Prescription for Disaster

Relatives of Stephen Schneider’s patients asked him about all the opioids they were taking. He said everything would be fine.Illustration by Stephen Doyle

In 2005, the medical examiner in Wichita, Kansas, noticed a cluster of deaths that were unusually similar in nature: in three years, sixteen men and women, between the ages of twenty-two and fifty-two, had died in their sleep. In the hours before they lost consciousness, they had been sluggish and dopey, struggling to stay awake. A few had complained of chest pain. “I can’t catch my breath,” one kept saying. All of them had taken painkillers prescribed by a family practice called the Schneider Medical Clinic.

The clinic was in Haysville, a working-class suburb of Wichita. The main industries in the area were aircraft and plastics, neither of which was doing well. A mile south of the clinic, there was little except wheat fields. The chief doctor was Stephen Schneider, a fifty-one-year-old osteopath with sandy hair and dimples. He treated the county commissioner and the chief of police, gave physicals to the boys at the Haysville high school, and did rounds at local nursing homes. One of his patients, Jeffrey Peters, told me that Schneider reminded him of the “kind of family doctor we had forty years ago, when I was growing up—a doctor who will sit down and listen to you and joke around and make you feel comfortable.”

On September 13, 2005, Schneider arrived at work to find the clinic cordoned off with police tape. He called his wife, Linda Atterbury, a blond, peppy forty-seven-year-old nurse, who was at home with their two young daughters, and told her to come to work. Agents from the Kansas Bureau of Investigation and the Drug Enforcement Administration led Schneider into one of the clinic’s fourteen exam rooms and asked him why he had been prescribing so many opioid painkillers. He responded that sixty per cent of his patients suffered from chronic pain, and few other physicians in the area would treat them. The agents wrote, “He tries to believe his patients when they describe their health problems and he will believe them until they prove themselves wrong.” When asked how many of his patients had died, Schneider said that he didn’t know.

After the raid, fifty patients signed a petition that said, “We stand united in support of Dr. Schneider.” A receptionist hung a banner on the front of the clinic, and patients scrawled appreciative notes on it. The Schneiders also received numerous letters from patients. One wrote, “I believe that you have saved my life many times. Sometimes just by listening.” A woman with a connective-tissue disease explained, “If you have never lived with chronic pain, you have absolutely nothing to say. . . . Chronic pain changes who you are. Without the medications I am on I have no life left!”

Schneider hadn’t thought of becoming a doctor until 1979, when his three-year-old daughter, Leigh Anne, developed pneumonia. She was confined to an oxygen tent for a month. He thought the hospital was a “neat and fantastic atmosphere.” At the time, he was next in line to become the manager of the meat department at Dillons, a local grocery store. He had imagined working there with his first wife, who was a cashier, for the rest of his life. But, once his daughter recovered, he enrolled at Wichita State University and, in 1983, became the first person in his family to graduate from college.

After his first wife left him, Schneider married Atterbury, who was drawn to what she called his “animal heart”—his tenderness toward pets, children, and the elderly. She encouraged him to apply to medical school, even though she worried that a “professional that high up may get a big head.” At the University of Health Sciences, a school of osteopathy in Kansas City, Schneider felt alienated by what he called the “Dr. God feeling.” He found some of his attending physicians “demanding and demeaning to patients and nurses.” Leigh Anne, who is now a doctor, told me that her father was “never comfortable with the level of status” that came with the job.

In 1995, the Schneiders adopted two girls, both toddlers, from an orphanage in Câmpulung, Romania, and raised them on a plot of land that Atterbury’s parents owned, in Haysville. Her parents and three siblings lived in houses surrounding a wheat field. Atterbury had been raised on the Midwestern carnival circuit. Her aunt was a trapeze artist, her grandfather owned a circus known for its elephant, and her father ran concession and game stands. Atterbury believed that her upbringing made her tougher and more discriminating than Schneider. She liked to joke, “My husband believes everybody, I believe nobody, so we kind of equal each other out.”

“If you laugh at all of God’s jokes, he’s never going to learn what’s funny.”

Schneider was hired by Riverside Hospital, in Wichita, to work at a small subsidiary clinic in Haysville. In a letter of recommendation, one of his mentors wrote that he had “the highest moral character.” Most people in town, including Atterbury and her family, referred to him as Doc. He treated routine ailments, like rashes, colds, and diabetes. Several patients came to him with chronic-pain conditions, but he didn’t feel comfortable prescribing opioids long-term, so he referred those patients to specialists in Wichita.

After Schneider had worked for the clinic for thirteen years, Riverside was bought by a larger hospital system, and he and his new employer couldn’t agree on a contract. In 2001, he set up a makeshift office at an optometry clinic. It was so small that people would bring lawn chairs and wait for their appointments in the parking lot.

