By Gilbert M. Gaul and Mary Pat Flaherty
Washington Post Staff Writers
Wednesday, October 22, 2003
Third of five articles
SAN ANTONIO -- At his worst, Ernesto A. Cantu was injecting himself 10 times a day with Demerol, swallowing tablet after tablet of hydrocodone, taking Ambien to sleep and using Valium for anxiety.
"I became addicted," the stocky 60-year-old doctor said. "It's an illness."
Even as Cantu wrestled with his own addiction, he was writing thousands of prescriptions for painkillers for customers of the Internet pharmacy thepillbox.com. Those orders were based on brief telephone conversations with patients Cantu never examined or even met. All together, he approved more than 1 million doses of hydrocodone and other dangerous drugs, court records show.
At least five of Cantu's customers were addicts or later became addicted, according to state and federal records. An Alabama patient suffering from chronic alcohol abuse and depression overdosed on hydrocodone and was hospitalized for nine months. A San Francisco patient addicted to narcotics developed liver damage after receiving multiple orders of the painkiller Darvocet. A New Jersey mother previously treated for substance abuse received more than 800 doses of hydrocodone from Cantu and other thepillbox.com doctors.
Cantu earned as much as $1,500 a day for writing Internet prescriptions. In nearly eight months, he said, he made $147,000. Other online doctors have made as much as $500,000 a year.
"This is not Albert Schweitzer on the other end of the computer box," said Lee S. Anderson, a physician and president of the Texas State Board of Medical Examiners. "The people who are doing this know exactly what they are doing -- and they are doing it for the money."
Across America, doctors beset by troubled histories work for rogue Internet pharmacies, grinding out tens of thousands of prescriptions each year for narcotics and other controlled substances. What passes for medicine in these online transactions is mostly a fiction. There are no medical records, examinations, lab tests or follow-ups.
The doctors are recruited by middlemen who link them to Internet customers seeking access to the coveted drugs. The result is a virtual pain-management industry that feeds millions of doses of highly addictive drugs into the shadow market for pharmaceuticals, bypassing the normal checks and balances in the physician-patient relationship.
"It's an easy way to make big bucks," said Jerry Ellis of the Drug Enforcement Administration's Houston office. "It's not like any of the doctors are truly practicing medicine or caring for the patients."
Internet pharmacies have attracted doctors with substance abuse problems, legal setbacks and financial woes.
David L. Bryson: After losing his job as a staff physician for a state facility in Texas, the 65-year-old joined thepillbox.com in 1999 after reading a newspaper article about its owner. Bryson had undergone alcohol dependency treatment in 1995 and filed for bankruptcy protection in 1999, according to Texas medical board records. In fewer than three years for thepillbox.com, he wrote 20,000 prescriptions for more than 4.7 million doses and collected nearly $1 million in fees, records show. About three-quarters of the prescriptions were for hydrocodone and Xanax. In 2002, the Texas board revoked his license for prescribing dangerous drugs to people he had not examined. A consultant to the board called Bryson's actions "a travesty." Bryson pleaded guilty last month in a related federal case and is awaiting sentencing. He declined to comment through his attorney.
Allen L. Browne: In 1999, the 46-year-old obstetrician pleaded guilty to sexual exploitation of a minor and was sentenced to 10 months in prison. Browne was caught secretly videotaping his girlfriend's 13-year-old daughter showering and using the bathroom in his home in Mesa, Ariz. He kept his license but closed his practice in March 2001. Soon after, he began writing prescriptions for hydrocodone, codeine and Alprazolam for a Web site based in a Mesa auto parts store. In seven months, Browne wrote 2,568 prescriptions, earning $36,520. He surrendered his medical license earlier this year. He admitted to the board that customers might have misled him to get pills. Browne could not be reached to comment for this story.
Marvin Gibbs: The 55-year-old gynecologist had recently lost privileges at an Arizona hospital, where he saw 90 percent of his patients, when he was approached in 2000 to write prescriptions for an online pharmacy. In 10 months, he wrote more than 9,000 prescriptions for more than 700,000 doses of controlled substances, according to records of the Arizona Board of Medical Examiners. "What in God's name were you thinking," a board member asked during a 2002 hearing, "prescribing to folks you have no idea who they are, where they're coming from, what they're doing with the medications?" In February, the board placed Gibbs on 10 years' probation. He did not respond to an interview request.
