Well past seven one evening in 1988, after the nurses and the office manager had gone home, as he prepared to see the last of his patients and return some phone calls, Dr. Lou Ortenzio stopped by the cupboard where the drug samples were kept.
Ortenzio, a 35-year-old family practitioner in Clarksburg, West Virginia, reached for a box of extra-strength Vicodin. The box contained 20 pills, wrapped in foil. Each pill combined 750 milligrams of acetaminophen, the active ingredient in Tylenol, with 7.5 milligrams of hydrocodone, an opioid painkiller.
Ortenzio routinely saw patients long after normal office hours ended. Attempting to keep up with the workload on this day, he had grown weary and was suffering from a tension headache; he needed something to keep him going. He unwrapped a pill, a sample left by a drug-company sales rep, certain that no one would ever know he'd taken it. Ortenzio popped the pill in his mouth.
"It was a feeling like I'd never felt before," he told me recently. "I'm tense and nervous, and that anxiety is crippling." The pill took the anxiety away. The sense of well-being lasted for four hours, carrying him through the rest of the night's work.
Back then, Ortenzio was one of Clarksburg's most beloved physicians, the kind of doctor other doctors sent their own families to see. His patients called him "Doc O." He made time to listen to them as they poured out the details of their lives. "To me, he wasn't like a doctor; he was more like a big brother, somebody I could talk to when I couldn't talk to anybody else," says Phyllis Mills, whose family was among Ortenzio's first patients. When Mills's son was born with a viral brain infection and transferred to a hospital in Morgantown, 40 miles away, Ortenzio called often to check on the infant. Mills never forgot that.
As a physician in a small community with limited resources, Ortenzio did a bit of everything: He made rounds in a hospital intensive-care unit and made house calls; he provided obstetric and hospice care. Ortenzio loved his work. But it never seemed to end. He started missing dinners with his wife and children. The long hours and high stress taxed his own health. He had trouble sleeping, and gained weight. It took many years, but what began with that one Vicodin eventually grew into a crippling addiction that cost Ortenzio everything he held dear: his family, his practice, his reputation.
The United States is in the midst of the deadliest, most widespread drug epidemic in its history. Unlike epidemics of the past, this one did not start with mafias or street dealers. Some people have blamed quack doctors—profiteers running pill mills—but rogue physicians wrote no more than a fraction of the opioid prescriptions in America over the past two decades. In fact, the epidemic began because hundreds of thousands of well-meaning doctors overprescribed narcotic painkillers, thinking they were doing the right thing for suffering patients. They had been influenced by pain specialists who said it was the humane thing to do, encouraged by insurance companies that said it was the most cost-effective thing to do, and cajoled by drug companies that said it was a safe thing to do.
Opioid painkillers were promoted as a boon for doctors, a quick fix for a complicated problem. By the end of the 1990s, Ortenzio was one of his region's leading prescribers of pain pills. It was a sign of the times that he didn't think there was anything wrong with that.
C larksburg sits atop rolling hills in northern West Virginia, halfway between Pittsburgh and Charleston. Lou Ortenzio came here in 1978, a recently married young resident out of the University of Maryland School of Medicine. "Small-town living seemed so much better than suburban life," he told me as we drove around town one afternoon. "In Clarksburg, every block had something going. We had mom-and-pop grocery stores in every neighborhood. All these houses were occupied by teachers, downtown business owners, and people who worked in glass factories."
Coal mining was the state's dominant industry, but in Clarksburg, the glass business boomed. Glass manufacturing had arrived at the turn of the 20th century, drawn by the state's high-quality river sand and rich fields of natural gas. Pittsburgh Plate Glass opened a factory in Clarksburg in 1915 and for years was one of the world's leading plate-glass producers. Anchor Hocking employed 800 people making tumblers, bottles, fruit bowls. The city had family-owned factories too: Rolland Glass, Harvey Glass, and others.
Unlike simple resource extraction, glassmaking required sustained technological investment to meet new demands from the marketplace. The mass production of plate glass made skyscrapers possible. Picture windows and sliding-glass doors made small homes look bigger and more luxurious. The industry forged a middle class in Clarksburg and even gave the city a cosmopolitan air. The glass factories attracted artisans from France and Belgium; French was commonly heard on the streets for years.
