Timothy Kroll got migraines. Bad ones. But he hated taking pills so he tried other things. Acupuncture. Trips to a chiropractor. Nothing worked.
Desperate, he finally saw a pain specialist. The doctor prescribed oxycodone. Timothy got hooked. He graduated to heroin and cocaine.
In 2009, four years after he first saw the doctor, Timothy died of a heart attack at home in Lindenhurst. He was 23.
His mom, Teri Kroll, tells the story like it was yesterday.
A decade later, the opioid epidemic drags on. And as time has passed, the war has widened: addicts are being pulled back from the brink of an overdose with another drug, Narcan; street dealers are facing a murder charge when a buyer accidentally ODs; and doctors are being watched — scrutinized — so they aren't doling out pills to patients desperate for relief.
The eyes on doctors are everywhere.
The state tracks the number of prescriptions that a doctor writes with an electronic database — a digital "gotcha" if the numbers increase.
Hospitals have tracking systems, too. Every narcotic pill is accounted for: who prescribed it, who administered it and who took it.
The safeguards, though, aren't foolproof.
Dozens of doctors in seven states, mostly in the Southeast, are facing federal charges tied to illegally prescribing 32 million pain pills. The Justice Department described the bust this week as the government's biggest opioid takedown ever.
On Long Island, all the measures put in place have paid off. Opioid prescriptions have dropped by more than a third, from a high of nearly 1.4 million in 2011 to 912,000 in 2017, state health records show.
All the tactics together — the Narcan, the tracking, the law enforcement work — are starting to bring down the number of opioid deaths, which total roughly 3,700 since 2011. The number fell last year to 483 after hitting a record 614 the year before, according to data from both counties.
The multipronged approach, including the policing of doctors, has “changed the trajectory” of the crisis, said Jeffrey Reynolds, a leading expert in addiction prevention and treatment on the Island.
“Just because you wear a white coat and a stethoscope doesn’t mean you [should] be treated any different from your average drug dealer,” said Reynolds, who heads the Family and Children’s Association in Mineola, a nonprofit social services agency. “If you are part of the problem, rather than the solution, you should be sitting in jail.”
Under a microscope
In New York, the days of doctors writing down prescriptions on paper or going over to the hospital cabinet and pulling out bottles of narcotics are long gone.
Now, virtually all prescriptions are electronic and many hospitals keep digital tabs on the dispensing process — from start to finish, said Dr. Kevin L. Zacharoff, who teaches at the Renaissance School of Medicine at Stony Brook University.
All 22 of the nonprofit hospitals that belong to the Nassau-Suffolk Hospital Council have electronic dispensaries, said spokeswoman Janine Logan. Authorized employees swipe a key card or input a pass code that triggers a tracking system, she said.
“There are controls in place," Logan said. "You can’t just walk up to a cabinet and take drugs.”
New Hyde Park-based Northwell Health is the biggest operator of hospitals on Long Island and uses the same protocol at all 12 of its locations.
Prescriptions for controlled substances are all electronic, said Dr. Annabella Salvador, Northwell Health's vice president of medical affairs.
The monitoring system flags a doctor who appears to be overprescribing and, in turn, the hospital acts, Salvador said. Depending on the seriousness of the matter, the action can be anything from a sit-down with a superior, to suspension, to criminal charges, she said.
After a doctor orders a prescription, Salvador said, a nurse retrieves the medication from an electronic dispensary by putting in his or her user name and fingerprint. Entering the unique identifiers creates an electronic record, another step in the tracking process.
Any medication left over has to be disposed of with two nurses present to ensure the extra amount isn't stolen, Salvador said.
Each hospital also has a central pharmacy that has layers of security, Salvador said. At Long Island Jewish Medical Center, for example, drugs are kept in a combination vault that can be opened only with an identification card, she said.
Cameras are mounted both inside and outside the vault to monitor the handful of pharmacists who are authorized to dispense the medication, she said.
At Stony Brook Medicine, every prescribing physician receives a monthly report of his or her prescription orders, which are tracked by what media relations manager Greg Filiano called an electronic medical records system.
Stony Brook Medicine also requires every staff member to answer a series of questions related to personal illegal drug use and attest to their prescribing practices, Filiano said.
New York's Internet System for Tracking Over-Prescribing, or I-STOP, has been in place since 2012, when New York enacted sweeping reforms that zeroed in on how doctors handle drugs.
The landmark legislation made New York the first state to make doctors check a patient’s prescription history before writing a prescription for opioids and required all prescriptions to be transmitted electronically to pharmacies.