Ricky Joe Nelson: Unemployed and reeling financially after the collapse of a business venture, the 47-year-old physician signed on in 2001 to write prescriptions for an Internet pharmacy in Oklahoma. In a few months, he wrote more than 5,000 prescriptions for controlled substances. In 2002, a federal jury convicted him of conspiring to distribute controlled drugs and launder $175,000 through an offshore bank account. He was sentenced to 51 months. He declined to be interviewed.
Many other cases bear out that there are few checks on doctors who hand out drugs over the Internet:
A Colorado doctor had a history of alcohol abuse. An Arkansas doctor was being treated for bipolar disorder and drug dependency. A Florida doctor had twice been cited for providing inadequate care to elderly patients, one of whom died. A Texas doctor was under investigation by the FBI for suspected Medicare fraud and later committed suicide. A California doctor was disciplined for operating under a fictitious name. A North Carolina doctor had held 22 jobs in five years.
Prescriptions Without Exams
Doctors who write prescriptions for Internet pharmacies maintain that the practice is safe and serves people who might otherwise not have access to painkillers and other medicines.
Cantu, for example, told The Washington Post in an interview that his earlier experience working in a hospital emergency room helped him identify online patients who might abuse drugs. "Yes, it would certainly be better if I saw them, but this is a new form of communication," he said.
Others stressed that many of their patients were between jobs, uninsured or had no regular doctor. The Internet sites allow them to refill prescriptions quickly without having to find another physician.
State and federal regulators say all of these arguments lead to a larger question: What should physicians reasonably be expected to do before they write a prescription for a dangerous drug?
In the past, the answer was relatively simple. Patients went to the doctor's office and were examined. The doctor saw the patient face-to-face "and could form an opinion whether there was drug-seeking behavior," said Anderson of the Texas State Board of Medical Examiners.
The rise of the Internet complicated matters. The doctor did not see or know the patient and the patient had little, if any, information about the doctor. Initially, all the patient had to do was fill out a short online form. Later, as regulators started to raise questions, many Web sites added a brief telephone consultation. But those were often little more than a few stock questions. And there usually were no medical records, tests or histories.
In 1999, the Texas medical board adopted rules for the Internet that require a face-to-face examination. "We were concerned that the Internet would foment drug-seeking behavior," Anderson said. "We also felt that the traditional physician-patient relationship was being sidetracked, especially for controlled substances. We just felt it was dishonorable."
Since then, other state medical boards have adopted similar rules. But not every state. There is a lingering debate over whether Congress should step in with a federal requirement.
"If each state would adopt and implement guidelines . . . there probably wouldn't be a need for federal legislation," said James N. Thompson, president of the Federation of State Medical Boards. "There is wide variation. Some states are very strict and some states have no enforcement whatsoever."
The borderless nature of the Internet works against state regulation. In one case, a customer in New Jersey visited a site in Arizona that used a doctor in Alaska, while a pharmacy in California filled the order. "Until this happened, medicine was not really an interstate commerce problem," Anderson said.
A uniform rule would allow regulators to track dangerous doctors across state lines.
"Right now if a California doctor did something to a kid in Texas, Texas has no authority over that," said Jon E. Porter, a lawyer who formerly directed compliance at the Texas medical board. "We have no idea how many people are being hurt. I think there are hundreds, if not thousands, of cases we don't know about. I think it is a huge crisis that the federal government has ignored."
In the late 1990s, Congress considered requiring Internet pharmacies to disclose basic information about themselves and the doctors they used. But the debate was bogged down in arguments over jurisdiction and fears of harming e-commerce. Currently, customers logging on to most online pharmacies and doctor referral Web sites receive little information.
Some Internet doctors have been hired by e-mail; others after they walked into pharmacies. Cantu was offered a job when he visited thepillbox.com to buy supplies for his diet center. Sandra G. LaFon, a board-certified internist from Texas, was hired in 2000 by thepillbox.com while she was home recuperating from a broken back.
LaFon said she originally thought the site was "a real business." But after a few months she became alarmed when customers began to call her asking for controlled substances.
"I had lots of people tell me they fell off the roof," she said. "I heard all kinds of lies. Alarms went off. I thought, this is getting out of control. When I found out a patient absolutely fabricated a whole story, I quit."
