How state regulators allowed Ohio's pill mill crisis to explode

Correction: An earlier version of this article incorrectly stated Dr. Nilesh Jobalia's plea. He pleaded not guilty.

Prescription for Failure

Prescription opioids have taken an unrelenting hold on Ohio in the last two decades. The crisis has left thousands dead in its wake. But how did it get to this point? A six-month investigation by WCPO's sister station in Cleveland goes back to the beginning and uncovers the regulators who were supposed to protect Ohioans enabled the crisis to explode.

Jenny Dunn chooses to remember her son, John Dunn, Jr., in a better light than when she last saw him.

 “He was full of life,” Jenny said with a smile. “He was such a happy kid [growing up]. They would always say, ‘He’s a momma’s boy.’ And I was always good with that.”

He wasn’t just her only child. John was kind and caring. He valued family and made his mom and 8-year-old daughter his priorities. And he showed it.

“He was one of the most loving people you would ever want to meet,” Jenny said. “[He’d] do anything for you.”

As John got older, he began to experience back pain. One day, in 2008, he visited a Columbus doctor he learned about through word of mouth – one who took only cash – that could help relieve the pain. This was convenient for John. He didn’t have insurance. 

“It was just readily available – very easy to get what he wanted,” Jenny said.

Sometimes, John didn’t even see the doctor. Every 28 days, “like clockwork,” Jenny said, her son got his painkiller prescriptions written there.

In what became a vicious cycle, he started to sell the pills – Soma, Xanax, Percocet, oxycodone – to get more cash. He’d then go back to the doctor and buy more.

Months went by. Jenny and the rest of the family were alarmed. They began to see a change in him. What was once a happy and loving person, was now a tired and lethargic John they didn’t know.

“I did not realize it was as bad as it was until…he had been going there for a few months,” Jenny said. “I noticed he was like a zombie, like, it wasn’t my kid. One time, he was eating a sandwich, and it fell. He couldn’t even feed himself.”

John’s last appointment was May 11, 2009. Four days later, he died of an overdose. He was 29.

What she didn’t know was that state regulators disciplined her son’s doctor before. Despite this, he was able to keep his license and ultimately go on to treat her son with painkillers.

“If somebody would have acted before they did, if somebody would have done something, my son would still be here,” Jenny said.

John’s doctor wasn’t the only one.

An exhaustive 5 On Your Side investigation found state regulators allowed doctors who have been seriously disciplined in the past to keep their licenses for years. Many of them later went on to operate the largest pill mills in Ohio.

The beginning

More than 70,000 people have died nationwide from overdose deaths that include prescription drugs, fentanyl, cocaine and other illegal opioids, according to the Centers for Disease Control and Prevention (CDC). There were 5,138 who died in 2017 alone.

In Ohio, prescription opioids have claimed the lives of more than 8,000 people since 2002, Ohio Department of Health (ODH) numbers show.

 

Opioid Overdose Deaths in Ohio 2005-2017

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And it was in a small Ohio town where the opioid crisis began to take hold.

It first found its place in Portsmouth, just two hours north of Kentucky, in 2001. With a population of just over 20,000, prescription pills seemed like a quick solution for pain relief for many.

But it spiraled.

From big pharma’s refusal to acknowledge its pills could be addictive, to the medical community searching for a solution to help patients deal with pain, there are multiple factors that allowed the opioid crisis to flourish in Ohio.

Doctors overprescribing painkillers was one of them.

The pills went from doctors offices straight to the streets, translating into addiction for many residents – and a business for many doctors.

Jessica Livingston remembers it vividly – waiting in the lines, taking the pills and feeling the addiction take hold of her.

“How did it destroy me? It took away everything,” said Livingston, a recovering user of prescription opioids who is now a counselor. “You could drive through Portsmouth and in specific places, there would be lines."

“I would take as much as possible,” she said. “That was the goal of the day. Take as much as I can until tomorrow.”

Portsmouth was also home to Dr. Paul Volkman, the number one purchaser in the country in 2004, according to the Drug Enforcement Administration. Federal prosecutors said he later supplied thousands of painkillers.

According to a federal indictment, Volkman, along with two other individuals, prescribed 1.5 million painkillers from October 2001 to February 2006 that led to the deaths of at least 14 people.