Each neighborhood was a self-contained world, with its own churches, grocery stores, and school; many had a swimming pool. High-school sports rivalries were fierce, and football games drew large crowds. When Victory played Roosevelt-Wilson, or Washington Irving went up against Notre Dame, people knew to arrive early to find a seat.
By the late 1970s, Clarksburg's older physicians were retiring. Like many small towns at the time, it had trouble attracting young professionals. Ortenzio was among the few physicians who moved there to fill the void. He and two other young doctors opened a practice in 1982. Almost immediately, Ortenzio was seeing 40 to 50 patients a day.
The people who came to see him were mostly older; many had served in World War II. They had the aches and pains to show for a lifetime of hard work in the glass factories or at the gas company, but they had retired with something approaching financial security. They owned homes and cars, had pensions and good health insurance.
Ortenzio's patients suffered from the ailments of the old—arthritis, diabetes, hypertension—and most of them did so stoically. This was partly generational and partly an Appalachian inheritance. One man, Ortenzio remembered, came to him thin and wasted away from cancer. "The disease was advanced, but he put up with it. I said, 'Why didn't you come in earlier?' He said, 'Well, I wouldn't want you to think I was complainy.' That was the Appalachian line—'I wouldn't want you to think I was complainy.' "
Ortenzio grew into his adopted city. In 1992, he established a free clinic where Clarksburg's uninsured could get medical care. The county chamber of commerce named him Citizen of the Year for that. He had been trained to treat patients holistically. Most of what a doctor needs to know to make a diagnosis, his professors had taught him, could be learned from taking time to listen to the patient. X-rays and lab tests were mostly to confirm what you gleaned from asking questions and paying attention to the answers. He'd also been trained to help his patients help themselves. Part of his job was to teach them how to take care of their bodies. Pills were a last resort. This careful approach endeared him to his patients, but it lengthened his day. "He would have office hours until 11:30 at night," says Jim Harris, a friend and the director of the free clinic. "People waited until then because he was worth the wait."
Drug salesmen visited him weekly. It was a stodgy profession back then. Ortenzio remembers the reps as older men who had grown up and lived locally and who cultivated long-term relationships with doctors. One of the reps for Eli Lilly was a deacon in a local Catholic church. Once a week, he would visit Ortenzio's office in a business suit, with information about the drugs Lilly produced. Like many in his profession in those years, he avoided hard-sell tactics. Ortenzio grew to rely on the salesman's counsel when it came to pharmaceuticals. Once, when the Food and Drug Administration removed a Lilly drug from the market, the rep dropped by Ortenzio's office, embarrassed and apologetic.
Before long, Ortenzio and his wife saw Clarksburg as home. They found a two-story, three-bedroom house in the Stealey neighborhood, southwest of downtown and at the foot of a hill. They set off to the bank for a 30-year loan. To their surprise, they were denied. "The house won't keep its value that long," the banker told them. "The best we can give you is a 15-year loan."
T he banker was right. It wasn't yet clear, amid the bustle of Main Street and Friday-night football, but the city's prospects were fading. Newer glass technologies required large factories, which meant stretches of flat land rare in West Virginia. Mexico and Japan emerged as competition in glass manufacturing, and plastic and aluminum emerged as alternatives to glass. Pittsburgh Plate Glass had closed in 1974. Anchor Hocking left in 1987. Its hulking concrete plant is slated for demolition, but for now it remains, just off Highway 50.
By the mid-1980s, the city was in decline. Glasswork was replaced by telemarketing. Downtown, locally owned stores began to disappear. Homeowners yielded to renters, many relying on Section 8 assistance from the government. The city eventually had to destroy dozens of abandoned homes, leaving streets with toothless gaps. The swimming pools, too, slowly closed; resident associations lacked the money to maintain them.
Ortenzio drove me by the massive Robert C. Byrd High School, home of the Eagles. It was built in 1995 to consolidate two smaller high schools in Clarksburg, whose population had receded. Replacing neighborhood schools with one centralized school allowed for better course offerings. But Byrd is far from any student's home. School consolidation extinguished the sports rivalries that had brought people together each week. Without local schools, neighborhoods lost their social centers.
