These Nashville doctors were running pill mills. Purdue Pharma sold to them anyway.

Brett Kelman | Nashville Tennessean

State officials say the red flags should have been obvious: In the health care mecca of Nashville, a handful of doctors were prescribing millions of tablets of OxyContin, then collecting much of their pay in cash.

At one suburban clinic, a doctor with a documented history of questionable opioid prescriptions was regularly giving patients more than five times the recommended dose.

At another clinic, a doctor allegedly admitted to a colleague he was running a “pill mill," where prescriptions were given with little or no justification.

And two more doctors were under investigation by police, suspected of flooding a small town with painkillers. One of them was already a convicted murderer.

To almost anyone, these would have been alarming stories about some of Tennessee’s most prolific prescribers of OxyContin, a powerful painkiller at the center of the nation’s deadly opioid epidemic. But according to a new lawsuit filed by the Tennessee attorney general, drugmakers not only ignored warning signs about these doctors but kept them stocked with opioids and pressured them to prescribe more pills in higher doses.

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Purdue Pharma, a giant pharmaceutical corporation behind OxyContin and other powerful opioids, has in recent years been sued by 22 states, each accusing the company of sparking the opioid epidemic with deceptive marketing that encouraged over-prescribing and downplayed the risks of addiction. The Fortune 500 company is headquartered in Connecticut and owned by the billionaire Sackler family, who have built a corporate empire on the controversial industry of pain management.

Tennessee’s lawsuit, which was filed in May and unsealed last week, says Purdue’s sales strategy specifically targeted doctors who were already among the state’s biggest opioid prescribers, ignoring clues that prescriptions were being abused because the sales were so profitable. Patients often paid these doctors in cash, which state officials say should have alerted Purdue that the prescriptions were likely being resold on the street.

The Purdue lawsuit specifically identifies four Nashville-area doctors — Mireille Lalanne, Visuvalingam Vilvarajah, Robert Cochran Jr. and James Pogue. All four have lost their medical licenses in the past decade but were once among Tennessee's top OxyContin-prescribing doctors.

A fifth local doctor, based in Antioch, also is accused of over-prescribing in the lawsuit but is not identified.

Instead of cutting off these doctors, Purdue doubled down. The lawsuit alleges that Purdue made dozens of sales calls to each of these top prescribers, pushing pills despite warnings from pharmacists or police. In some cases, the sales calls didn’t stop until the doctors were on the verge of losing their medical licenses or already in handcuffs.

Purdue has denied all allegations in Tennessee’s lawsuit and insists it actually helped identify doctors with questionable prescriptions.

In an email statement Tuesday, company spokesman Bob Josephson said the lawsuit ignores how Purdue kept records on the doctors it would no longer call, then reported 75 of these "suspicious health care providers" to the state in 2013.

Purdue also has defended its practice of promoting drugs to doctors, insisting the claims it made about OxyContin were approved by the Food and Drug Administration. The company says it stopped using sales staff to promote opioids in February.

“We vigorously deny the state’s allegations,” a Purdue statement said. “The Attorney General claims Purdue acted improperly by communicating with prescribers about scientific and medical information that FDA has expressly considered and continues to approve. We believe it is inappropriate for the state to substitute its judgment for the judgment of the regulatory, scientific and medical experts at FDA.”

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Doctor, murderer, drug trafficker

It was 1989 when Dr. Visuvalingam Vilvarajah's wife filed for divorce. As she packed her suitcase to move out, he pulled a gun and shot her in the head, then turned the gun on his mother-in-law, killing her, too.

Vilvarajah, then a Memphis-area doctor, was convicted of two counts of second-degree murder. He was sentenced to 20 years in prison but was paroled after only five.

A decade later, Vilvarajah found a new life and a renewed career in Nashville.

The Tennessee Board of Medical Examiners had given Vilvarajah back his medical license. He had a new wife, Dr. Mireille Lalanne, and together they were running a new clinic on Charlotte Avenue. The couple later divorced but stayed business partners, and their clinic became one of the top painkiller prescribers in Tennessee. In just three years, Lalanne wrote more than 6,500 OxyContin prescriptions for more than 300,000 pills.

In the new lawsuit against Purdue, Tennessee’s state attorneys say the drug company ignored rampant red flags about the couple — and they mean more than just murder. The lawsuit alleges that Purdue continued to make sales calls to the doctors despite being aware that two of Vilvarajah's patients had died from overdoses and that the pair were under investigation for drug trafficking.

State officials say Vilvarajah told Purdue sales reps on two occasions that one of his patients had died from an opioid overdose. During one of these phone calls, Vilvarajah allegedly “wanted to know the highest dose of OxyContin that had been studied,” according to internal Purdue documents cited in the lawsuit.

Purdue got an even more explicit warning about the doctors in 2007. The suit says the company was alerted by police that an unusual number of the doctor's patients were driving to Nashville from Harlan, Kentucky — a small town nearly five hours away.

