associates-Prescription Drug Research Center

Learning Objectives

1. Identify challenges and strategies related to investigating a provider Rx drug case.

2. Distinguish the possible charges that could be filed.

3. Explain how to prepare for and prosecute a criminal trial against a medical professional.

PROSECUTING A PRESCRIPTION DRUG CASE:

FROM COMPLAINT TO CONVICTION

--How investigations are initiated -Constructing an investigation plan-Identifying Drugs-Conducting the investigation-Collecting evidence-Putting it all together-Prosecution and legal issues

Course Overview:Course Overview:

PEOPLE V. TSENGPEOPLE V. TSENG (LESS THAN 3 YEARS) (LESS THAN 3 YEARS)

PC 187PC 187

PC 187PC 187

PC 187PC 187

CONSUMER COMPLAINTCONSUMER COMPLAINT

-Patient

-Family member

-Another physician

-Pharmacist

INITIATION OF INITIATION OF INVESTIGATIONINVESTIGATION

SPECIAL AGENT ROBERT HARKINS

BEGAN INVESTIGATION IN SEPTEMBER OF BEGAN INVESTIGATION IN SEPTEMBER OF 2008:2008:

TIPPED OFF BY LOCAL PHARMACISTSTIPPED OFF BY LOCAL PHARMACISTS

CONDUCTED SURVEILLANCE ON THE CLINIC CONDUCTED SURVEILLANCE ON THE CLINIC REVEALED LINES OF YOUNG PEOPLEREVEALED LINES OF YOUNG PEOPLE

SET UP A SERIES OF UNDERCOVER SET UP A SERIES OF UNDERCOVER OPERATIONSOPERATIONS

INITIATION OF INITIATION OF INVESTIGATIONINVESTIGATION

DEATH OF A PATIENTDEATH OF A PATIENT

--Report from a coroner (802.5)Report from a coroner (802.5)

-Family member reports death-Family member reports death

-Law enforcement-Law enforcement

RYAN LATHAMRYAN LATHAM

KELLY RALPHKELLY RALPH::Had back pain with unknown source but appearedHad back pain with unknown source but appearedto be a sports injury.to be a sports injury.Thought 5 hydrocodone per day was safe.Thought 5 hydrocodone per day was safe.

DECEASED

DECEASED

INITIATION OF INITIATION OF INVESTIGATIONINVESTIGATIONPDMPPDMP

CRIMINAL VERSUS ADMINSTRATIVE ACTIONSCRIMINAL VERSUS ADMINSTRATIVE ACTIONSOver Prescribing

Fraudulent Prescribing

Money Laundering / Structuring

Tax Fraud

Insurance Fraud

Prescribing Without a Legitimate Medical Purpose

Prescribing to Addicts

Homicide

Sales/Distribution of Controlled Substances

Unlicensed Practice of Medicine

INVESTIGATIVE RESOURCESINVESTIGATIVE RESOURCESPros and Cons of Requesting Medical Records via

Written request, SDT or Search Warrant

THE SEARCH WARRANTS2010 2012

SOME PATIENTS HAD BLANK RECORDS IN 2010 THEN HAD

COMPLETED RECORDS IN 2012STEVEN OGLESTEVEN OGLE

2010 2012

INVESTIGATIVE RESOURCESINVESTIGATIVE RESOURCES

PHARMACY RECORDS


IMPORTANT IMPORTANT to obtain original prescriptions early in an investigation to avoid the destruction of the prescriptions and

loss of evidence.


A pharmacist should act as a second screener and is obligated to verify prescriptions in which the legitimacy is questioned.

A pharmacist has obligations to go over proper usage of medications in the form of “patient consultations.”