Lou Ortenzio began to see people in economic as well as physical pain. Many were depressed, worn out by work or the fruitless search for it. Obesity became a more common problem. Some patients began to ask whether he could get them on workers' compensation or disability. Others left to seek job opportunities in New York, North Carolina, Florida. "I was always calling people out of state telling them how sick their parents or grandparents were," he said.
When Ortenzio had opened his practice, he'd tended to see young people only for pregnancies or the occasional broken leg. By the mid-1980s, younger people were showing up in larger numbers. They were coming in with ailments that their parents and grandparents had borne in silence—headaches, backaches, the common cold. "The new generation that came in the 1980s, those kids began to have the expectation that life should be pain-free," Ortenzio said. "If you went to your physician and you didn't come away with a prescription, you did not have a successful visit."
The shift was not peculiar to Clarksburg. Americans young and old were becoming accustomed to medical miracles that allowed them to avoid the consequences of unhealthy behavior—statins for high cholesterol, beta-blockers and ACE inhibitors for hypertension and heart failure, a variety of new treatments for diabetes. Fewer patients showed up for annual physicals or wanted to hear what they could do to improve their wellness. They wanted to be cured of whatever was ailing them and sent on their way. Usually that involved pills.
The medical establishment, to a large degree, abetted this shift. In the 1980s, a new cadre of pain specialists began to argue that narcotic pain pills, derived from the opium poppy, ought to be used more aggressively. Many had watched terminal cancer patients die in agony because doctors feared giving them regular doses of addictive narcotics. To them, it was inhumane not to use opioid painkillers.
The specialists began to push the idea that the pills were nonaddictive when used to treat pain. Opioids, they said, could be prescribed in large quantities for long periods—not just to terminal patients, but to almost anyone in pain. This idea had no scientific support. One author of an influential paper later acknowledged that the literature pain advocates relied on to make their case lacked real evidence. "Because the primary goal was to destigmatize, we often left evidence behind," he said.
Nevertheless, an alliance of specialists who saw their medical mission as eradicating pain was soon joined by the pharmaceutical companies that manufactured opioids. Medical institutions—the Department of Veterans Affairs, the Joint Commission on Accreditation of Healthcare Organizations, hospitals and medical schools across the country—bought into this approach as well.
By the late 1990s, medical schools, when they taught pain management at all, focused on narcotics. By the early 2000s, doctors were being urged to prescribe the drugs after almost any routine surgery: appendectomy, ACL repair, wisdom-tooth extraction. They also prescribed them for chronic conditions such as arthritis and back pain. Chronic pain had once been treated with a combination of strategies that only sometimes involved narcotics; now it was treated using opioids almost exclusively, as insurance companies cut back on reimbursing patients for long-term pain therapies that did not call on the drugs.
The U.S. drug industry, meanwhile, was investing heavily in marketing, hiring legions of young salespeople to convince doctors of their drugs' various miracles. Nationwide, the number of pharmaceutical sales reps ballooned from 38,000 in 1995 to 100,000 a decade later. The old style of drug rep, grounded in medicine or pharmacy, largely passed from the scene.
"It went from a dozen [salesmen] a week to a dozen a day," Ortenzio remembered. "If you wrote a lot of scrips, you were high on their call list. You would be marketed to several times a day by the same company with different reps."
Most drug companies in America adopted the new sales approach. Among them was Purdue Pharma, which came out with a timed-release opioid painkiller, OxyContin, in 1996. Purdue paid legendary bonuses—up to $100,000 a quarter, eight times what other companies were paying. To improve their sales numbers, drug reps offered doctors mugs, fishing hats, luggage tags, all-expenses-paid junkets at desirable resorts. They brought lunch for doctors' staff, knowing that with the staff on their side, the doctors were easier to influence. Once they had the doctor's ear, reps relied on specious and misinterpreted data to sell their product. Purdue salespeople promoted the claim that their pill was effectively nonaddictive because it gradually released an opioid, oxycodone, into the body and thus did not create the extreme highs and lows that led to addiction.
The reps were selling more than pills. They were selling time-saving solutions for harried doctors who had been told that an epidemic of pain was afoot but who had little time, or training, to address it. For a while, Ortenzio still suggested exercise, a balanced diet, and quitting smoking, all of which can alleviate chronic pain. But his patients, by and large, didn't want to hear any of this, and he was busy. So he, too, gradually embraced pain pills. Nothing ended an appointment quicker than pulling out a prescription pad.