He was at the optometry clinic for only a few months before he and his wife took out a two-million-dollar loan to build a larger medical center. Atterbury, who would manage the office, said that she found an “architect to build my dream for him.” The clinic, which had its own X-ray room and blood lab, was designed in the Pueblo Revival style, with tan stucco walls, two fountains, and a sky dome. Schneider asked a Catholic priest to bless the property and sprinkle the ground with holy water. He envisioned an alternative to the emergency room: the clinic would be open seven days a week, and all patients could be seen the day they called. He recruited three physician assistants and a family doctor, as well as a cardiologist and a spine surgeon, who would visit the clinic once a week. The Haysville Times featured a photograph of the mayor of Haysville, the chief of police, and Schneider, in white construction hats, standing in front of a billboard that said, “Future Site of Dr. Schneider.”

Schneider was one of the few doctors in the area to readily accept Medicaid, which, he said, reimbursed less than a fifth of the cost of his appointments, and he quickly attracted a large population of patients who were on disability. Many suffered from lower-back pain after years spent assembling aircraft machinery. In medical school, Schneider had been taught that opioids were so addictive that patients should not be prescribed them unless they were dying, but the thinking in the field had evolved. Doctors began using opioids more liberally in the seventies, after the emergence of the palliative-care movement, the first branch of medicine to make the relief of suffering its primary aim. In the eighties, physicians treating patients who had cancer (whether or not it was terminal) prescribed opioids more freely, too. A 1989 article in the New England Journal of Medicine stated, “To allow a patient to experience unbearable pain or suffering is unethical medical practice.”

By the nineties, this ethos was being applied to all kinds of pain. In 1995, the American Pain Society, an organization of health professionals across disciplines, recommended that doctors consider pain the “fifth vital sign,” monitoring it as regularly as they measure pulse.

Schneider said that, when he opened his own practice, “pharmaceutical reps came in and enlightened me that it was O.K. to treat chronic pain, because there is no real cure. They had all sorts of studies showing that the long-acting medications were appropriate.” In 2002, shortly after the clinic opened, a pharmaceutical representative from Purdue Pharma, which produces OxyContin, arranged for Schneider and Jon Parks, a pain doctor in Wichita, to have dinner at a steak house. Parks described his practice and gave Schneider a copy of his pain-management contract, which required his patients to submit to urine tests. Schneider distributed the contract to his own patients and, with little training, began treating chronic pain. When a Wichita pharmacist asked Schneider if he would be willing to take all the pain patients of a local family doctor who had recently died, Schneider said, “Sure, just send them over.”

Like most doctors, Schneider asked his patients to rate their pain on a scale from one to ten (“pain as bad as it can be”). Many patients scored their pain a ten or ten-plus, and complained that they felt emasculated or useless, and often depressed. Schneider said, “The aircraft industry, like any industry, wears out its people.” But he did find himself wondering why his patients seemed to have become “wimpier.” They were no longer willing to endure any pain; they wanted it instantly eradicated. Schneider occasionally referred them to physical therapists or anesthesiologists, but for the most part he gave them the relief they requested. In a letter of thanks to Schneider, one patient wrote, “I call you the pick-up doctor, why? Because after these other doctors screw your life up from negligence in surgery (like the disc on my back), they do not want to bother with you anymore. So you get referred to Dr. Schneider.”

“Do you mean good, or good for a pumpkin?”

Pain is inadequately treated, particularly among the poor and the mentally ill, in part because there are lingering doubts about whether such a subjective experience is proportional or “real.” Bob Twillman, the founder of the inpatient pain-management program at the University of Kansas Medical Center and the director of policy and advocacy for the American Academy of Pain Management, told me, “The system is not well designed to treat these patients. What you end up with is a primary-care doctor who is stuck wanting to do something for his patients but doesn’t have the resources to do much of anything but write another prescription.” Although about a hundred million Americans suffer from chronic pain, according to a recent report by the Institute of Medicine, medical schools devote, on average, only nine hours to pain, and only about four thousand physicians are board-certified as pain specialists. Twillman said that he knew few doctors in Wichita who were willing to accept “all the hassle and uncertainty associated with chronic pain.” He sensed that Schneider was “trying to do the right thing,” and he referred patients to him.

In its first full year, the Schneider Medical Clinic took in $1.37 million in patient fees, and had a net income of two hundred and twenty thousand dollars. There was often a sign in the lobby informing patients that there would be at least a two-hour wait. Atterbury knocked on the doors of exam rooms if she thought that clinicians were spending too much time with their patients. When the chairs in the waiting room filled, patients sat on the edge of the fountains or milled about under the portico. Appointments were generally scheduled every ten minutes. Justin Brawner, a machine operator with a herniated disk, told me that in the waiting room some patients nodded off in their chairs. Others were sweaty, jittery, and irritable. He observed patients who moved freely until they were called into the doctor’s office, at which point they developed an exaggerated limp. Brawner said that he heard them “planning their tactics.” They’d make up stories about how they needed extra pills because they were leaving the state or their medication had slipped into the sink. Brawner asked for early refills, too. Schneider would chide him for coming in too soon and then say, “We’re going to go ahead and write the script, because I know you need it.”