PHARMACISTSPHARMACISTS

ALFONSO VERCUEIL ANGELA LI LYDIA BRAY KIMBERLY QUACH

• YOUNG WHITE MALESYOUNG WHITE MALES• PAYING LARGE AMOUNTS OF CASHPAYING LARGE AMOUNTS OF CASH• ASKING FOR BRAND NAMESASKING FOR BRAND NAMES• APPEARING HEALTHYAPPEARING HEALTHY• REQUESTING UNUSUAL COMBINATIONS OF DRUGSREQUESTING UNUSUAL COMBINATIONS OF DRUGS• SOME APPEARED UNDER THE INFLUENCESOME APPEARED UNDER THE INFLUENCE• SOME APPEARED ANXIOUS OR AGITATEDSOME APPEARED ANXIOUS OR AGITATED

ANGELA LIANGELA LI: THE NUMBER OF PRESCRIPTIONS DID NOT DROP : THE NUMBER OF PRESCRIPTIONS DID NOT DROP EVEN AS SHE WAS REFUSING THEMEVEN AS SHE WAS REFUSING THEM

LYDIA BRAYLYDIA BRAY: IN 38 YEARS SHE HAS NEVER SEEN QUANTITIES : IN 38 YEARS SHE HAS NEVER SEEN QUANTITIES AND STRENGTH LIKE THIS AND HASN’T SINCEAND STRENGTH LIKE THIS AND HASN’T SINCE

AUTOPSY REPORTS


TOXICOLOGY REPORTSTOXICOLOGY REPORTS



Toxicology results are often provided with an autopsy report.

Typically, a 1 page summary report is provided with the end results of the tests.

Be cautious of who signs the toxicology report, as MULTIPLE toxicologists most likely ran tests and may not have signed the report.

TOXICOLOGY


Find out the lab’s retention policies and request that the samples for your case be held longer if necessary.

Get information of chain of custody. Whose hands touched the vial?? TOXICOLOGY


Understanding the results…

Positive / negative versus quantitative

Contributing factor of death versus substantial factor

Therapeutic versus non-therapeutic

TOXICOLOGY


Metabolites- what are the metabolites of certain prescription drugs

Metabolism – half life of a drugTOXICOLOGY

INVESTIGATIVE RESOURCESINVESTIGATIVE RESOURCESDealing with multiple contributing factors from multiple sources

TOXICOLOGY

INVESTIGATIVE RESOURCESINVESTIGATIVE RESOURCESWitnesses

How do I identify witnesses?

PDMP reportsSurveillanceInterviewsPharmacy recordsComplainant

INVESTIGATIVE RESOURCESINVESTIGATIVE RESOURCESWitnesses: The Interview

How did the patient hear about the subject? Did the patient have a legitimate medical condition? How far did the patient travel to the clinic? How did they pay? Cash? Insurance? How long did they wait to see the subject versus length of

exam? Did the subject recommend a specific pharmacy? Did the patient reveal a history of addiction to the subject?

When? Show the patient a 6-pack and ask that they identify the subject Did they consume the pills? Sell?


Be sensitive to their needs / fears / hesitations

Don’t judge their addiction or behaviors to obtain medication

Talk to your prosecutor about witness concerns and discuss immunity (case by case basis)

Witnesses

“Holy TrinityHoly Trinity” – combination of three drugs (Soma, Xanax, Vicodin) which create a euphoria like heroin

IDENTIFYING DRUGSIDENTIFYING DRUGS

Addiction CertificateAddiction Certificate Methadone prescribed for addiction requires a special

certificate issued through the DEA(Methadone prescribed for pain does not require this certificate, however the use of the medication must be documented in the chart)



Identify Drugs in your Investigation Report

Include a brief summary identifying drugs in your case

Include brand name, generic name and schedule

Note for what condition drug is used Cite current schedule at the time the

drug was dispensed or administered

THE UNDERCOVER OPERATIONS

SPECIAL AGENT STEPHANIE MORELANDSPECIAL AGENT STEPHANIE MORELAND APRIL 25, 2008APRIL 25, 2008

• TOLD DEFENDANT SHE NEEDED SOMETHING FOR CRAMPS AND A HEADACHE

• TOLD THE DEFENDANT SHE WAS COMING FROM OCEANSIDE

• NO PHYSICAL EXAM WAS GIVEN• DEFENDANT SAID SHE WOULD PRESCRIBE VICODIN TO

TAKE THE EDGES OFF

UNCHARGEDUNCHARGED

Pain vs No painRecording Devices (should you have them? Where

should you put them?)How many buys are necessary?Establishing a rapport the doctorTestifying after your U/CEntrapment / Red flags

Undercover Investigations: IssuesUndercover Investigations: IssuesCONDUCTING THE INVESTIGATIONCONDUCTING THE INVESTIGATION

CONDUCTING THE INVESTIGATIONCONDUCTING THE INVESTIGATION

THE “MEATY” STUFFTHE “MEATY” STUFF


SEARCH WARRANTSSEARCH WARRANTS

What are you trying to obtain?

