Records show drug diversion as major contributor to illegal pill mills, self-prescribed narcotics abuse

NEW HAVEN, Connecticut (InvestigateTV) — When it came time for Soryorelis Henry to have an egg retrieval procedure -- a routine part of IVF treatment for couples who’ve struggled to conceive, her doctor assured her she wouldn’t feel a thing.

But throughout the surgery, she said she repeatedly cried out in anguish, clenching her fists and sobbing to get through the procedure, telling the physician her pain was at a 10.

“Something was clearly wrong,” Henry said. “It was horrific.”

Her distress was a surprise to her doctor, who indicated that pain medication had been administered and should have been taming any discomfort.

Afterward Henry told her husband, “I felt deceived. I felt betrayed. I didn’t understand what happened. I questioned myself, like, is it me? Has my pain threshold changed?”

Then months later, she learned the shocking truth. This wasn’t an oversight or accident at the Yale fertility clinic. It was a crime.

A nurse at the clinic had stolen Henry’s pain medication.

Yale case turns national spotlight on medical providers diverting drugs for personal gain

For months in 2020, a nurse working for a fertility clinic run by Yale Medicine had been secretly stealing fentanyl from the medical supply, court records show.

Nurse Donna Monticone’s betrayal went beyond simple theft, as investigators learned she had been draining the drug vials for her own use, refilling them with saline, and putting them back on the clinic shelves.

So instead of getting potent painkillers during their procedures, attorneys say at least 95 fertility patients received the medical equivalent of salt water.

“I was shocked. I was relieved to know what happened. But then the anger kicked in because I could not believe someone would do this,” Henry said.

Monticone was convicted in March of 2021, pleading guilty to tampering with a consumer product – the fentanyl intended for patients.

What she did falls into a special category of deception called drug diversion - where medical professionals redirect medications from their intended, legitimate use for illegal purposes or distribution. It’s an issue occurring nationwide.

“They’re everywhere,” said Ian Iacoviello, a former Maryland detective who worked for an FBI task force that investigated diversion cases and healthcare fraud. “If you can operate with no oversight and really, nobody is questioning what you’re doing, you just keep doing it.”

Board records nationwide show hundreds of medical providers disciplined for diversion

InvestigateTV discovered dentists, nurses, and physicians of all specialties engaged in diversion from coast to coast. We examined disciplinary records for state regulatory boards nationwide dating back to 2018 and found that nearly 300 medical professionals had been punished for diversion.

Records show medical providers stealing from tracking machines kept in hospitals or clinics, diverting pills meant for patients, holding or taking leftover medication instead of throwing it away as required, as well as writing prescriptions for themselves, people they knew, or known drug abusers.

“When you start putting letters before and after someone’s name, they’re looked at differently,” Iacoviello said.

The former investigator turned drug awareness coordinator has the experience to know, having spent years working with the FBI and local authorities on pharmaceutical cases. His work helped convict an oral surgeon in Maryland for second-degree murder.

“That was the craziest three weeks of my life,” he said. “That case still gets me.”

The case involved Dr. James Ryan who was profiled as part of an InvestigateTV investigation into troubled dentists who are allowed to surrender their professional licenses to avoid discipline from their regulatory boards, despite committing serious acts of malpractice or misconduct.

Court records show Ryan was diverting painkillers from his practice, routinely supplying and even injecting his girlfriend with IV drugs meant for his patients. Sarah Harris, a pageant queen prosecutors said had been turned into an addict by Ryan, died in the couple’s home in January 2022, surrounded by bottles of sedation drugs like Ketamine, Versed, and Propofol – some still with needles stuck insides.

Ryan’s case is under appeal with his attorneys declining to comment. It’s just one of the dozens of egregious examples InvestigateTV uncovered in disciplinary records. They include:

• A doctor getting his partners to sign blank prescriptions so he could stockpile hundreds of pain pills for himself,

• A dentist who wrote prescriptions for sedation drugs for dozens of patients she never saw,

• A dentist who ordered thousands of Xanax through a dental distributor to fuel his own habit,

• Nurses who took home opioids that went unused during their shifts gave themselves morphine injections, took drugs from needles in the sharps container, and even used pills meant for patients, claiming they’d been given when the person complained of pain.

