How Did a Couple of Florida Construction Workers Start the Opioid Epidemic?

By Ellie Robins 10/14/15

John Temple's American Pain goes inside the operation that flooded the southeastern United States with prescription opiates.

John Temple and American Pain
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Like many Americans, John Temple had followed the opiate epidemic in the news. He had noticed its effects in his hometown, too: “I saw it among my students,” he told me—he’s a professor at West Virginia University. “Pretty much everyone I know seems to know somebody or have someone in their family who’s having problems.”

Temple shows us a tragic progression of American pain over the past few decades, beginning with Big Pharma’s success in capitalizing on chronic physical pain.

But John couldn’t figure out just what had happened, where this crisis had come from. Then he saw an article about Chris and Jeff George and Derik Nolan, who were on trial in Florida for running pain clinics that had handed out 20 million opiate pills between 2008 and 2010. His journalistic instinct kicked in, and he started to delve into the story. Even in his wildest dreams, he couldn’t have imagined what he’d find.

The book that emerged from his research, American Pain, takes us right inside an operation that flooded Florida and the southeastern United States with prescription opiates. At the center of the story is Chris George, a construction worker and convicted felon in his late twenties, who, along with his brother Jeff, had been selling steroids illegally in Florida for years when a doctor told him the real money was in prescription painkillers.

They were dubious at first, but Chris decided to give it a try, and brought his pal Derik onboard, too. (Jeff would later open his own clinic.) Derik had met Chris through the construction industry; he was three years older than Chris and a keen user of steroids, and he’d also spent time in jail. Chris opened a small pain clinic and made Derik manager: it was nothing more than a couple of doctors who were willing to write prescriptions for large quantities and a safe full of drugs bought from a wholesaler. Soon enough, they were taking in so much money that cash registers were useless: they had cashiers simply dump money into trash bags, filling many every day. They were catapulted into the kind of lifestyle they’d always dreamed of, buying expensive cars and blowing thousands of dollars at strip bars. By the time they were arrested two years later, the business had brought in $40 million.

And while they enjoyed their cars and their cash, they were saturating whole swathes of America with Oxycontin and other opiates. The clinic’s fame spread, and people began traveling from states with more stringent drug laws to get their hands on the pills. Most commonly, they came from Kentucky or Tennessee. Hundreds of copycat clinics popped up in Florida when people saw how much money there was to be made, but Chris and Derik’s operation was always the largest by many scales of magnitude. The street price of prescription opioids plummeted in the southeastern United States, and thousands of people were plunged into the misery of addiction. Families and whole communities were devastated, particularly in previously sleepy Appalachian areas.

As hundreds of customers started arriving every day, desperate to hand over huge wads of cash, and sometimes shooting up there and then in the parking lot, it seemed impossible to Chris and Derik that the substances they were dealing with were legal. And yet they were—so long as they were prescribed by a qualified doctor who had reason to believe that the patient was truly in pain. That’s a very difficult thing to judge, and that difficulty leaves a lot of room for manipulation. There are all kinds of best practices in place to avoid abuse of these drugs, but as Chris and Derik discovered, for every procedure, there was someone willing to flout it. For a start, there were the doctors: a simple ad on Craigslist would bring them numerous doctors prepared to write high prescriptions on the flimsiest of evidence.

“I began to realize over time what a huge network of other individuals and companies were supporting this, turning the other way and not asking questions,” John told me.

“Among them were MRI companies that sprang up specifically to serve this flow of out-of-state patients into Florida, who wanted quick turnaround times. They gave a little bit of legal cover to the pill mills. There were doctors out there—radiologists, presumably—just going through one MRI scan after another. I can’t believe they didn’t know what they were doing. There were obviously pharmacies that catered to this, there were pharmaceutical manufacturers—you cannot convince me that they didn’t know where those pills were going. These billion-dollar companies tend to know where their product goes.”

To give an idea of the scale of the problem, there were also people who sold jars of urine at flea markets a thousand miles from the clinic, in Kentucky. Clients would take them on the long car journey to Florida, then transfer them into condoms they kept in their pockets until they had to perform a urine test. These condoms often split, covering the waiting room or the clinic’s employees with urine. It was blindingly obvious what was going on, but so long as it looked like they’d covered all the bases, the proprietors of American Pain didn’t care.

So many details make it clear that these men knew they were promoting drug abuse: for a start, those condoms full of urine and the recurring problem of clients shooting up in the parking lot. Then there were the frequent seizures in the waiting room, the doctors’ attempts to cling on to their consciences by having Derik Nolan eject clients with visible track marks, the fact that one of the doctors was known to call the pills “candy.” Factors like these helped to win the proprietors of the clinics lengthy jail terms. And yet as John Temple observes, even outside of such clear abuses, “There is an inherent problem with the idea that these drugs are safe for long-term use.”

The book details the process by which opioid pills became an acceptable prescription for chronic pain back in the '90s, helped along by a very powerful marketing campaign by Oxycontin’s manufacturer, Purdue. Until then, these drugs had only ever been prescribed for short-term use, commonly by terminal cancer patients. “I’m not qualified to say there are no situations in which someone should use these on a long-term basis,” says John. “But I will say that if a doctor is going to prescribe these on a long-term basis, then he or she should have a thorough grounding in pain medicine, and a thorough grounding in addiction medicine. That shouldn’t even be controversial.”

Added to the difficulty of assessing pain—and judging a doctor’s assessment of pain—were Florida’s remarkably lax systems for tracking controlled substances. All these factors meant that despite local news broadcasts featuring clearly intoxicated clients, crashes on local roads caused by people nodding out at the wheel, and anguished reports from the families of clients who had overdosed and died days after visiting the clinic, the DEA and other agencies had to mount a complex racketeering case rather than simply prosecuting the Georges and Derik Nolan for dealing controlled substances. And while they took the time to assemble that case, more and more opioids were pumped out into the United States.

Florida now has greater protections, not to mention the precedent of sending these infamous ringleaders to prison. But in so many ways, the damage has already been done. In the Appalachians and other communities where 90% of the pills ended up, heroin started to flow in when the supply of prescription opiates dried up. And as John Temple points out, that’s a natural progression: “It’s the same plant, it’s the same high, it’s the same addiction. It’s not a worsening of the disease, it’s an economic decision, based on price.” Talking about the devastation he’s seen in his own community, John told me: “It’s awful. I’m just shocked at how many people are coming up to me now and saying that someone close to them died. I shouldn’t be shocked, after writing this book, but it’s so many. It’s horrifying.”

Chris George changed the clinic’s name a few times in attempts to pass under the radar. “American Pain” was its final incarnation, and the phrase was chosen very casually. In this excellent book of the same name, Temple shows us a tragic progression of American pain over the past few decades, beginning with Big Pharma’s success in capitalizing on chronic physical pain. Now, America is dealing with pain of a different kind and on a different scale: the agony of communities ravaged by addiction.

“All over the country,” John says, “there are people whose lives have been destroyed by this epidemic that didn’t need to happen, that happened through a series of decisions. You can’t even count it.”

Ellie Robins is a writer and translator based in Los Angeles. She last wrote about meth and memory.

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Ellie Robins is a writer and translator based in Los Angeles. Find out more about Ellie on Linkedin. You can also follow her on Twitter.