Too many pills, too little oversight

Lorraine McNulty says she thinks her son Nicholas Rallis turned to heroin because it is cheaper than the prescription drugs he got from Thomas Barone. The doctor has acknowledged no wrongdoing.

Pat McGuckin barely recognized her 39-year-old son. Once a personal trainer and bodybuilder, Michael now was exhausted, his limbs bloated, his mood so volatile that he ripped the phone off her wall.

He told his worried mother that he was in pain from a car accident but that a doctor was helping him.

On Oct. 21, 2007, his younger brother found Michael in bed, his body cold. A few days later, their mother stared at the words on the death certificate, struggling to understand what had killed her son.

She dialed Richard J. Hollawell, a friend of Michael's since childhood in Northeast Philadelphia.

"I said, 'Rick, it says 'adverse reaction to prescription drugs.' How could that be? He was under a doctor's care,' " Pat McGuckin recalled.

Hollawell soon would learn from medical records that his friend was being prescribed nearly 200 narcotic pain and anxiety pills every week in dosages that easily could be fatal, an expert said. And the doctor who wrote those prescriptions operated on a cash-only basis, which meant no insurance company could flag the extreme pattern.

For Hollawell, now a lawyer in South Jersey, that call - and what he said he discovered about his old buddy's care - triggered what has become an eight-year quest. In seeking justice for three casualties in the national epidemic of painkiller overdoses, he is taking aim at the small number of doctors who play an outsize role in the crisis.

Hollawell had known Michael McGuckin ever since the boys, both students at Our Lady of Calvary grammar school, would hang out at the McGuckin home next door, playing video games. They followed different paths as adults, but kept in close touch.

Several years after McGuckin died, Hollawell got a call about the death of a second childhood friend. The cause was heroin, but his addiction began with pain pills, almost 20,000 prescribed over four years.

His source was the same as McGuckin's, a physician with a solo practice near Rittenhouse Square named Thomas C. Barone.

Hollawell pursued medical-malpractice lawsuits in both cases. McGuckin's went to trial four years ago but was settled for $1 million against Barone before the jury's verdict could be read in court. The second was also settled, for more than $800,000, two years later.

A third suit, involving another death, was filed last month.

"He got them all sick instead of helping them," Hollawell said. "He literally gave them an illness, and that illness was addiction. And they never came back from it."

The cases illustrate key issues in the deadly drug crisis: Many addictions begin in medical offices, when patients seek help for pain. Without appropriate monitoring, patients can obtain astonishing quantities of drugs that hook them, kill them, or lead them to prescription opioids' street relative, heroin.

Anyone, from any background, can fall prey to prescription-drug addictions.

Meanwhile, as a frustrated Hollawell would learn, regulators and other officials charged with protecting the public can be slow to act.

In Barone's case, state action came four years after the first of Hollawell's three complaints. A fourth death was found by state investigators. Barone has temporarily lost his medical license and cannot practice.

He did not respond to repeated efforts by The Inquirer to reach him by phone, in person, and by mail.

Expert witnesses at the 2011 civil trial painted vividly different pictures of Barone's treatment of Michael McGuckin.

"I found it to be appropriate. I found it to be caring. I found it to be within the standards of care," Gerald Hansen, a physician at Abington Memorial Hospital who is board-certified in family medicine and pain management, testified for the defense.

Warren Wolfe, a trained pharmacist and board-certified family physician who practiced in Cherry Hill for 40 years, said the treatment was "reckless." Barone failed to record basics such as the patient's weight and temperature, review records from other doctors, and ignored obvious signs that the patient was in trouble, Wolfe said. "He is seeing Mr. McGuckin every two weeks, with the same pain, giving him more and more medicine. . . . There is no treatment plan," said Wolfe, who is now retired in Virginia. "There are so many other things he could have done."

Barone has never been charged criminally and did not admit guilt in negotiating his license suspension.

His license could be reinstated next summer, at the end of an 18-month suspension.

Call for help

Not long after Pat McGuckin called Hollawell to help her understand what had happened, she showed him prescription bottles that the family had found in Michael's bedroom. Hollawell was no expert in narcotics, but he recognized some of the names on the labels: highly addictive opioid pain relievers as well as antianxiety medications known to enhance the high that users get from opioids. TV news was reporting about Florida "pill mills" so notorious they drew customers from around the nation.

"That's when the alarms started to go off," he said. "I just knew that they were dangerous drugs."

Hollawell, a partner in the small Marlton firm of Console & Hollawell, was a personal-injury lawyer who had handled some medical malpractice, but this case required him to dig into a world that was almost entirely new to him.

At first he was driven by emotion. "I went to elementary school with Mike," he said. "I was on Little League baseball with Mike."

As a youngster, he often went home for lunch with Mike to his boisterous household, always full with six McGuckin children and all their friends.