Schneider didn’t socialize much with other doctors. He felt that many of them were sheltered and “didn’t know how to talk to real people.” He almost always took his patients’ side when they complained about doctors who had “discriminated” against them for needing opioids. Schneider told me, “I don’t even know the actual quote for the Hippocratic Oath, but aren’t you doing harm if there’s a treatment for something and you refuse to use it?”

His patients’ numbers descended on the pain scale, but their ability to function normally did, too; several quit their jobs, applying for disability with Schneider’s help. When family members questioned the amount of opioids that their loved ones were taking, Schneider assured them that everything would be fine. A recent college graduate who accompanied his depressed mother to appointments said that he repeatedly asked if she should see a psychiatrist. Schneider told him, he said, that the sadness would subside with the pain: “There’s a light at the end of the tunnel—you’ll see it. I’ve brought people back from this before.” The patient eventually killed herself. Her son said that the problem wasn’t that Schneider was deceptive; it was that he was “so flipping happy.”

Nearly a dozen sales representatives from pharmaceutical companies came to Schneider’s office each day. They took him out for meals, sent him to seminars and conferences, and gave him free samples and gifts. Schneider’s cluttered office contained a Lexapro clock, Viagra pens, and a cup featuring the logo for Nasonex nasal spray. The clinic never had to buy its own tissues, because drug companies contributed boxes branded with their name. Atterbury wondered how physicians could stay grounded when the pharmaceutical representatives were always flattering them. She said, “They treat the doctors like they are above everyone else, listening to them, catering to them, dressing well for them, saying, ‘Where do you want to eat tonight?’ ”

“Good arm.”

After listening to presentations by the company Cephalon, Schneider became one of the few family physicians in Wichita to regularly prescribe Actiq, a raspberry-flavored lollipop that contains fentanyl, which is eighty times more potent than morphine. The Food and Drug Administration has approved Actiq only for acute cancer pain, but Cephalon’s pharmaceutical representatives, who called themselves “pain-care specialists,” told Schneider that it worked well for all sorts of pain, particularly migraines. Although it’s legal for doctors to prescribe medications for uses that have not been approved by the F.D.A., pharmaceutical companies are prohibited from marketing drugs for such purposes. According to whistleblower suits later filed against the company (and settled, in 2008, for more than four hundred million dollars), the “pain-care specialists” sought out doctors who did not treat cancer. They were instructed to respond to questions about off-label use of the drugs by saying, “Yes, we are indicated for cancer pain, but wouldn’t you agree that pain is pain?” The company sent Schneider’s physician assistant to New York for an “Actiq consultants meeting”; it paid for her to stay at the W hotel and to ride a boat on the Hudson. In 2003, Schneider was sent to an Actiq conference in New Orleans, sponsored by Cephalon. He said that a specialist there told him, “You could stick multiple Actiq suckers in your mouth and your rear end and you still wouldn’t overdose. It’s clinically impossible.”

Three years after his clinic opened, Schneider attended the first meeting of the Sedgwick County Pain Society, a group of doctors and law-enforcement officers working to minimize the abuse of prescription drugs. Schneider was one of the first people to speak, and he asked if anyone would be willing to take some of his Medicaid pain patients. He told me that all the doctors in the area had taken the “good insurance patients” and given him their leftovers, the ones with multiple illnesses and unreliable histories. Gregory Lakin, a family physician and a former prosecutor who runs the largest addiction-treatment center in Kansas, was moderating the meeting, and he asked for a show of hands. There were twenty doctors, nurses, and physician assistants in the room, but no one volunteered to take any of Schneider’s patients. “I felt embarrassed about it,” Lakin told me. He had previously accepted Medicaid, and he did not want to do it again. He told me, “I do think Steve had a little bit of the martyr in him. He’s isolated, being in a small town, and he saw himself as a rescuer, a savior of the downtrodden, and that overrode his ability to assess the warning signs.”

In the fall of 2004, FirstGuard, a Kansas Medicaid contractor, told the Schneider Clinic that it was concerned about its quality of care, particularly its off-label prescriptions of Actiq. FirstGuard’s medical director visited the clinic and later told the D.E.A. that his “over-all impression” was that it was a “sophisticated practice with gaps in its process, but making an effort to serve” an area in which there were few medical services. He also thought that the clinicians “needed to be better educated.” (Since 2011, the F.D.A. has required doctors to get extra training before prescribing rapid-onset opioids, like Actiq.)