“I don’t know that we fully grasped the gravity of it as a society at the time,” said Portsmouth Police Chief Robert Ware. “The quantities they handed out are mind-boggling.”

In 2005, drug enforcement agents raided his former clinic. Despite evidence that at least seven people had already died, the medical board did not revoke Volkman’s license. Instead, it reached a consent agreement with the doctor in 2006 that prohibited him from practicing medicine and surgery in Ohio.

It wasn’t until 2008, prompted by a DEA investigation, that the medical board revoked his license.

Volkman was indicted in 2007 for operating a pill mill from 2001 to 2003. He’s now serving four life sentences in prison.

Fueling the opioid crisis

The Ohio Medical Board regulates doctors and decides whether someone keeps or loses his or her license. Its mission, according to its website, is to “protect health and safety through effective medical regulation.”

The board is comprised of nine doctors and three public members. It meets once a month to decide whether doctors will be disciplined.

Over six months, our team analyzed thousands of records, including state medical board documents dating back to 2000 when opioid usage began to increase dramatically across the U.S, as well as federal indictments and other court records.

We found doctors previously disciplined for issues, including having sex with patients, felony drug convictions and unprofessional conduct, were permitted by the medical board to practice and retain their licenses – only later to be accused by prosecutors of contributing to Ohio’s massive opioid crisis by operating pill mills.

DIG DEEPER: You can search if your doctor has ever been disciplined by the state medical board here.

Prosecutors have used the phrase “pill mills” to describe doctors, who, in most cases, prescribe thousands of painkillers to patients without performing a single medical test and accepting only cash as payment.

We also reviewed three dozen of Ohio’s largest pill mill cases involving physicians prosecuted by both federal and state prosecutors since 2010 when pill mills began to come under increased scrutiny by law enforcement.

We found 11 — nearly one-third — continued to practice for years leading up to being convicted for operating pill mills and fueling the opioid crisis in Ohio.  

Our analysis also uncovered in the first decade of the opioid crisis, and as the death toll continued to rise, only 47 doctors lost their licenses for improper prescribing – far less than in recent years.

In the last seven years, it has nearly doubled to 112 doctors who have lost their license.

The doctors

In one case, we found three physicians were convicted of operating a Columbus-based pill mill that was prescribing opioids for 12 years before federal prosecutors filed criminal charges in 2014 and shut it down, according to the U.S. Department of Justice.

Prosecutors found hundreds of patients showed up daily outside the Columbus Southern Medical Center and obtained prescriptions for painkillers like oxycodone and hydrocodone, while the percentage of patients receiving them rose from 60 percent in 2004 to 92 percent by 2009.

At the same time, two of the three physicians convicted of distributing painkillers had serious disciplinary backgrounds for drug addiction. But the board did not revoke their licenses.

Dr. Terry Dragash

Dr. Terry Dragash was one of them. He pleaded guilty to distributing oxycodone in May of 2014.

But records show the medical board’s first encounter with Dragash was years before that.

As far back as November of 2008, a medical board enforcement attorney took a deposition from Dragash focusing “on the care and treatment of a patient who lived with Dragash and who was arrested for cocaine possession at Dragash’s home.”

During the deposition, the board’s attorney asked Dragash whether police had told him the patient indicated “you were using cocaine.”

Dragash denied it, and the board did not revoke his license.

Three years later, the board cited Dragash for alleged “impairment of ability to practice,” and for “cocaine dependency.” Again, Dragash kept his license.

Even more alarming, medical board records reveal Dragash admitted for a two-year period between 2009 and 2011 that he “enjoyed” using cocaine and “couldn’t wait till the next weekend so he could get some more,” spending $100 a night and using “greater and greater” amounts on weekends.

Despite this, Dragash kept his medical license and was permitted to see patients.

One of his patients was 29-year-old John Dunn, Jr. who died of an overdose of painkillers in 2009 after being treated by Dragash a year earlier.

“He was my world,” said John’s mother, Jenny. “And they helped turn my world upside down.”

Three years later, in December of 2012, Dragash was cited again for “failure to maintain minimum standards” by the medical board related to the care of 16 patients and their treatment with painkillers.

Still, the board did not revoke his license.

It wasn’t until July of 2013 when Dragash voluntarily surrendered his license.

