Gambling Addicts Look to Beat Odds
Patrick Kampert, Chicago Tribune- 10/12/2003

ST. CHARLES, Mo. -- The brick-lined streets at the hulking Ameristar Casino in this St. Louis suburb try hard to convey a nostalgic Midwest charm, a soothing contrast to the brassy lights of the gambling palace crowded with weekend revelers. To the left of the casino entrance,many first-time customers queue up to get their Star Awards card, which they will use to gain entry into the gambling room and place their bets. The line wraps around several ropes and seems to never wane.
    John Hartin is not among those at the casino. Hartin, who has voluntarily banned himself from the casino, is a recovering gambling addict. And though he lost thousands of dollars, he is one of the more fortunate ones, emerging with his family and home intact. What distinguishes a gambling addict such as Hartin from an occasional Ameristar visitor--and what steps help or hinder recovery--is what Harvard University researchers hope to find during the next two years by studying some of the 5,700 people who, like Hartin, have voluntarily banned themselves for life from Missouri's casinos. (From January to August of this year, an additional 928 gamblers banned themselves from the boats.)
    The Kansas City Port Authority, a governmental agency, recently awarded Harvard's Institute for Research on Pathological Gambling and Related Disorders a grant of $297,000 for the study. Missouri, whose 11 casinos had revenues of more than $1.3 billion in fiscal 2003, generally is considered the strictest regulator. Besides the Missouri Gaming Commission's Voluntary Exclusion Program--which includes criminal penalties if a banned person is caught on a gambling boat--the state also limits losses to $500 for every two hours. (The Missouri legislature recently defeated an effort to repeal the limit.)

$500,000 in the red
Hartin estimates that during a 12-year span he won $2 million but lost $2.5 million. He occasionally bet at racetracks in Illinois and Missouri, but said the arrival of casinos in the two states initiated his descent. "The boats came out," he said, "and I was ruined." Hartin, a one-time Chicago Cubs minor leaguer who played AA ball in the late 1970s in Midland, Texas, said four stints in rehab failed before treatment through the Compulsive Gambling Center in Baltimore and a renewed commitment to his Christian faith helped him begin to deal with his addiction in November 2000. "It gets to a point where it's not about the money," said Hartin, 48, sitting at the kitchen table inside his home in Pacific, a town just west of St. Louis. "It's about the high--winning that six grand in blackjack. It was a good, numbing feeling."
    Liesa Hartin filed for divorce twice; they were separated for about four years. "I saw a man who was successful in so many areas just become unsuccessful, a bottom-rung feeder," she said, watching her husband take on two of their children--Tori, 15, and Blake, 13--in a game of basketball in their driveway. "John is very smart. He was an excellent salesman. He's nice-looking. But because of this addiction, he just bottomed out completely," she said. The family is bonding again but still healing, Liesa Hartin said.
    John Hartin said his wife's parents provided $100,000 to prevent the family from going hungry or becoming homeless; his parents added $50,000. His sister and brother-in-law bailed him out of $20,000 in debts and paid for his treatment in Baltimore, which he said cost about $35,000. To get gambling money, he told lies to anyone with a wallet. He bounced checks. The worst offense hit at the core of his family's life. "I opened the video cabinet to show a Walt Disney video to our kids; he had pawned all the kids' videos," Liesa Hartin said.

Recalling the hardship
John Hartin doesn't have as many nightmares as he used to, but he does remember the 23 days spent sleeping in his car, the time he wore the same socks 10 days in a row and the occasions when he was awake for 96 consecutive hours. He said he and the casinos were partners in his addiction. "It's not fun and games for everybody," he said. "Ninety percent of the time, I saw 90 percent of the same people."
    Troy Stremming, vice president of Ameristar Casino and president of the Missouri Riverboat Gaming Association, disputes the notion that the industry makes most of its money off gambling addicts like Hartin."Ninety-nine percent of our customers don't have a problem with gambling; they utilize it responsibly," he said. "Those are the people we're seeking to bring here."
    Missouri's self-imposed casino ban has been copied to varying degrees by several other states. Illinois also has a lifetime ban with at least 800 people signed up, but it is less strict because it has an escape clause. After five years, a person can petition the gaming board to get off the list and resume gambling with an affidavit from a licensed mental health professional saying the patient is no longer a compulsive gambler.
    The status of Missouri as a pioneer in the field of helping gambling addicts makes it ideal for the study, said Chris Reilly, executive director of the Harvard gambling research institute. "It's an incredible database of information that can tell us a lot about the disorder," she said. "It's important for the Missouri Gaming Commission to figure out whether this is effective for the people who excluded themselves. Not all prevention works. Not all treatment works."
    Counselors trained to treat gamblers say the voluntary exclusion program has had mixed success with their clients. "Some of my clients are so afraid of going to jail that it has worked for them," said Stan Bier of Tri-County Mental Health Services of Kansas City, which received a Port Authority grant of $21,900 for gambling prevention programs that target teachers and children. "It has not worked for everybody," Bier said. "For some, it escalates the excitement of gambling by being there illegally, so they go there with a false ID."
    To sign up for the lifetime ban, a compulsive gambler must return to the scene of his or her temptation--one of the casinos--or go to a Missouri Gaming Commission office. Three clients asked Kate Lewis, a St. Charles psychotherapist, to accompany them to casinos when they filed their request out of fear they would gamble again if they went alone.

Ban process not easy
"It's not a five-minute process," Lewis said. "You walk in and you ask, `Where do you go to get banned?' Nobody seems to know. So you stand there with all the bells and whistles going off and you wait forever." Lewis said neither she nor a gambler's family members are allowed into the office where the sign-up occurs. "As clients describe it, they are almost pushed not to do it," she said. While Lewis said she understands the process needs to be difficult because the ban cannot be rescinded, she considers the program problematic. "It is harder than it should be and certainly not as effective as it should be," she said.
    Kevin Mullally, executive director of the gaming commission, acknowledges that the self-exclusion program isn't perfect, and said that's why the Harvard study is important. "We designed this program more on art than science. We've done it with public-policy theory and things that are based on practical experience," he said. "Now, the time has come for us to apply some science to this and see what we can learn from analyzing real data." Mullally said his staff may adjust the program, perhaps adding venues at which gamblers can sign up for the ban. He noted the lifetime aspect of the ban may be scaring compulsive gamblers away from the program and, thus, from getting treatment. So several options in the length of a ban may be offered in the future.
    For Hartin, who hasn't gambled for almost three years, the choice is obvious. "I cannot make another bet, because it might lead to 50,000 more," he said. The road to recovery is full of bumps, Hartin acknowledged, but he is grateful to be on the right path. So far, it's working. Hartin recently got his old job back.