In response, the clinic recruited a nurse practitioner to perform psychological evaluations once a month, but patients didn’t show up for her visits, and after a few months the nurse stopped coming. Schneider guessed that patients skipped her visits because “they didn’t want to be thought of as nuts.” The clinic also tightened its policies, requiring patients to submit to pill counts and frequent urine tests. But the clinic’s records were so chaotic that clinicians occasionally ended up seeing patients without their charts. A few times, when there was a long line of patients, Atterbury reportedly instructed medical assistants to copy whatever vital signs had been marked during the previous visit, rather than perform the tests again. There was one fax machine for more than ten thousand patients. When the coroner’s office called the clinic to request records for a deceased patient, Atterbury took the calls and, according to one receptionist’s testimony, didn’t always relay the news to her husband. She was in charge of hiring decisions, and she gravitated toward single women who were struggling. “I hire misfits,” she told the agents who investigated the clinic. “I’m like the mother to all these single women. . . . I take care of most of my girls there because they can’t make it in the real world.” The administrative staff had a high turnover, and Atterbury ended up hiring six members of her family, as well as an illegal immigrant whom she had met on a trip to Mexico and called her “adopted son.”

The clinic “fired” more than nine hundred patients for misusing their drugs. But discharged patients often returned to the clinic and requested to see a new provider, who would unknowingly prescribe the prohibited medications again. The clinic began putting the medical records of terminated patients in bright-red folders. When some patients were discharged, they became belligerent, yelling at the providers, throwing soda cans, or spitting in their faces. The physician assistant Kim Hébert later testified that she called the local police more than twenty times. “Patients threatened to stalk me, patients threatened to cut me up in multiple pieces, patients threatened harm on my family,” she said. Schneider offered to bring a can of Mace to work. Hébert described Schneider as a “gentleman,” a “good person,” but she thought that he was too laid-back. He was so proud of the clinic and of his wife, whose management decisions he deferred to, that he was unable, or unwilling, to reflect on its flaws.

“You folks are grazing on my land.”

Patients from the clinic were often admitted to the emergency room at Wesley Medical Center, in Wichita. Schneider’s daughter, Leigh Anne, who was doing her residency there, said that doctors would “roll their eyes and say, ‘Oh, that’s another Schneider patient. He’s probably a drug-seeker.’ ” Leigh Anne said that her father was “so naïve” about his wife’s ability to manage the clinic. She said, “He is insanely in love with her, and always has been,” adding, “I have a whole list of drugs I would never prescribe, because you need to know so much.”

Opioids are unique among medications, because there is no maximum dose. Unlike painkillers such as aspirin or Tylenol, consuming large quantities is unlikely to permanently damage the organs. In 2001, the Joint Commission, which accredits health-care organizations around the country, urged doctors to recognize that subjective reports of pain should be the standard upon which interventions are based. The Joint Commission’s guidebook to pain management, which was sponsored by Purdue Pharma, suggested that doctors have been operating under exaggerated and outdated fears of addiction, and says that if patients became tolerant of the medications the dose could be increased.

Schneider taught the providers at his clinic to prescribe “whatever it takes to improve function and quality of life without sedating.” When a former cocaine addict and exotic dancer named Kandace came to the Schneider Clinic after spine surgery, in 2003, complaining that “every bone in my body feels crushed,” she was prescribed, at various times, OxyContin, Actiq, and a Duragesic patch, which releases fentanyl through the skin. Months later, Kandace complained to Kim Hébert that her pain was still “out of control.” Hébert had just been to a seminar called “Kadian Connect,” sponsored by the pharmaceutical company Faulding, and she gave Kandace a voucher for Kadian, a long-acting morphine.

Kandace began taking the drug immediately, even though the other medications were still in her blood. Later that day, Kandace’s mother noticed that Kandace’s thinking was “kind of foggy.” The next day, Kandace complained to her mother of chest pain, and a few hours later she died in her sleep. Hébert went to the funeral, and, the next time she saw the Kadian pharmaceutical representative, she told him about the death and said that she was “not interested in hearing about his product.”

In 2002, Asa Hutchinson, the administrator of the Drug Enforcement Administration, told members of the American Pain Society that the agency had been tracking the proliferation of opioids and had seen a shift from “recreational abuse to addiction.” While acknowledging that the “D.E.A. does not intend to play the role of doctor,” Hutchinson said that the agency would target “unscrupulous medical professionals.” Later that year, a report by the Department of Justice’s inspector general found that only ten per cent of D.E.A. field investigators were addressing the abuse of prescription painkillers. The report recommended that the agency devote far more resources to the problem, employing the same tactics used to catch drug dealers: undercover agents, surveillance, and confidential informants.