What probable cause is needed to obtain those items?

Do you have probable cause?

Can you ever have too much information in a SW?

Tools to assist with SW writing

PREPARING SEARCH WARRANTSPREPARING SEARCH WARRANTS

SEARCH WARRANT SEARCH WARRANT LOCATIONSLOCATIONS

HOMEHOMEBUSINESSBUSINESSSTORAGESTORAGE





Getting your warrant signed

- Finding a judge - Educating your judge- Know your case (the judge will probably ask questions)

EXECUTING THE

WARRANT

COLLECTING EVIDENCECOLLECTING EVIDENCE


EXECUTING A WARRANT

Securing the evidence:

If computer equipment is expected to be taken, consider staff / subject destroying evidence upon entry.

Do you have a technical team that can safely remove digital data without compromising the data?

COMPUTER RECORDSCOMPUTER RECORDS


Specific language in SW to search computer files

Agency assist in collection of files

Agency assist in analyzing data- DOJ, FBI, locals, etc.

Consider turn around time for data to be recovered

Search warrant return – language for additional time for digital data

Consider the cloud

LUIS SALAZARLUIS SALAZARNO DAMAGE TO NO DAMAGE TO

THE COMPUTERSTHE COMPUTERS

KNOW YOUR TARGETSKNOW YOUR TARGETS

WHO WAS THEREWHO WAS THERE

PHYSICIANPHYSICIAN WAS THE DOCTOR WITH A WAS THE DOCTOR WITH A PATIENTPATIENTWAS THE DOCTOR WAS THE DOCTOR COOPERATIVECOOPERATIVEDID THE DOCTOR SUBMIT TO DID THE DOCTOR SUBMIT TO BE INTERVIEWEDBE INTERVIEWEDDOES THE DOCTOR HAVE A DOES THE DOCTOR HAVE A PRIOR RECORDPRIOR RECORDWHAT WAS THEIR CHIEF AREA WHAT WAS THEIR CHIEF AREA OF PRACTICEOF PRACTICEWHAT BOARD WHAT BOARD CERTIFICATIONS DO THEY CERTIFICATIONS DO THEY HAVEHAVE


PHYSICIAN’S ASSISTANTPHYSICIAN’S ASSISTANT

WAS HE SEEING PATIENTSWAS HE SEEING PATIENTSWHAT DUTIES WERE WHAT DUTIES WERE DELEGATED TO HIMDELEGATED TO HIMIS THERE A DELEGATION OF IS THERE A DELEGATION OF SERVICES AGREEMENTSERVICES AGREEMENTWHAT IS HIS SKILL SETWHAT IS HIS SKILL SETWHAT HOURS DOES HE WORK IN WHAT HOURS DOES HE WORK IN RELATION TO THE DOCTORRELATION TO THE DOCTOR


MEDICAL ASSISTANTMEDICAL ASSISTANTRECEPTIONISTRECEPTIONIST WHAT ARE THEIR DUTIESWHAT ARE THEIR DUTIES

DO THEY HAVE MEDICAL DO THEY HAVE MEDICAL TRAININGTRAININGHOW DO THEY INTERACT WITH HOW DO THEY INTERACT WITH PATIENTSPATIENTSWHO DOES BOOKKEEPINGWHO DOES BOOKKEEPINGHOW ARE RECORDS KEPTHOW ARE RECORDS KEPTHOW DOES THE FRONT OF THE HOW DOES THE FRONT OF THE OFFICE RUNOFFICE RUNWHAT TYPES OF PATIENTS ARE WHAT TYPES OF PATIENTS ARE SEENSEEN


RUNNERSRUNNERSCAPPERSCAPPERS

WHAT ARE THEIR DUTIESWHAT ARE THEIR DUTIESHOW WERE THEY TRAINEDHOW WERE THEY TRAINEDHOW ARE THEY PAIDHOW ARE THEY PAIDWHAT IS THEIR RELATIONSHIP TO WHAT IS THEIR RELATIONSHIP TO THE DOCTORTHE DOCTOR