Harlan had fewer than 2,000 residents, but Lalanne and Vivarajah had prescribed opioids to more than 350 people there. Kentucky law enforcement officials specifically told Purdue they were suspicious of the doctors.

But that didn’t stop Purdue. Sales reps called the doctors at least 48 more times after being warned by police, the state lawsuit says.

The calls finally ended in February 2009 — after both doctors were arrested.

Lalanne and Vilvarajah were handcuffed in Nashville and extradited to Kentucky, where they were accused of organized crime and drug trafficking. Kentucky prosecutors later charged Lalanne with murder because of an overdose, but those charges were dropped as part of a plea agreement, according to Department of Justice records.

Ultimately, Lalanne and Vilvarajah agreed to Alford pleas — a plea deal in which a defendant does not admit guilt but agrees to be convicted. They were each sentenced to four months of probation for a misdemeanor charge of facilitating drug trafficking.

The pair attempted to get their medical licenses back in 2011 but were denied.

When questioned for this article, Purdue provided no explanation for why it continued to make sales calls to Lalanne and Vilvarajah after being alerted to their patient overdoses and the Kentucky law enforcement investigation.

However, Josephson, the company spokesman, pointed out that while state officials were critical of Purdue working with Vilvarajah, it was a state licensing board that gave him his medical license back in the first place.

"It is inconsistent for the state to argue that Dr. Vilvarajah’s conviction dating back two decades and not in any way related to prescribing OxyContin should have been a red flag to Purdue when the Board permitted Dr. Vilvarajah to prescribe controlled substances notwithstanding his conviction," Josephson said.

Tennessee's top OxyContin prescriber

For 10 years, nobody prescribed more than Dr. James Pogue.

Pogue, a Brentwood family doctor, wrote the most OxyContin prescriptions in Tennessee from 2006 to 2016, and his customers often paid with cash or Purdue-branded savings cards, which functioned much like coupons, according to the state lawsuit.

Pogue didn't just prescribe often; he also prescribed big. Internal records show Pogue prescribed OxyContin to at least 20 patients at two to 10 times the cautionary limit advised by the Centers for Disease Control and Prevention.

In one instance, the doctor told a patient to take an 80-milligram OxyContin pill — one of the strongest dosages of the drug — 16 times a day for 12 days. That prescription is more than 21 times the CDC limit.

With dosage like this, it was "extremely likely" Pogue's prescriptions were being resold on the street, Tennessee officials allege in their lawsuit.

And Purdue must have known, the suit says.

“Dr. Pogue's prolific prescribing habits and use of OxyContin prescription savings cards for cash paying patients were indicative of red flags of which Purdue had knowledge,” the lawsuit states.

Pogue's prescriptions had gotten him in trouble before. In 2009, the Tennessee Board of Medical Examiners reprimanded the doctor for giving injections of human growth hormone, or HGH, to patients without keeping sufficient records.

The Tennessee lawsuit alleges that Purdue sales reps called Pogue 53 times between 2005 and 2012 — with more than half of these calls occurring after this reprimand.

Josephson, the Purdue spokesman, said Pogue's reprimand didn't warrant a reaction from the company because HGH injections have "nothing to do with" OxyContin abuse.

However, the state's lawsuit says there were other red flags, too. Purdue also received warnings about Pogue from Nashville pharmacists in 2010 and 2012, and at one point a pharmacist told the company he was no longer willing to fill Pogue’s prescriptions, the lawsuit states.

Pogue's prescriptions were made public in the summer of 2012 when an undercover investigation by Nashville’s NewsChannel 5 exposed the most alarming signs of abuse to date. The news report showed Pogue’s clinic was so busy that cash-paying patients were waiting in his parking lot for six to nine hours to get OxyContin prescriptions. Some patients admitted they planned to resell the drugs.

Within days, the NewsChannel 5 report had circulated within Purdue, according to the state lawsuit. However, the company waited another 75 days before it instructed sales reps to stop calling Pogue. His medical license was suspended indefinitely four months later.

The state’s lawsuit against Purdue also identifies one more Nashville-area doctor, Robert Cochran Jr., alleging that for several years he prescribed more than 1,000 opioids per month and collected much of his pay in cash.

The lawsuit states that in 2012 at least three medical colleagues reported Cochran to Purdue — including one who said Cochran admitted to her he was “running a pill mill" — but the company kept Cochran on its sales call list. Purdue finally stopped calling Cochran in February 2013 after it became aware the doctor was under investigation by the medical examiners board. Cochran lost his license a few weeks later.

None of the four doctors identified in this story could be reached for comment. Multiple phone numbers listed for Pogue, Lalanne and Vilvarajah were either disconnected or went to voicemail. Messages were not returned. Cochran died in 2016.

Brett Kelman is the health care reporter for The Tennessean. He can be reached at 615-259-8287 or at brett.kelman@tennessean.com. Follow him on Twitter at @brettkelman.