Web only rx16 presummit pillmills-mon_200_investigating and prosecuting pill mills

Investigating and
Prosecuting 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 187
PC 187
PC 187
PC 187
PC 187
PC 187

CONSUMER COMPLAINTCONSUMER COMPLAINT
-Patient
-Family member
-Another physician
-Pharmacist
INITIATION OFINITIATION OF
INVESTIGATIONINVESTIGATION

SPECIAL AGENT ROBERT HARKINS
BEGAN INVESTIGATION IN SEPTEMBER OFBEGAN INVESTIGATION IN SEPTEMBER OF
2008:2008:
TIPPED OFF BY LOCAL PHARMACISTSTIPPED OFF BY LOCAL PHARMACISTS
CONDUCTED SURVEILLANCE ON THE CLINICCONDUCTED SURVEILLANCE ON THE CLINIC
REVEALED LINES OF YOUNG PEOPLEREVEALED LINES OF YOUNG PEOPLE
SET UP A SERIES OF UNDERCOVERSET UP A SERIES OF UNDERCOVER
OPERATIONSOPERATIONS

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 appeared
to 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

PDMPPDMP

CRIMINAL VERSUS ADMINSTRATIVE ACTIONSCRIMINAL VERSUS ADMINSTRATIVE ACTIONS
Over 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 RESOURCES
Pros and Cons of Requesting Medical Records via
Written request, SDT or Search Warrant

SOME PATIENTS HAD BLANK
RECORDS IN 2010 THEN HAD
COMPLETED RECORDS IN 2012STEVEN OGLESTEVEN OGLE
2010 2012

PHARMACY RECORDS

IMPORTANTIMPORTANT 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 drug
TOXICOLOGY

Dealing with multiple contributing factors from multiple sources
TOXICOLOGY

Witnesses
How do I identify witnesses?
PDMP reports
Surveillance
Interviews
Pharmacy records
Complainant

Witnesses: 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 pain
Recording Devices (should you have them? Where
should you put them?)
How many buys are necessary?
Establishing a rapport the doctor
Testifying after your U/C
Entrapment / Red flags
Undercover Investigations: IssuesUndercover Investigations: Issues
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 WARRANTSEARCH WARRANT
LOCATIONSLOCATIONS
HOMEHOME
BUSINESSBUSINESS
STORAGESTORAGE

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 SALAZAR
NO DAMAGE TONO DAMAGE TO
THE COMPUTERSTHE COMPUTERS

KNOW YOUR TARGETSKNOW YOUR TARGETS

WHO WAS THEREWHO WAS THERE
PHYSICIANPHYSICIAN WAS THE DOCTOR WITH AWAS THE DOCTOR WITH A
PATIENTPATIENT
WAS THE DOCTORWAS THE DOCTOR
COOPERATIVECOOPERATIVE
DID THE DOCTOR SUBMIT TODID THE DOCTOR SUBMIT TO
BE INTERVIEWEDBE INTERVIEWED
DOES THE DOCTOR HAVE ADOES THE DOCTOR HAVE A
PRIOR RECORDPRIOR RECORD
WHAT WAS THEIR CHIEF AREAWHAT WAS THEIR CHIEF AREA
OF PRACTICEOF PRACTICE
WHAT BOARDWHAT BOARD
CERTIFICATIONS DO THEYCERTIFICATIONS DO THEY
HAVEHAVE

PHYSICIAN’S ASSISTANTPHYSICIAN’S ASSISTANT
WAS HE SEEING PATIENTSWAS HE SEEING PATIENTS
WHAT DUTIES WEREWHAT DUTIES WERE
DELEGATED TO HIMDELEGATED TO HIM
IS THERE A DELEGATION OFIS THERE A DELEGATION OF
SERVICES AGREEMENTSERVICES AGREEMENT
WHAT IS HIS SKILL SETWHAT IS HIS SKILL SET
WHAT HOURS DOES HE WORK INWHAT HOURS DOES HE WORK IN
RELATION TO THE DOCTORRELATION TO THE DOCTOR

MEDICAL ASSISTANTMEDICAL ASSISTANT
RECEPTIONISTRECEPTIONIST
WHAT ARE THEIR DUTIESWHAT ARE THEIR DUTIES
DO THEY HAVE MEDICALDO THEY HAVE MEDICAL
TRAININGTRAINING
HOW DO THEY INTERACT WITHHOW DO THEY INTERACT WITH
PATIENTSPATIENTS
WHO DOES BOOKKEEPINGWHO DOES BOOKKEEPING
HOW ARE RECORDS KEPTHOW ARE RECORDS KEPT
HOW DOES THE FRONT OF THEHOW DOES THE FRONT OF THE
OFFICE RUNOFFICE RUN
WHAT TYPES OF PATIENTS AREWHAT TYPES OF PATIENTS ARE
SEENSEEN

