Aren’t opioid pain medications like OxyContin© “addicting”? Even my family is concerned about this.
Drug addiction means using a drug to get “high” rather than to relieve pain. You are taking opioid pain medication for medical purposes. The medical purposes are clear and the effects are beneficial, not harmful. If you or your family have concerns about addiction, please talk to your doctor or another member of your healthcare team. This fear should not stand in the way of relief from pain.
—LATE 1990S PURDUE PHARMA PATIENT BROCHURE: OXYCONTIN: A GUIDE TO YOUR NEW PAIN MEDICINE
Alli Walton couldn’t take the pain anymore. Her limbs ached. Her bones hurt. Her head throbbed. She was sweating, shaking, and anxious, a mess of cravings and illness. She called her doctor—he was on vacation. She went to the hospital—they refused to give her what she knew she needed. There was only one place left to go.
There were men and women waiting, chatting, smoking, and wheeling-dealing outside of 132-59 41st Road in Flushing, Queens. Alli recognized some of them and kept her head down. There were rules in this place and she was about to break every one of them. She stepped down the dirty concrete stairs, past the graffiti and urine stains, to the basement level. There she opened the door and hurried down the hall, then to the right, toward the green metal door, darting past all the other patients. The closer she got, the harder they glared. Would anyone call her out for cutting when they had all been waiting since the early morning? She couldn’t care—she felt like her body was giving up, and there was no other way. It wasn’t about feeling good anymore. That had ended ages ago. It wasn’t even about feeling normal anymore. She couldn’t even remember “normal.” The first time she’d come, just over a year earlier, she’d been a healthy nineteen-year-old, with a loving family, a boyfriend, college ambitions, and a future in the family business. Now all she wanted was to survive. To stop the tailspin, to hold still, to breathe, to quit the consuming, hungry pain of withdrawal. It used to be about the feeling she had when she took the pills—they numbed everything in her body and she just drifted out of reality. Now the only thing she felt was not having them, never having enough.
The receptionists stared at her. “I need to see the doctor,” she told them. “I’m sick. I need to see him now.” The receptionists glanced around the waiting room, filled with others who looked just like her: tense, pale, anxious, impatient. They looked up her name. You’ve been discharged, they said, you can’t see him. She knew it was useless to argue with the receptionists—she’d been there often enough to know it wouldn’t get her anywhere, and she didn’t want to risk drawing the attention of other patients. Without another word, she turned and ran down the hallway toward the office where she’d seen the doctor go on his lunch breaks. She opened the closed door. He was there, in his white lab coat, sitting at the table and eating.
“I’m sick,” Alli said. “Please help me.” She couldn’t hold herself together anymore and began sobbing. “I’m so sick. I need more; please help me. You started me on this, and now I can’t stop anymore. I tried everything. I can’t get another doctor; I can’t get more pills.”
“I told you not to come back,” he said. “It wouldn’t look good. I told you not to come. You’re not my patient anymore.”
“I know,” she cried. “I know, but you don’t understand, I’m so sick.”
The doctor pulled out his prescription pad and pen. He began writing, then stopped. “You have the money?”
“I’m short,” she said. “Please.”
He stopped writing. He returned his prescription pad to his pocket. “No, no, no,” he said. “No. I can’t give it to you. This is not a free service. You have to pay.”
“Please,” she begged. “I’ll get more. I’ll go get more.”
The doctor waved his arms, gesturing at her to get out, go away.
She ran out, past the receptionists, down the hall, up the stairs, down the street. She ran until she found a cash machine, hoping she’d have enough. Once she finally held the cash in her hand, she ran back to the office, down the steps, down the hall.
Lunch break was over. “He’s with a patient,” one of the receptionists said. “You have to wait.”
“I have the money,” she said, holding the cash. “I need to see him.”
She hovered by the door to the office where the doctor saw patients, trusting that she wouldn’t have to wait long. The door opened, a patient emerged, and she swooped in, unfolding the bills on the desk in front of the doctor: $150 in cash. “I need my prescription,” Alli said. “Please, if you just give this to me you will never have to see my face again.”
The doctor took the money and put it into the pocket of his white coat. Without another word, he wrote out a prescription for oxycodone.