Sweden Rethinks Care of Mental Patients
Karl Ritter, Associated Press- 10/12/2003

STOCKHOLM — With the arrest of a mentally troubled man in the killing of their foreign minister, Swedes' grief has turned to outrage over shortfalls in their psychiatric care system. Even before Sept. 10, when Anna Lindh was fatally stabbed while shopping at a department store, a spate of deadly attacks by mentally deranged offenders had raised fears that the Scandinavian welfare state could not protect its citizens from psychotic people. Then, the day after Lindh was attacked, a 23-year-old mental patient from an open-doors psychiatric clinic wandered into a kindergarten in Arvika, 240 miles west of Stockholm, and stabbed a 5-year-old girl to death.
    Three decades of reforms have softened Sweden's once-coercive approach to psychiatric care, in which lobotomies and sterilizations were common practice. But the even more liberal approach instituted in the 1990s has gone too far, critics say, and now innocent people are paying with their lives. "Death is on the loose It's a lottery which one of us runs into him," Jan Guillou, a best-selling author, wrote in a recent newspaper column. "In this massacre, Anna Lindh became victim No. 4." Guillou was including two attacks in May in the Stockholm area — an assailant wielding an iron bar who killed an elderly man and injured six people outside a subway station, and a driver who intentionally plowed into a crowd, killing two and injuring 30.
    As debate raged about the mentally deranged roaming the capital, news broke that Lindh's suspected attacker had prior convictions and documented psychiatric problems. The suspect, Mijail Mijailovic, a Swede of Yugoslav origin, hasn't been charged and says he's innocent.
    Further stoking the outcry was a letter in the tabloid Aftonbladet from Anders Moquist, whose daughter Sabina was killed at the kindergarten, bitterly denouncing the psychiatric reforms of the 1990s that were intended to help mental patients integrate into society. "Without this worthless new approach, maybe our recently murdered daughter would have been allowed to live," he wrote.
    Sweden takes great pride in its socialized health care. But now many are calling for special prisons and coercive powers to protect the public from psychotic residents. "The way the law looks now, we must release them even though we know there is an imminent risk that they take drugs again, that they become psychotic again and start fighting again," said Anna Aaberg Wistedt, head of one of two psychiatric emergency care units in Stockholm.
    Not everyone, however, believes straitjackets and forced medication are the right cure. "It makes me a bit nervous if you're going to solve the problems with a new law on coercive treatment," said Johan Cullberg, a psychiatry professor working for the Stockholm county health care authority. "We must not turn back the clock." Cullberg experienced Swedish psychiatry's dark era, before laws were changed in 1976, when 30,000 people were sterilized under coercion or pressure. Cullberg and others championed giving patients more say in their treatment. The old mental hospitals were closed, and most patients moved to open-door clinics or government-provided apartments. The number of hospital beds for the mentally ill dropped to 6,000 from more than 30,000 in the 1960s. The number of mental patients forcibly hospitalized fell to 2,250 in 2001 from nearly 10,000 in 1979, according to the National Board of Health and Welfare.
    "Hospital care and coercive treatment have been reduced to the point that a growing number of mentally ill are out in society without adequate support and without demands that they take medication," said Sten Levander, a forensic psychiatry professor at Lund University. "They become homeless, they abuse drugs and periodically become psychotic. It's in that phase that they commit crimes." He blamed the left-leaning Social Democratic governments that have ruled Sweden for six of the last seven decades and built its welfare state. They based psychiatric reforms on ideological assumptions that all coercion is bad and that all people, even convicted criminals, are good, Levander said. "The psychiatry that Cullberg represents is in a ditch on the left. Now we need to get back on the road, and it's quite far to the right."
    The present Social Democratic government staunchly defends the reforms and says county and municipal authorities are at fault for not enforcing them properly. But it promises psychiatric care will get budget priority and undergo a national review.



Upscale, But Within Meth's Grasp
William Lobdell & Mai Tran, Los Angeles Times- 10/12/2003

As the mother of a former crystal-meth addict, Marla Herman isn't surprised by what the drug can do. She watched her daughter, Renee DeMontreux, a former cheerleader at Redondo Union High School, go from a college student with a full-time job to a methamphetamine addict, dealer and drug-maker in less than a year. The change was "devastating and really quick," said Herman, 48, a Rancho Palos Verdes resident, adding with a bitter laugh: "That is the wonderful thing about meth."
    For those with firsthand knowledge of the drug, it wasn't a shock that Orange County sheriff's deputies arrested 22-year-old Adriean Volz last month on suspicion of converting her parents' 5,000-square-foot home in a gated Laguna Niguel community into a meth lab capable of producing $1-million worth of the drug each year.
    Though stereotyped as the drug of rural and lower-class neighborhoods, methamphetamine has become ubiquitous among drug-using teens and young adults no matter their economic or social status, say authorities and experts. "The drug doesn't hold any boundaries," said Ed Smith, 34, a former meth addict and now a director of Narconon Southern California, an inpatient rehabilitation center based in Newport Beach. "I've sold crystal meth to junkies and to businessmen inside million-dollar homes."
    Nor did it surprise meth experts that authorities said Volz and the three men arrested with her — including a pair of parolees — had used their profits to fund the Nazi Low Riders, a prison and street gang. Even those with affluent upbringings say that once hooked on methamphetamine, they quickly adopted "the meth lifestyle," which includes befriending a new group of people — fellow addicts, many of whom are involved in crime.
    In an interview, DeMontreux, 24, said she exchanged her well-to-do suburban friends for gang members and criminals after becoming addicted. "My boyfriend was in jail, and my dealer — who I helped cook the meth with — was shot and killed," said DeMontreux, a baby-faced blond who lost 50 pounds from her 5-foot-1 frame and was arrested three times during her addiction. Twice she was convicted of misdemeanor drug offenses and both times sentenced to probation on condition of undergoing treatment. She now helps others get off drugs and said she's been clean for nine months.
    Orange County sheriff's investigators say something similar happened to Volz. On Sept. 9 they arrested her and three male friends on suspicion of building a meth lab that nearly filled the large, expensive house where Volz lived. The woman's parents, who were undergoing a divorce, lived in other family homes. Police said the parents were unaware of the drug operation. The young woman's parents — including father George Peterson, president of an Irvine construction and development company — could not be reached.
    The high-profile bust underscored what authorities and meth experts have known for some time: Crystal meth's popularity has spread to all neighborhoods. "It's not only a poor person's drug," said Sgt. Chuck Chapman, an Orange County sheriff's deputy in charge of the countywide Proactive Methamphetamine Laboratory Investigative Task Force, formed in 1997. He added that in recent years meth labs have been found in upscale Dana Point, Niguel Shores, Irvine, Laguna Beach and San Clemente. "We don't get them often in multimillion-dollar homes," Chapman said. "It's a little unusual. You always find them in standard middle-class homes."
    Mike Szyperski, detective of the narcotics unit of Newport Beach Police Department, said 80% of his division's time is spent curbing meth use. "Everyone is doing it," Szyperski said. "It's the drug of choice." State Bureau of Narcotic Enforcement officials seized 51 meth labs in Orange County in 2002. So far this year, they have busted 40. According to the attorney general's office, the state confiscated more than $38 million in drugs during seizures in 2002. Of that figure, $5.5 million was from meth. In 2002, Los Angeles officials seized 163 meth labs. This year, as of Aug. 30, 82 labs have been seized.
    Jerry Hunter, a special agent in charge of a Los Angeles police task force, said many labs are set up in motel rooms, where they are called "kitchen" or "stove" labs that can produce about an ounce of meth at a time. Because methamphetamine can be produced using store-bought ingredients, the labs — which leave behind toxic chemicals and can produce devastating explosions — can be set up anywhere, though manufacturers usually prefer more isolated locations. "Even if you're rich, it doesn't seal you off," Hunter said.
    Crystal meth has other appeals for drug users living in the suburbs. First, it's manufactured locally and distributed to affluent communities. "You can avoid much of the risk of getting cocaine in a section of town where you might get hurt in a variety of ways, lose your money and still not get any drugs," said Dr. Thomas R. Kosten, a professor of psychiatry at Yale University. "The police are also less likely to be looking intently for drug dealers in the affluent parts of suburbia."
    Also, Kosten said upscale users can afford to feed their addictions. "They get used to the drugs and have more money to spend," Smith said. "The more they do, the more screwed up they get." Studies show that one in seven meth users becomes dependent, Kosten said. Former users say the first couple of hits — you can snort it, smoke it or inject it — are euphoric. The stimulant allows users to stay up for days at a time. "The rush that you get from it is so strong, you feel like Superman," said Smith, who grew up in middle-class Livermore Valley in Northern California, the son of a firefighter and prominent real estate broker.
    DeMontreux said she believed in the beginning that she had stumbled upon a miracle drug. "With it, I could go to school, work full-time and I was losing weight," DeMontreux said. "I thought it was this glorious thing." Smith, DeMontreux and others say the pleasant high didn't last long, and their days and nights were soon consumed by the search for their next fix.
    "The attraction of crystal meth is its long-acting stimulation of the brain," said Dr. David F. Musto, a professor at the Yale University School of Medicine and an expert on the drug. "The problem is that it drains the brain of normal and necessary elements. The user feels the need to keep using it to hold off crashing."
    In order to concentrate fully on the drug, Smith folded a welding business he operated. DeMontreux quit college and was fired as manager of a fast-food establishment for erratic behavior and stealing money. Both ended up making and selling the drug. "Everything you're doing is for the drug," DeMontreux said. "Every person you speak to, every move you make, is about meth."
    Musto said it's not surprising that users congregate "because they are in a world of their own" with only one goal in mind: the next high. The signs of addiction — erratic behavior, weight loss, lying, stealing, change of friends — may be recognized by family and friends, but often little can be done. "Meth users often think they are OK," Musto said. "How can being so euphoric be bad? Nonusers can see the true situation, but getting meth users into treatment is difficult."
    Former meth users said there was nothing their family or friends could have done —compassion, tough love or anything in between — to get them off the drug. They needed to decide on their own. DeMontreux said it took her third arrest and a friend killed before she agreed to go into treatment. For Smith, staring down the barrel of SWAT team rifles served as his wake-up call during a bust of his meth lab. "It was just like on TV," said Smith, who said he's been clean for four years. "I thought, 'This is it, meth. My life is going to be different from now on.' "


