August 15, 2012 — The legal problems of 2 Florida physicians accused last year of participating in a massive painkiller "pill mill" deepened last month when federal prosecutors charged them with the overdose deaths of 9 patients.
Those deaths, prosecutors say, are part of a much higher body count in a criminal operation that attracted drug addicts and traffickers from all over the Eastern United States.
The 2 physicians, Cynthia Cadet, MD, and Joseph Castronuovo, MD, were among 13 physicians and 19 nonphysicians originally indicted on lesser charges in a federal court in Miami, Florida, in August 2011. Of the 13 physicians, 10 eventually pleaded guilty to conspiracy to commit money laundering or conspiracy to commit wire fraud. An eleventh indicted physician, Irwin Beretsky, MD, died last October at the age of 77 years while awaiting trial.
All 13 physicians initially pleaded not guilty, and Drs. Cadet and Castronuovo are the only ones maintaining their original pleas. The 2 physicians also have pleaded not guilty to the new charge of dispensing a controlled substance for illegitimate purposes that leads to the death of a patient, which is punishable by life in prison. Their lawyers contend that federal prosecutors have drummed up the new charges to punish them for not pleading guilty like the others.
"I think it's a vindictive process," said Michael Weinstein, Dr. Cadet's attorney, in an interview with Medscape Medical News.
A fourteenth physician who allegedly participated in the pill-mill operation was charged in a state court with first-degree murder in an overdose death. That physician, Gerald J. Klein, MD, is awaiting trial.
When the 14 physicians and the 19 nonphysicians were originally indicted last year in federal and state courts, an FBI agent described them as "the nation's largest criminal organization" involved in illegally distributing oxycodone and other opioid analgesics.
Garbage Bags Full of Cash
As in other recent cases of criminal medicine, including Medicare fraud, the 14 physicians in the South Florida pill mill did not run the show, but answered to nonphysicians, according to prosecutors.
The bosses, convicted felon Christopher George and his twin brother Jeffrey George, operated a string of pain-medicine clinics and hauled in more than $40 million from illegal drug sales over one 2-year span. Most of the patients hailed from other states, descending on Florida because it lacked a prescription drug-monitoring program during the period covered by the indictment.
The clinic where Dr. Castronuovo worked — called Executive Pain — specialized in treating pain-med seekers who were discharged from a sister clinic because needle track marks and scars identified them as intravenous drug users, according to prosecutors.
The George brothers paid their physicians according to how many patients they saw per day, which averaged 40 to 100. They also received thousands of dollars for allowing the George brothers to store controlled substances at the clinics using their Drug Enforcement Administration numbers. Altogether, the average physician earned more than $1 million a year.
Prosecutors say the physicians prescribed a standard "cocktail" of controlled substances — specifically, oxycodone and alprazolam — on an assembly-line basis without obtaining prior medical records, ordering alternative treatments such as physical therapy, or referring anyone to specialists. The clinics also dispensed the prescribed pain pills and accepted only cash or credit cards as payment to avoid the scrutiny of third-party payers. The cash was hauled to the bank in garbage bags.
Earlier this year, Christopher George and Jeffrey George each pleaded guilty to a federal charge of racketeering conspiracy and received prison sentences of 17.5 years and 15.5 years, respectively.
The physicians who have pleaded guilty so far have fared a little better. Seven were given prison sentences ranging from 4 years to 6.5 years. Another physician received a 6-month sentence, and yet another, 4 years on probation. Jacobo Dreszer, MD, the father of convicted defendant Roni Dreszer, MD, pleaded guilty only to die several weeks before he was scheduled to be sentenced.
The ignominious ending of medical careers, the prison sentences, and the deaths of Dr. Dreszer and Dr. Beretsky were not the only circumstances darkening the case with tragedy. US District Judge Kenneth Marra recommended that 4 of the physicians whom he sentenced to prison enroll in a 500-hour substance-abuse program behind bars.
Number of Overdose Deaths May Never Be Known
The greater tragedy in the case was the death toll among patients. Prosecutors have charged Dr. Cadet with 7 overdose deaths and Dr. Castronuovo with 2, all of them involving oxycodone. However, there were many other deaths associated with the entire pill-mill operation, as US District Attorney Paul Schwartz recounted to US Magistrate Judge Linnea Johnson in an arraignment and pretrial detention hearing last year regarding Dr. Cadet.
"We found that there were over 53 overdose deaths that we have been able to identify with this case alone, just in Florida," Schwartz said. "Again, we don't know how many kids died behind barns in Tennessee, Ohio, Kentucky, and West Virginia, and 87% of the patients came from out of state.
"Seven Floridians per day die from drug overdoses. This is because of physicians like this who abrogate their duty to do no harm."
Dr. Castronuovo has maintained his innocence regarding the overdose deaths attributed to him. He claims that 2 expert forensic pathologists reviewed the 2 patient deaths and concluded that neither was caused by the medications he prescribed, according to court records.
Thomas Sclafani, Dr. Castronuovo's attorney and a former federal prosecutor, described his client as a conscientious physician, especially when it came to patients who feigned illness and exaggerated their pain levels in the quest for opioids. "Dr. Castronuovo was able to use his 35 to 40 years of practice to weed out the people who were not legitimate," Sclafani told Medscape Medical News. "He threw them out."
Dr. Castronuovo, in his early 70s, has asked the court to sever his case from that of Dr. Cadet, arguing that the enormous amount of evidence to be entered against her will taint him. The government opposes that move.
Dr. Cadet, in turn, contends that her actions were legitimate and medically appropriate. A former attorney of hers noted in the arraignment and pretrial detention hearing last year that Dr. Cadet offered to take an FBI polygraph test to exonerate herself, a proposal turned down by US District Attorney Schwartz.
"She's been screaming from the rooftop since day one that she's innocent," said Michael Weinstein, Dr. Cadet's current attorney. "Just because another doctor takes a plea doesn't mean that she's done something wrong."
The government has asserted that Dr. Cadet, in her early 40s, should have figured out that the George twins were operating a criminal enterprise, which was acknowledged by the physicians who eventually pleaded guilty.
"They saw hundreds of...junkies lined up every morning before the clinic even opened," said Schwartz in last year's hearing. "They saw fights in the waiting room. They saw seizures in the waiting room. They saw the cops come in every day.
"They cannot distance themselves from the facts of the case. They can try to argue medicine, but the facts in this case sink them."
Weinstein counters that Dr. Cadet was hired to see patients, not help run the clinic. "There's no connection between her care of patients and the day-to-day operation of the clinic," he told Medscape Medical News.
US Magistrate Judge Linnea Johnson had something to say on that subject, too.
"It doesn't take a rocket scientist to know a pill mill," she said during Dr. Cadet's hearing last year. "So it is a little difficult for one to assume that the physicians behind the desk don't see what the folks standing on the corner see regarding these pill mills, but (Dr. Cadet's) guilt or innocence remains for a jury."
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