On that Saturday, November 27, 2010, I did not know Alli Walton. I did not know the doctor or his practice. In that moment, everything and everyone remained unconnected, unexamined. There was no team and no investigation. All the facts and records were out there, accumulating: cash transactions, patient files, prescription forms, prescription data, witnesses, bank records, autopsy reports, and insurance claims. Dozens of human lives intersected in the Flushing clinic: some unraveled as others thrived; some already had been lost while others still might have been saved.
In November 2010, I was a rookie ADA in the Office of the Special Narcotics Prosecutor (OSNP) for the City of New York, on assignment from the Manhattan DA’s Office. I’d just taken on my first pill case, involving a Russian supermodel, forged prescriptions, and a lot of Vicodin. Even as an ADA and a thinly stretched, separated mother of two small children, I lived in a state of privileged innocence: I believed neighborhoods were safer without drug dealers and that those suffering from addiction could find help; I had faith in lawyers fighting for justice and I trusted doctors to do no harm. On Saturday, November 27, 2010, specifically, I was four days away from launching an investigation that would consume the next four years of my life—and that doctor in Flushing, Queens, with a roll of cash in the pocket of his white coat, was three years, three months, and twenty-two days away from being the criminal defendant in a groundbreaking legal case.
It was dark outside. I’d been working late. Piles of paperwork required attention and, regardless, I didn’t want to go home. I could bear my empty office more easily than my empty apartment.
The long, wide hallways that during the day echoed with the hurried footsteps of ADAs, the sputter of police radios, and our civilian-alert system for undercover detectives (“UCs, clear the halls!”) had gone silent. Any ADAs still around worked quietly at their desks, writing motions, preparing trials, or filling out indictment paperwork that still involved carbon-copy forms.
On my way to the ladies’ room, I passed my bureau chief’s office and was surprised to see her sitting at her desk after hours, illuminated by a reading lamp. She was rigorous in her use of office time, relentlessly organized, and committed to her family dinners. Also, rumor had it that “ice-cold water” ran through her veins and that she sometimes did a few minutes of yoga behind closed doors. In other words, she was an excellent and efficient boss who happened to be a working mother.
My chief spotted me and waved. From the far reaches of her oblong office, a Red Sox outpost in Yankee land, she stretched out her arm to hand me a tiny yellow Post-it.
“I got a call from an NYPD detective,” she said as I took the note. “They’ve received a complaint.” This was it:
Dr. Stanley
41st Rd
She’d scrawled the detective’s name and phone numbers in the margins.
“It’s about this Dr. Stanley,” she said. “According to the complainant, he is prescribing medication to young kids who don’t need it. Can you look into it?”
To this day, I don’t know whether my assignment to this case happened by mere coincidence. Had I done a good job on my other pill case? Or did she pass me the tip simply because I happened to walk by?
What kind of medication? I asked. Did we know anything about the tipster? Is the doctor selling pills or just writing prescriptions? The chief’s smile and expression revealed that she had no further information. It was up to me to find the answers. I returned to my office, armed with the tiny square of paper that would change my life.
In that moment, the doctor’s world and mine intersected for the first time. Although he long may have feared the authorities, he did not know there was a prosecutor in an office just a few miles from his clinic who was about to start asking a lot of questions.
When I first spoke to the NYPD detective, he gave me the street address and told me that the doctor’s name was, in fact, Stan Lee, “like the Marvel guy.” We agreed to name the case Operation Marvel, even though it wasn’t a formal investigation yet, just a new, empty folder on my desk.
Days passed. I called the detective again. When could I meet the complainant? The detective assured me he would set up the meeting soon, but there were just a few bureaucratic hurdles to overcome first, just “routine.” Then—nothing.
Turning away from my chipped wooden desk, toward the computer table to my right, I decided to do some research. My children had scotch-taped drawings to the wall on either side of my screen during a visit to the office, and now their love always framed my work. I found a pain management practice at 132-59 41st Road, but the doctor’s name wasn’t Stanley or Stan Lee: it was Stan Xuhui Li.
The fifty-seven-year-old physician had excellent credentials: medical school in China, a fellowship at the University of Pittsburgh Medical Center, a residency at the Rutgers New Jersey Medical School, board certification in Anesthesiology and Pain Management, a license to practice medicine in New York and a job as an anesthesiologist at a teaching hospital in New Jersey. How did he run a pain management practice in Flushing if he was employed full-time by a hospital in New Jersey? Could this really be the guy?