The D.E.A.’s new campaign stood in uneasy relation to the medical establishment’s move to treat pain more aggressively. The D.E.A. began investigating about six hundred and fifty doctors a year, particularly those at “pill mills”—clinics where doctors sell drugs in exchange for cash, with little regard for the practice of medicine—but the agency’s tactics did little to slow drug abuse. Deaths from opioids have quadrupled in the past ten years. Prescription drugs contribute to half of all deaths by overdose, accounting for more fatalities than heroin and cocaine combined. The D.E.A.’s efforts represent a costly and baroque way of addressing only a small, anomalous piece of the problem. The agency has cracked down on the part of the supply chain that is out in the open and easiest to reach. According to the National Survey on Drug Use and Health, less than twenty per cent of people who misuse painkillers received them from doctors. The majority borrowed, bought, or stole the drugs from relatives, friends, or dealers. When doctors prescribe too many opioids, it is not typically because they are corrupt; more often, they are rushed, uninformed, or concerned about their patient-satisfaction ratings. In rural regions, where there are few specialists, opioids become a default solution: unlike psychological or physical therapies, which are poorly reimbursed, writing a prescription is cheap and quick.

After the Schneider Medical Clinic was raided, in September, 2005, Atterbury discouraged her husband from continuing to see pain patients. But he told her, “We are doing the right thing—we don’t have to be fearful.” Schneider was under the impression that there had been fewer than a dozen deaths, and that nearly all of these patients had abused their medications. He said, “It hurt me that they were pulling the wool over my eyes.” There was only one patient whose death had shaken him deeply, a woman named Robin, who had been taking Actiq as prescribed. “I still have a hard time believing she overdosed,” he told me. “She was a fantastic person. I really loved her.”

“Good luck getting a job now.”

Following news reports of the raid, several patients filed malpractice suits, and three clinicians resigned. Schneider decided to sell the clinic, but, as he waited for a buyer, he went on treating patients, mostly those with chronic pain, because his other patients found new doctors. With a diminished staff, Schneider didn’t have enough time to see all of his patients in one day. Sometimes there were so many people lined up in the morning that Atterbury told the D.E.A. agents, “I felt like we were selling concert tickets.”

In March, 2006, there was a second raid, which seemed never to end. Although the clinic remained open, federal agents kept returning to pull more charts. The Schneiders became accustomed to officers following them. They noticed agents parked at the car wash across from the clinic, and on a side street near their home. Their daughter Zoyie, who was fourteen, said that an agent stood in the back of the church while her family attended a Sunday service. Atterbury’s sister, Pat, who runs a funnel-cake business, said that she was alarmed when a man in a van, with a computer on his lap, was parked in front of her house for several hours. “It was like they were waiting for the Mexicans to ride on their horses into Linda’s yard,” Pat told me.

The D.E.A. sent at least one undercover officer to the clinic to request heavy quantities of painkillers. The recording is barely audible, but Schneider’s voice can be heard giving instructions for using a Duragesic patch. The fake patient said that she wanted Actiq, too, but he told her, “I like to only do one thing at a time. . . . So try the Duragesic patch. . . . And then the next time we can talk about that possibility.” He gave her Percocet for breakthrough pain, and, when she asked for a higher dose, he refused and then laughed, seemingly embarrassed by the interaction. “I mean, I just don’t want to get you into a stupor,” he told her. “I don’t want you to be a zombie or anything.”

On December 19, 2007, the Schneiders and their two children spent the day doing Christmas errands. For hours, an unmarked police car followed them. The Schneiders said they took several wrong turns while trying to find a clothing shop, and then left the store immediately. The agents concluded that the family was attempting to evade them, and decided that they were a flight risk. Later that day, the Schneiders went to a friend’s house and took family pictures. As they were pulling out of the driveway, two cars blocked their way.

Schneider and Atterbury were taken to the county jail, where Schneider recognized, among the inmates, two of his former patients. He and his wife were charged with causing the deaths of three people through the unlawful distribution of controlled substances—a charge that carries a mandatory minimum sentence of twenty years. The indictment described the Schneider Clinic as a “narcotics delivery system” and linked it to the deaths of sixty-eight patients. In addition to the opioid-overdose deaths, there were patients who had died after mixing their painkillers with street drugs or alcohol, or after taking pills from friends who had been patients of Schneider’s. Others had heart disease, which made their heavy use of narcotics lethal. Schneider said that he found the charges so confusing that he made it through only a few passages of the sixty-page indictment. “I started, but it appeared terrible,” he said. “I couldn’t read that.”

After Schneider’s arrest, the Sedgwick County Medical Society was overwhelmed by calls from former patients requesting referrals. The society held a meeting to discuss what to do about Schneider’s patients, who complained in letters to him that no one wanted them. Jon Parks, the Wichita pain specialist, said he told the doctors at the meeting, “There has always been a Dr. Schneider in our community.” He said that doctors in the area dealt with chronic pain inappropriately, by administering nerve blocks, one of the few forms of pain treatment that were reimbursed well. “These doctors stick needles in, take their cash, and run,” he said. When the procedures failed, patients were on their own, and ended up in Haysville. He said to the doctors, “No offense, but this is self-wrought.”

