PROLOGUE Gavin Awerbuch had a long commute, but often he arrived at work before dawn. After an hour and a half ''s drive, his headlights would swing into the parking lot, illuminating a one-story beige brick building that resembled a shopping plaza, divided into storefronts. It was Saginaw, Michigan. In the winters it was frigid. Awerbuch would get out of his Chevrolet HHR, and when he was the first one there, he would unlock the door. He worked in the unit farthest to the right, where his name was stenciled in white letters on the glass door. Awerbuch was too busy to pay much attention to his appearance. His graying hair sprouted in every direction, and he was often unshaven.
At the office, he wore casual clothes--a sweatshirt and jeans, perhaps. He was disheveled enough that people wondered if he had slept in his outfit. His lab coat looked as if it could use a wash. He would shrug it on over his street clothes after he arrived at the office. Then the people would come, in a constant flow. Awerbuch was a doctor. He was educated at Michigan State, the University of Arizona, and Wayne State University in Detroit. In 1989, he completed the specialized training to become a neurologist, treating conditions of the nervous system.
In the early years, his prac- tice evolved from focusing on disorders such as stroke and multiple sclerosis into managing pain in a broader set of patients. People came to him suffering from migraines, neck pain, back pain. By 2012, Awerbuch''s clinic was a major medical destination in the area, about ninety miles northwest of Detroit, not far from Flint. Awerbuch had around five thousand active patients, pouring into the small office suite at a rate of perhaps fifty a day. Some of them drove for hours to see him, from as far away as Michigan''s Upper Penin- sula. The wait was long once they got there. Awerbuch had opened his clinic in the area in order to cater to an underserved population. The city core of Saginaw is predominantly black, but Awerbuch''s clinic was located on the outskirts, where the city gives way quickly to farmland with a majority-white, blue-collar population.
In the wake of the global financial collapse, jobs were in short supply. With the near collapse of the Big Three carmakers, a top local employer, an auto-parts manufacturer, had become a shell of its former self, shedding workers and entering bankruptcy before being purchased by Chinese interests. A lot of Awerbuch''s patients wore work jackets or camouflage. Many were retired or on disability. More than half were on Medicaid or Medicare. Walkers, braces, and wheelchairs were a common sight at the clinic. To patients, Dr. Awerbuch appeared to be a man of great decency, ministering one at a time to their deeply personal needs, with the unpretentious air of a social worker.
He was a small man and never intimidating or confrontational. He wasn''t one of those doctors who let you know that he had power over you. He cared for his patients, many of them said. He took their pain seriously. By this time the medical community was grappling with the fact that the prolonged boom in opioid prescribing that had begun in the late 1990s had helped to create a nationwide health crisis. Now, heightened scrutiny and changing medical opinion were altering the landscape of pain management. Many physicians were beginning to turn away from prescribing opioids over the long term or at high doses. Instead, doctors were referring patients struggling with chronic pain to specialists such as Awerbuch.
This was not simply a matter of deferring to the experts; it was also a way of dumping a difficult problem on someone else. Treating pain is demanding and sensitive, and liability comes with the territory. Awerbuch became, for many patients, a port of last resort, a man who would give them the potent medications they depended on when other doctors would not. IN JANUARY 2013, a regular patient made the trip to the clinic in Saginaw. He told Dr. Awerbuch that his back pain was manageable, ranging from a 3 to a 4 on a scale of 1 to 10. He had been riding motorcycles lately, he added, making conversation. The patient said the Vicodin that Awerbuch had put him on seemed okay, but he asked for a prescription of the painkiller OxyContin.
Awerbuch told him that he ought to try a new medication instead, and showed it to him. The doctor held in his hand a small plastic bottle with a spout that extended from the top like a periscope. The medication was a liquid spray, and Awerbuch explained that you shoot it under your tongue. The drug had only just been approved the previous year. It was called Subsys. It is an opioid many times more powerful than OxyContin. What Awerbuch didn''t know was that the patient at this appointment was an undercover agent. The whole encounter was covertly recorded on video.