T he number of people on pain pills grew from a tiny fraction of Ortenzio's practice to well over half of his patients by the end of the 1990s. The shift was gradual enough at first that he didn't recognize what was happening. Patients with medical problems unrelated to pain migrated to other doctors. Still, Ortenzio was working 16-hour days, seeing patients who had been scheduled for the afternoon at 9 p.m.
The more drugs Ortenzio prescribed, the more he was sought out by patients. Many would use up a month's supply before the month was out; in need of more pills, they were insistent, wheedling, aggressive. Many lied. Some would curse and scream when Ortenzio told them that he couldn't write them a new prescription yet, or that he wanted to lower their dosage.
The pills were soon on the streets of Clarksburg as well. They replaced beer and pot at many high-school parties. Phyllis Mills, Ortenzio's longtime patient, had two daughters who abused the pills. Theirs did not come from Ortenzio, at least not directly, but the supply of pills was exploding, due in large part to doctors like him who were overprescribing them.
Ortenzio should have noticed what the pills were doing, to his patients and his community, but he was less and less himself. After his late-night encounter with Vicodin in 1988, he had begun his own slide into addiction. By the late 1990s, he was using 20 to 30 pills a day, depleting even the plentiful supply of free samples from the ubiquitous sales reps.
Desperate to get his hands on more pills, he found a friend he could trust, a middle-aged accountant and a patient of his. "I'm in some trouble," Ortenzio told him. "If I write you this prescription, can I ask you to fill it and bring it back to me?"
"Sure thing," the man said, without asking for an explanation. "If you gotta have it, you gotta have it. You're the doc."
Soon a dozen or so trusted patients were helping Ortenzio. He knew he was out of control and needed help—even the amount of acetaminophen he was consuming was toxic—but he feared that seeking treatment for his addiction might cost him his medical license. Around 1999, he found a new way to get his fix. He began writing prescriptions in his children's names.
Ortenzio could plainly see that the claim that these pills were nonaddictive was untrue. He would try to quit and feel the symptoms of withdrawal. "I couldn't be away from my supply," he said. His patients, too, were terrified of going without. One, a nurse at a local hospital suffering from chronic pain as well as depression and anxiety, would approach him in his office parking lot, often bearing gifts of quilts or canned goods, insisting that she needed her pills that morning, that she couldn't wait for her monthly appointment.
Ortenzio saw no way to break the cycle the pills had created for the people in his care. He never found a way to get his patients down to lower doses of narcotics. They rebelled when he suggested tapering; just cutting people off made them sick. The area didn't have enough pain clinics or addiction specialists to refer them to, and insurance companies wouldn't reimburse for many pain treatments that did not involve pills. Without good alternatives for his patients, he kept on writing prescriptions.
A ddiction and overwork had estranged Ortenzio from his wife and children. As Clarksburg declined, his wife moved the kids to Pittsburgh to find better schools. In 2004, after more than a decade of living in different cities, they divorced. Raised Catholic but without much feeling for the Church, Ortenzio joined a Protestant congregation. Ultimately, he found Jesus in his exam room. During an appointment one day, he and a patient, a Baptist, talked of his search for redemption. The patient knelt with Ortenzio on the linoleum floor and prayed for the doctor. Ortenzio marks that moment as his new beginning. He had advantages many addicts don't have: a home and a car, financial resources, generous friends and colleagues, and, later, the support of a second wife. He managed to taper off the drugs. A couple of months later, he was baptized in a deep section of Elk Creek, where baptisms have taken place since the early 1800s.
Not long after that, federal agents raided his office. They interrogated his staff and confiscated hundreds of patient records. The investigation dragged on for nearly two years. His children had to testify before a grand jury that they knew nothing about the prescriptions their father had written in their names.
In October 2005, prosecutors charged Ortenzio with health-care fraud and fraudulent prescribing. That year, 314 West Virginians died from opioid overdoses, more than double the number of people five years earlier. By 2006, according to the Centers for Disease Control and Prevention, physicians were writing 130 opioid prescriptions for every 100 West Virginians.