Mental Illness Clues
Linda Marsa, Los Angeles Times- 10/12/2003

Ian Lipkin thinks germs can trigger mental illness. The Columbia University neurologist acknowledges his theory is provocative but, he points outs, it could explain much about the ailments that cripple millions of Americans. Scientists already know that some people have an inherited susceptibility to mental illnesses. Yet not everyone with this genetic predisposition actually gets sick. Perhaps something in their environment causes some people to become debilitated, believes Lipkin, a researcher in the School of Public Health. Infections that occur in the womb, or in infancy, may be the missing puzzle piece, he believes.
    Mental illness is not contagious, he adds, but the injury done to fetuses' or infants' developing brains by infections may make them more susceptible to such neurological ills as schizophrenia, depression, autism, Parkinson's disease, multiple sclerosis and even the mental decline that can accompany aging. "We know a mother's use of alcohol, tobacco and cocaine can harm a developing fetus," says Lipkin. "It's also plausible that maternal infections during a period of vulnerability in the nervous system's development can damage a gestating infant."
    This notion is controversial, says Dr. Lori L. Altshuler, director of the mood disorders research program at UCLA. "Some scientists believe it is plausible that infections might be associated with an underlying vulnerability to developing a psychiatric illness," Altshuler says. "But many are skeptical." However, a growing body of scientific evidence is lending credence to the notion that pathogens can spark neurological illnesses.
    Viruses such as West Nile can cause encephalitis, for instance, while the bacterial infection toxoplasmosis has been linked to schizophrenia. Studies also have revealed that the Borna disease virus, which causes encephalitis and behavioral disturbances in horses and other animals, is present in nearly everyone with schizophrenia or depression, yet in only one out of three healthy adults.
    The presence of the virus doesn't automatically mean it's the cause of these mental illnesses, says Lipkin, who was the first to isolate the Borna virus from human brain tissue, and was head of the lab that deciphered the virus' genome. The results of a large-scale study, due in December, may yield more definitive evidence. Lipkin, and researchers at UC Irvine and UCLA, collected tissue specimens from more than 2,100 patients with schizophrenia, bipolar disorder and major depressive disorder, looking for telltale traces of Borna disease virus.
    Even if the study proves there is a link, however, are microbes the culprits — or are they just innocent bystanders? Perhaps it's not the bugs themselves that are causing all the trouble, says Lipkin, but the chemicals the mother's immune system releases to repel these invaders. In one recent experiment, for instance, mice in utero were exposed to cytokines, which are proteins the immune system dispatches to kill germs. After birth, the mice exhibited marked behavioral abnormalities. "The results were striking," Lipkin says.
    Still, much more research needs to be done. But if infections do turn out to be a cause of some mental illnesses, many seemingly intractable psychiatric disorders might be tamed with antivirals, antibiotics, vaccines or anti-inflammatory drugs to dampen the immune response. "The brain continues to grow after birth," Lipkin says. "If we can identify individuals who are at risk, we can intervene early and find ways to enrich their lives, and thereby prevent these debilitating ills."
    To firmly prove a link between microbes and neurological disorders, scientists need to study a large group of people — and discover the common factors in those who develop such problems. Neurologist Ian Lipkin and his team have initiated such a study. It eventually will track the pregnancies of 100,000 Norwegian women enrolled in the Scandinavian nation's medical birth registry. Lipkin chose Norway because pregnant women there are closely monitored to prevent birth defects. Every woman who gets pregnant is part of the registry. The research team plans to follow these women through childbirth and beyond to determine if maternal infections, toxins or stress spark the development in their children of such neurological disorders as attention deficit hyperactivity disorder, autism, learning disabilities and mental illness. "It'll give us an unprecedented look at what happens during pregnancy and in the postpartum environment," Lipkin says.

Haunting Reality Triggers Yates' Return to Psychosis
Tony Freemantle, Houston Chronicle- 10/14/2003

The trouble with normal for Andrea Pia Yates is that this is where her demons live.   A month ago, the woman who drowned her five children in a bathtub in their Clear Lake home because she believed she was possessed by the devil seemed to be edging back from the mental illness and depression she said caused her to commit the crime.  She was tending a prison garden at the Texas Department of Criminal justice's psychiatric unit in Rusk, where she is in the early stages of serving a life sentence. She was making friends, functioning, being constructive, her lawyer says.  She was also inexorably becoming lucid enough to be haunted by what she had done, so haunted she began believing her children were in purgatory and only her death would free them from limbo and allow them to reach heaven.
    In four short weeks, Yates has spiraled back into psychosis. She is alone and on suicide watch in her cell at the Skyview unit, heavily medicated, refusing to eat, her eyes sunken, her hair matted.  "What I want for Andrea is inner peace," her lawyer, George Parnham, said Monday. "If in order to block out the psychotic illusions she needs to be heavily medicated, then I'm all for that."
    Texas prison officials will neither confirm nor deny that Yates, who was convicted of capital murder in March 2002 for killing three of her children, is on suicide watch.  But her husband, Russell Yates, who visited her Saturday, said she has been stripped of all her possessions, including her eyeglasses, and is kept alone in her cell for 23 hours each day.  "They do have her on a suicide watch," Russell Yates said Monday. "When she relapsed, they took out all her possessions from her cell. She doesn't have anything -- no support, no mail, no nothing."
    Parnham said Yates is showing some signs of recovery from the psychotic episode that began about four weeks ago. Within two weeks, the lawyer said, her physical condition had deteriorated to such an extent her prison doctors were considering transferring her to the University of Texas Medical Branch at Galveston, where she could be fed intravenously.  "Her condition is not as urgent now as it was a couple of weeks ago," Parnham said. "If she is attempting to kill herself, and I believe because of the psychotic delusions that may be what she is doing, then being where she is may be the best thing."
    A jury rejected the contention asserted by Yates and Parnham that on June 20, 2001, when she methodically drowned her children, she was legally insane. For some time prior to the crime, Yates had been mentally ill and was experiencing acute postpartum depression after the birth of her fifth child.  Yates has been receiving psychiatric care while incarcerated in the Harris County Jail and the state penitentiary. Parnham and Russell Yates said she was showing signs of improvement over the spring and summer.  With medication forcing her back into the real world, Parnham said, she had to face the stark reality of what she did, probably triggering the psychotic episode in which she began to believe that only her own death would free her children from purgatory.   "She has a tremendous burden," Russell Yates said. "She's grieving. She's very sad about what happened. At some point she is going to have to work through that, and quite honestly I'm a little concerned because of where she is that she will not be able to do that. She isn't in an environment where she can recover."
    Parnham said his appeal of Yates' conviction, which he hopes to have ready to file by December, will in part be based on a law that prevents a jury from being told the consequences of finding a defendant not guilty by reason of insanity.  Had jurors been told that by finding Yates not guilty but insane she would have been sent to a state mental hospital and not set free, they might not have been so eager to convict her of capital murder, Parnham said.
    Yates' suicidal tendency isn't so unexpected. Women who purposefully kill their children for irrational reasons, whether arising from mental illness or a personality disorder, often will attempt to kill themselves later, doctors have observed.   Dr. Cheryl Meyer, co-author of Mothers Who Kill Their Children, said her research showed that more than half the mothers who fall in that category of maternal filicide have a record of suicide attempts. Many intend to kill themselves along with their children and fail to follow through, she said. Others are psychotic at the time of the killings and want to kill themselves only after they receive treatment and begin to have a more realistic appreciation of what they have done. 
    Renowned forensic psychiatrist Phillip Resnick, who testified for the defense at Yates' trial, said the guilt ultimately can be overwhelming for women whose impulse to kill their children was -- in their distorted view -- altruistic.  "Even if they are found insane, they have a hard time forgiving themselves," Resnick said. "They may recognize they were out of their mind at the time, but they will blame themselves for not getting help earlier, for not staying on their medication or whatever. The incidence of suicide attempts is not small. In the short time after the crime, it is very high."