Four years later, state lawmakers passed another law intended to reduce oversubscribing. They lowered the limit for initial opioid prescriptions for acute pain from 30 days to no more than seven days. The law includes exceptions for chronic pain and pain being treated as a part of cancer treatment, hospice or other end-of-life care.
The state Health Department periodically monitors and analyzes I-STOP's electronic database to determine whether a doctor has violated the law or breached professional standards. A violation can lead to a one-year prison sentence, permanent revocation of the practitioner’s license and a fine up to $2,000.
"At the state level, they are really embracing the idea that the state has a significant role in trying to curb the opioid overdose epidemic," Zacharoff said.
Doctors policing themselves
The roots of the opioid epidemic are in massive overprescribing, said Dr. Anna Lembke, a psychiatrist at Stanford University who wrote a bestseller titled "Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop.”
Still, Lembke is quick to point out that so-called pill mill doctors are the exception to the rule.
Most pills, she said, are prescribed by well-intentioned doctors caught in a health care system that forces them to see dozens of patients a day, many complaining of constant pain and wanting immediate relief.
On Long Island, doctors are increasingly recognizing their role in the prescription drug crisis.
"We acknowledge that we are part of this and that we have to be part of the solution," said Dr. William Spencer, an ear, nose and throat specialist in Huntington.
Spencer, also a Suffolk County legislator, laid part of the blame on the pharmaceutical industry for misrepresenting the addictive properties of painkillers.
Dr. Thomas F. Jan remembers how stunned he was 10 years ago when a dentist prescribed 90 Vicodin pills for his 16-year-old son after he had a wisdom tooth pulled.
"I was like, 'Are you kidding me?' " said Jan, a pain and addiction specialist in Massapequa.
And many doctors are setting their own limits.
"I routinely do not prescribe opioids unless it is post-surgical," said Dr. Adam Bitterman, an orthopedic surgeon in Huntington.
Moreover, he said, patients are educating themselves about the dangers of narcotics.
"Patients do not want them in the house," Bitterman said.
Jan is troubled that a good number of doctors have become skittish about prescribing opioids because of all the oversight. They worry about the state always watching, maybe pulling their license.
"A lot of them don't even want to bother anymore," Jan said. "If a doctor is doing the right thing, they have nothing to fear from the state."
Dr. Thomas Madejski has seen the same reluctance statewide in his role as president of the Medical Society of the State of New York.
"They're telling their patients, 'You're going to have to find somebody else,' " said Madejski, who practices upstate in Orleans County.
Catching the bad guys
Leading the criminal crackdown on Long Island is the Drug Enforcement Administration's Tactical Diversion Squad, which has officers from the Nassau, Suffolk, Port Washington and Rockville Centre police departments as well as members of the federal Department of Health and Human Services.
Since 2008, the Island-based task force has arrested 33 clinicians — 17 doctors, six physician assistants, seven pharmacists, a nurse, a medical assistant and a pharmacy clerk, according to DEA Associate Special Agent in Charge Keith Kruskall.
“These are individuals that were driven by greed to cut corners,” Kruskall said.
The bad actors operated two ways, said DEA Special Agent Erin McKenzie-Mulvey. Some sold directly to patients for up to $300 a prescription and others worked with patients who sold the drugs to street dealers, she said.
The Long Island clinicians together dispensed millions of pills, often without medical exams and occasionally without even meeting with patients, she said.
Dr. Ernesto Lopez, for example, operated clinics in Franklin Square, Manhattan and Jackson Heights, Queens. Between 2015 and 2017, federal prosecutors said, Lopez made an estimated $2 million by writing more than 8,000 oxycodone prescriptions without examining any patient. A jury convicted Lopez on nine felonies in February; his sentencing date is in June.
“I-STOP has helped us close the gap and catch some of the low-hanging fruit,” said Nassau County Police Commissioner Patrick Ryder, referring to doctors brazenly ignoring the law. “As a result, the doctors are not as blatant as they once were.”
Timothy Kroll, the young man with migraines, had reported his doctor, Dr. Saji Francis, to law enforcement.
In 2009, the same year Timothy died, Francis was videotaped by a surveillance camera selling prescription drugs to undercover officers in his office — a block from Massapequa High School.
Francis pleaded guilty to nine felonies of illegally selling oxycodone and lost his medical license but wasn't charged in Timothy's death. Eventually, he was deported to his native India.
“It disgusts me as a mom," Teri Kroll said. "He should have been charged with murder or manslaughter.”
Today, Teri Kroll is an advocate for families struggling with addiction and a strong voice for holding rogue doctors accountable.
“These are not doctors. They are drug dealers,” she said. “And they should be tried as criminals."