Former ‘pill mill’ owner opens Kaua‘i clinic

KAPA‘A — A former Florida “pill mill” owner has made Kaua‘i his new home and place of business.

Editor’s note: This is the first of a multi-part series on prescription drugs. The focus of the next part, to be published in Monday’s edition of The Garden Island, will be on the challenges the legal community faces in fighting this nationwide epidemic.

KAPA‘A — A former Florida “pill mill” owner has made Kaua‘i his new home and place of business.

World-champion wakeboarder Darrin Shapiro opened Kaua‘i’s only opioid-prescribing and marijuana card-issuing pain management clinic, run by Dr. Sian Evans, in June. That same month, a pain clinic Shapiro owned in Florida was raided in a coordinated, multi-agency effort between a Central Florida drug enforcement task force, the Health Department and Federal Bureau of Investigation.

Shapiro insists the Florida raid had nothing to do with him, and that it’s not the reason he moved his family across the country to the Garden Isle. He said he moved to Kaua‘i to raise his young children and he opened a pain clinic in Kapa‘a because doctors at a local hospital told him there was a need for such services.

Shapiro said he sold his two Florida pain clinics — Pain Relief Orlando and Casselberry Relief Center on Lake Mary Jane Road — to Dr. Riyaz Jummani in October 2010. Jummani was the physician Shapiro had hired to operate his Florida clinics when they opened in 2009.

Jummani was not arrested during the June raids, but his license to practice medicine was placed on emergency suspension and the clinics were shut down.

Orlando raids

In addition to the raid on Pain Relief Orlando, agents raided a second clinic on June 3 called Pain Relief Center of Orlando, Inc., also run by Jummani, and owned by Shapiro’s mother, Angel Shapiro.

“I don’t know anything about that,” Shapiro said in a recent interview. CorporationsWiki links Darrin, Angel and Darrin’s father, Lew, to the Pain Relief Center clinic.

In an on-camera news interview at the scene of the raid, Florida Department of Law Enforcement Special Agent Supervisor Tom Foy said, “These two facilities — the one here (Pain Relief Orlando) and the one on Woolco Way (Pain Relief Center of Orlando) — are probably the worst in the state, maybe in the country, to the point where Dr. Jummani in a quarter has prescribed over half a million oxycodone pills.”

That’s more than prescribed during a whole year by the entire state of California, investigators said.

“If you take all the states in the country and combine the amount of pills that have been prescribed, it does not meet what Florida has,” he said. “It’s a bad practice. That’s why we’re here. We’re going to put somebody in jail next time.”

Investigators closed down the clinics and seized records. But four days later, Florida’s WFTV reported both were back open for business, with “significant traffic” moving in and out. WFTV called Pain Relief Orlando and was told patients were being sent to a Lake Mary Jane office, where there was a new doctor on staff writing prescriptions.

Undercover investigation

A July 22 DOH administrative complaint against Jummani details the findings of two undercover drug agents who posed as a couple exhibiting drug-seeking behavior during six visits to Pain Relief Orlando between May 11 and Oct. 21, 2010, the time during which Shapiro says he owned the clinic.

One agent’s complaint was a stiff back, the other a sore knee. Before seeing the doctor and determining whether there was a need, the receptionist scheduled their return appointments. The office visit fee was $175 per person per visit, payable by cash or credit card only. In the crowded lobby, the officers saw a menu of controlled substances available for purchase that day.

In Jummani’s office, the officers observed no medical instruments or equipment, except for a padded examination table, the report states. There was no hand sanitizer or hand-washing station.

During the agents’ five separate monthly appointments, they told Jummani they were experiencing minimal-to-no pain without medication. Yet, Jummani prescribed hydrocodone (Lortab) and eventually oxycodone (Percocet) without performing an examination other than an initial range-of-motion test.

While agents waited to have their prescriptions filled on site, they overheard several other patients discussing their involvement in narcotics trafficking, the complaint states.

Between January and April, law enforcement performed additional surveillance of Pain Relief Orlando and Pain Relief Center of Orlando, during which time they observed a high volume of patients arriving at the clinics, with multiple groups of patients arriving in the same vehicle. Most of the vehicles were registered outside of the county.

The DOH complaint concluded with two counts against Jummani: one for dispensing controlled substances other than in the course of professional practice and one for failing to perform medical examinations. In light of the action, Jummani voluntarily surrendered his medical license.

