COVER STORY
Corporate indictment implicates local doctors as ‘pill mill’ trial begins JASON JOHNSON/REPORTER
Illustration/Laura Rasmussen
A second superceding indictment added what federal prosecutors refer to as “death enhancements,” which connect the doctors to deaths of four patients, but those charges
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t’s been more than a year and half since two prominent pain doctors in Mobile were indicted in an alleged conspiracy to recklessly distribute a plethora of controlled medications, but only recently have criminal cases in other states shed light on why it’s taken that long to have their day in court. The trial of Dr. John Patrick Couch and Dr. Xiulu Ruan began last week in the midst of a continuing nationwide pushback against opioid abuse and addiction that a number of federal agencies are calling “an epidemic.” An opioid is any “opium-like” substance that binds to the opioid receptors in the human brain, which includes heroin but also substances like hydrocodone, oxycodone and morphine found in prescription painkillers. In the face of a death toll that’s increased 30 percent over the past decade, federal law enforcement officials across the United States have made the prosecution of drug traffickers and medical professionals who improperly prescribe opioids a top priority. That effort created “Operation Pillution” in 2015, a Drug Enforcement Administration effort specifically targeting prescription drug abuse in the South. When DEA agents raided two Physicians Pain Specialists of Alabama (PPSA) locations in Mobile, which Couch and Ruan coowned, they also hit other pain clinics and pharmacies in
Arkansas, Alabama, Louisiana and Mississippi. Couch and Ruan’s indictments also followed a successful case against Dr. Joseph Mwau N’dolo of Fairhope, who was accused of writing improper prescriptions for painkillers, sometimes in exchange for sexual favors from patients. N’dolo was convicted and sentenced to two years in federal prison in late 2014. However, one of the things that sets the accusations against Couch and Ruan apart from other alleged “pill mill” busts is the sheer amount of controlled medications the doctors are alleged to have prescribed. “Together they wrote over 300,000 prescriptions for controlled substances between Jan. 1, 2011, and May 20, 2015,” Assistant U.S. Attorney Christopher J. Bodnar said in his opening remarks last week. “This was not a pill mill in a traditional sense. PPSA was not cash only; they required referrals from another doctor and they took insurance … This was a money mill.”
The case
In addition to the PPSA locations in Mobile, located on Springhill Avenue and Airport Boulevard, Ruan and Couch also co-owned and operated the C&R Pharmacy. In May 2015, both doctors were indicted on conspiracy charges for illegally prescribing controlled prescriptions
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and for alleged health care fraud. Later, 17 additional charges were added in a superseding indictment accusing the pair of engaging in mail fraud, racketeering and receiving kickbacks from pharmaceutical companies. A second superseding indictment added what federal prosecutors refer to as “death enhancements,” which connect prescriptions the doctors wrote to the deaths of four patients, but those charges were dropped before the trial started. “There’s two main questions you need to ask yourself: What did they do, and why did they do it?” Bodnar told the jury. “What did they do? They prescribed controlled substances with no legitimate medical purpose and outside the usual course of professional practice. Why did they do it? For money.” Those statements were Bodnar’s attempt to simplify a fairly complex case that’s expected to result in an equally complex two-week trial. Couch and Raun wrote numerous prescriptions for Schedule II controlled substances, prescriptions that would be legal if they were written appropriately. Even Bodnar acknowledged both doctors had some legitimate patients that received treatment exactly as they should have. “There were some patients that had very legitimate pain, and there were definitely some that were treated very appropriately, but that’s not why we’re here,” he added. “We’re here for the times they were prescribing drugs outside of that legitimate course of professional practice.” However, in his opening statement defense attorney Jack Sharman, who is representing Couch, said his client has always served as a “doctor of last resort,” and by the very nature of his practice would have prescribed a high number of prescription painkillers. Sharman said the case was going to boil down to three things: “medicine, judgment and decisions.” He told the jury the “government wants to turn a two-way street — a doctor’s judgment and a patient’s decision on what to do with it — into a crime.” According to Sharman, the prosecution’s description of the volume of prescriptions Ruan and Couch wrote was taken out of context. Specifically referring to Bodnar’s 300,000 figure, Sharman said when divided by the 8,000 patients PPSA had during the time period covered by the indictment, those numbers come out to “about one prescription, per patient, per month.” Sharman also took issue with the term “pill mill,” which he said was “a lazy term the media uses because it rhymes.” He also said it it doesn’t describe anything close to the businesses in Mobile that Couch and Ruan ran for years. Unlike pill mills, Sharman said PPSA didn’t demand cash; they required insurance, kept patient records and performed a number of procedures before and in addition to using prescription pain medicine. He said the defendants handled their billing in “a large, public compliance arena” because their company received reimbursements from the Veterans Administration, Medicare and Blue Cross and Blue Shield of Alabama — all of which “saw exactly what Dr. Couch was doing,” Sharman said. Ultimately, Sharman said Couch had only “tried too hard to treat too much pain,” telling the jury that the prosecution’s case would only focus on “a few dozen” of PPSA’s “thousands of patients.” “You’ll hear a lot about the hardships of addiction, but what you don’t hear a lot about are the hardships of living with chronic pain,” he added. “It limits what you can do. It limits productivity, if you’re even able to work. It reduces quality of life, and we also know that it stigmatizes those affected by it.” Though both defendants have retained a number of attorneys, Ruan is primarily being represented by Dennis Knizley. Like Sharman, Knizley claimed the doctors had run a legitimate business and had gone above and beyond requirements for prescribing controlled substances. He told jurors that PPSA patients had to be referred from other doctors and undergo an initial examination upon their first visit. Ruan and Couch also required patients receiving opioid painkillers to sign an “opioid agreement” that — among other things — required routine urine analysis to ensure patients were taking the medicine they were supposed to and not using any other drugs.