PHYSICIAN’S OFFICE –Photos, Photos, Photos


STORAGE ROOM

HALLWAY

TODAYTODAY

THE FUTURETHE FUTURE

FINANCIAL RECORDSFINANCIAL RECORDS


BANK RECORDSBANK RECORDS



ITEMS ESTABLISHING DOMINION AND CONTROL OF PREMISESITEMS ESTABLISHING DOMINION AND CONTROL OF PREMISES (utility bills, leases, etc.)

SPECIFIC MEDICAL SPECIFIC MEDICAL RECORDS LISTED BY RECORDS LISTED BY

PATIENTPATIENT

Include a description of what a medical record is. (i.e. physical / electronic charts, x-rays, phone messages, insurance billing, labs, prescriptions, etc)



MEDICAL CHARTMEDICAL CHART BILLING STATEMENTBILLING STATEMENT

PHENTERMINEPHENTERMINE

COLLECTING EVIDENCECOLLECTING EVIDENCECELL PHONE INFORMATION VIA SEARCH WARRANTCELL PHONE INFORMATION VIA SEARCH WARRANT

WHERE EVIDENCE WAS RECOVEREDWHERE EVIDENCE WAS RECOVERED

IN A DRAWER:IN A DRAWER:

WAS IT CLOSED (KNOWLEDGE)WAS IT CLOSED (KNOWLEDGE)

WAS IT LOCKED (ACCESS)WAS IT LOCKED (ACCESS)

IN WHAT AREA OF THE CLINIC (POSSESSION/CONTROL)IN WHAT AREA OF THE CLINIC (POSSESSION/CONTROL)

WHO HAD KEYS (SHARED RESPONSIBILITY/DELEGATION)WHO HAD KEYS (SHARED RESPONSIBILITY/DELEGATION)


ON A SHELF:ON A SHELF:

HOW WERE THE RECORDS ARRANGED (STANDARD OF HOW WERE THE RECORDS ARRANGED (STANDARD OF CARE)CARE)

WHO WAS RESPONSIBLE FOR MAKING NOTATIONS WHO WAS RESPONSIBLE FOR MAKING NOTATIONS (KNOWLEDGE)(KNOWLEDGE)

WHO HAD ACCESS TO THE RECORDS (DELEGATION)WHO HAD ACCESS TO THE RECORDS (DELEGATION)


IN A BATHROOM:IN A BATHROOM:

WHO HAD ACCESS (STANDARD OF CARE)WHO HAD ACCESS (STANDARD OF CARE)

WERE CONTROLLED SUBSTANCES MIXED WITH NON-WERE CONTROLLED SUBSTANCES MIXED WITH NON-CONTROLLED SUBSTANCES (NEGLIGENCE)CONTROLLED SUBSTANCES (NEGLIGENCE)


IN A PILL ROOM:IN A PILL ROOM:

WERE THERE LOOSE PILLS (NEGLIGENCE)WERE THERE LOOSE PILLS (NEGLIGENCE)

WERE THERE NON-MEDICAL ITEMS LOCATED WERE THERE NON-MEDICAL ITEMS LOCATED (STANDARD OF CARE)(STANDARD OF CARE)

WHO HAD ACCESS TO THE ROOM (CONTROL)WHO HAD ACCESS TO THE ROOM (CONTROL)


IN A CAR:IN A CAR:

WERE ITEMS LOCKED AND SECURED (STANDARD OF WERE ITEMS LOCKED AND SECURED (STANDARD OF CARE)CARE)

WERE ITEMS LABELED OR SCRIPTS FILLED OUT WERE ITEMS LABELED OR SCRIPTS FILLED OUT (MOTIVE)(MOTIVE)


UNCONVENTIONALUNCONVENTIONALEVIDENCEEVIDENCE

PHARMACYPHARMACYSIGNATURE LOGSSIGNATURE LOGS


APPLICATIONS FOR CERTIFICATIONAPPLICATIONS FOR CERTIFICATION


DIVERTED MEDICATION BOTTLESDIVERTED MEDICATION BOTTLES


PHARMACIST

STEVE MAZLIN

INTERVIEWS WITH PHARMICISTS:INTERVIEWS WITH PHARMICISTS:WARNINGSWARNINGS

Chloral Hydrate is a very Chloral Hydrate is a very powerful respiratory powerful respiratory suppressant. You don’t want suppressant. You don’t want to end up on the cover of the to end up on the cover of the “National Inquirer.”“National Inquirer.”