In March 2006, Ortenzio pleaded guilty. His sentencing occurred shortly after a 2005 Supreme Court decision made federal sentencing guidelines nonmandatory and individual sentences up to judges' discretion. Despite what he'd done, Ortenzio was still beloved in Clarksburg. More than 100 people wrote to the judge on his behalf. He received five years of supervised release plus 1,000 hours of community service, and was ordered to pay $200,000 in restitution. He would serve no prison time, but he did lose his medical license.
At 53, Ortenzio was unemployed. A temp agency offered him a landscaping job at the Stonewall Resort, where, as a doctor, he had taken his family for Sunday brunch. He'd never worked outdoors in his life, but he took the job. It paid $6.50 an hour.
He worked at the resort for a couple of months, then as the janitor at a local community center before returning to Stonewall as a full-time groundskeeper. He also found a night job.
Tom Dyer is one of northern West Virginia's leading defense attorneys; Ortenzio had been his client. One night in 2006, Dyer ordered a pizza from Fox's Pizza Den in Bridgeport, a town near Clarksburg. When the doorbell rang, he opened the door and there stood Lou Ortenzio, holding a pie. It took a minute before Dyer realized: Doc O was now a pizza-delivery guy. "I was just speechless," Dyer told me.
"I made pizza deliveries where I used to make house calls," Ortenzio said. "I delivered pizzas to people who were former patients. They felt very uncomfortable, felt sorry for me." But, he said, "it didn't bother me. I was in a much better place."
Ortenzio eventually left pizza delivery. But the way he told me the story, the job was an important step in his recovery: Every pie he delivered liberated him. He was free of the lies he'd told his colleagues, his family, and himself to hide his addiction. He liked hearing kids screaming "The pizza guy's here!" when he knocked on the door. "You make people happy," he said. "That was what I liked about being a doctor."
T oday, Ortenzio spends his days trying to atone. He does this through constant work. There are places in and around Clarksburg where addicts can get help, and Ortenzio can be found at most of them.
The Mission opened in 1969, in Clarksburg's Glen Elk neighborhood, at the time a small red-light district with bars and backroom gambling. The shelter started with a few beds, intended for alcoholics and homeless veterans. A neon-blue jesus saves sign outside has remained illuminated for all the years since, as the shelter has expanded. Today, many of its 120 beds are occupied by opioid addicts.
One afternoon, I met Ortenzio in a small, windowless office at the Mission. Now 66, he is thin, gray-haired, and bespectacled; he dresses in a hoodie, blue jeans, and sneakers. He does a bit of everything at the Mission, from helping the addicted find treatment to helping them find a coat, or shoes for their children, or a ride to the probation department. He is a volunteer adviser there, too, and at the county's drug court, where he guides addicts through the criminal-justice system.
Ortenzio is also involved with two newer initiatives, which suggest the challenges of repairing the damage done by opioids. A wood-beamed downtown church is home to Celebrate Recovery, a Christian ministry founded in Orange County, California. Celebrate Recovery has grown nationwide due in large part to the opioid epidemic. On the cold Tuesday night I visited, the service featured an electric band singing the kind of fervid new gospel music that is common to nondenominational Christianity: "You are perfect in all of your ways …"
Ortenzio is Celebrate Recovery's lay pastor in Clarksburg, running its weekly services. The flock is about 100 or so strong. One evening, a young mother named Sarah stood before the congregation to give her testimony. Sarah's story started with parents who married too young and divorced before she was 3. It featured father figures who were coal miners and truck drivers and a stepfather who molested her repeatedly, beginning when she was 8. Then a life of illicit drugs, marriage, divorce, and addiction to prescription pain pills.
Clarksburg's traditional congregations have dwindled along with the city's population; many rely on support from former residents who commute in from elsewhere on Sundays. The place these churches once held in this community has been taken by new churches proclaiming a gospel of prosperity, insisting that God wants us all to be rich. And by ministries such as Celebrate Recovery.
Ortenzio coordinates the training of recovery coaches at the church, people who can help addicts as they try to wean themselves from narcotics. Addiction, however, seems as present as ever in Clarksburg. At the Mission one day, I met a group of recovering young drug users. Several of them had started out on heroin but then turned to meth. In Clarksburg and many other parts of the country, meth is coming on strong, poised to be the fourth stage in an epidemic that began with prescribed pills, then moved to heroin, and then to fentanyl. Meth seems to reduce the symptoms of withdrawal from opioids, or maybe it's just a way to get high when anything will do. Whatever the case, like the various forms of opioids before it, meth is now in plentiful supply in Clarksburg.