Shapiro denies claims

“He’s a 70-year-old man ready to retire and I think he was more than happy to finish working. He was a workaholic — worked for multiple clinics,” Shapiro said of Jummani. He is adamant that Pain Relief Orlando and Jummani did not dispense pain medications and suggested that investigators may have been confused.

“We never had an in-house pharmacy. We never had a single bottle of medication at any time,” he said. “It’s completely invalid and incorrect. We never dispensed medications.”

Shapiro said that although he owned the clinic and was Jummani’s employer, he was unaware of the clinic’s activities and does not believe he is responsible.

If Jummani prescribed more than 500,000 pain pills in one quarter as investigators assert, and the average office visit resulted in a prescription for 120 pain pills, as undercover officers found, that means Jummani may have seen more than 4,000 patients in only three months, or an average of 70 per day. At $175 per office call, that’s nearly $3 million per year just in appointment fees. This does not include potential profits on the pills.

“I make sure the bills are paid. I don’t tell the doctor what to do,” Shapiro said, adding that “every clinic should be investigated.”

He said he believes the investigators’ issue was that they saw too many patients a day, and that’s why he left the business.

Fifty thousand pain pills — just one-tenth of what investigators say Jummani prescribed in one quarter — have a potential street value of $1.5 million, according to The Orlando Sentinel.

FDLE Special Agent Jack Massey told The Garden Island this month that pain pills are a lucrative business, so much so that crack cocaine dealers have switched to pill-pushing.

‘Pill mill’

“‘Pill mill’ is a term used primarily by local and state investigators to describe a doctor, clinic or pharmacy that is prescribing or dispensing powerful narcotics inappropriately or for non-medical reasons,” Dr. Andrea Trescot said in a recent CNBC interview.

Drug agents said the Shapiros’ clinics bore signs of being pill mills because of long lines stretching out the door, patients who are known drug users and dealers, armed security guards and no visible medical instruments in the office.

“Pill mill clinics come in all shapes and sizes, but investigators say more and more are being disguised as independent pain-management centers,” Trescot said. “They tend to open and shut down quickly in order to evade law enforcement. Although the problem is nationwide with recent arrests in New York, Ohio and Chicago, Drug Enforcement Administration officials believe the highest concentration of pill mills are in Florida and Texas.”

Shapiro said that although Pain Relief Orlando wrote a lot of prescriptions, it was not a pill mill because it did not dispense medication.

In October, Pain Relief Center of Orlando placed an employment ad on SimplyHired.com: “Expanding clinic in the Orlando area is seeking a pain management physician. Young exciting atmosphere. Part time and full time available. Dispensing practitioners license a plus.”

‘There will be justice’

Are those who profit from the high-volume pain clinics legally responsible if investigators discover wrongdoing by the doctor? In the noted Florida raids, it appears authorities have only targeted the Shapiros’ hired physician. However, Foy told TGI on Wednesday that the investigation is still open an ongoing.

“All parties can absolutely be held responsible, especially the ownership,” Foy said. “The investigation into Pain Relief Orlando is ongoing. At this point, charges are pending further investigation.

“These types of investigations take longer than most; but in the end, there will be justice for the many lives that have been affected by the distribution of powerful pain killers without medical necessity,” he said. “The Shapiro’s are not exempt from future prosecution.”

Perception on Kaua‘i

In February, Shapiro placed an advertisement on Craigslist seeking a doctor to run a pain management clinic on Kaua‘i. Dr. Sian Evans, who was living on O‘ahu at the time, said she responded to the ad and was subsequently hired to run Shapiro’s new Kapa‘a office.

“If you’ve seen Dr. Evans, she has a real interest in pain management,” Shapiro said. “She’s lived it. She’s got burns over half of her body.”

The clinic’s brochure states that in 1981, Evans suffered 45 percent second- and third-degree burns that required extensive hospitalization and more than 30 reconstructive surgeries.

In April, Shapiro obtained a business license. In June, they opened Kaua‘i Chronic Pain Center, 4-1177 Kuhio Hwy. According to its brochure, the clinic focuses exclusively on two things: the medical management of long-term pain and assisting patients in obtaining permission from the state to use marijuana for medical purposes. The clinic does not distribute medication or marijuana.