George Watson, formerly the chief of staff at Riverside Medical Center, in Wichita, wrote a letter to the Kansas Board of Healing Arts, explaining that Schneider “sees the rejects of medicine that WE won’t see. He sees the people who have had all the surgeries and epidural steroid injections that insurance would buy, before it ran out, AND they still have pain.”

“This job is going nowhere.”

Although Schneider had never been interested in politics, he found himself adopting his patients’ rhetoric about their “right to pain relief,” a notion that has been championed by leading pain doctors. In a widely cited 2007 paper in Anesthesia & Analgesia, three scholars wrote that “the unreasonable failure to treat pain is poor medicine, unethical practice, and is an abrogation of a fundamental human right.” One of the co-authors, Daniel Carr, the director of the Pain Research, Education, and Policy program at the Tufts University School of Medicine, told me that people have misinterpreted this statement to mean that patients have the right to narcotics rather than the right to thoughtful and competent care. “Opioids are a tiny little piece of pain management,” he said.

Although opioids are beneficial when taken for less than three months, studies of long-term use show that the drugs, while they may relieve pain, do little to improve function. Those who take the drugs for the longest periods of time, and in the heaviest doses, tend to be patients with psychiatric and substance-abuse disorders—a phenomenon that Mark Sullivan, a professor of psychiatry at the University of Washington, has called “adverse selection.” Sullivan told me that in poor, rural regions doctors are using opioids to treat a “complex mixture of physical and emotional distress.” He said, “It’s much more convenient for both patient and physician to speak in the language of physical pain, which is less stigmatized than psychological pain.” Some of these patients could be said to be suffering from what his colleague calls “terribly-sad-life syndrome.” “These patients are at a dead end, life has stymied them, they are hurting,” he said. “They want to be numb.” He believes that doctors are inappropriately adopting a “palliative-care mentality” to “relieve the suffering of people who have had very tough lives.”

Two months after the Schneiders’ arrest, Siobhan Reynolds, the president of the Pain Relief Network, an advocacy organization in New Mexico, moved to Wichita. She told the Schneiders that the case was “going to be the big one,” her “chance of a lifetime.” Reynolds’s late husband had suffered from a connective-tissue disorder, an extremely painful condition, and his doctor, William Hurwitz, had been imprisoned in 2004 for excessively prescribing opioids. Reynolds’s husband died two years later, of a brain hemorrhage, which she believed was induced by elevated blood pressure caused by his pain. Testifying before a House Judiciary subcommittee in 2007, she declared that the “D.E.A.’s actions have served to warn the rest of the medical community not to treat serious pain in all its forms.”

Reynolds did not have a degree in law—her background was in theatre—but the Schneiders let her pick their defense team and rented an apartment for her and the attorneys in Wichita, next to the courthouse. While Atterbury was in jail, her sister, Pat, told her on the phone, “Your guardian angel showed up.” Pat explained that Reynolds had been fighting for prosecuted doctors around the country. “She is so much like us,” Pat said. “She is a spitfire.”

In another telephone call, Pat explained that “she’s calling this a play. She says she’s putting all the people in their positions to do the play.”

Reynolds erected a billboard on the central highway in Wichita that said, “Dr. Schneider Never Killed Anyone.” When one of Schneider’s pain patients was admitted to the emergency room, Reynolds organized a vigil at a Walgreens across from the hospital. Six people stood outside, praying and singing. A Schneider patient who was treated for back pain after a car accident said that she became disillusioned with the Pain Relief Network on the night of the vigil, when another patient tried to sell her his Klonopin.

Less than two months after the billboard went up, Tanya Treadway, an assistant U.S. Attorney, initiated a grand-jury investigation into the Pain Relief Network, which she accused of obstructing justice. Reynolds and the defense team’s paralegal were served with subpoenas requiring that they turn over all correspondence with the Schneiders and their patients. Reynolds refused, arguing that her First Amendment rights were being violated, and that the prosecution was trying to intimidate potential witnesses. Reynolds was fined two hundred dollars a day for four months before she agreed to turn over the documents. By the time the trial began, in April of 2010, the Pain Relief Network was insolvent.

Treadway did not disclose the grounds for the grand-jury investigation, which remains sealed. She had already asked the judge to issue a gag order preventing the Pain Relief Network from communicating with the media. It was refused. A former high-school teacher, Treadway began crying when she discussed the deaths. She said that the Schneider patients fell into two groups. “There were patients who absolutely loved Dr. Schneider and believed in him and thought he was a wonderful doctor and person,” she said, “and there were patients who thought he was the Devil incarnate.”