Addiction to Painkillers Hard to Overcome
Jeff Donn, Associated Press, 10/16/2003

BOSTON - Rush Limbaugh is not alone. Addiction to prescription painkillers has boomed in recent years, and they can be as tough to kick as heroin. The number of Americans who begin misusing painkillers each year has almost quadrupled from 1990 to 2001, according to government figures. And many abusers don't recognize the insidious slide into addiction. "It's just so much more acceptable in society for people to be taking prescription drugs," said Sean Evans, 31, of Everett, Mass., a construction worker who became addicted to the pain reliever OxyContin, then moved on to heroin. "You can always rationalize the reason to take it."
    Limbaugh, the conservative radio commentator, told his audience Friday he is addicted to prescription painkillers that he began taking after spinal surgery "some years ago." He said he had checked himself in for treatment twice before, without success. This time, he said he was headed to a rehab center for a month "to once and for all break the hold this highly addictive medication has on me."
    Limbaugh may be overly optimistic about the time frame, said Alice Young, a psychology professor and a drug researcher at Wayne State University in Detroit. "He had said he was going into treatment and lick it within 30 days. I think that's probably an unrealistic expectation," she said. Limbaugh didn't name the medication, but the National Enquirer, which first reported his abuse, said Limbaugh's drug connection said he used OxyContin and other painkillers. Most patients who become addicted have taken more medication than their doctors prescribed. However, addiction can take hold quickly - within weeks - for some drugs. The addicts often buy their drugs on the street when their prescriptions run out.
    Doctors say the biology and treatment of addiction are similar in many ways for both legal and illegal drugs - from tobacco, alcohol and prescription painkillers to cocaine and heroin. Addiction sets in when users become dependent on the intense feelings evoked as the drug works on primitive pleasure points within the brain. "In our field, a drug is a drug is a drug," said Bill Carrick, program manager at the CAB Boston Treatment Center. Evans, the construction worker, was undergoing detoxification there.
    Initial treatment often entails detox, sometimes with a substitute drug such as methadone. Long-term therapy may aim to substitute healthy rewards in family or work life for drug-induced euphoria. Some abusers of painkillers are no longer in pain and take the drug purely for pleasure. Others, as Limbaugh said of himself, are also getting relief from pain. During their treatment, nonaddictive pain relievers can be used. Such patients may also receive electrical stimulation, acupuncture, counseling and other treatments to help cope with their pain.
    Even with all the techniques, however, patients and therapists agree that it is difficult to overcome the addiction to many prescription drugs. "Honestly, I think OxyContin is a lot harder to come off than heroin," said Evans, who has been treated for both. The maker of OxyContin, Purdue Pharma, disputes the notion that the painkiller is stronger than heroin, saying there is "absolutely no scientific basis" for such a contention.
    While Limbaugh joins a long list of celebrities who became hooked on prescription drugs - actress Marilyn Monroe, pop entertainer Michael Jackson, country singer Tammy Wynette and football player Brett Favre among them - many more ordinary Americans succumb to this kind of addiction. Evans, for example, started taking painkillers when he had his wisdom teeth pulled. The rate of abuse has risen dramatically for such drugs. About 2.4 million Americans began misusing prescription pain relievers in 2001, almost quadrupling from 628,000 in 1990, according to the federal government's Survey on Drug Use and Health. An estimated 6.2 million Americans, or 2.6 percent of adults, misuse prescription drugs of all kinds. About 4.4 million of them misuse pain relievers, taking more than their prescribed amount. The rate of full-blown addiction is about 0.3 percent, but patients who don't follow their prescriptions are considered at risk. Other abused prescription drugs include sedatives for anxiety and stimulants prescribed for attention deficit disorder and obesity.
    It isn't clear why more Americans appear to be misusing prescription drugs. Howard Chilcoat, a drug-use researcher at Johns Hopkins University, said more may be available through illegal channels, more abusers of illegal drugs may be switching, and people may be more aware of the power of prescription drugs through news stories.



Children's Mental Health Care Varies by Home State
Ellen Barry, Boston Globe- 10/17/2003