Ten months later, in April of 2014, Dragash was indicted by federal prosecutors for his role in supplying painkillers to 50 to 100 patients a day while working at the Columbus Southern Medical Center.

“There’s no words, there’s no words,” Jenny said. “They’re supposed to help save lives, you know? Not take lives.”

Dr. David Rath

Dragash is not the only doctor at the same pill mill that the medical board allowed to continue to practice despite red flags in his background.

Dr. David Rath first came under scrutiny by the medical board in September of 2005 — a full decade before he pleaded guilty in December of 2015 to distributing oxycodone while working at the same clinic as Dragash.

In July of 2005, while serving as the coroner of Delaware County, Rath admitted he stole a “vile of Morphine” from a crime scene. 

He was charged with felony theft and offered treatment in lieu of criminal conviction.

In September of 2005, the medical board found there is “clear and convincing evidence that the doctor’s ability to practice is impaired” and that his continuing practice “presents a danger of immediate and serious harm to the public.”

But the board did not revoke his license. Instead, it was suspended in 2006 and later reinstated in 2007 with conditions of probation that required monitoring, drug screening and treatment.

Then, one year later, Rath requested and was granted repeated requests to modify the terms of his probation. The terms were continually granted until July 2012 when his probation ended.

But at the same time Rath was earning the approval of the medical board, he was employed at the Columbus Southern Medical Clinic, where he was distributing oxycodone for nearly three years from Oct. 4, 2010 until May 13, 2013, federal prosecutors later found.

Wrath was found dead in his home in January of 2016, a month after pleading guilty to operating a pill mill.

Dr. Nilesh Jobalia

In June of 2018, federal prosecutors filed criminal charges related to opioid prescriptions against another Ohio doctor with a troubled past.

Dr. Nilesh Jobalia is accused in a 114-count indictment alleging patients were prescribed Fentanyl, oxycodone, methadone and morphine without actually being seen by him. Jobalia has pleaded not guilty to charges and remains free on bond. His trial date is scheduled for July of 2019.

But we found Jobalia first appeared on the medical board’s radar in 2008 as the opioid crisis continued to surge.

Jobalia at his home with Chief Investigative Reporter Ron Regan.

A board investigation found that Jobalia had “repeated sex with three of his patients” and “had pre-signed” blank prescriptions. 

Despite this, he kept his license and the board only gave him a two-year suspension.

But in a June of 2018 indictment, federal prosecutors later alleged Jobalia began operating the Cincinnati Center for Pain Relief in March of 2013 and continued seeing patients until December of 2017.

Johnna Morgan was one of them.

“There’s not a day goes by that I don’t wish my mom was here,” said Wayne Rogers, whose mother Johnna saw Jobalia for back pain. He said she trusted doctors, but he doesn’t believe the system protected her when she sought pain relief after she fell and hurt her back.

Court records alleged Jobalia prescribed Morgan 560 doses of painkillers in the just three months before she died of a massive overdose of prescription painkillers in March of 2015. An autopsy report found the cause of death was due to a “combination of drugs including morphine.”

Her death came after the board found Jobalia violated minimum standards of care years earlier in April of 2008.

Rogers was shocked to learn of Jobalia’s past disciplinary action and believes the system let his mother down.

“I don’t feel enough action was taken, honestly,” Rogers said. “There should be more questions as to whether this guy should be allowed to actually see a patient let alone prescribe them anything.”

The same system allowed Jobalia to earn more than $100,000 in fees paid by the leading maker of painkillers, Insys Therapeutics. The company recently settled a multi-million dollar lawsuit filed by the U.S. Department of Justice, which accused the company of paying kickbacks and engaging in other unlawful practices to promote Subsys, a powerful opioid painkiller.

And despite a history of discipline, the medical board never revoked Jobalia’s medical license.

Instead, he voluntarily surrendered it in November of 2017 just months before he was indicted for running a pill mill from March of 2013 until December of 2017 that “distributed hundreds of thousands of doses of prescription painkillers” and allegedly contributed to the death of “J.M.” (Johnna Morgan), according to the indictment.

When contacted for comment on this story, Jobalia said, “I really can’t say anything at all, really.”

A pattern of problems

Our investigation found additional examples of other pill mill doctors across Ohio with serious disciplinary histories whose licenses were not revoked by the past medical board.