The boys went through high school together. After Fordham University and Widener Law School, Hollawell got married, and McGuckin was there.

McGuckin started at Temple University but quit after a year and a half to concentrate on bodybuilding. He won trophies and paid his expenses by training others. But after hurting his back in a 2005 car crash and starting on painkillers, he began to spiral downward.

Reviewing the medical records after he died, the family pieced together what had happened.

Warning signs that might suggest drug abuse were included in Barone's brief medical notes. The doctor wrote that McGuckin told him he had lost pills in his luggage on a trip. Another time his patient said he had accidentally spilled the pills down the drain. He also claimed they were stolen when his car was towed.

Each time, Barone wrote new prescriptions.

Barone testified he did eventually have concerns that McGuckin might be lying about how many pills he was taking. He asked McGuckin to bring in his pill bottles, but McGuckin did not.

"I could have decided at that point that I can't treat him anymore," Barone testified during the civil trial. "But he expressed to me how appreciative he was, thankful for the care that I gave him, the treatment that I gave him, and that he really was not getting adequate treatment or care from his other doctors. So I felt that responsibility that I could not abandon him."

Pat McGuckin sees it differently.

"You trust a doctor to do the best for his patient," she said in an interview at her home, where Michael grew up. "He didn't. He was just 'Here, here's your prescription, see you.' I'm heartbroken that a doctor would do that."

Barone testified that he never performed routine checks such as recording Michael McGuckin's height and weight, or ordering blood work or urine tests. He decided McGuckin had a "possible lumbar disk bulge/herniation," but said he had not needed diagnostic tests to confirm it.

Yet he doled out more and more pills.

By the time McGuckin died, Barone was writing on average 210 Percocets (10 mg.), 104 OxyContins (80 mg.), and 70 Xanax (2 mg.) every two weeks.

"That's a huge dose," Larry Axelrod, a physician whose South Philadelphia practice is devoted to workers' compensation injuries, said in an interview. Knowing nothing else about the case, he guessed that the patient had died. Axelrod is hired by insurers to review other doctors' records when excessive prescribing is suspected. But Barone would not have been flagged by any insurer. He accepted only cash, a practice typical of pill mills, a spokesman for the U.S. Drug Enforcement Administration said.

'Rogue providers'

More than 100,000 people have died in the U.S. of opioid overdoses in the last decade, according to federal data. No one knows how many deaths can be attributed to "rogue providers," as Gary Tuggle, special agent in charge of the DEA's Philadelphia Division, dubs the doctors, dentists, and others who prescribe drugs without proper care.

But Tuggle would characterize the problem this way:

"It's really big," he said, explaining that if even just 1 percent of the more than 50,000 providers registered to prescribe narcotics in Pennsylvania "go off the reservation to become rogue distributors, that's a lot."

Barone began practicing in Center City in 2004. He grew up in North Jersey and graduated in 1995 from the Philadelphia College of Osteopathic Medicine, where he is currently teaching as a part-time clinical associate professor. (Asked about his status, a spokeswoman emailed on Friday that "his role at the College is solely academic, which does not require him to have a license - he has no contact with patients nor oversight of any prescription medication.")

Barone, 46, is board-certified in family medicine but not pain medicine, and had admitting privileges at Thomas Jefferson University Hospital until the state's first action against him last year. In spring 2013 he was elected to a two-year term as a trustee of the Pennsylvania Osteopathic Medical Association, an independent group.

He did not respond to repeated messages left in person and by phone at his former office in the Medical Tower office building on South 17th Street. He signed a receipt for a certified letter sent to his home a few blocks away.

Arthur K. Hoffman, a lawyer in Harrisburg who represented Barone in his license-suspension case, said he was not authorized to comment.

A different kind of case

A typical case of medical malpractice involves a direct line between cause and effect: A physician fails to diagnose a cancerous nodule, the patient develops cancer.

Hollawell's lawsuits were different. Patients who are addicted to prescription drugs often lie to doctors and pharmacists to feed their habit, which means jurors might blame them for their own deaths.

"People just think it's your fault," Hollawell said. "Everybody was telling us how difficult it would be to prove the case."

Hollawell disagreed. "You get hooked, your behavior changes, all you want to do is get what the doctor's giving you."

Talking to jurors after the McGuckin trial - though it was settled before their verdict was recorded - showed Hollawell his argument was persuasive. But he faced a tougher test when he took on the case of another childhood friend, Nicholas Rallis.

Rallis died at age 40 of a heroin overdose. When his body was found in an empty Kensington warehouse in September 2011, it had been more than two years since he had received a painkiller prescription from Barone.

Today, experts attribute much of the recent surge in heroin use to people who started on prescription opioids. Hollawell said he always has been certain this was true for Rallis.

"Barone made him the addict," he said. "He would have never encountered heroin had he not met Barone."