At a hearing, the judge, Monti Belot, expressed concern that Treadway had “overcharged this case.” In a phone conversation with her boss, he spoke of the “oppressive nature of this prosecution” and recommended that Treadway be more closely supervised. In her preparation, Treadway used the depositions taken by Larry Wall, the attorney handling most of the malpractice cases, who was similarly emotionally invested; both his brother and his son, who have since died, struggled with addictions. Wall said, “I know survivors of the heroin epidemic of the seventies, and, when they found out about the Schneider case, they said, ‘It’s going to create a legacy of death for years to come. People will try and fail to kick their addictions.’ ”

The Schneiders’ defense team was ill-equipped to counter all the evidence that the prosecution had collected. They seemed to hope that they could win based on a theoretical argument about the inaccessibility of pain care to people without good insurance. Atterbury’s lawyer, Kevin Byers, who was romantically involved with Reynolds, opened the trial by declaring that the case was about “chronic pain treatment, propriety of it, the availability or unavailability of it in America.” Schneider’s lawyer (who has since left the field to become a screenwriter) filed a motion to have the jury leave the courtroom and tour the Schneider Medical Clinic. The motion was denied, but the Schneiders were convinced that once people saw the facility they would realize that it didn’t house a criminal enterprise.

Treadway told the jury that the clinic “looks a little like a Mexican restaurant. And, much like a Mexican restaurant, people lined up at the front door waiting to get in.” She said that the Schneiders “created an environment where their need for volume, their choice of quantity over quality, simply left no time to practice medicine.” She argued that the Schneiders were in such a rush to make a profit that they treated overdoses as “acceptable casualties.”

Seven weeks of testimony established Atterbury as an irresponsible and imperious manager, while employees who had known Schneider for years testified that he didn’t want to hear bad news. After learning of an overdose death, he told a physician assistant, “We are doing a good job. . . . We are going to attract the wrong crowd, but . . . when you get a bunch of grapes, you’re going to have some bad grapes and we’re going to have to weed them out.”

Much of the testimony was devoted to reëxamining the death of Robin, a forty-five-year-old woman with chronic migraines, who had visited numerous specialists before coming to the Schneider Clinic. She was prescribed a hundred and sixty Actiq suckers a month and became increasingly tolerant of the drug; eventually her dose was doubled. In August, 2006, she wrote a letter to Schneider, thanking him. “You prescribed medicine for me that I had not ever heard of,” she wrote. “From that day on I have received my life back.”

Her husband testified that, after two years of improvement, Robin became too sleepy to socialize; she slurred her words, and, a few times, for no reason, she spoke with a British accent. After she died, beside him in bed, he sued the clinic for malpractice, but Robin’s mother, Phyllis Rowland, refused to participate in the lawsuit. At the trial, she testified on behalf of the defense. “I know how bad the pain was before she was at Schneider’s,” she said.

On the way to the courthouse each morning, Atterbury said, she was “amazed at how many people would drive by and yell out their window and honk their horn and say, ‘Good luck Doc.’ ” Their lawyers assured them that they were winning. “They didn’t want to pop the top of the bubbly, but they were pretty giddy,” Atterbury wrote to me. But Schneider said that he had little hope once he heard the evidence against him. He was “horrified” when he heard the testimony of the defense’s expert witness, whom Reynolds had chosen. The witness insisted that it was impossible to tell whether patients had died of overdoses or of underlying heart diseases, a line of argument that Schneider found strained. It upset him every time his practice was called a “pain clinic,” since his primary concern had always been family medicine.

Schneider and Atterbury waited at home for seven days while the jury deliberated. They weren’t sure their wedding rings would meet prison regulations, so, just in case, Schneider went to Kmart and bought two simple gold bands. Atterbury was making dinner when her lawyers called to say that the jury had reached a verdict. As Schneider drove to the courthouse, she and their two daughters bowed their heads and prayed.

“That means you, pal!”

They were both found guilty. Schneider was sentenced to thirty years in prison and Atterbury to thirty-three. The judge, Monti Belot, said, “I have the distinct belief that had she not been involved in the operation of the clinic, or had she approached her role there in a professional and responsible way, none of us would be here.” He criticized the Kansas Board of Healing Arts for insufficiently investigating the clinic, the Pain Relief Network (“a ship of fools if there ever was one”), and the doctors in the community, who never reported their concerns. Belot acknowledged that drug-seekers are savvy about inventing their symptoms, but he said that Schneider had plenty of time to learn about their deceptions. He concluded that Schneider deserved a harsher punishment than ordinary drug dealers, because they have “no duty or obligation, legal or otherwise, to do no harm to their customers.”

Schneider was sent to the Forrest City Federal Correctional Complex, in Arkansas, and Atterbury to a prison in Connecticut and then to an institution in Texas. They can’t speak to each other on the phone, but they write each other several letters every week. Letters to friends are often signed “Linda & Steve,” no matter who wrote them. “If they could just put us together in the same cell, we would be good forever,” Atterbury told me.