I had to correct Dr. Eroshevich on I had to correct Dr. Eroshevich on the dosing on her prescription.the dosing on her prescription.


HARD COPY PRESCRIPTIONSHARD COPY PRESCRIPTIONS


ANNA NICOLE SMITH’S MEDICAL HISTORYANNA NICOLE SMITH’S MEDICAL HISTORY HOWARD K. STERN’S MEDICAL HISTORYHOWARD K. STERN’S MEDICAL HISTORY

INTAKE PATIENT PROFILESINTAKE PATIENT PROFILESCOLLECTING EVIDENCECOLLECTING EVIDENCE

EMAILSEMAILSCOLLECTING EVIDENCECOLLECTING EVIDENCE

SURVEILLANCE VIDEO OR STILLSSURVEILLANCE VIDEO OR STILLS


PERSONAL PHOTOGRAPHS: CORROBORATIONPERSONAL PHOTOGRAPHS: CORROBORATION

MAKE: CANON MODEL: CANON EOS DIGITALREBEL XT DATE: 2006:09:21 TIME: 02:13:36


12/19/0612/19/06EXTERNALEXTERNAL

HARD DRIVEHARD DRIVE

PERSONAL PHOTOGRAPHS: MOTIVEPERSONAL PHOTOGRAPHS: MOTIVECOLLECTING EVIDENCECOLLECTING EVIDENCE

LOCATIONS WHERE PATIENTS LIVELOCATIONS WHERE PATIENTS LIVE

DOCTOR’S OFFICE

PATIENT RESIDENCES30 MILES


LANA RAULANA RAU

20072007

20082008

20092009

PATTERNS OF PRESCRIBINGPATTERNS OF PRESCRIBING


Coroner’s ReportsWitness / family statements made to coroner investigatorsAdmissions of doctor to coroner staff / investigatorsCoroner investigator notes (not included in autopsy report)Photos:


CORONER’S RECORDS AND NOTES


PILL COUNTS



EXPERTREVIEW AND

OPINION


EXPERT OPINIONS

Once evidence is obtained, determine if an expert opinion is necessary.

Make sure the expert has the entire picture of the case, not just a snap shot (for example, just having an expert review a PDMP report)


EXPERT OPINIONS

Expert opinions are critical to most over-prescribing cases. Consider the strength of your case depending on your expert’s findings: no departure, simple departure, extreme no departure, simple departure, extreme departure and lack of knowledgedeparture and lack of knowledge

DR. WALTER STRAUSERDR. WALTER STRAUSER

THE STANDARD OF CARETHE STANDARD OF CARE“THE LEVEL OF SKILL, KNOWLEDGE AND CARE IN DIAGNOSING AND TREATING THAT A REASONABLY PRUDENT PHYSICIAN WOULD EXERCISE IN SIMILAR CIRCUMSTANCES.”

THE SAME STANDARD OF CARE APPLIES TO ALL PHYSICIANS

AN EXTREME DEPARTURE FROM THE STANDARD OF CARE:

GROSS NEGLIGENCE AND LACK OF SCANT CARE

No inquiry into who the other doctors wereand why so much medication at his age

MEDICAL OPINIONSMEDICAL OPINIONS

EXTREME DEPARTUREEXTREME DEPARTURE


TOXICOLOGISTTOXICOLOGIST

TOXICOLOGIST

TOXICOLOGIST “The Opana was 3-4 X therapeutic levels and the main contributor. Xanax was at therapeutic levels. Opana was the substantial cause of death.”