Massachusetts children are far more likely to receive mental health services than children in other states, although the services may not be going to those who need it the most, researchers found in the first-ever comprehensive study of state-to-state disparities.
     Nearly 12 percent of Massachusetts children surveyed had received some type of mental health treatment -- substantially more than the 7.05 percent of children who, the researchers deemed, displayed need of the services. Massachusetts' rate of "unmet need" -- those children who receive no services while displaying obvious symptoms -- was the lowest of any of the 13 states surveyed, but still left more than half the youths untreated.
    The study by a RAND Corp. economist, which appeared in this month's journal Pediatrics, revealed vast differences in the way adults in different states decide which children should get mental health care. Although the researchers found gaps based on race and income, with black children and poor children receiving the most services, the largest discrepancies were based simply on where the children lived.
    "You would like to think that everyone's got a fair shot at things in this country," said Dr. Peter Jensen, director of the Center for Advancement of Children's Mental Health and a Columbia University psychiatrist, who was not involved in the study. "We've known about disparities according to income or race. Those are modest differences compared to what we've found here."
    It has long been clear that mental health care is unevenly distributed. Already, researchers have sketched out vast disparities in the use of psychiatric drugs: White children, for example, are twice as likely as black children to receive methylphenidate, a stimulant best known by the brand name Ritalin, according to a Maryland study. Prescription rates vary from state to state -- New Hampshire residents consume four and a half times as much methylphenidate as Hawaii residents -- and even more wildly from county to county.
    The study by RAND, a California-based think tank, found that in some states, such as Texas, the rate of treatment is low and children of wealthy families are more likely to find themselves in therapy sessions or receiving psychiatric medications. But in a range of other states with stronger social service networks, such as Massachusetts, the reverse situation has developed: More services are offered to everyone and poor children are more likely to receive mental health services than rich ones. "These are value judgments as to when a child is beginning to suffer," said Dr. Michael Jellinek, chief of child psychiatry at Massachusetts General Hospital. "We don't only treat the most serious ulcers."
    But, according to the RAND survey, states such as Massachusetts, where a large number of children receive services, may be doing a bad job of providing them to the children who really need them. "Any mental health system does have a hard time getting the right services to the right kids at the right time," said Richard Dougherty, president of Dougherty Management, which consults on health care with human service agencies. "That may be the key issue in the findings."
    Among children who received mental health services in the Bay State, only 31.78 percent displayed need for them, according to the symptom survey used by Roland Sturm, a senior economist at RAND who specializes in health care research. Sturm examined survey results from the parents of 45,000 school-age children across 13 states. As part of the National Survey of American Families, the parents were asked six questions, including whether their child was doing well in school, getting along with peers, dramatically gaining or losing weight, lying or cheating. Sturm used their answers to determine each child's need for mental health services ranging from a school guidance counselor to therapy to hospitalization.
    Several psychiatrists, including Jellinek, questioned whether Sturm could adequately determine a child's need for care through only six simple questions. And some said his definition of "need" -- and the whole mental health care system -- targets only the most advanced and extreme cases, long after the children might have been helped.
    "We've really targeted the high-end kids, the ones that end up in the hospital," said Suzanne Hannigan, project director of Worcester Communities of Care, a state-supported project that seeks to provide services for emotionally disturbed children at home. "We're put a lot of our efforts into building up that system."
    Jellinek said he is skeptical about the study's suggestion that Massachusetts treats more children than necessary. He estimates that about 22 percent of the state's children need mental health care -- far more than the 12 percent who receive it. Although a state like Alabama, which provides care for just over 6 percent of its children, may succeed at targeting the most severe cases, it offers only bare-bones services, leaving the vast majority untreated. "If you create a keyhole that accommodates one-third of an estimate of need, you're going to be very efficient," he said, but "I'm not excited about creating an Alabama."



Boston Called Ecstasy 'Hot Spot'
Jim Geraghty, Boston Globe, 10/18/2003

WASHINGTON -- Boston teenagers are among the nation's leading abusers of the drug ecstasy, according to the White House's Office of National Drug Control Policy. But parents do not seem to be addressing the rising danger. "These are the notorious hot spots," said Steve Pasierb, president of the nonprofit Partnership for a Drug-Free America, pointing to a map that highlighted Boston, Baltimore, Philadelphia, Miami, Chicago, Detroit, Minneapolis, Denver, and Seattle. "It's heavy in the Northeast, and spreading around the country."
    Comcast Cable, with about 2 million subscribers in Boston and millions elsewhere in New England, announced yesterday that the company is donating $51 million in advertising time over three years to help the Partnership launch the nation's first media campaign warning teenagers and parents about the dangers of ecstasy.
    Pasierb said his organization launched the campaign in response to a 71 percent jump in teenagers' use of ecstasy between 1999 and 2001. One in nine American teenagers has taken ecstasy at least once. But a recent survey of 1,200 parents by the Partnership found that while 90 percent of parents said they had heard of ecstasy, only about a quarter had talked to their children about it. "We think there are two possible explanations," Pasierb said. "One, parents are more comfortable talking about drugs that they have firsthand or secondhand experience with, whether it's alcohol, tobacco, marijuana, cocaine, or other drugs. Ecstasy is new to the scene." He said the second reason parents do not talk about the drug is the widespread sense that their child is not likely to use or encounter the drug -- a perception that is wrong, he added. "It's out of the club scene and into the mainstream," Pasierb said.
    Ecstasy is a synthetic drug with the simultaneous qualities of an amphetamine, like speed, and a hallucinogen, like LSD. According to the US Department of Health and Human Services, emergency room visits involving the drug increased from 253 in 1994 to 4,026 in 2002. Karen Tandy, administrator of the Drug Enforcement Administration, called the drug "one of the fastest-growing threats to the youth of our country." She said most ecstasy consumed in the United States is smuggled from the Netherlands.
    The public service announcements probably will be broadcast on channels popular with teenagers, such as MTV, ESPN, and Comedy Central during after-school hours. One announcement parodies popular prescription drug commercials. The ad begins with images of teenagers frolicking through fields. A logo for ecstasy splashes across the screen, and a teenage girl gushes that "ecstasy changed my life" in a tone mimicking the enthusiastic appreciation of patients in pharmaceutical ads. But the voice-over announcer quickly warns that the drug's side effects "may include depression, severe anxiety, hypertension, heat strokes, seizures, heart attacks, liver damage, kidney, or cardiovascular system failure, worried parents, loss of friends, isolation, emptiness." The field suddenly looks barren and the teenagers look sickly and collapse.The announcer says: "Ecstasy is not for everyone. In fact, it's not for anyone." Comcast president Steve Burke said "about 10 to 15 percent" of the firm's donation will be used to target Boston cable viewers.

Embracing Change, Vermont Neglected Its State Hospital
Ellen Barry, Boston Globe- 10/20/2003