Early this spring, I visited Schneider in prison. His hair was thinning, and his mustache had turned gray. When I said that Atterbury had asked me to buy a Diet Coke for him, he smiled, shook his head, and said, “She is the gas that makes me go.”

Schneider’s friends say that he was too trusting, a justification that I viewed with skepticism until Schneider began talking about the prison culture. “It’s surprising how nice these inmates are,” he told me. “It’s almost unbelievable, the camaraderie. People act like they’re in gangs, but I can’t say I ever felt I was in jeopardy. The blacks associate with whites, the whites with Mexicans.”

Schneider worked as a clerk in the library, earning about forty cents an hour. Twenty-five dollars was taken out of his paycheck every three months and paid into a restitution fund for his victims. He was hurt when he read his patients’ claims. “I had no idea they felt that way,” he said. He was especially surprised by a lawsuit filed by a young woman whom he had treated since she was a child. She had panic attacks about going to work—she was an exotic dancer—so he prescribed Xanax for her, and, later, hydrocodone, for migraines. Then she became addicted. He’d heard that, after she got money from her lawsuit, she had trouble with the law, and ended up in jail. He added, “I thought she was a really nice girl.”

Schneider said that he hadn’t experienced severe physical pain for more than a few days in his life. “Mental pain—that’s the one that bothers me now,” he told me. He said that most of his chronic-pain patients had a “chart this thick”—he held his hands a foot apart—“and, more often than not, they were bipolar.” He went on, “We probably were not diligent enough in digging into the mental part of it. We saw the physical part, but the mental part was on the edge.”

I excused myself to go to the bathroom, and when I returned Schneider was staring at the ceiling with an expression of despair. He said that a guard had asked him why he agreed to the interview and told him, “You know she’s just going to tear you apart.” A few minutes later, when I asked what he would do differently if he were to start the clinic again, he seemed offended by the question. “I would have been more political,” he finally responded. “I would have been more involved in the medical community. I can’t say I ever felt like I was part of the clique.”

His sense of exclusion had heightened after his daughter, Leigh Anne, was fired from her residency. After his trial, she said that the doctors at her hospital suddenly began criticizing her work, even though she’d previously received exemplary reviews. When she applied for residencies at other Wichita hospitals, her recommendations never failed to include a sentence about her father’s prosecution. She hadn’t practiced medicine in two years. “I can’t even identify who I am now,” she told me.

Schneider was struggling with his new identity, too, though some inmates still called him Doc and came to him with medical questions. The day before, he’d been approached by an inmate who had just shot up morphine, and the skin on his arm was infected. Drug use was flourishing in Atterbury’s prison, too. She wrote me, “Even here in a controlled environment, I can’t BELIEVE all the narcotics being sold.”

“Do you need an anthropomorphic car with a monkey chauffeur in the city? No. Do you want it? Definitely.”

Schneider seemed most at ease when we talked about his wife. He described their first date, on the top floor of the Holiday Inn in Wichita, repeating the jokes she had told him that night. “It was magical,” he said. For a second, his shoulders shook involuntarily. When the conversation returned to the clinic, he had trouble focussing. He seemed to feel there was something inevitable about the clinic’s trajectory, and couldn’t easily imagine how things would have unfolded differently. The clinic had offered negligent and reckless pain care, but there had been little incentive to do otherwise. He had become the kind of bad doctor that the system compensates best: he saw huge numbers of patients for brief periods of time by pleasing the customer, writing the prescriptions they desired.

All his appeals had been exhausted. In 2011, Siobhan Reynolds and one of the Schneiders’ lawyers, the one she’d been dating, died in a plane crash. The Schneiders couldn’t help wondering if this was the government’s final attempt to silence her. They both had a tendency to see conspiracy theories and cosmic connections. Last year, Atterbury was told by another prisoner, a Cambodian psychic, that they’d be released by the beginning of 2014. Atterbury prayed for verification of the message through a sign: squirrels having sex. Within two days, she saw two squirrels copulating in a tree.

Schneider and Atterbury decided that when they got out they would be missionaries. Schneider missed his conviction that he was alleviating people’s suffering. He seemed torn between the belief that his patients should have the right to make their own choices about what they put into their bodies—if they asked for the pills and used them improperly, he didn’t see why he was culpable—and the sense that he was the only one who could help them. In his own way, he seemed to thrive on what he had referred to as the “Dr. God feeling.” His patients told him that he was the only doctor who understood the depth of their pain. “They gave me so much positive feedback,” he said. “It was gratifying to help those people who really needed me—people who I thought needed my help,” he said, correcting himself. “I probably needed them more than they needed me. What a humbling experience.” ♦