A couple of years ago, Ortenzio decided to open a sober-living house downtown, where recovering addicts could spend six months or more stabilizing their lives. He said God had instructed him to undertake the project, and had told him, in fact, where to do it—in a house right around the corner from the duplex where Clarksburg's first resident overdosed on fentanyl. In 2017, more than two West Virginians a day were being claimed by opioids. Recovering addicts needed places where they could maintain sobriety. "We thought, This is going to be great. They'll throw a parade for us ," says Ben Randolph, a businessman whom Ortenzio helped recover from pill addiction.
Instead, the idea of a sober-living house outraged many in town. The principals of two local schools were concerned that the house was too close to their campuses. Owners of local businesses worried that the house might further tarnish the city's image. "The property value of the homes around it are going to plummet. You're going to have both drug dealers and recovering addicts in one area, so they'll have a captive market," one resident told The Exponent Telegram .
But Ortenzio persisted, and a bank eventually granted him a mortgage. Since July 2017, he has run a six-bed home for men, with daily supervision and no problems—no spike in crime nearby, no complaints of loitering—reported so far. A similar home for women opened last May. Nevertheless, the episode showed where the city, perhaps even the country, was when it came to addiction: afflicted mightily and wanting it to go away, but not knowing how to make that happen.
L ou Ortenzio was the first Clarksburg doctor prosecuted for improperly prescribing pain pills. He was the first person most residents I talked with recall as putting a different face on addiction. He was the first to show that this was a new kind of drug plague, and the first to puncture the idea that the supply came from street dealers. He was also the first to publicly work at his own recovery without shame.
He was not, however, alone. In 2005, another local doctor, Brad Hall, gathered with members of the West Virginia State Medical Association concerned about addiction among physicians in a state that cannot afford to lose them. They started the Physician Health Program, which has helped some 230 West Virginia doctors with substance-abuse problems get confidential treatment and retain their license to practice. Many are overworked, as Ortenzio had been. Some were self-treating emotional and physical problems. About a quarter abused opioids.
Ortenzio managed to escape drugs, but he's still living with the effects of his addiction. He is working to repair his relationship with his youngest son; Ortenzio didn't attend his wedding and has yet to meet a young grandson. He leans on his faith to keep him going. Many of his encounters with addicts prompt sudden, public prayers, Ortenzio bowing his head as he clasps the person's shoulder. His faith has humbled him, relieving him of a sense of hubris that got him into trouble as a doctor: the idea that he could heal an entire community, if he just kept the office open a few hours longer.
Doc O will never practice medicine again. Yet his work at the Mission doesn't seem so different from his routine as a family physician, tending to the needs of one person after another. One morning, he took a resident to a clinic, then talked on the phone with an addicted doctor living in a halfway house. A pastor from the coalfields of southern West Virginia called to ask how to set up a Celebrate Recovery ministry in his large but dying church. A 24-year-old mother of four from a West Virginia mountain town was looking for $225 to pay the utilities for an apartment she was trying to rent. Ortenzio promised to reach out to the Mission's supporters for a donation.
As the morning wore on, a gaunt 26-year-old man from North Carolina, a construction worker addicted to heroin and meth, showed up to report that he'd had five of his teeth pulled. The dentist had prescribed a dozen hydrocodone pills. The construction worker couldn't fill the scrip without proper ID, which he didn't possess. Ortenzio sat and listened as the young man, slumped beneath a baseball cap, stared at the floor and insisted on his need for the painkiller.
The dentist had probably figured that the fellow had lost a lot of teeth, that a dozen pills weren't many. If that were the case, it would mark a change. Not that long ago, the dentist might have prescribed 20 to 40 pills.
Ortenzio offered the construction worker a prayer. The man clearly still wanted the drugs. Ortenzio, who as a doctor had prescribed pills by the hundreds each day, could only give him packets of ibuprofen.
"You want to stay away from hydrocodone," he said.
This article appears in the May 2019 print edition with the headline "The Penance of Doc O."
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