WATERBURY, Vt. -- When federal inspectors emerged from Vermont's tiny state mental hospital this summer, they described conditions that can best be called archaic. Patients paced the halls, or sat in isolation, while staff members ignored them. One woman had not bathed in more than four months. A man had not had his psychiatric evaluation updated since he was admitted -- in 1980. When night came, patients on one ward were ordered to bedrooms that were locked from the outside, with no access to bathrooms. During the review, the situation got worse: Within a span of six weeks, two patients committed suicide in their rooms. One, a 19-year-old woman whose treatment plan specified that she be stripped of her shoelaces, hung herself with a shoelace, according to an advocate who had represented her in grievances against the hospital.
    The revelations, shocking anywhere, came as a particular surprise in Vermont, a state much admired for its progressive mental health policies. Among New England states which embraced the idea of removing mentally ill people from institutions, Vermont emptied its state hospital more quickly and more completely. Vermont boasts one of the nation's most sweeping mental health parity laws, which requires insurance companies to cover mental illness and substance abuse as fully as physical illness. Most remarkably, doctors and consumers seem to agree on the thorniest civil rights question in mental health: Patients in Vermont always have the right to refuse medication, even when they're committed to the hospital.
    In his run for president, former governor Howard Dean moved early to stake out the territory of mental health for himself, delivering a speech Sept. 12 that promised "real solutions to the mental health care crisis" and holding up the Vermont system as a model. But the state's neglected mental hospital shows the limits of the Vermont success story. Last month the hospital lost its right to collect an annual $700,000 in funds from Medicaid and Medicare -- a rare sanction that was brought against only one psychiatric hospital in the country last year, of 477 that receive the funds. The small community of mental health activists and providers here found themselves examining the old shared dream that the state hospital would no longer be necessary. In the end, they say, what happened was that the most seriously mentally ill patients had fallen off government's radar. "It's one of those attempts that never went as far as it should go. It clearly didn't close the hospital," said Ed Paquin, a former legislator who is now director of Vermont Protection and Advocacy, which advocates for mental health consumers. "What was left came off everybody's front burner," Paquin said. "It was not right to forget about it when we did."
    In 1995, Governor Dean announced that the state hospital would be closed for good within two years. The red-brick campus was a potent reminder of a past when patients spent days in straitjackets; in a 1990 survey ranking Vermont as having the nation's best state mental health system, the Public Citizen Health Research Group said the state had "designated itself as a national experiment," discharging patients from the hospital "with an enthusiasm bordering on evangelistic fervor." The hospital population had dwindled from 1,300 to an average of 50 patients at any given time. But in the eight years that have passed, that number has stayed virtually unchanged.
    The 50 who are left represent the most seriously ill of Vermont's population, about a third sent for forensic examination after being accused of a crime, and the rest judged suicidal or dangerous. They range from patients with personality disorders who make repeated attempts to hurt themselves to patients who suffer delusions and hallucinations, said Susan Besio, Vermont's commissioner of developmental and mental health services. All are in the hospital against their will. But one right they do have, under Vermont law, is to refuse to take psychiatric medication. Typically, between 10 percent and 20 percent of them, or five to 10 patients, are refusing to take medication, Besio said.
    Marsha Kincheloe, who retired from the hospital as director of nursing two years ago and coauthored a history of the hospital, said federal surveyors had always been skeptical of patients' right to refuse medication, but that noncoercion worked well while she was there. During daily activities, staff could gradually gain a person's trust, talking over the resistance to taking drugs. When they changed their minds, Kincheloe said, it marked a sincere effort. "I really think it's better for patients to choose medication, and that may mean working at it for a year or eight months," she said. "None of us would want to be tackled to the floor and injected with something."
    Years of state budgets, anticipating the hospital's closure, channeled money to community services instead. The nursing staff dwindled and the psychiatric technicians, who had increasing authority over the wards, were the lowest-paid people in state government, Besio said. This summer, in a scathing report, surveyors from the Centers for Medicare and Medicaid Services charged that patients were not receiving treatment of any kind. A surveyor interviewed "Patient D," who appeared "distinctly paranoid." The patient's treatment plan did not include antipsychotic treatment, because the patient had refused medication, but instead included such limited goals as "persuade patient to release old psychiatric information" and "verbalize an understanding that the findings of his neurological evaluations do not support heavy metal poisoning."
    Therapy sessions were canceled for lack of interest, as patients paced the halls or sat alone in their bedrooms. Xenia Williams, a 54-year-old activist and mental health worker who has herself been committed to the hospital several times, said she spent her days at Vermont State Hospital "watching pigeons come and go from the roof of the south rotunda." Other patients did the same, she said. Refusing to participate in group therapy, anger management, or other scheduled activities was "the only way they can assert their human dignity," she said. Meanwhile, staff often refused to befriend or speak with patients, giving them a sense of profound rejection, she said. "Staff would sit there playing cards all day while we wandered around forlornly," she said. "Not surprisingly, I got a command hallucination" -- an imagined voice giving orders -- "to tip over the card table."
    When staff were unable to use medication to control behavior, they used physical restraints, said Paul Poirier, of Vermont Protection and Advocacy. Often, these means were used against the small group of patients refusing medication, typically diagnosed with personality disorders. The woman who hung herself in September was one of these, and had undergone 134 seclusions, restraints, individual supervision, or involuntary medication treatments since Jan. 1, said Poirier, who represented her in grievances against staff. Besio said she could not comment on the case because of patient confidentiality. "We prefer not to use involuntary procedures," Besio said. "If something like that occurs around a patient, it's certainly an extreme. It is in no way the norm."
    Last week, Vermonters were struggling to square their ideology with the reality that state authorities still need to lock mentally ill people in an institution -- and that they will continue to do so indefinitely. Peter Van Vranken, who was Dean's health policy adviser when he was governor, said he "really doesn't have an answer" to how the hospital was allowed to deteriorate. "During the Dean administration, we were focused absolutely on community-based care," Van Vranken said. "We were attempting to eliminate the state mental hospital entirely, but it just didn't work out that way."
    Already, Governor Jim Douglas has included a 21 percent increase in funding for the hospital in the 2004 budget, and numerous staff positions have been added. Advocates have pushed plans to add peer counseling or trauma counseling for patients who, they say, are not now treated for their histories of physical or sexual abuse. In January, federal inspectors will return to determine whether to reinstate Medicaid and Medicare funds.
    There has been no talk of challenging the right to refuse medication within the hospital. As an opponent of coercive treatment, Besio said it is strange to find herself defending the existence of a hospital at all. "We're down to the core where everybody has had their rights abridged," she said. "That's kind of the microcosm of that issue." But, said one advocate, if there's one lesson to be drawn from this summer's revelations, it's this: Ignoring Vermont State Hospital won't make it go away. "You can't let something slide just because your goal is pushing you in the other direction," said state Representative Anne Donahue, a Northfield Republican who is a member of the group Vermont Psychiatric Survivors. "We all let it happen."

Internet Trafficking in Narcotics Has Surged
Gilbert Gaul and Mary Flaherty, Washington Post- 10/20/2003

LAS VEGAS -- In July 2001, regulators at the Nevada State Board of Pharmacy noticed something unusual among the reams of data that flow into the busy agency each day. Buried along with the other numbers was a report from a small Internet pharmacy that had filled 1,105 prescriptions for painkillers and other dangerous drugs that month.  The same tiny pharmacy had dispensed just 17 prescriptions in the prior six months.  Virtually overnight, prescriptiononline.com had become one of the largest distributors of controlled substances in Nevada. Over the next year, the online pharmacy shipped nearly 5 million doses of highly addictive drugs to customers scattered across the country. By the time regulators shut the Las Vegas firm in January, prescriptiononline.com accounted for 10 percent of all hydrocodone sold in Nevada, regulators said.  It turned out that the booming business was owned by a 23-year-old former restaurant hostess. But it was run by her father, who had been convicted of a felony in 1992.  "For any single pharmacy to account for 10 percent of any drug is incredible," said Louis Ling, general counsel to the Nevada pharmacy board. "The fact that it was a highly addictive painkiller and an Internet site run by a convicted felon was even more troubling. This was unlike anything we had ever seen."
    With little notice or meaningful oversight, the Internet has become a pipeline for narcotics and other deadly drugs. Customers can pick from a vast array of painkillers, antidepressants, stimulants and steroids with few controls and virtually no medical monitoring.  There are dozens of legitimate online drugstores and mail-order pharmacies. Unlike rogue sites, they require customers to mail in prescriptions from their doctors. Typically, the legitimate sites offer a full range of medications, with painkillers accounting for less than 20 percent of their business.  In contrast, a majority of the rogue sites' sales are for hydrocodone, Xanax, Valium and a few other addictive drugs. Many work with middlemen who set up the sites' customers with doctors who are veritable script-writing machines. Some of those doctors have financial problems and histories of substance abuse or medical incompetence, records show.
    The online merchants now feed a sprawling shadow market for prescription drugs, frustrating medical leaders alarmed by the threat to public health and investigators hard-pressed to keep up with nimble Web sites that can open and close at a moment's notice.  "It's like rabbits," said Wayne A. Michaels, a senior investigator for the Drug Enforcement Administration. "Every day, there are more of them. They're up, they're down, they're foreign, they're domestic."
    The DEA recently created a six-person task force solely to track the online trade in narcotics. But officials acknowledged the effort is a form of "triage" amid an escalating crisis. "We're afraid it's going to overwhelm us, once we've identified all these sites," said Elizabeth A. Willis, chief of the DEA's drug operations section.  The multimillion-dollar industry has appeared overnight, pumping millions of pills into some of America's smallest and most economically distressed communities.
    The Washington Post obtained and analyzed a Nevada pharmacy board database of 30,000 orders filled by prescriptiononline.com. The analysis found that four of every 10 pills poured into four southern states with widely documented prescription-abuse problems. A disproportionate share of those drugs went to customers in small towns.  Some small Tennessee towns received 50 times more painkillers per capita than large cities, the analysis found. For example, Church Hill got 1,013 pills for every 1,000 residents; Nashville, just 26. Bristol got 1,584; Memphis, 14.   "It's a no-brainer why you see high volumes in these little places," said Tammy Meade, a narcotics prosecutor in Nashville. "Users and people who want to get their hands on enough to distribute can't doctor shop in places like that. And if they use the Internet, someone like me . . . is going to have a tougher time finding out."
    Stretching from Florida to California, the Internet pipeline has left a trail of deaths, overdoses, addictions and emotionally devastated families.  "It absolutely blew my mind that you could get these drugs online," said Sue R. Townsend, the coroner in Aiken County, S.C. Her son Douglas, 30, died after driving his car into a fence in September 2001. His family said he had taken a generic form of the tranquilizer Xanax, which they said he had purchased from myprivatedoc.com, a now-defunct Web site in Mesa, Ariz. Townsend's family sued the Web site, the pharmacy and the Arizona doctor who wrote the prescription, accusing them of selling the drug without a proper medical consultation. The case was recently settled with no admission of liability.   "Losing Doug has broken our hearts," Sue Townsend said, fighting back tears. "He had a young wife and a baby boy who will never know his daddy. Somehow we have to tell how dangerous this is, because it's happening all over."
    In a typical purchase from a rogue site, a customer logs on and orders hydrocodone (generic Vicodin and Lortab). The Web site steers him to a middleman, often another Web site, which arranges a telephone consultation with a doctor. The customer and the doctor talk briefly, after which the doctor writes the prescription and sends it electronically to the Internet pharmacy. The pharmacy ships 60 pills to the customer by overnight mail. Total cost: $290. The pharmacy pockets $190 for the hydrocodone and the doctor and the middleman split the remaining $100 as a consultation fee. There are no face-to-face meetings, lab tests, X-rays or follow-ups.
    There are dozens of Web sites selling narcotics in the United States, with scores more operating offshore. Federal prosecutors have shut Web sites, filed indictments and won guilty pleas from several owners. But it often takes years to prove a case. In the meantime, the pills move.  For each site closed, "two or three more open," said Jennifer Bolen, a former federal prosecutor in Knoxville, Tenn. "It is so easy for them to close down a site one day and open a new one the next."
    For the DEA, an agency already responsible for everything from drug cartels to street drugs, trying to police the growing number of online pharmacies "is like trying to work every corner drug dealer," said Laura M. Nagel, the agency's deputy assistant administrator. "We can't do it all."  When prosecutors shut the Internet pharmacy operations at thepillbox.com in San Antonio, much of the business shifted to prescriptiononline.com in Las Vegas, records show. When that site was closed two years later, Nevada regulators suspect the business shifted yet again -- this time to Florida.
    Some Web sites have dozens or even hundreds of affiliate sites. Others are designed to appear as though they are headquartered in the United States when they are really offshore, in such places as Namibia, Thailand and Sri Lanka. The growing numbers of foreign online pharmacies operate with near impunity. The Food and Drug Administration's strongest recourse is to send a warning letter, which usually is ignored.  "As an investigator, it's incredibly frustrating," said Robert J. West, a special agent with the FDA's Office of Criminal Investigations. "All we can do is bang away and try to draw attention to what these guys are doing. Right now, I don't think people have any idea how widespread or dangerous this is."