RUNNERSRUNNERS
CAPPERSCAPPERS
WHAT ARE THEIR DUTIESWHAT ARE THEIR DUTIES
HOW WERE THEY TRAINEDHOW WERE THEY TRAINED
HOW ARE THEY PAIDHOW ARE THEY PAID
WHAT IS THEIR RELATIONSHIP TOWHAT IS THEIR RELATIONSHIP TO
THE DOCTORTHE DOCTOR

PHYSICIAN’S OFFICE –Photos, Photos,
Photos

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 MEDICALSPECIFIC MEDICAL
RECORDS LISTED BYRECORDS 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

CELL 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 OFHOW WERE THE RECORDS ARRANGED (STANDARD OF
CARE)CARE)
WHO WAS RESPONSIBLE FOR MAKING NOTATIONSWHO 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 LOCATEDWERE 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 OFWERE ITEMS LOCKED AND SECURED (STANDARD OF
CARE)CARE)
WERE ITEMS LABELED OR SCRIPTS FILLED OUTWERE ITEMS LABELED OR SCRIPTS FILLED OUT
(MOTIVE)(MOTIVE)

UNCONVENTIONALUNCONVENTIONAL
EVIDENCEEVIDENCE

PHARMACYPHARMACY
SIGNATURE 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 veryChloral Hydrate is a very
powerful respiratorypowerful respiratory
suppressant. You don’t wantsuppressant. You don’t want
to end up on the cover of theto end up on the cover of the
“National Inquirer.”“National Inquirer.”
I had to correct Dr. Eroshevich onI 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 PROFILES

EMAILSEMAILS

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

12/19/0612/19/06
EXTERNALEXTERNAL
HARD DRIVEHARD DRIVE
PERSONAL PHOTOGRAPHS: MOTIVEPERSONAL PHOTOGRAPHS: MOTIVE

LOCATIONS WHERE PATIENTS LIVELOCATIONS WHERE PATIENTS LIVE
DOCTOR’S OFFICE
PATIENT RESIDENCES
30 MILES

LANA RAULANA RAU
20072007
20082008
20092009
PATTERNS OF PRESCRIBINGPATTERNS OF PRESCRIBING

Coroner’s Reports
Witness / family statements made to coroner investigators
Admissions of doctor to coroner staff / investigators
Coroner investigator notes (not included in autopsy report)
Photos:

CORONER’S RECORDS
AND NOTES

PILL COUNTS

EXPERT
REVIEW 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, extremeno 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 were
and 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
+TheThe unlawful killingunlawful killing of a human being,of a human being,
+WhetherWhether intentionalintentional,, unintentionalunintentional, or, or
accidentalaccidental,,
+WhichWhich occurs duringoccurs during the commissionthe commission
or attempted commission of a felony,or attempted commission of a felony,
+When the perpetrator had theWhen the perpetrator had the specificspecific
intentintent toto commit that specified felonycommit that specified felony
= MURDER

FELONY MURDERFELONY MURDER
+TheThe unlawful killingunlawful killing of a human being,of a human being,
+WhetherWhether intentionalintentional,, unintentionalunintentional, or, or
accidentalaccidental,,
+WhichWhich occurs duringoccurs during the commissionthe commission
or attempted commission of felony,or attempted commission of felony,
+When the perpetrator had theWhen the perpetrator had the specificspecific
intentintent toto commit that specified felonycommit that specified felony
= MURDER
CALIFORNIACALIFORNIA
OVER-PRESCRIBING STATUTESOVER-PRESCRIBING STATUTES

22ndnd
DEGREE MURDERDEGREE MURDER

SECOND DEGREE MURDER
DANGEROUS TO LIFE
1. The killing resulted from an intentional act,
2. The natural consequences of the act are
dangerous to human life, and
3. 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 isWhen the killing is the direct result of such an act, it is
not necessary to prove that the defendant intended thatnot 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.

EXPRESSMALICE
IMPLIEDMALICE
IINTENDTOKILLSOMEONE
IINTENDTODOSOMETHING
THATIKNOW
CANKILLSOMEONE
ANDIDON’TCARE
MURDERMURDER MURDERMURDER
-------------------------
-------------------------

20072007 20082008
20092009
20102010
STAVRONSTAVRON
DEATHDEATH
LATHAMLATHAM
DEATHDEATH
COOKCOOK
OVERDOSEOVERDOSE
KENNEYKENNEY
DEATHDEATH
NGUYENNGUYEN
DEATHDEATH
OGLEOGLE
DEATHDEATH
KATSNELSONKATSNELSON
DEATHDEATH
CHAMBERSCHAMBERS
DEATHDEATH
GOMEZGOMEZ
DEATHDEATH
HUGGARDHUGGARD
DEATHDEATHROVEROROVERO
DEATHDEATHBENDERBENDER
DEATHDEATHMATAMATA
DEATHDEATH
TIMELINETIMELINE APPRECIATIONAPPRECIATION
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 time
in the restroom at AAA.