I took a virtual stroll down 41st Road: Dr. Li’s clinic occupied a quiet section between College Point Boulevard and Flushing’s Main Street. Around his block, an adult daycare center, an office for the National Committee of the Democratic Party of China, a dental practice, and a pharmacy adjoined small residential homes and low-rise apartment buildings. Li’s office was on the basement level of a beige brick residential building, which also held an internal medicine practice. A gray cement staircase descended from the street straight into the basement, with a small sign in Chinese and English indicating the pain clinic.
What defined the specialty of pain management? I wondered. What kind of conditions do pain management physicians treat? What are the range of available treatment options and common medications used? Apparently, these included opioid painkillers, such as oxycodone and morphine, as well as other medications I knew to have addictive potential and high street values, such as Vicodin and OxyContin.
I read about Purdue Pharma, the manufacturer of OxyContin. A page on their website proclaimed partnerships with law enforcement to prevent diversion and abuse of the medication. This seemed curious. I tracked the initiative back to the 2007 settlement of “misbranding” lawsuits brought against the company and certain executives for having misrepresented the drug’s addictive potential. I read about the company’s relentless, misleading, and highly effective marketing of the drug, which included the slogan “OxyContin: The One to Start With and the One to Stay With.” Partners from my own previous law firm had represented one of the Purdue executives. Gulp. How had I not known about this? Had I been so deep in document review, marital strife, and maternal guilt? My former law firm’s involvement did not sit well.
Reading about the appeal of cheaper, more accessible heroin for those who had first become addicted to opioid painkillers, and the increase in supplies of heroin on the streets, I realized this meshed with what we’d been hearing and seeing as Special Narcotics ADAs—but there was still so much that didn’t make sense. If these cases were settled in 2007 with a clear understanding that the medications were, in fact, addictive and easily abused, how, in 2010, could overprescribing and addiction still pose such a problem, where an increasing number of Americans were dying of accidental overdoses?1 Hadn’t this case pointed to clear areas requiring oversight and caution? Of the more than thirty-seven thousand drug overdose deaths in 2009, almost twenty thousand had involved at least one opioid—nearly two thousand more human beings than in 2007.2
Was there any treatment for opioid addiction? I discovered that Dr. Li, of all people, was an authorized prescriber of buprenorphine and Suboxone, medications used to treat opioid addiction—he even appeared in an online directory of opioid addiction treatment providers. I made a note to follow up: at the very least, this additional licensing might indicate that he had been trained in the diagnosis and treatment of opioid addiction. What did this training entail? More cynically, I wondered about Dr. Li’s application of this knowledge: If, in fact, he sold prescriptions without a medical basis, did he also treat patients for addiction in order to profit on both ends? This would be a new low.
It was an unlikely scenario. After all, I was dealing with a well-educated, well-trained, licensed physician. He was accused of writing prescriptions for patients, but that’s what doctors do. The complaint alleged that the doctor sold those prescriptions in exchange for cash, without medical reason, but from this distance I couldn’t verify his rationale for the prescriptions or even the form of payment used at the clinic. All I had was this tip—a Post-it note and a few words—and I didn’t even have the tipster.
The Criminal Branch of the New York State Supreme Court shared the dark, glassy building at 111 Centre Street with the New York State Civil and Housing Courts. The Honorable Michael R. Sonberg, a graduate of Harvard Law School and former president of the New York Association of Gay and Lesbian Judges, presided over “Part 21,” the vast courtroom at the end of the hall on the ninth floor. Compact and keen, with his natty bow ties, long black robe, and neat goatee, Judge Sonberg held an iron grip on all proceedings and unleashed sharp commentary on unprepared attorneys. Under his supervision, and as soon as we had picked a jury, my team and I would try to reconstruct the events that had taken place years before in Dr. Li’s basement clinic. For the unforeseeable future, the courtroom, with its long, empty wooden benches and high ceilings, was about to become our second home. As I waited for the trial to begin, I read, over and over again, the brass letters on the wall: “In God We Trust.”
I sat at the prosecution table, in the part of the courtroom near the judge’s dais we called “the well,” inside the barrier that separated us from the public seating area. Our table was closest to the jury. Dr. Li sat next to his attorney, at the defense table to my left, near the court clerk. Between us, a chasm: he resented our prosecution and we rejected his brand of criminal indifference.