Among them include:

• Dr. Marcellus Gilreath. The doctor worked at a pill mill from January of 2009 to June of 2011 with two other doctors. He was indicted by federal prosecutors in 2012, but he had a disciplinary history with the medical board dating back to 1995. His license was never revoked by the board – he surrendered it in 2013. 

• Dr. Robert Reeves, Jr. In 2017, Reeves pleaded guilty to 20 felonies related to questionable prescribing from his office in Norwalk. He was sentenced to three years and 11 months in prison. But the medical board was aware of issues with Reeves dating back to 1982, when the doctor admitted to drug and alcohol dependence. In 1998, he relapsed, which involved three patients, and continued to have issues for years that the medical board knew of. But the board never revoked his license. He voluntarily surrendered it this year. 

was not revoked by the board until 2013. He was later indicted and sentenced to five years in prison in 2015.

• Dr. Darrell Hall: The medical board knew of Hall’s drug and alcohol dependency in 2001. After a license suspension, it was reinstated a year later. He went on to operate a pill mill from August of 2008 to May of 2009. The board revoked his license in 2010 based on a DEA investigation. In 2013, he was sentenced to five years in prison.

Inside the system

As part of this investigation, we spoke with key people who’ve worked either for or with the medical board to help us understand how the regulatory arm makes its decisions about whether or not to revoke a doctor’s license.

Frank Younker, a former agent with the DEA, ran the federal agency’s drug diversion program in Southern Ohio at the height of the opioid crisis.

He also supervised the investigation into Volkman, who was the top purchaser of painkillers in the country in 2004.

Younker believes more problem doctors would have been held accountable earlier on had the medical board been proactive with discipline.

“I would say it’s my general impression wherever I’ve been that medical boards are pretty much always reactive,” Younker said. 

He also said the board would often wait for the DEA to take action before it took action against a doctor, even if the individual had a history of discipline, like in the cases of Volkman and Hall.

“There would typically be some issue, some discipline in his past…where maybe [the board] was going to suspend his license, but they didn’t,” Younker said. “They stayed the suspension. [The doctors] would have to take some classes or those type of things.”

We asked Younker what the medical board’s reaction would be if he called them about a problem doctor.

“It would depend on who you would talk to,” Younker said.

Mike Staples, a former medical board investigator, said a hearing officer would sometimes recommend a license revocation for a doctor, but the board could ignore those recommendations.

As an investigator who has worked on sometimes more than 100 cases each year, he said the “most frustrating” aspect was what he called a lack of consistency by the board when it came to decisions on disciplining doctors.

“Those recommendations were solely recommendations,” Staples said. “Dr. A may have done this, this and this, and Dr. B did this, this and this. You send them both to the board, and there was no consistency. Dr. A may get a reprimand, Dr. B might have their license revoked.”

Last year, the medical board received 5,553 complaints about doctors.

It found no action was warranted in almost 50 percent of the cases it received.

Of those investigated, 2,822 complaints were closed after an investigation with no action warranted.

Only 261 complaints, or nearly 5 percent of total complaints, resulted in disciplinary action.

 

Complaints Doctors

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Conflict of interest?

Our investigation found the regulators whose main focus is to decide discipline for problem doctors could also have a conflict of interest.

We found members of the medical board can own as much stock as they want in drug companies – even those that make or distribute painkillers, like the global company Cardinal Health.

Current medical board President Robert Giacalone served as Cardinal Health’s senior vice president of regulatory affairs before joining the medical board five years ago.

Last spring, a former Cardinal top executive appeared before Congress, which was investigating the role Cardinal and other companies played in fueling the opioid crisis. Cardinal denied it contributed to the crisis. But its stock value doubled in the same years.

We questioned Giacalone about the potential conflict of interest that would arise when someone, who owns stock in drug companies, must also sit in judgment of doctors accused of improper prescribing.

“I can’t explain what other people think,” Giacalone said. “I don’t view it as a conflict because I don’t think they’re that top of mind.”

While there is no evidence that stock ownership has influence medical board discipline, a leading public watchdog organization, Public Citizen Health Research Group, said it raises red flags.