MICHAEL COOKMICHAEL COOK
Went to clinic on April 25, 2008.
Patient’s screen was positive
for opiates. Doctor said he’d taken
6 Opana yesterday.
MATTHEW BRIONESMATTHEW BRIONES

NAYTHAN KENNEYNAYTHAN KENNEY
ERIN 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

4 DAYS
4 DAYS
SEPTEMBER 16, 2008SEPTEMBER 16, 2008

STRAUSERSTRAUSER
No medical record except date of
visit, blood pressure and pulse or no
examination 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
ANDERSONANDERSON
CAUSE OF DEATH: OXYCODONECAUSE OF DEATH: OXYCODONE
AND METHADONEAND METHADONE
BOTH AT TOXIC LEVELSBOTH AT TOXIC LEVELS
OXYCODONE IN THE “HIGHER ECHELON” OF TOXICOXYCODONE IN THE “HIGHER ECHELON” OF TOXIC

CREATING A CAPTIVE AUDIENCECREATING A CAPTIVE AUDIENCE
MICHAEL 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 AIMPACT OF NOTIFICATION OF A
PATIENT DEATH ON THEPATIENT DEATH ON THE
PRACTICE OF MEDICINEPRACTICE OF MEDICINE
““I THINK THAT A PATIENT DYING INI THINK THAT A PATIENT DYING IN
ONE’S CARE WOULD HAVE AONE’S CARE WOULD HAVE A
PROFOUND IMPACT AND WOULD MAKEPROFOUND IMPACT AND WOULD MAKE
ME GO BACK AND TRY TO FIGURE OUTME GO BACK AND TRY TO FIGURE OUT
IF THERE WAS SOMETHING THATIF THERE WAS SOMETHING THAT
COULD HAVE BEEN DONE DIFFERENTCOULD HAVE BEEN DONE DIFFERENT
TO PREVENT THAT DEATH.”TO PREVENT THAT DEATH.”
““DIDN’T CREATE AN ISSUE IN THE OFFICE. WASDIDN’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 INCREASEDCASH INCREASED
FROM $500-$600 PERFROM $500-$600 PER
DAYDAY
TO $2,000 SOMETIMESTO $2,000 SOMETIMES
$3,000 PER DAY$3,000 PER DAY
““They’re druggies, theyThey’re druggies, they
can wait.”can wait.”
PER ADVANCED CAREPER 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

PEOPLE V. CONRAD MURRAYPEOPLE V. CONRAD MURRAY
INVOLUNTARY MANSLAUGHTER
CONVICTEDCONVICTED
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
CONVICTEDCONVICTED
BY JURY OFBY JURY OF
ALL 14ALL 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

PEOPLEPEOPLE
v.v.
HSIU-YING “LISA”HSIU-YING “LISA”
TSENGTSENG

3 COUNTS OF SECOND DEGREE MURDER3 COUNTS OF SECOND DEGREE MURDER
20 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.”

SEPTEMBERSEPTEMBER
20082008
KENNEYKENNEY NGUYENNGUYEN
MARCHMARCH
20092009
5 ½ MONTHS5 ½ MONTHS 4 WEEKS4 WEEKS
OGLEOGLE
APRILAPRIL
20092009
KATSNELSONKATSNELSON
APRILAPRIL
20092009
8 DAYS8 DAYS
ROVEROROVERO
DECEMBERDECEMBER
20092009
8 MONTHS8 MONTHS
PATTERNPATTERN
APPRECIATION OF THE RISK/CONSCIOUS DISREGARDAPPRECIATION OF THE RISK/CONSCIOUS DISREGARD

ISSUESISSUES
CAUSATION—DOCTOR SHOPPING
MISDIAGNOSIS DUE TO FALSE INFORMATION
PROVIDED BY PATIENT

OUT ON BAILOUT ON BAIL
DR. THOMAS LINDR. THOMAS LIN
$450,000$450,000
$1,000,000$1,000,000 PHARMACY AUDITPHARMACY AUDIT
HEALTH & SAFETYHEALTH & SAFETY
CODECODE
1115511155

$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 Niedermann
jniedermann@da.lacounty.gov
(213) 257-2126

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