FELONY MURDERFELONY MURDER+The The unlawful killingunlawful killing of a human being, of a human being,

+Whether Whether intentionalintentional, , unintentionalunintentional, or , or accidentalaccidental,,

+Which Which occurs duringoccurs during the commission the commission or attempted commission of a felony,or attempted commission of a felony,

+When the perpetrator had the When the perpetrator had the specific specific intentintent to to commit that specified felonycommit that specified felony

= MURDER

FELONY MURDERFELONY MURDER+The The unlawful killingunlawful killing of a human being, of a human being,

+Whether Whether intentionalintentional, , unintentionalunintentional, or , or accidentalaccidental,,

+Which Which occurs duringoccurs during the commission the commission or attempted commission of felony,or attempted commission of felony,

+When the perpetrator had the When the perpetrator had the specific specific intentintent to to commit that specified felonycommit that specified felony

= MURDER

CALIFORNIACALIFORNIAOVER-PRESCRIBING STATUTESOVER-PRESCRIBING STATUTES

INTENTINTENT

22ndnd DEGREE MURDER DEGREE MURDER

SECOND DEGREE MURDERDANGEROUS TO LIFE

1. The killing resulted from an intentional act,2. The natural consequences of the act are

dangerous to human life, and3. The act was deliberately performed with

knowledge of the danger to, and with conscious disregard for, human life.

• When the killing is the direct result of such an act, it is When the killing is the direct result of such an act, it is not necessary to prove that the defendant intended that not necessary to prove that the defendant intended that the act would result in the death of a human being.the act would result in the death of a human being.

EXPR

ESS M

ALIC

EIMPLIED MALICE

I INTE

ND TO

KILL

SOMEO

NEI INTEND TO DO SOMETHING

THAT I KNOW CAN KILL SOMEONE

AND I DON’T CARE

MURDERMURDER MURDERMURDER- - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - - -

20072007 20082008

20092009

20102010

STAVRONSTAVRONDEATHDEATH

LATHAMLATHAMDEATHDEATH

COOKCOOKOVERDOSEOVERDOSE

KENNEYKENNEYDEATHDEATH

NGUYENNGUYENDEATHDEATH

OGLEOGLEDEATHDEATH

KATSNELSONKATSNELSONDEATHDEATH

CHAMBERSCHAMBERSDEATHDEATH

GOMEZGOMEZDEATHDEATH

HUGGARDHUGGARDDEATHDEATHROVEROROVERO

DEATHDEATHBENDERBENDERDEATHDEATHMATAMATA

DEATHDEATH

TIMELINETIMELINE APPRECIATION APPRECIATION OF THE RISKOF THE RISK

MICHAEL COOKMICHAEL COOK

It never took long in the exam room and no physical exam was done. Started adding prescriptions to what I wanted. Overdosed 3 times in 2 days, the last timein the restroom at AAA.

MICHAEL COOKMICHAEL COOK

Went to clinic on April 25, 2008.Patient’s screen was positivefor opiates. Doctor said he’d taken6 Opana yesterday.

MATTHEW BRIONESMATTHEW BRIONES

NAYTHAN KENNEYNAYTHAN KENNEYERIN WHITNEY:

•DOCTOR’S RECEPTION AREA LOOKED LIKE A PAROLE OFFICE

• PEOPLE IN THERE HAD LOTS OF TATTOOS

• DRUG DEALING AND PEOPLE EXCHANGING NUMBERS

• 2 TO 3 PEOPLE IN EACH EXAM ROOM

•SHE RECEIVED PRESCRIPTIONS FROM THE DEFENDANT WITH NO EXAM, NO X-RAYS

NAYTHAN KENNEYNAYTHAN KENNEY

4 DAYS4 DAYS

SEPTEMBER 16, 2008SEPTEMBER 16, 2008

NAYTHAN KENNEYNAYTHAN KENNEY

STRAUSERSTRAUSER

No medical record except date ofvisit, blood pressure and pulse or noexamination of the patient while giving controlled substances is an Extreme Departure from the standard of care. It falls outside the scope of practice.