The clinic’s website lists the price of an initial office visit at $175. Subsequent office calls are $150 each and are scheduled every four weeks. Like the Florida clinic, Kaua‘i Chronic accepts only cash and credit card payments.

Shapiro said they invited more than 175 members of the medical community to Kaua‘i Chronic’s open house; three showed up.

“Doctors form an opinion before they’re invited to look under the hood,” Shapiro said.

Preventing abuse

In August, TGI met with Evans at Kaua‘i Chronic Pain Center, and she explained her self-developed “Octopus Program.”

On a white board, she drew with a marker the body of an octopus representing the patient. She said its numerous tentacles represent different pain management options. One tentacle was called “group therapy,” another “medication,” another “spiritual” and so forth.

She said she hoped to soon offer expanded services, such as acupuncture and massage, but for the time being she was referring patients to outside providers.

“Nearly a third of people have chronic pain syndrome. One of the biggest determinants in the success of chronic pain is whether there’s a chronic pain physician,” Evans said, adding that most doctors haven’t received her level of specialized training in pain management. She defined chronic pain as pain lasting more than three months.

“Most of the time, we tell them they need to get with their primary care physician before they come. We need them to have seen somebody who has said, ‘Yeah, you’ve got pain.’ … A lot of people like pain medications, but that doesn’t mean they don’t need it.”

Shapiro said new patients are screened for everything from appearance to their medical records. Evans said patients should bring a record of their last three visits with their primary care provider and either an x-ray or MRI.

 As an additional screening measure, she said, “We have people sign a contract and ask them to come in three days later to do a pill count. We also do urine drug screening on the first visit. We do things to prevent abuse.”

 The clinic’s website says new patients are taken on a walk-in basis, must be 18 years old, have a photo ID and “an MRI/CT scan or some other type of document showing your pain.” It says a pharmacy printout of pain treatment and medications “would be helpful.”

 Inside Evan’s examination room, TGI observed there was no visible medical equipment or hand-washing station, only a padded table. It fit the description agents provided in the Orlando investigation report. However, unlike the Florida clinic, there were no patients waiting in the lobby, no line outside the door, no armed security guards and no menu of available drugs.

An office assistant at Kaua‘i Chronic’s reception desk said since its opening in June, the clinic has been busy and is “fully booked all week.”

On Aug. 11, Hawai‘i Medical Board fined Evans $1,500 and placed her license to practice medicine on probation for six months for failing to failing to notify the Board of a 2007 medical malpractice judgment within 30 days.

A Merced County, Calif., jury said Evans should pay $2.5 million for bungling a procedure in 2001 to remove a cyst from a patient’s buttock. Evans, who was a practicing surgeon at the time, severed her patient’s sphincter muscle while trying to drain an infected cyst. Although the 43-year-old man was eventually able to return to work as a telephone lineman, he will have to wear a diaper for the rest of his life, the civil claim states.

Evans moved to Hawai‘i four months after the botched surgery, but she downplayed its significance. “The average number of lawsuits is six in 10 years,” she said.

Past patients speak up

Peter Candrilla of Anahola said he began seeing Evans in July after being denied pain medication by a Kaua‘i Medical Clinic physician.

“I’m probably not a textbook case, but I am a textbook mess,” Candrilla said. “The pain needs management or it will manage me.”

His spine has been reconstructed using cadaver bones and titanium screws, he said, and he complains of problems with the discs in his lower back, three tumors in his brain and cysts on his liver.

“I’m not saying I’m not addicted. Addiction is a side effect of the medication,” said Candrilla, adding that he has been on pain medication for 10 years. “The point is there are people like me who are being overlooked, disregarded. But I’m not going to tell you I don’t see people that don’t belong there.”

Evans requested he submit to urine testing during each of his three visits, he said, but she has not done a pill count.

Martin Mills, a Kaua‘i Chronic patient and former PTA treasurer who served jail time for growing marijuana, forwarded to TGI a response letter that he received from Kaua‘i Medical Clinic regarding his inquiry into seeking pain management services outside of KMC.

“If a patient seeks pain management with a non-KMC physician, then the KMC provider will continue to see their patient only for other medical conditions,” states the letter signed by KMC Chief Medical Officer Geri Young. “The primary care provider will no longer treat them for pain management.”

Young said she could not comment on the letter because of patient privacy rights and KMC policies.

