I spent a lot of time between 1990 and 2015 taking part in investigations of pill mills, which are clinics, doctors, or pharmacies that dispense or prescribe powerful narcotics inappropriately or for nonmedical reasons. These cases were rarely a slam dunk and usually required background and surveillance work for up to a year before we could get a search warrant.

The reason for this tedious investigative work was to confirm, or deny, that a target was operating a criminal enterprise. There were often signs of this occurring, and we likely had confidential informants supplying us with information. But we found that it was still easy for investigators to go down the wrong path.

Once a search warrant was served, it was likely that the public would soon know about it, which could hurt a dispenser or prescriber’s reputation. We tried to tread carefully, because the last thing we wanted to do was harm the reputation of people who had done nothing wrong.

This is a point I have stressed in many training sessions with members of law enforcement and regulators across the country. Unfortunately, zealous investigators and prosecutors sometimes pursue individuals based on high dispensing or prescribing rates without looking deeper into the situation. Coupled with the climate of demonizing pharmacies, pharmaceutical manufacturers and wholesalers, and prescribers, this could lead investigators to go after those who are helping legitimate pain patients. Separating those involved in nefarious activities from those who are doing their job is a ton of work.

Our investigators became aware of suspect prescribers through a variety of means. One of the most important, and reliable, was the retail pharmacist. In one of our first cases in the early 1990s, the detectives were visiting each pharmacy to introduce themselves and our new pharmaceutical unit. In discussions with the pharmacists, particularly those on the west side of Cincinnati, we were repeatedly told about a certain doctor’s prescribing practices and how they either would not fill his prescriptions or were very wary of doing so.

Additional information poured in once the public knew that we had a dedicated police unit that worked on these kinds of cases. Relatives told stories about their loved ones and how the prescriber had addicted them, even that some had ultimately overdosed and died or were hopelessly hooked on the medication. This added to the probable cause information we were getting from our pharmacists but still did not rise to the level of a search warrant.

These investigations required countless hours of surveillance and collaboration with other agencies, such as state regulators and insurance carriers, assuming health care insurance was being used at a practice. Grand jury subpoenas for the insurance carriers’ records and consultation with the insurers’ health care employees who helped us understand the billings and their potential for being legitimate were crucial if a health care fraud charge was our ultimate goal.

In addition, we spent hours interviewing current and past patients as they came forward either as individuals who truly wanted to help or because they had a criminal charge against them. The latter were always in need of scrutiny, as they were criminals themselves and usually looking for lighter sentences. Some were confidential informants and could be weeded out quickly, because they were unreliable. But if we were lucky, they could prove reliable and truthful and could
really help a case.

It is very difficult to explain how much work goes into these kinds of investigations, and there are several hurdles, including the fact that doctors and pharmacists have the legal right to prescribe and dispense controlled substances and it can be difficult to show they are not operating legitimately. Many times, we were targeting a pillar of the community, someone who actual patients trusted implicitly.
 
Cmdr. John Burke is a 40-year veteran of law enforcement, the past president of the National Association of Drug Diversion Investigators, and the president and cofounder of the International Health Facility Diversion Association.