William A. Stallknecht, the owner of thepillbox.com, pleaded guilty to illegally dispensing controlled substances. He declined to comment through his attorney.
For her role in thepillbox.com, LaFon, 39, was fined $1,000 by the Texas medical board and ordered to take 10 hours of continuing medical education in risk management. She considers herself lucky. "I could have lost my license over this. I'm not like those other guys. I didn't write 400 scripts a day. The moment I found out things stunk, I got out."
A Doctor's Downfall
Sitting in a glass-enclosed visitors cubicle in a federal prison in San Antonio, Ernesto Cantu's voice falls to a whisper as he wonders whether there is any chance he will get his medical license back. His drab blue prison garb bears a vague resemblance to a surgeon's gown, but otherwise there are few hints of his medical past. Ever so slowly, Cantu's mouth tightens into a sad smile. "I guess that's wishful thinking," he says, answering his own question. "But I can still hope."
At the moment, all Cantu faces is the prospect of more time in prison. In October 2002, he pleaded guilty in two state cases for attempting to buy Demerol with a fictitious prescription and for sexually molesting a 13-year-old girl. That same month, he also pleaded guilty to a federal charge of conspiracy to dispense controlled substances for thepillbox.com.
He was sentenced to six years on the state charges. He is now being held in the federal facility while awaiting sentencing for the federal charge. He faces as many as five years in prison and a $250,000 fine.
Cantu has fallen far.
He grew up in Brownsville, Tex., on the Mexican border, the eldest of six children. His parents owned a fencing company and encouraged their children to study. Cantu was a good student and worked as a pharmacist in south Texas for several years before completing medical school in Guadalajara, Mexico.
After finishing an internship in Camden, N.J., and working in emergency rooms in south Texas, Cantu relocated to San Antonio in 1987. He eventually set up a diet center in a strip mall, where he worked in the mornings. In the afternoons, he ran a small general practice on the other side of town.
Cantu described his practices as busy, adding that he was clearing $8,000 to $10,000 a month. Still, he had a significant financial problem. He owed the Internal Revenue Service about $80,000. He eventually filed for bankruptcy protection "to keep the IRS from putting liens on me."
That was not his only legal headache. In May 1992, he was charged with assault and making terroristic threats toward his live-in girlfriend. "We had some domestic disputes," Cantu said. The case was dismissed. A 1995 arrest on suspicion of possession of a controlled substance also was dropped.
Cantu started writing prescriptions for thepillbox.com in late 2000 and continued through the summer of 2001. He said he purchased supplies from the Pillbox Pharmacy but did not know that its owner, Stallknecht, had started an Internet business. "I didn't know him that well," he said. "One day he asked me, 'How would you like to join up as a consultant?' "
Cantu said he made informal inquiries into whether prescribing for Internet customers was legal and was assured that it was. Initially, he said, he wrote about 10 prescriptions a day, gradually increasing to 30 or more. He was paid $45 per prescription.
Thepillbox.com used a middleman to arrange the telephone consultations. Cantu said he received some medical records. But as time went on, "the medical records and the diagnoses started to decrease," he said. "I'm not going to sit here and say I had a medical record for every patient."
In hindsight, Cantu said, "I am thinking it is not a good way to practice medicine because there is no way to evaluate the progress of the patient and also make sure the patient is not abusing the medication."
One patient who took advantage of the system was Connie Cuccaro, 44, a New Jersey mother with a 10-year history of substance abuse. Between Dec. 8, 2000, and Jan. 17, 2001, she received 300 tablets of Vicodin, a brand-name version of hydrocodone, from thepillbox.com. That was at least 100 tablets more than the manufacturer's recommended dose for that time period, according to an investigative report prepared for the New Jersey attorney general.
Cuccaro declined to be interviewed. However, in a February 2001 deposition she testified that Cantu never asked her if she had a drug problem.
Q: He never inquired?
A: No. The conversation was less than 10 minutes. Very simple, very quick. I was very surprised when I hung up. I couldn't believe it was that easy.
Cuccaro admitted taking more of the Vicodin than needed. "I am a prescription-drug addict," she told investigators.
