Before building a multimillion-dollar pill mill—an operation where doctors prescribe pain pills for profit—with one of America’s deadliest motorcycle gangs, Philadelphia physician William J. O’Brien, 49, went by the name “Doctor Bear.”

The logo for his now-defunct website is an oversized cartoon bear with bright blue eyes, a white sling, and an eye patch. “Our friendly staff is dedicated to giving our patients timely service... our goal is to provide the best health care!” the website reads. Alongside the bear is a picture of his sharply dressed staff in 2008; dozens of attractive doctors and nurses beam on the steps of a red brick building.

“Pediatrics, geriatrics, physical therapy, acupuncture”—his team, according to the website, did it all. But apparently, it wasn’t enough. After filing for bankruptcy in November 2010, O’Brien allegedly obtained a hyperbaric oxygen chamber. The treatment, most often used for decompression sickness, allows patients to breathe in 100 percent pure oxygen at a pressurized level, helping the body repair itself.

Most often used as a solo device, O’Brien’s was a 10-person chamber that the FDA had not yet authorized, and which he “contemplated” using on people with autism. In 2011, the FBI raided his offices and seized it. Doctor Bear, who at the height of his practice employed 90 people at seven locations, was forced to start over. What does an osteopathic doctor scorned do next? Easy: start writing more prescriptions.

O’Brien again made local headlines this January when he and his 29-year-old receptionist, Angela Rangione, were arrested on 26 counts of illegally distributing oxycodone and Xanax.

O’Brien’s case, at first, seemed to align with the other “pill mill” operations. A doctor abusing his power, an office employee helping him do it. Two people acting outside the law for their own profit.

If it weren’t for a newly unsealed indictment from the U.S. District Attorney, O’Brien’s case may have faded into the background of our nation’s opioid epidemic. But as detailed in the 88-page document, O’Brien’s case is not like the others.

His pill mill scheme was on a level all its own. It wasn’t just a mom-and-pop pain clinic; it was a sophisticated drug ring run with the Pagan motorcycle gang. The accusations in the document are as shocking as they are disturbing. Beyond raking in millions on phony prescriptions with the help of Nazi-loving white supremacists, O’Brien allegedly exchanged prescriptions for sex, and caused a man to lethally overdose. While his individual allegations are disturbing, the participation of the Pagans is even more dangerous. Their participation is significant not just to this case, but the entirety of the opioid epidemic. It appears doctors aren’t the only ones cashing in on pain.

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Of the nine new defendants added to the case (one being O’Brien’s ex-wife), five are members of the Pagan motorcycle gang, a group that started as a nonviolent organization in the late 1950s. According to Complex, the gang’s violent turn coincided with a new leader in the 1970s, John “Satan” Marron.

A 2002 report from the National Drug Intelligence Center, which closed in 2012, says Lou Dobkins, who started the Pagans, did so to recognize the “comradeship” of his 12 bike-mates. After Satan took power, the group began spreading up and down the Eastern United States. With anywhere from 350 to 900 members nationwide (an official number doesn’t exist), they are smaller than other gangs but equally as threatening.

“The FBI views the Pagan’s as an incredibly dangerous organization, largely due to their connections with gangs like the Aryan Brotherhood and the Italian Mafia,” reads an article on the 10 Deadliest Motorcycle Gangs. “Members of the Pagans are regularly tied to arson, bombings, and murders, and one of the gang’s favorite hobbies is stockpiling machine guns.”

In 2002, 73 Pagans were arrested in Long Island, New York, after charging into a catering hall with bats and knives to attack their bitter rivals, the Hell’s Angels. Ten people were wounded, one fatally. In September 2010, authorities arrested 19 Pagans after uncovering a plot to murder Hell’s Angels members with grenades.

While they’ve been caught trafficking things like cocaine and PCP, their involvement with O’Brien is the only documented instance of the Pagans’ involvement with opioids.