Little Regulation
States regulate pharmacies, creating widely different rules governing Internet sites. Under-staffed pharmacy boards barely have time to inspect brick-and-mortar pharmacies, let alone virtual ones. Many online pharmacies have ignored state efforts to register them. Only one state -- California -- has a full-time agent investigating doctors writing prescriptions for Internet pharmacies.  The lax oversight comes amid Congress's inability to pass legislation requiring even minimal disclosure by Internet pharmacies.
    In 1999, then-Rep. Ron Klink (D-Pa.) issued a warning at a committee hearing: "I am concerned a 'Wild West' world is unfolding before us, where many consumers are accessing potentially dangerous drugs with little or no practical guidance. Yet because it is e-commerce, there is a mentality: It must be progress."  In 2000, the FDA, the General Accounting Office and several House members urged that online pharmacies be required to disclose their owners, locations, doctors, affiliated pharmacies and telephone numbers. But Congress never followed through. Nearly four years later, there is still no disclosure requirement.  "Getting a bill regulating the Internet is about as hard as it gets," said William K. Hubbard, the FDA's senior associate commissioner. "You have all of these people worrying about stifling this wonderful thing . . . and they don't want the bad Feds in there."
    A Post reporter sent e-mail asking for identifying information to 15 online pharmacies specializing in painkillers. Only one responded. It declined to say who owns the site or where it is located. One online pharmacy included a telephone number for customer service that linked to a freight forwarding company in Miami. When a reporter called, a secretary said that it moved shipments for a customer in Costa Rica.
    In late 1999, the National Association of Boards of Pharmacy instituted a voluntary system for certifying online pharmacies, including inspections and disclosure. But of the hundreds of Internet pharmacies now operating, only a "dozen or so" signed up, said Carmen Catizone, the board's executive director. Most of those are large, legitimate sites, such as drugstore.com.  One pharmacy that received certification was prescriptiononline.com. "I can't explain what happened there," Catizone said. "I know we certified it originally, and then later on we got some complaints, and we suspended their certification. Obviously, if we knew then what we do now, we never would have certified them."

Easy Licenses
Regulators in Nevada faced a similar situation in April 1999 when Terri Suarez applied for a license to operate an online pharmacy called prescriptiononline.com.  No one at the Nevada State Board of Pharmacy had ever heard of Suarez. She was not a pharmacist. She was not even from Nevada. She was based in Louisiana. But all Suarez had to do to get a license was show that she had a corporation.  "At that time, our whole application was essentially a page and a half," said Ling, the board's counsel. "It was essentially nothing. I don't even think she had to prove she had a business license."  Her application was approved.
    Nevada regulators did not know that Suarez operated a closed-door pharmacy in Jefferson, La., called Pharmaceuticals Southwest Inc. On paper, the tiny company was set up to sell discounted drugs to nursing homes. But when an inspector showed up in November 1999, there were no drugs to be found.  "It was definitely a front," Carlos M. Finalet III of the Louisiana Board of Pharmacy said later. "It had no stock. The pharmacist sat there reading a book."  Suarez denied buying any drugs, even when she was confronted with invoices bearing her signature, according to a complaint that the Louisiana board filed against Suarez's company. The board determined that Suarez had indeed purchased drugs -- $1.2 million worth in two months from Bindley Western Industries Inc. But inspectors could not find them.  Based on Suarez's "complete disregard for pharmacy laws," the board revoked the company's license and fined it $100,000. But the board has been unable to collect, and Finalet said Suarez's whereabouts are unknown .
    Nevada regulators did not know about Suarez's troubles when her name resurfaced in March 2001. That month, they received notice that she had sold her interest in prescriptiononline.com to Melissa Cosenza, 23.  The regulators blanched. Cosenza's father is Michael R. Cosenza, who has a long history of working at the margins of drug distribution in Nevada and elsewhere.  "We knew immediately that he was using her as a front," Ling said. "What we didn't know was what he was up to."   At a hearing, Melissa Cosenza confirmed that her father was going to be a consultant to prescriptiononline.com. "She had supposedly bought the company for $50,000, payable at $5,000 a year," Ling recalled. "Who buys a pharmacy for $50,000? It sounded as hokey as could be. We started asking her questions. It was pretty obvious she didn't know anything about the business." 
    In April 2001, Melissa Cosenza submitted an application for a license, stating that she owned all of the company's stock. She gave a home address near San Diego. Under work history, she listed jobs as a restaurant hostess and salon receptionist.    Nevertheless, she qualified for a license. "I suppose it looks pretty embarrassing but really there wasn't much we could do," Ling said. Under the board's existing rules, "I really can't deny someone a license just because they come from a family and I know they are going to do something bad as soon as I give them a license."
    Nor was there much the board could do about Michael Cosenza, 60, whose consulting business Med-Pharm Inc. would be running prescriptiononline.com.  Cosenza had pleaded guilty to grand theft in 1992 in Inyo County, Calif., for stealing more than $100,000 from a health care construction project, court records show. He later was incarcerated in 2000 for six months on a charge related to the earlier case. In October of that year, he had that case dismissed and expunged from his record.  "There was no way Michael as a convicted felon could qualify for a license," Ling said. "But under the law at the time, we didn't have the ability to take action against a pharmacy based on who was employed. It's probably still unclear today if we could stop him from operating the company."
I    t was not the first time Cosenza had worked around his past.  In April 1997, the California Board of Pharmacy said that Cosenza was operating two closed-door pharmacies licensed under the name of his wife, Barbara Jackson Cosenza. According to the board's official accusation, the two pharmacies were supposed to purchase prescription drugs at a discount and sell them to nursing homes.  "In reality, both pharmacies were actually wholesale businesses in which hundreds of thousands of dollars of dangerous drugs were . . . sold to other wholesale companies," the state board alleged. "Some of these drug shipments were delivered to the San Diego office of a courier and picked up by non-licensed agents. . . . Upon occasion, these dangerous drugs stayed with the courier for days without proper storage or supervision by a registered pharmacist."  According to the accusation, Michael Cosenza had held himself out as the owner of the two pharmacies "and conducted business transactions on behalf of both pharmacies." The California regulators said he did not qualify for a license because of his 1992 felony conviction. In December 1998, Cosenza's wife agreed to surrender the two licenses.
    In January 2002, Barnes Wholesale Drugs Inc., a California drug distributor, sued Cosenza. The wholesaler charged that it was owed $529,000 for drugs purchased by an Oregon company called Pharmaceuticals Northwest Inc. The firm was run by Cosenza's stepfather, George Kemmler, 74, a retired snack food deliveryman with diabetes and "blindness in one eye." Barnes alleged that Cosenza paid Kemmler $1,500 a month to act as a straw man. Kemmler declined to comment for this article.  Barnes also alleged that the company was diverting drugs meant for nursing homes to another wholesaler in Las Vegas.
    In a deposition, Cosenza denied any role in the diversion. He settled the lawsuit in 2002 by agreeing to pay Barnes $514,000. But he fell behind on the payments, and a judgment was entered against him for $658,000.  Cosenza and his daughter declined to be interviewed for this article. In a court filing in 2003, his lawyer said that prescriptiononline.com was a legitimate pharmacy that complied with all of Nevada's laws and regulations.