From the original tip I received in December 2010 to the execution of a search warrant in Dr. Li’s office in November 2011, through two indictments and hundreds of hours of work, the case had grown from a team of one to a team of many, from a few questions to an indictment, from a tense and suspenseful investigation conducted in secrecy to a high-stakes public trial. It was the first time in New York State that a doctor faced homicide charges related to the overdose deaths of his patients—and those were but two of the 211 counts we would seek to prove at trial.
My earliest partner on the case, Senior Investigator Joe Hall, a veteran NYPD homicide detective, had gumshoed his way through the boroughs of New York City with his fellow investigators for years, tracking Dr. Li’s patients, his employees, the relatives of his victims, and all the people who had tried to warn or stop Dr. Li along the way.
We’d rounded up seventy-two witnesses and enough physical evidence to weigh down a rickety two-tiered, four-wheeled, four-foot-long cart. This cart, sagging under the weight of several bulging boxes, would soon take its place between us and Dr. Li. We believed the documents would prove Dr. Li’s guilt. He and his lawyer believed they would exonerate him; more accurately, they believed that some of the documents would exonerate him and fought to keep the others out of the jury’s sight.
For the next eighteen weeks, the evidence cart would roll into court every morning under the custody and watch of an investigator. Over the course of each day, we discharged some of its contents onto our table, into the hands of the defense attorney, up to the witness stand, and onto the projector. At the end of each day, we gathered up all the exhibits and folders and replaced them onto the cart, and off it went with its official escort, laden with boxes full of patient files, boxes full of manila folders, boxes, boxes, and more boxes, everything labeled and stickered and carefully preserved and piled up high. When our first cart crumbled, we received approval to replace it with a tougher model, a sturdier cart that had mountain-bike wheels we hoped would survive the trial.
Each box, each folder, each slip of paper, each witness, resulted from years of work. Not just my work—the work of a small, committed army of professionals and civilians determined to seek justice and outraged by the damage that Dr. Li had caused.
After each day in court, we’d emerge to find Joe waiting in the hallway. From our years spent working together on this case, he could always tell just by looking at me how the day had gone. He raised an eyebrow. I shrugged. We checked the hallway for jurors before speaking.
“That good, huh?” He gave a chuckle and tried to relieve me of the giant binders I carried. I resisted: “It’s the only exercise I get!” Joe and I walked as a pair, while our analyst, Jon Courtney, steered the evidence cart and maintained a sarcastic banter with my trial partner, Assistant District Attorney Peter Kougasian. Much as I enjoyed Joe’s company, I knew he wasn’t there to mingle. Instead, he ensured chain of custody for the evidence and never let it out of his sight, except when it was in court or locked up for the night.
At the end of our trial days, the four of us always rode the elevators down in cautious silence, then swept out of the building for the short, liberating two-block walk from the courthouse to our offices at 80 Centre Street. Under Joe’s eye and with his occasional assistance, Jon wrangled the cart over and around bumps, curbs, and potholes. We all enjoyed a few rare minutes of “fresh” New York City air as we crossed between the two buildings where we spent the majority of our time. Once in front of our office, Jon and Joe veered off to make the dicey descent down the steep driveway with the cart, while Peter and I rode—again in silence—up to the sixth floor, to the OSNP where we all worked, to prepare for the next day of trial. We were just another two tired schlumps in the elevator, sharing a lot of responsibility and a mercurial working relationship. For all the years I’d been working in the office, working with Peter, working on this case, I still wondered when it would all get easier—or if any of it would ever get easier.
The first time I had entered this building, I’d ridden up to the eighth floor, crammed in with a bunch of fresh-faced law school graduates in brand-new suits. Despite emerging from more than four years in a law firm as a married thirty-four-year-old “lateral” with two children, I was just another rookie Manhattan ADA. My fellow rookies, most of them a decade younger, were excited, energetic, and looking forward to the social lifestyle that came with the job as much as the job itself. I, on the other hand, was distracted by tricky timing—the overlap of my first week in a new job with the first week of my kids’ school—and shell-shocked by the recent realization that my marriage was in tatters.