The names of the Pagan suspects in the indictment are colorful nicknames. Michael Thompson goes by “Mikey” or “Tomato Pie”; Peter Marrandino as “Nose”; Joseph Mehl is “Joseph Montanero”; and Patrick Treacy just “Redneck.” A red-and-blue logo distinguishes Pagans from other gangs, sewn onto cut-off jean jackets with patches of their other mentors: Nazis and white supremacists.

With curly black hair, thin-rimmed glasses, and a small mustache, O’Brien doesn’t look the type to make friends with a motorcycle gang. But that’s exactly what happened. Authorities traced the relationship back to March 2012, when O’Brien apparently struck a deal with a Pagan leader named Joseph Mehl. A tow-truck driver by day, Mehl agreed to start referring car crash victims to O’Brien. In return, Mehl would get free prescriptions of oxycodone, which he would then sell on the street.

Soon, Mehl enlisted four other members of the Pagans to act as “patients,” so they could obtain large quantities of opioids—some to keep and some to sell. In time, the Pagans were tapping outsiders, referred to as “recruits,” to pose as patients and obtain prescriptions. Profits from sales of the pills were shared and the cycle started all over again.

According to an undercover agent, any “patients” of O’Brien’s were thoroughly vetted by his secretary. A connection to another “patient” was required before acceptance, as well as an in-as person meeting. Following this, the “patient” would come in for a consultation with Dr. O’Brien—no examination, but a $250 fee.

Once a relationship was established, O’Brien would write prescriptions—sans a legitimate diagnosis—for $200 a pop. The indictment lists four locations where these “appointments” took place: three nondescript buildings in Philadelphia and one rundown “mega gym.” None of the locations are noteworthy or even memorable—which was, undoubtedly, the point. Inside, O’Brien was raking in millions by upcharging for in-demand prescriptions delivered to people he’d likely never meet. In an effort to keep said practice legal, O’Brien would spend time falsifying patient records to add “legitimate medical reasons” for the prescriptions he wrote.

O’Brien’s basic plan—to get rich off America’s opioid epidemic—was not novel. With 26 million to 36 million people abusing opioids nationwide, pain clinics like his are big business. Florida alone, unofficially the “pill mill capital” of the U.S, at one point had 856 of them.

But O’Brien’s practice took pill mills where they’ve never been before—into the hands of a notoriously violent, drug-dealing gang on wheels. Deeper into the indictment, things get even worse.

His counterparts were not only given an endless amount of prescriptions; some had full access to patients’ medical records. During Patrick (“Redneck”) Treacy’s initial visit, he wrote his own diagnosis: scribbling down that he had been “pregnant” several times, was “menstruating,” and had just undergone a “PAP” test. Using that “diagnosis,” O’Brien prescribed 30 oxycodone and 60 Xanax pills.

Other sections detail the shady ways in which the pills were exchanged and “patients” were recruited. At one point, the Pagans began enlisting the help of dancers from a local strip joint called the Oasis Gentleman’s Club. In at least two cases, O’Brien provided the dancers with prescriptions in exchange for oral sex.

In a matter of years, the man formerly known as Dr. Bear had prescribed 238,895 oxycodone (30 mg) pills; an estimated 11,649 oxycodone (15 mg) pills; approximately 128,370 oxycodone (10 mg) and acetaminophen pills (also known as Percocet); and approximately 160,492 methadone (10 mg) pills. Market value of the pills was $5 million, $2 million of which O’Brien pocketed.

Of all the shocking allegations in the report, the most disturbing comes from count 124, titled “Distribution of Controlled Substances Resulting in Death.” In December 2013, O’Brien’s actions apparently led to the death of one person, identified only as “patient 21.” The victim died from the lethal combination of prescriptions from O’Brien, which included 120 oxycodone pills, 60 methadone, and 540 of cyclobenzaprine (treatment for muscle spasms).

With the amount of pills prescribed and sold, it’s hard to imagine that patient 21 is the only casualty of Dr. O’Brien and the Pagans’ scheme. According to the Centers for Disease Control and Prevention (CDC), an estimated 15,000 people die each year from prescription painkiller overdose. If the pills were being sold to strangers, it’s unlikely the deaths can be tracked.

O’Brien, who still sits in federal prison, has a lot of time to think it over.