Back at Archbishop Ryan High School, Hollawell knew Rallis as a smart kid who would go on to be an A student at Drexel University. "He had a nice job with Coca-Cola in finance," the lawyer recalled.

Rallis started seeing Barone for treatment of a back injury in 2005 and recommended the doctor to McGuckin, Hollawell said. In the four years Rallis was his patient, Barone wrote prescriptions for 19,935 pills, according to records compiled by Hollawell.

Some time after his last visit to Barone, he turned to heroin. His mother, Lorraine McNulty, thinks it was because heroin is much cheaper than prescription medication.

McNulty said her son tried hard to beat drugs, including two stints in rehab.

"I watched him cry many times when it was just him and I over the way his life had turned out and how he wanted to cure himself from this disease and demon," she said.

Rallis would have turned 45 on Oct. 4. His mother keeps a series of unanswered text messages she sent her son the day he died: "Hi, what are you up to? . . . Are you at a meeting? . . . Are you OK: have not heard from you."

On his birthday, she pulled out her phone, read the messages, and cried.

Malpractice settlement

When Hollawell threatened to file a lawsuit on behalf of Rallis' estate, the doctor's malpractice insurers settled for $825,000, according to court records.

Both Pat McGuckin and Lorraine McNulty said what they really wanted was to stop the doctor from practicing medicine, permanently.

Back in 2010, Hollawell said, he shared his evidence against Barone in the McGuckin case with the state Board of Osteopathic Medicine, which issues and oversees licenses. He later did the same with the records he compiled in the Rallis case and again in his most recent lawsuit.

It took four years and a fourth death, which state investigators found on their own, before the board suspended Barone's license in September of last year. It then negotiated a consent agreement that required him to get additional training in prescribing narcotics and a skills assessment during the 18-month suspension.

Barone admitted no wrongdoing. Neither the February consent decree nor the osteopathic board's one-paragraph public announcement mentioned any deaths.

The board can revoke licenses but rarely does so. A request to interview board chairman Jeffrey A. Heebner, a family-practice doctor in Montgomery County, was denied. A spokeswoman for the Department of State said that as a matter of policy no members of any of Pennsylvania's 29 licensing boards speak to reporters.

Opioids for migraines

Joey Caltagirone went to see Barone for migraines in 2005. Medical guidelines generally recommend against using opioids for migraines, because they can cause even worse headaches when patients go off them.

But Caltagirone left that first appointment with a prescription for 100 Percocets, according to the lawsuit filed by Hollawell in Philadelphia Court of Common Pleas.

Over the years he got more narcotics, but the headaches continued, said his father, Joe. His marriage crumbled. He lost his room-service job at the Marriott Downtown, where his father still works.

Worried about him being alone, Caltagirone suggested that he live with him in Kensington a few years ago.

"He was my best friend. A beautiful boy. Kind heart. Quick to laugh. My soul mate," the father said.

Though Joey could not use his health insurance for his visits to Barone's cash-only practice, he did use it to pay for the medications. In 2009, Express Scripts, the pharmacy benefit manager, notified Barone that his patient was getting large quantities of narcotics, including fentanyl, oxycodone, and Percocet.

His father repeatedly found Joey collapsed on the floor. One day, Joey told him about his doctor and the drugs. His father called Barone:

"I said to the doctor, 'Why does he have to take Percocet every single day when all he has is migraines? This is insane.' " He said Barone told him that he would reduce the dosage.

Eventually, father and son went together to see a specialist at Thomas Jefferson University Hospital's Headache Center. "He said to Joey, 'You have been taking lethal doses of medication, and we are going to get you into a hospital,' " Caltagirone said.

Shortly after his release, medical records show, Barone wrote Joey a prescription for methadone, an opioid he had never taken before. Methadone is best known as a highly regulated treatment for addiction, but can be prescribed by any doctor for pain. The risk of overdose is particularly high.

Six days after the first prescription, Barone wrote a second for twice as many tablets. Three days later, on May 15, 2014, Joey Caltagirone died at age 39.

Manner of death, according to the medical examiner's report: methadone toxicity.

"Too much methadone can kill you," Stephen M. Thomas, a pain specialist from Pittsburgh, testified at Barone's license-suspension hearing in Harrisburg five months later.

Barone knew that the patient had been behaving like an addict for years, with his pill-taking "out of control," Thomas said in a phone interview Friday. "It is one thing if I put paper on a fire that is already burning. It is another thing if I put gasoline on," he said, adding that the death was entirely predictable.

A few days after Joey died, Barone called the Caltagirone house. "He said, 'Can I talk with Joey?' " the father recalled. "I said 'He died.' "

The doctor then asked if he could come to the funeral, he said, and added a request:

"He said, 'Sometimes the family is hostile against the doctor. Can you make sure that I'm all right?' "