At least three agents had been seeing Awerbuch for many months, posing as patients and concocting fake medical complaints. At the outset of their investigation, the authorities were looking into the doctor''s prolific billing for certain diagnostic tests, which measure electrical activity in nerves and muscles. Their suspicions turned out to be well founded. Over and over in their undercover visits, Awerbuch used needles and probes that may have looked right to patients, but the exams were bogus--a brief pantomime performed for show. Sometimes the needles and probes weren''t even connected to a machine. Agents at the U.S. Department of Health and Human Services Office of Inspector General, or HHS-OIG, see a lot of insurance fraud like this.
It''s a major drain on federal programs. Some doctors look at the checks that come back from Medicare or Medicaid when they invoice for testing and they get ideas: Who would know if the tests they administered were even real? They might rationalize their cheating with the thought that the patients aren''t getting hurt. But prescribing Subsys for moderate back pain--that was some- thing different. Awerbuch''s permissiveness with opioids had already raised flags, but the HHS-OIG special agent on the case, Marc Heggemeyer, straightened up and took notice when Subsys appeared unprompted in that undercover visit. "That was where we first started really drilling into it, the amount he was prescribing," he recalled. "Because once you did the research on that drug, it was like, ''Whoa, this is serious stuff.'' " The liquid in the Subsys spray bottle that Awerbuch held in his hand was fentanyl. For decades after it was first synthesized in 1960, fentanyl had been approved only for patients under medical supervision, in hospital settings.
Subsys doses are measured in micrograms-- one-millionth of a gram--because fentanyl is up to a hundred times as powerful as morphine, and roughly fifty times as potent as heroin. At the time of the investigation, illicitly manufactured fentanyl, often pressed into counterfeit pills or spiked into heroin, was starting to become the leading culprit in the opioid crisis, the deadliest drug epidemic in American history. By 2017, fentanyl and its analogs would be implicated in more than half of all opioid fatalities. Subsys had been approved by the Food and Drug Administration solely to treat a relatively small group of people in dire circumstances: cancer patients who are already taking an around-the-clock regimen of opioids but still suffering from so-called breakthrough cancer pain. The term refers to spikes of pain that pierce through the protection of a longer-acting painkiller such as OxyContin. Drugs in Subsys''s class are valuable for this use because they''re fast. They can combat pain so severe that the patient might otherwise go to the emergency room. They can give comfort to a person near the end of life.
The narrow profile of this powerful drug was not stopping Dr. Awerbuch from handing out an extraordinary number of Subsys prescriptions. -- Heggemeyer and a special agent at the Federal Bureau of Investigation, Travis Lloyd, set out together to interview some of Awerbuch''s Subsys patients. They were disturbed by what they found. They visited a young mother named Kendra. She was a tall woman in her early twenties, with a narrow face, light-colored hair, and a wispy voice. It took her some time to answer the door. She seemed worried that she was in trouble.
In the family room of her small house, the two agents sat on one wing of an L-shaped couch while she sat on the other. Little natural light penetrated the room. Awerbuch had treated Kendra''s mother, who was glad to find him after she had been passed around by other providers. Kendra had gone to the doctor complaining of back and neck problems stemming from a car crash, among other chronic conditions. She had never had cancer, nor did she know that Subsys was only approved to treat cancer pain, she said. She gazed at the agents with glassy eyes, they recalled. It was as if she were looking through them. They asked for her driver''s license.
"The young woman in the photo was not the person we saw sitting before us," Lloyd recalled. "It looked like the life had been drawn from her face." Across the room, a young girl played at a toy kitchen. They worried for the child. Heggemeyer sensed that Kendra was initially hesitant to implicate Awerbuch. They wondered if she didn''t want the prescriptions to stop coming. This became a recurring issue in their interviews; patients were protective of Awerbuch, for a range of reasons. They seemed loyal to the doctor they thought they knew.
When the agents went to see another woman Awerbuch had put on Subsys, however, her husband had no problem condemning the doctor. He was furious. Awerbuch had kept feeding his wife opioids.