In November 2000, Cuccaro was scheduled for another consultation with Cantu but missed the call when she left on a three-day anniversary trip with her husband, Joe. A few days after returning, Cuccaro contacted the doctor referral service to reschedule. The manager said it was not necessary, records show. Her medical chart showed she had already had the consultation. A few days later, Cuccaro received her next shipment of Vicodin, with the number of pills increased from 90 to 100.
At that point, Joe Cuccaro was begging thepillbox.com to stop the shipments, he told The Post.
"They basically laughed at me," he said.
Cantu said he would never have sent Cuccaro more pills without a consultation. "It's not something I would do."
It is easy for patients with drug problems to fool doctors, he said. "They were the ones trying to get these meds. They were the ones who asked for certain meds, who gave symptoms that led you to prescribing certain meds."
Road to Addiction
Cantu's own road to addiction started with the pills he said he took 20 years ago for back pain. "I initially started with Darvocet in the '80s and around 1995 I started using hydrocodone." In October 2000, Cantu added Demerol to the mix. "I briefly became addicted to it."
At the time, Cantu was living with Anne Malley and her teenage daughter in a gated community known as the Enclave.
Although Cantu's signature appeared on the prescriptions he wrote for thepillbox.com, he allowed Malley "to represent herself as Dr. Anne Cantu and provide the telephone consultations with patients," according to the Texas medical board.
Cantu said Malley "did answer the phone at times and speak with patients. But she would not prescribe any medications."
Malley's name appeared on a summary sheet of physicians prescribing drugs for thepillbox.com, according to a 2001 affidavit prepared by a Food and Drug Administration investigator. The affidavit states that she was paid $42,340 by the Internet pharmacy, and used several of the checks as a down payment for a 2001 Mercedes-Benz E350 costing $54,575.
Cantu frequently wrote prescriptions for Demerol in the names of patients and employees who had not sought the drugs, state investigators said.
"The fictitious prescriptions were for the purpose of obtaining Demerol for Respondent's girl friend, Anne Malley, and/or the Respondent himself," the Texas medical board later stated. "There is probable cause to believe that Respondent abused Demerol and/or that he has knowingly aided his girl friend, Anne Malley, in abusing Demerol."
When federal agents searched Cantu and Malley's home in October 2001, they found 96 empty vials of Demerol and syringes in the trash. "At that time," Cantu said, "I did not feel either of us was abusing. But at that time both of us were addicted."
Malley did not respond to repeated interview requests.
Cantu said he was taking as many as 10 tablets of hydrocodone during the day and injecting himself with as many as 10 ampules of Demerol at night. "I didn't use the Demerol during office hours," he said.
He insisted that his addiction did not interfere with his practice of medicine. "Just because a person takes hydrocodone and is addicted to it doesn't mean he can't function in a normal way," he said.
Anderson, head of the Texas medical board, wondered why the board did not catch Cantu sooner. "What he did is shocking," Anderson said. "It is absolutely shocking behavior, and it's totally out of control."
The board did have Cantu on its radar. In October 2000, it alleged that he prescribed "frequent high doses of narcotics" to a patient, including numerous painkillers. Cantu was ordered to complete at least 50 hours of continuing medical education.
Porter, the board's former head of compliance, described the settlement as "garbage." He said Cantu "was handing out drugs left and sideways." Porter said he was worried that Cantu was going to repeat his mistake "and probably hurt somebody."
Cantu said that on Thanksgiving 2001 he prepared a turkey and watched as Malley's daughter and two neighborhood girlfriends roasted marshmallows in the fireplace. He had taken Demerol, Soma (a muscle relaxant), Valium and Ambien. He said he went to bed and blacked out.
According to court records, Cantu returned to the living room, where the girls were sleeping, and fondled a 13-year-old neighbor. The girl raced from the house.
Cantu said he cannot recall the incident. "As to what happened, I have no idea," he said. "I don't remember anything else."
He was charged with indecent sexual contact with a child.
The next month, on Dec. 7, 2001, Cantu's Texas medical license was suspended. But a week later he appeared at a local pharmacy with a prescription he had written for himself for Demerol. An alert pharmacist contacted the DEA and Cantu was arrested. When police searched his car, they found a .22-caliber rifle that Cantu said he purchased at a gun show. Police said it was stolen from the Nashville Police Department.
"It was broken," Cantu said. "Here in Texas everybody has a rifle."
Cantu hopes that he will be released soon and that he will get his license back.
Anderson said, "That is very unlikely."