“Is it plausible to think that a doctor, who has a lot of stock in a drug company, is going to have a different attitude about what constitutes misprescribing and overprescribing, than a doctor who doesn’t have any kind of financial interest in a drug company?” the organization’s co-founder Dr. Sidney Wolf said. “And the answer is clearly yes.”

We asked Giacalone why the board, whose mission is to protect the public, was slow to act in the early years of the crisis as hundreds of Ohioans continued to die.

“It’s hard to say,” Giacalone said. “I’m not trying to duck and dodge. I can only tell you then when I got on the board, we were definitely more attuned to the issues – not just in prescribing, but in sexual boundaries. We could go down the line.”

While he said he couldn’t speak on doctors who were disciplined under the past medical board, he said of the doctors, “if that was an individual today, he would not have his license.”

He acknowledged doctors were able to stay in business because they kept their licenses in some instances.

Our analysis shows that in recent years, the current medical board has gotten tougher.

In the last seven years, the number of doctors who lost their licenses for improper prescribing has more than doubled since the first decade of the opioid crisis.

But we found another state medical board sets automatic triggers for investigating doctors suspected of overprescribing.  

North Carolina: Finding a solution

As Ohio wages its own fight, North Carolina is taking a different approach to combating their own opioid crisis.

In North Carolina, the medical board sets specific limits on doctors that would prompt an automatic investigation. This includes the doctor exceeding a fixed threshold of opioid prescriptions and having two or more patient deaths.

The state maintains a prescription drug database that contains this data, as well as records of every patient’s prescription history.

“We have a system in place that allows us to proactively identify those who might be prescribing inappropriately – high volume, high dose and associated opioid toxic deaths,” said Dr. Karen Burke-Haynes, chief medical officer with the North Carolina Medical Board.

Ohio has the same database, called the Ohio Automated Rx Reporting System, (OARRS). But it’s operated by the state pharmacy board – not the medical board.

Last year, there were 89 million queries in OARRS to see how many opioids a patient has been prescribed. As a result, both opioid prescribing and doctor shopping have significantly decreased.

“To be honest with you, I don’t see the difference because we’re doing the same thing,” Giacalone said. “We’re looking at OARRS data with the Board of Pharmacy.”

“But there’s no threshold that automatically triggers,” Chief Investigative Reporter Ron Regan said.

“No, but...well, no,” Giacalone replied.

“Hard and fast rules tend to become arbitrary in terms of results,” he added.

When asked if there’s merit in North Carolina’s system, Giacalone said, “So, great, they’re looking at their numbers, but so what? What are their physicians – their frontline people – doing to make sure that…look, you can play catch up all day. But you have to get on the front end.”

Haynes said despite having a pharmacy board, working with their DEA and having their own team of investigators who answer and investigate complaints filed with the board, they still feel the need to take extra steps.

She said she believes this is saving lives in North Carolina.

“The statistics on the number of deaths – we need to make a difference in the epidemic,” she said. “It was very important that we find a different way to approach this problem, to do our part.”

Ohio progress

Ohio has taken significant steps to combat the growing opioid crisis.

An ODH annual drug overdose report shows an eight-year low in prescription opioid deaths. From 2016 to 2017, these deaths declined 7 percent. They also declined during the second half of 2017 by 23 percent.

Other initiatives include:

• 2011: Governor John Kasich signed House Bill 93 into law, shutting down “pill mill” pain clinics

• 2012: Ohio hosted first statewide Opiate summit, drawing more than 1,000 addiction, law enforcement, policy and medical professionals

• 2015: Ohio Pharmacy Board trains local law enforcement on how to conduct drug overdose investigations, including use of the OARRS

• 2017: State budget for 2017 to 2018 contains $2 million to be distributed by the Ohio Department of Health to reimburse Ohio coroners for toxicology testing performed as part of drug overdose death investigations

• 2017: Attorney General Mike DeWine unveiled a 12-point “Recovery Ohio” to combat the crisis

• 2017: DeWinesued five opioid manufacturers

• 2018: DeWine sued four opioid distributors

The opioid crisis in Ohio is now the focus of the U.S. Justice Department’s opioid initiative. Attorney General Jeff Sessions has authorized two special prosecutors for Ohio to prosecute pill mills and problem doctors. We went to Washington D.C. and shared our findings with Sessions. You can watch his reaction to our investigation in our exclusive sit-down interview with him here.