DECEASED

DECEASED

NAYTHAN KENNEYNAYTHAN KENNEYANDERSONANDERSON

CAUSE OF DEATH: OXYCODONE CAUSE OF DEATH: OXYCODONE AND METHADONEAND METHADONE

BOTH AT TOXIC LEVELSBOTH AT TOXIC LEVELSOXYCODONE IN THE “HIGHER ECHELON” OF TOXICOXYCODONE IN THE “HIGHER ECHELON” OF TOXIC

CREATING A CAPTIVE AUDIENCECREATING A CAPTIVE AUDIENCEMICHAEL COOK: WITHDRAWAL IS HELL. THE BODY GETS WEAKER AND THE TOLERANCE GROWS. IT’S AN EQUATION FOR DISASTER.

JUSTIN SMITH: WOULD WAIT 2-3 HOURS EACH TIME BECAUSE HE NEEDED TO GET HIS MEDICATION. WHEN YOU ARE ADDICTED, YOU DON’T REALLY CARE WHAT YOU TAKE OR WHAT YOU DO. IF IT MAKES YOU NORMAL OR HIGH, THEN IT WORKS. AND THERE IS A RISK OF DYING ALMOST EVERY DAY.

LANA RAU: FELT LIKE SHE WAS GOING THROUGH WITHDRAWALS EVERY MORNING AND NEEDED THE MEDICATION JUST TO FEEL NORMAL.

ALEXANDER HUY: HE WOULD WAIT UP TO 6 HOURS JUST TO GET HIS PRESCRIPTION.

DR. EZEKIEL FINKDR. EZEKIEL FINK

IMPACT OF NOTIFICATION OF A IMPACT OF NOTIFICATION OF A PATIENT DEATH ON THE PATIENT DEATH ON THE PRACTICE OF MEDICINEPRACTICE OF MEDICINE

““I THINK THAT A PATIENT DYING IN I THINK THAT A PATIENT DYING IN ONE’S CARE WOULD HAVE A ONE’S CARE WOULD HAVE A PROFOUND IMPACT AND WOULD MAKE PROFOUND IMPACT AND WOULD MAKE ME GO BACK AND TRY TO FIGURE OUT ME GO BACK AND TRY TO FIGURE OUT IF THERE WAS SOMETHING THAT IF THERE WAS SOMETHING THAT COULD HAVE BEEN DONE DIFFERENT COULD HAVE BEEN DONE DIFFERENT TO PREVENT THAT DEATH.”TO PREVENT THAT DEATH.”

““DIDN’T CREATE AN ISSUE IN THE OFFICE. WAS DIDN’T CREATE AN ISSUE IN THE OFFICE. WAS AN ORDINARY CALL, MOSTLY FYI.” AN ORDINARY CALL, MOSTLY FYI.” Dr. Gene Tu

GLORIA RODRIGUEZGLORIA RODRIGUEZ

CASH INCREASED CASH INCREASED FROM $500-$600 PER FROM $500-$600 PER

DAYDAYTO $2,000 SOMETIMES TO $2,000 SOMETIMES

$3,000 PER DAY$3,000 PER DAY

““They’re druggies, they They’re druggies, they can wait.”can wait.”