While the other rookies compared assignments, traded rumors about the various trial bureaus to which they had been assigned, speculated about the cases they might expect to have on their dockets within a few months, and planned the evening’s drink outings, I checked email to make sure I had given the babysitter the right information for my elder child’s school dismissal and wondered how I could fix my life. Public service had been my goal and dream for years: I had always wanted to work on behalf of crime victims. I was finally in the right place, especially with my first assignment to the Appeals Bureau, but my head and heart were torn.
My husband and I had been together for nine years. We used to laugh together until we cried. We’d adored, understood, and found solace in each other. Shortly after our marriage in 2001, my French-Tunisian grandmother yelled, “Bébé! Bébé!” at my new husband over a long-distance call, making clear her impatience for great-grandchildren. My husband and I laughed, confident that it would all work out, that we would be great parents together.
Unfortunately, my grandmother died when I was eight months pregnant with our first child. I’d missed so many opportunities to go see her in France because it was never “the right time.” I was so angry at myself for having let that happen. Was it an accident, one of those things in life you can’t control? Was it the result of my bad choices? Was it an early symptom of the expanding deadlock that would eventually condemn our marriage?
In the meantime, my husband and I were lucky: we had two healthy babies. In September 2008, our son, Charlie, was two years old. He had curly brown hair, the softest cheeks in the world, and a tiny little huggable body. He didn’t speak much yet, but he loved to sing—especially “Hit the Road, Jack,” in his phonetic toddler mumble. His big sister, Nina, was about to turn five. She spoke French with me, English with her dad, and both languages at the same time when she really, really needed something—like chocolate. She loved everything about school—the fresh pencils, the glue sticks, the songs, the lunch boxes—and hated bedtime.
More than anything, I wanted to be a good mother and have a happy, steady family. I had a pretty good idea of what that should look like, from movies and books and childhood, so why wasn’t it happening? Well, I worked long hours at the law firm despite my “part-time” status; I couldn’t seem to help Nina feel safe and comfortable at bedtime; I couldn’t fix my husband’s work conflicts, prevent his unhappiness, understand our complicated relationship, get enough sleep, make one week go by without having it all rip at the seams, shake the feeling of guilt and anguish that gutted me every morning the minute I woke up and caught me in the throat during the day or in the middle of the night when I wondered who I was, what I was doing with my life, and why everything felt so frantic and so wrong and so unstable. Was there someone to blame? Was it me?
By the time I joined the DA’s Office in September 2008, my husband and I couldn’t seem to have a simple conversation or plan a simple outing. We’d lived in several apartments and never managed to settle in any of them: we’d start with big ideas and end up with temporary arrangements, tangled cables, unpacked boxes, and unfinished projects. We couldn’t align our schedules and lifestyles enough to share a meal or agree on even the smallest parenting decisions, like whether the kids were hungry or tired. We both had such clear ideas of what a relationship and family should look like, but we’d just never realized they were so different. Like tectonic plates, we were out of alignment, each resistant and defensive and aggressive in protecting our turf, occasionally building up so much tension that it all exploded. Our incessant, cumulative conflicts suffocated me, but I clung to our children and our fantasies of a happy family life.
The month of August had been raw, unpredictable, scary, and demoralizing: incompatibility had turned into outright hostility. With my insides jumbled and my home life uncertain, the predictability and community of rookie training offered relief—and over time the job got better at providing the purpose I needed to survive.
During my first two years at the DA’s Office, in the Appeals Bureau, I studied New York State criminal law and wrote briefs, emerging only for short bursts of adrenaline-fueled arguments in the Appellate Division’s ornate courthouse near Madison Square Park. With the help of an antidepressant, my blind anguish gave way and I became functional again. With functionality, however, came the stark realization that my marriage might be over. My work was taking shape—but was my life about to fall apart?
The OSNP unfolded around a lengthy ring of hallway, with certain sections extending so far that, seen through the haze of late-night eyes, they seemed to bend at the end like a mirage. Even at its busiest, the place never quite bustled, but I suspected there was a lot happening behind all those closed doors.