“The letter is the only source we have of any kind of definition of policy,” Mills said. “Dr. Evans is right. There’s this culture of grit your teeth and bear the pain. I’m a fan of Dr. Evans. The people on the other side of the equation are the DEA, and they’re like the SS.”

‘Up for the battle’

When they opened the clinic, Evans said she had envisioned working with primary care physicians but discovered a different welcoming.

“Some people here want to shut us down,” she said. “There’s an unwillingness to be accepted in local medical community.

“Some doctors are telling patients that they won’t work with them if they use our clinic,” Evans said. “One pharmacist outed a patient to their doctor. I think there are some people who are afraid. We’ve had patients visiting in disguises.”

Some pharmacies, such as the one inside Kaua‘i Medical Clinic, won’t fill prescriptions written by Evans, a pharmacy clerk said.

“Doctors call us or we call them and they say, ‘Oh, you’re having trouble filling your prescriptions over there, aren’t you?’” Shapiro said.

“Well, how did you know that? It’s because their buddies are pharmacists and they’re saying don’t fill Dr. Evans’ scripts, and everywhere we turn it’s like somebody trying to beat us down,” he said. “We’re up for the battle.”

Clarity will come

“I had no idea there would be a stigma. It completely blindsided me,” Evans said. “I’m going to go to Wilcox, put my face there and meet people. If we’re helping people, it’s going to become clear.”

At least one side of the island seems to have accepted the new clinic.

“Mostly all over the Westside, doctors seem very happy to send their patients to us,” Shapiro said. “All we get from doctors on the Eastside is people who are just trying to bully us out.”

Past physicians’ misdeeds and politics have played a role in the clinic setting up shop on Kaua‘i.

“If you knew the painstaking efforts involved in the politics of pain management and how many times I’ve been through the wringer with misinformation and how much effort we put into having responsibility in the community to not allow any bull**** to happen, it’s an emotional thing,” Shapiro said. “It’s draining. It’s really tough.”

Shapiro argued that it’s physicians like Waimea’s former “dial-a-doc” that have ruined it for those just trying to help people, people who have a true need for pain relief.

“It’s doctors trading sex for drugs. It’s doctors selling drugs out of the backseat of their car. It’s doctors that are full-on criminals and drug users,” Shapiro said. “It’s a nasty deal because we’re dealing with medications that can go either way.

“They can make a person blossom or can turn them into an addict,” he said. “Without the management and a doctor that has a really good grasp on that, and the staff who can weed out the drug seekers and weed out people who are obviously starting to show a problem, you know, it’s either got to be done right or you just can’t do it. So that’s what our days revolve around.”

In a follow-up telephone interview in October, while Shapiro was in Florida, he said doctors at Kaua‘i Medical Clinic and Wilcox Memorial Hospital were starting to send patients to his clinic through referrals.

‘Legalized drug dealer’

Dr. Graham Chelius of West Kaua‘i Medical Clinic said patients who he has been seeing for years are now getting their pain pills through Kaua‘i Chronic.

“We have a legalized drug dealer in town,” Chelius said. “(Evans) is not a chronic pain specialist. Because she’s not a centralized doctor, there’s no tracking. It’s essentially a carbon copy of the problem in Florida.”

He has made calls to the Narcotics Enforcement Division in Honolulu and the DEA, he said, and has receives calls from physicians, wives and husbands asking how they can put a stop to it.

“Heroin and oxycodone work the same way,” he said. “It’s so easy to smoke an oxy, it’s almost like the drug company designed it to be abused. The underbelly of Kaua‘i has a real dependency problem. We’re going to have people end up dead.”

An epidemic

Some Kaua‘i residents have already lost their lives to prescription pills.

Kapa‘a resident Aureo Moore, 34, was shot to death on Dec. 17, 2010, at Anahola Beach Park. Hooked on prescription drugs, family members said he was at the park to buy oxycodone. The trial of Vicente Hilario, who was charged with first-degree murder, was postponed last month until February.

World-champion surfer Andy Irons’ death on Nov. 2, 2010 was also connected to drug use. The autopsy report, released in June, showed heart attack as the primary cause and acute mixed drug ingestion to be the secondary cause of death. The Irons family had an independent pathologist review this determination, finding that the recreational and prescription drugs found in the 32-year-old Hanalei resident’s system were at “therapeutic levels” and he died from hardened arteries.