PER ADVANCED CARE PER ADVANCED CARE AAA TAX RETURNSAAA TAX RETURNS

2007-20102007-2010+ $5,000,000+ $5,000,000

IN MILLIONS

ADVANCED CARE AAAADVANCED CARE AAA

CASES OF INTERESTCASES OF INTEREST

PEOPLE V. ESTIANDANPEOPLE V. ESTIANDAN PEOPLE V. KAPOOR, STERN & EROSEVICHPEOPLE V. KAPOOR, STERN & EROSEVICH

PEOPLE V. MURRAYPEOPLE V. MURRAY PEOPLE V. TSENGPEOPLE V. TSENG

MURDER vs

MANSLAUGHTER

PEOPLE V. CONRAD MURRAYPEOPLE V. CONRAD MURRAY

INVOLUNTARY MANSLAUGHTER

CONVICTED CONVICTED BY JURYBY JURY

ISSUESISSUES

THE “WEANING” DEFENSE

PATIENT’S VOLUNTARY INTERFERENCE WITH TREATMENT

PEOPLE V. CARLOS ESTIANDANPEOPLE V. CARLOS ESTIANDAN

13 FELONY COUNTS OF PRESCRIBING WITHOUT A LEGITIMATE MEDICAL

PURPOSE

1 FELONY COUNT OF PRESCRIBING TO AN ADDICT

CONVICTED CONVICTED BY JURY OF BY JURY OF

ALL 14 ALL 14 COUNTSCOUNTS

ISSUESISSUES

FORMER ADDICT AND “PATIENT” AS A WITNESS

ENTRAPMENT DEFENSE

LESLIE GREENBERGLESLIE GREENBERG

DEPUTY LEO NOYOLADEPUTY LEO NOYOLA

CONSPIRACYCONSPIRACY

A conspiracy is an agreement entered into between two or more persons with the specific intent to agree to commit a crime, followed by an overt act committed in this state by one or more of the parties

for the purpose of accomplishing the object of the agreement. Conspiracy is a crime.

WHAT IS A CONSPIRACY?WHAT IS A CONSPIRACY?

PEOPLE V. KAPOOR, EROSEVICH AND STERNPEOPLE V. KAPOOR, EROSEVICH AND STERN

ISSUESISSUES

ADDICT VERSUS PAIN MANAGEMENT

CELEBRITY EXCEPTION

INDUSTRY STANDARD TO PROTECT PRIVACY

JURISDICTION

PEOPLE PEOPLE v. v.

HSIU-YING “LISA” HSIU-YING “LISA” TSENGTSENG

3 COUNTS OF SECOND DEGREE MURDER3 COUNTS OF SECOND DEGREE MURDER20 FELONY PRESCRIBING COUNTS20 FELONY PRESCRIBING COUNTS

DR. EZEKIEL FINKDR. EZEKIEL FINK

ON KNOWLEDGE OF ABUSE

“WHEN A PATIENT COMES IN AND TELLS YOU THAT THEY’RE AN ACTIVE HEROIN ADDICT, YOU CANNOT TURN AROUND, HAND THEM A PRESCRIPTION, AND SAY, ‘I JUST HAD NO CONTROL OF THAT PRESCRIPTION.’”

“THE PATIENT TOLD YOU THEY DIDN’T HAVE CONTROL. YOU HAD THE OPPORTUNITY TO ACTUALLY MAKE A CHANGE AND BRING THEM BACK FROM THAT CLIFF, BUT YOU PUSHED THEM.”

SEPTEMBER SEPTEMBER 20082008

KENNEYKENNEY NGUYENNGUYEN

MARCHMARCH20092009

5 ½ MONTHS5 ½ MONTHS 4 WEEKS4 WEEKS

OGLEOGLE

APRILAPRIL20092009

KATSNELSONKATSNELSON

APRILAPRIL20092009

8 DAYS8 DAYS

ROVEROROVERO

DECEMBERDECEMBER20092009

8 MONTHS8 MONTHS

PATTERNPATTERNAPPRECIATION OF THE RISK/CONSCIOUS DISREGARDAPPRECIATION OF THE RISK/CONSCIOUS DISREGARD

ISSUESISSUES

CAUSATION—DOCTOR SHOPPING

MISDIAGNOSIS DUE TO FALSE INFORMATION PROVIDED BY PATIENT

FEARED CHILLING EFFECT

OUT ON BAILOUT ON BAIL

DR. THOMAS LINDR. THOMAS LIN

$450,000$450,000

$1,000,000$1,000,000 PHARMACY AUDITPHARMACY AUDITHEALTH & SAFETYHEALTH & SAFETY

CODECODE1115511155


$120,000$120,000

DR. GERARD GORYLDR. GERARD GORYL


$1,000,000$1,000,000




$2,000,000$2,000,000

CONCLUDING CONSIDERATIONS FOR FILINGCONCLUDING CONSIDERATIONS FOR FILING

SPECIFIC CRIMINAL INTENT

STRENGTH OF EVIDENCE

NUMBER OF VICTIMS

RESOURCES NEEDED TO PROSECUTE

PRIOR CRIMINAL BEHAVIOR

POTENTIAL DEFENSES

Administrative discipline Closure Public letter of reprimand Cite and fine Medical education courses Probation Revocation

Criminal discipline Probation Jail / Prison time Fines

Administrative vs. Criminal OutcomesAdministrative vs. Criminal Outcomes

DDA John [email protected]

(213) 257-2126

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