The City had founded the OSNP in 1971 in response to a sweeping heroin epidemic. As we learned in OSNP rookie training, Governor Rockefeller’s vision of curing addiction through institutional residential treatment had failed, his eponymous drug laws were about to take effect, and the office was expected to either handle or coordinate all of the City’s felony narcotics prosecutions. While the other boroughs agreed to participate to varying degrees, the Manhattan DA’s Office channeled their entire felony narcotics caseload to OSNP and continued to do so until the crack epidemic in the late 1980s overwhelmed OSNP’s capacity. Through the stories, photos, and archives of old-timers, we learned about those times: undercover officers wearing bulky recorders taped to their chests; the office’s first surveillance van, upholstered in plaid fabric; the ravages of heroin abuse and crack addiction on human bodies, on families; the outdoor drug markets; the days of nonstop court appearances; the stark rise in incarceration rates. Nobody viewed them as glory days: those were hard, dark times and their legacy was under constant scrutiny. The agency was committed to learning, evolving, and doing everything within its power to protect the public from another epidemic.
The 1970s left their mark on our office décor, if nothing else. The wooden doors had pebbled glass cutouts with old-fashioned lettering; large offices had high ceilings, drab upholstered chairs, and banged-up metal filing cabinets. With warm amber lights, a quick polish of the wood, some steaming white take-out containers, and a group of photogenic ADAs debating the law around a table, you’d have gotten close, if you really, really squinted, to a classic crime procedural movie scene. But in real life, we worked in dusty offices, snagged our budget suits on peeling laminate strips and rusty fixtures, wondered why the electrical sockets on our walls stood at eye level, and found 1980s-era Chinese food menus stuck behind our desk drawers, along with hairballs and old pennies. Bedbug-sniffing beagles were called in at least once a year, and when we worked late we budgeted ten to fifteen minutes round trip to pick up our food deliveries from the security desk downstairs because the hallways were so darned long and most of the elevators went to sleep in the evening.
My boss, Special Narcotics Prosecutor Bridget Brennan, occupied a corner office overlooking Foley Square. Bridget was the first woman to serve in her position. She had been appointed by the elected district attorneys of the five boroughs in 1998 and continued to lead the agency with a discreet and innovative efficiency. A former journalist from Wisconsin who’d served as a homicide assistant in Manhattan during the crack epidemic, Bridget had two compulsions: fact-checking and public safety.
She created the Narcotics Gang Unit, the Money Laundering and Financial Investigations Unit, and expanded the agency’s commitment to drug treatment programs as well as community outreach, reinvesting forfeited funds back into the affected neighborhoods. With OSNP indictments down from seven thousand a year in the days of the crack epidemic to under two thousand and a renewed focus on treating addiction as a disease rather than a crime, the office developed a specialty in prosecuting violent drug organizations and identifying emerging threats.
When I joined in June 2010, Bridget was as much of a mystery to me as she was to many assistants: while she addressed us with warmth and often walked the halls, stopping to inquire about cases of interest, her attention and concern seemed trained on a longer horizon. In fact, Bridget was on high alert: she had been tracking the emergence of a grave threat.
“Typically,” she later testified before a New York State Senate Committee Roundtable, “our work has involved illegal substances […] which come in from outside the country. And there are relatively predictable organizations behind the distribution of these drugs—cocaine and heroin primarily. With prescription drugs, it’s a whole different ballgame. […] [W]hen I reviewed our cases [in 2010], I saw a good 15 to 20 percent of our cases involved opiate drugs, opiate drugs mixed with heroin and cocaine, opiate drugs mixed with guns, opiate drugs found in search warrants, all over the city. And it was clear to me we had a problem. I then tried to figure out the source of the problem because there is a very robust black market in these drugs. But I was […] stunned to learn that the number of opiate prescriptions in New York City had increased by about 100 percent, between 2007 and 2010. So I knew that, while we may have a black-market problem on our hands, we also had a problem with respect to the drugs being prescribed.”3
Bridget had access to the latest, freshest data about illegal drug supplies, suppliers, and drug-related deaths. Nevertheless, she labored to make sense of the numbers. While we all sensed danger, we had no idea of the horrors that lay ahead. All of us would have been sickened to know that, by 2016, the death toll in the United States would have doubled that year alone. By 2016, more than sixty-three thousand human lives would be lost from drug overdoses alone, and that more than forty thousand of those deaths would involve at least one opioid.
If anyone out there had enough information to understand what was happening, to stem the tide and save those lives… why weren’t they doing so? That’s the painful reality of prosecution: as we try to piece together the past, criminals are still hard at work profiting from future disaster.