Police discovered prescription bottles of alprazolam and zolpidem, along with methadone pills in the Texas hotel room where he died.

More Kauaians have died from abusing prescription pills, officials said, but not all make headlines.

Chelius said the community sorely needs an adolescent drug treatment center and must demand that something happens.

Prescription painkiller overdoses are at epidemic levels, according to a Nov. 1 report by the Centers for Disease Control and Prevention. Overdoses involving narcotic pain relievers like hydrocodone (Vicodin), methadone, oxycodone (Oxycontin) and oxymorphone (Opana) kill more Americans than heroin and cocaine combined.

The CDC reports the death toll has more than tripled over the last decade, with more than 40 people dying every day from narcotics.

“Seven people die a day in Florida,” Foy said. “Thank God we’re now starting the drug monitoring program.”

Florida limits licenses

In July 2010, Florida enacted a law that limits the ownership of pain-management clinics to doctors. Shapiro, who is not a physician, told TGI that he was the owner of Pain Relief Orlando and Casselberry Relief Center after the new law went into effect.

Jack Massey, Florida Department of Law Enforcement Resident Agent In Charge, told TGI, “Business owners sometimes transfer the clinic — in name only — to a doctor, but they’re still involved.”

A year after Shapiro says he sold his Florida pain clinics to Jummani, D&B reports and state databases still show Shapiro and his mother as persons of record at the respective clinics. Darrin Shapiro insists he’s no longer involved.

“Not one percent,” he said from Florida in a telephone interview.

Hawai‘i monitoring

Hawai‘i is in the process of improving its drug-monitoring program, making it more accessible to physicians who wish to track their patients’ prescription-drug activity.

Hawai‘i’s current law does not require a physician to check drug history, but it does require the state to develop an oversight program, said Keith Kamita, NED deputy director.

“We’ve had one in place since 1993,” said Kamita, referring to the state’s Drug Monitoring program. “What the law says now is that all dispensers must transmit data to the Narcotics Enforcement Division.”

In other words, when a person fills a prescription for opioids at a pharmacy, the pharmacy by law is required to enter the person’s information into NED’s database. It is then up to NED to review prescription histories for signs of abuse.

If a doctor suspects a patient is abusing pain medication, the physician must send a request to NED for the patient’s record. The state’s revamped database will give physicians direct access with the use of a password, he said.

Kamita said the improved system should be ready by January.

Pill-popping popularity

“Some kids are taking hydrocodone in high amounts,” Kamita said. “The danger is the acetaminophen in the pills. When you take seven, eight, nine at a time, it damages the liver and kidneys.”

In Hawai‘i, the most abused prescription medication is hydrocodone (Vicodin) and the third most abused is oxycodone, Kamita said. Second is benzodiazepines, such as Valium, which is taken in conjunction with pain killers to enhance the effect.

Pharmaceutical drugs are the most prevalent drugs in Hawai‘i, just after alcohol and marijuana, he said. It outranks all other illicit drugs, such as cocaine and heroine for abuse.

“Pharmaceutical drugs are often stronger than heroin; some are 10 times stronger,” he said. “Pharmacists have corresponding liability when filling prescriptions, so they have a right to refuse a prescription.”

When asked if pain management clinics are an issue around the state, Kamita said there’s a lot of them on O‘ahu.

“The hard part is that there isn’t really a license required for a pain management clinic,” he said. “Any physician can do pain management.”

Prescription tourism

Some states are linking their drug-monitoring databases together to prevent doctor shopping over state lines. It’s called drug tourism, and it’s becoming a major problem in the U.S, a recent USA Today report states. Drug enforcement agents arrested a man in Connecticut who confessed he would travel to Florida several times a week, buy as many as 8,000 pain pills at a time, and bribe airport officials and police officers to facilitate his return travels home.

The report also said new restrictions for Florida pain management clinics are driving owners into other states with more lenient policies.

Pain clinics increase local demand for painkillers, Foy said, which leads to the opening of more pain clinics.

Craigslist last month had an employment wanted ad for a chronic pain doctor on O‘ahu.

“You may have a doctor there that may be freely writing a lot of prescriptions and, in the end, you’ll end up with a lot of deaths,” he said.

• Vanessa Van Voorhis, staff writer, can be reached at 245-3681 (ext. 251) or by emailing vvanvoorhis@thegardenisland.com.