Booming Business
With Michael Cosenza behind it, prescriptiononline.com's business surged. Between July and December 2001, the online pharmacy filled 18,499 prescriptions, compared with just 17 in the prior six months. Nearly all were for controlled substances.  "Normally, with any retail pharmacy, you would expect 15 to 20 percent of the sales to be painkillers," Ling said. "Prescriptiononline turned that upside-down. They reversed the model."
    Located in a small business park in northwest Las Vegas, prescriptiononline.com did not employ its own physicians. Unlike some other sites, it relied on doctors to steer business its way. All of those physicians were in other states and were associated with middlemen who arranged brief telephone conversations with patients in return for a fee. Two of the doctors -- Jon S. Opsahl and William Dale from California -- quickly became the two most prolific prescription writers in Nevada, regulators said.
    In March 2002, Ling told prescriptiononline.com's attorney that he was concerned about the volume of controlled substances. Sherwood N. Cook wrote back that prescriptiononline.com believed that its product mix was consistent with that of other Internet pharmacies, and that "a majority of the drugs filled by Internet and mail-order pharmacies are controlled substances."
    One of prescriptiononline.com's customers was Nancy Harler, a former nurse, of Columbia, S.C. She had been getting her painkillers from thepillbox.com. But after that site's legal problems arose, prescriptiononline.com began filling her orders for hydrocodone.  Harler said she had started ordering hydrocodone online for migraines and arthritis in February 2000. In all, she estimated that she spent $10,000 and used more than 1,500 pills. "It just got to the point where I was no longer in control and knew I needed help," she said.  Harler is now undergoing methadone treatment for her addiction, which she said was fed by the online pharmacies. "If you ask them anything about the money, they say we'll be glad to pull the plug. They know they have addicts on the line," she said.
    Most of prescriptiononline.com's customers sought painkillers. The Post's analysis showed nearly 90 percent of the orders were for controlled substances, including hydrocodone and the generic equivalents of Valium and Xanax.  For years, hydrocodone has been one of the most used and abused drugs, according to the DEA. Sales have soared, and so have thefts of the drug and hydrocodone-related emergency room admissions.  The street value of hydrocodone is also climbing, said Tony King, the agent in charge of the DEA's Louisville office. A single generic tablet that costs an online pharmacy 15 cents may be sold to Internet customers for $1.50. On the street, that same tablet may go for "$3 to $5," King said. Overall sales of hydrocodone in Kentucky have doubled in the past four years, to 120 million tablets.  The surge began a few years back, when doctors alarmed by OxyContin abuse began switching patients to hydrocodone, King said. "But hydrocodone is equally dangerous," he said. "It's kind of like: Do you use a .38- or .40-caliber gun to shoot yourself?"
    A breakdown of prescriptiononline.com's sales by Zip code revealed that four of every 10 pills flowed into Alabama, Tennessee, Louisiana and Kentucky. Those four states routinely rank among the top five nationally in the per-capita use of hydrocodone and Xanax, according to law enforcement data.  The pills poured into small towns. In Hope, Ky., with a population of 152, customers bought 7,910 pills -- an average of 52 pills for each resident. In Gunlock, Ky., population 430, customers bought 2,910 pills, about seven per person. By contrast, in Louisville, Kentucky's biggest city with a population of 206,239, customers bought 5,810 pills, about 0.03 per person.  In some cases, these orders went to multiple customers listed at the same address. For example, over five months 2,030 pills were shipped to five customers at one home in Baileyton, Ala. More than 80 percent were hydrocodone.
    In an interview, Opsahl, the California physician who wrote the prescriptions, said he was aware that customers occasionally listed the same address, but not to the extent detailed in The Post analysis. "I didn't have that data at the time," he said, calling the information "very disturbing. You've presented some information that certainly gives me some pause how this whole system can be blatantly abused and easily abused."  Still, Opsahl maintained that most Internet patients have legitimate needs.
    That view is not shared by Mike Vories, a physician who runs a pain management clinic in Hazzard, Ky.  "How in the world does an Internet Web site have any control over whether that controlled substance is going to a patient with a legitimate complaint?" he wondered. "Really, come on. Let's call this for what it is. A few maybe are legitimate and have pain. For the majority, it is a source of income."

Long Investigation
Alarmed by prescriptiononline.com's sales of controlled substances, Nevada regulators alerted the Las Vegas office of the DEA in the summer of 2001. Ling hoped for quick action. But the investigation stretched over months.  In the fall of 2001, DEA agents made undercover purchases from the Web site. In March 2002, DEA agents searched prescriptiononline.com's small office and seized business records. But the agents allowed the company to remain in business.  It would be 10 months before the DEA took away prescriptiononline.com's license to sell narcotics, declaring it "an imminent danger to the public health and safety" and seizing 21 boxes of drugs worth $143,000. By then, the company had moved about 1.8 million more doses of dangerous drugs.
    When the DEA acted, the pharmacy board formally accused prescriptiononline.com of more than two dozen violations, including dispensing dangerous drugs where there was no valid physician-patient relationship.  On Jan. 22, Michael Cosenza and prescriptiononline.com agreed to relinquish the company's license and pay $200,000 in fines. The deal prohibited Cosenza or any member of his family from applying for a pharmacy license in Nevada for two years.  Melissa Cosenza did not attend the hearing.