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Big pill mill trial begins

WEST PALM BEACH - Even as they knew their patients were dying, two doctors used rubber stamps to prescribe millions of doses of oxycodone to thousands of Appalachian customers, a federal prosecutor told a jury Friday.

In a trial related to the nation's largest pill mill organization, Assistant U.S. Attorney Paul Schwartz said the defendants prescribed and dispensed millions of pain pills that killed nine people. Seven of the dead patients were from Kentucky, Tennessee and West Virginia.

"These drugs, obtained for a dollar or two in a pill mill in South Florida, would sell back home in Appalachia on the street for $20, $30, $40 or more," Schwartz said in his opening statement in U.S. District Court.

The trial of Dr. Cynthia Cadet, 43, and Dr. Joseph Castronuovo, 74, began Friday.

See blog: The Painkiller Epidemic 

Seven of Cadet's patients and two of Castronuovo's patients later died of drug overdoses, Schwartz said. Among other charges, the doctors are charged with possession with intent to distribute controlled substances, resulting in death. They could face up to life in prison and $2 million fines.

Defense attorneys say the clinic owners took pains to make their clinics appear legitimate, and the doctors didn't realize the clinics were part of a drug conspiracy. 

"(Cadet) was duped," said her attorney, Michael Weinstein.

Cadet and Castronuovo conducted medical examinations of all their patients and collected MRIs and other records. Their attorneys say they should not be held responsible for the deaths of patients who concealed their drug addictions.

Schwartz said the doctors knew the clinics were illegal. Many patients were clearly drug users, some with tracks on their arms from intravenous drug use. The atmosphere at the clinics was chaotic.  Fights broke out in the waiting room and some patients overdosed in the parking lots.

Clinic doctors were hired via Craigslist advertisements and given rubber prescription stamps with pre-printed quantities and strengths of oxycodone. Patient examinations took an average of four minutes, and almost every patient left with large prescriptions. The flagship clinic, American Pain, was a Walmart-like operation, with five doctors seeing up to 500 patients a day.

The clinics' parking lots were jammed with cars with out-of-state tags, Schwartz said.  Eighty to 90 percent of the clinics' patients lived in other states, including Kentucky, Tennessee, Ohio and West Virginia.

"Why would a doctor with years of training who is sworn to treat people do something like this?" Schwartz asked the jury. "Millions of dollars, that's why."

Doctors at the clinics wrote prescriptions for some 18 million oxycodone doses between 2008 and 2010, raking in approximately $40 million, prosecutors say.

Twenty-eight people associated with the clinics have already pleaded guilty, including nine doctors and the twin brothers who operated the pain clinics, Chris and Jeff George, 32. Chris George is serving more than 17 years in prison.  Jeff George is serving more than 15 years in prison.

Cadet and Castronuovo say prosecutors unfairly targeted them, adding the nine overdose charges because they refused to plead guilty like their former coworkers.

"(Cadet was) dragged into this case by a dragnet investigation," Weinstein told the jury.

In 2009, Cadet and three other physicians at American Pain were ranked among the top nine purchasers of oxycodone in the U.S., according to the Drug Enforcement Administration's controlled substances monitoring system. At that time, Florida law allowed doctors to order and dispense controlled substances, instead of writing prescriptions to be filled elsewhere.

Prosecutors say Cadet prescribed approximately 2.5 million oxycodone pills and Castronuovo approximately 750,000. But Cadet's lawyer said those numbers don't mean the doctor was guilty.

"The government will never prove that Dr. Cadet knew about this conspiracy," Weinstein said. "They're saying she should have known.  But there's not one piece of evidence that shows she was complicit in this conspiracy."

Prosecutors say the clinics' wild success prompted a mad rush of Florida pill mills that attempted to copy the Georges' business and marketing practices.

The George clinics were raided and shut down in 2010.

Investigators cross-referenced the George clinics' patient records with death records in Florida and other states and discovered that hundreds of former patients had overdosed.  In previous hearings, they said the nine deaths are the ones that could be most directly linked with Cadet and Castronuovo.

The indictment provides no information about the alleged victims' ages, hometowns or places of death.  But public records indicate that one patient of Cadet's was from Boone County and died in 2010.  Other alleged victims appear to have been from Kentucky, Tennessee and Florida.

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