See something, say something is key to busting cases, investigators say

In some cases, discipline records show, the diverters were snagged by a prescription paper trail. Others were caught on camera or flagged when the records for automated medication machines used in many medical settings didn’t add up.

But in many cases, the diversion came to an end simply because someone spoke up.

“When something isn’t right, there is a good chance that frankly, we can even go back to an elementary school principal - somebody is going to tattle,” said Eduardo A. Chávez, the special agent in charge of the Drug Enforcement Administration’s Dallas field office.

In one of Chávez’s biggest cases, somebody did - busting open a massive diversion case in Texas. The cases resulted in charges filed against 49 people in 2020, including two doctors, a nurse practitioner, and five pharmacists. Ultimately prosecutors secured 46 convictions related to the case.

InvestigateTV got exclusive access to the wiretaps and undercover footage used in the DEA sting, known as “Operation Wasted Daze”. The operation captured a network of recruits on video – bringing so-called “patients” from homeless shelters to the suburban clinic used as a hub for the business.

Records show the two physicians running the clinic were operating a pill mill, writing prescriptions for cash, and filling the prescriptions with the prescriptions filled by pharmacies that were in on the scam. Those drugs they prescribed were ultimately diverted for resale on the street.

“What’s amazing to me is how you could get so many people to agree to the same criminal activity, not waiver, and do it for so many years. In essence, the process was as insulated as it could be,” Chávez said.

The doctors were so secretive that prosecutors said they wrote $18 million worth of prescriptions– with the profits often mailed between the pages of magazines. They did it, Chávez said, by spacing out appointments, specifying no refills, and adding things like mineral ice to pain pill prescriptions or antibiotics to go along with cough syrup that contained narcotics.

“So, if the DEA, if the pharmacist, if the medical board happens to take a look at that - they see, ‘Oh someone must have come in for a bum knee, and here’s this doctor prescribing exactly what you might think would be a remedy for that’. So, they knew just enough,” he said.

It was enough for those involved to escape detection by the DEA for nine years.

Although the agency is tasked with handling both random and scheduled audits of prescribing habits, its agents must keep an eye on hundreds of thousands of registered prescribers nationwide. As a result, experts tell InvestigateTV that a small number of smooth operators can slip through the cracks while the vast majority play by the rules.

Iacoviello, the former pharmaceutical investigator, said state prescription monitoring programs created in the wake of the opioid epidemic can help flag potential diversion cases. But he said from his experience, much of the focus is on people who doctor shop rather than the doctors themselves - professionals who may be writing prescriptions that push pills the wrong direction.

That’s one reason why people speaking up is key. “Unless somebody steps out of that closed environment and says, ‘I think you all need to hear this.’ There’s really nobody,” he said.

In Soryorelis Henry’s case, it wasn’t the cries of agony from patient after patient at Yale’s fertility clinic that cracked the case. It was somebody who noticed a loose cap on a fentanyl bottle and sounded alarms for an investigation.

Monticone, the nurse who’d been diverting the drug meant for patients, was sentenced to three years of supervised release, four weekends of incarceration, and three months of home confinement. She surrendered her nursing license in 2023. Her attorney didn’t respond to multiple requests for comment.

In September, Yale University settled a lawsuit with more than 150 patients impacted by the mass diversion at its facility, including Soryorelis Henry. The university had previously paid more than $300,000 to the U.S. Department of Justice to resolve allegations of failing to “guard against the theft and diversion of controlled substances”.

According to a spokesperson for the university, Yale Medicine has instituted new measures to ensure their facilities have the most rigorous processes, procedures, and safeguards in place since the Monticone discovery.

“We will continue to do everything we can to ensure our patients and staff feel heard and that we have the strongest protections in place for them,” they said in a statement supplied to InvestigateTV.

For Soryorelis Henry, the healing isn’t over.

“It broke my trust in the healthcare system. I just didn’t understand even as a nurse how that could have happened,” Henry said.

She now is a nurse practitioner with the power to prescribe and has a four-year-old daughter. She said that she is determined to be the kind of patient advocate she didn’t have during her retrieval surgery. Protection is the goal, she said, so patients are never betrayed by medical professionals they trusted, “Not under my watch.”

Associate Producer Mackenzie Bruns contributed to the research for this report.

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