Journal News
Teacher dead. Pill doc arrested. Did state miss warning signs?
By David Robinson
October 28, 2015

Psychiatrist Alfred Ramirez

Psychiatrist Alfred Ramirez

Police found Daren Gajdusek’s lifeless body at his Yonkers apartment in March. He had just started a dream job teaching elementary school, and his family desperately wanted answers. An empty pain-pill prescription bottle offered a clue: the name of Dr. Alfred Ramirez.

By October, Ramirez, a psychiatrist, was arrested and charged with illegally selling scripts from his gold Lexus and office for nearly 10,900 oxycodone pain pills, including those that killed Gajdusek at the age of 31.

The law enforcement probe of Ramirez lasted about six months, although a related pain-pill epidemic had already sparked a heroin wildfire claiming hundreds of lives in the Lower Hudson Valley. The doctor was in custody as the case proceeded in federal court.

But Ramirez should have been on law enforcement’s radar more than a decade before Gajdusek’s death, The Journal News/lohud.com has found.

The Ramirez trail goes all the way back to 2003, to a high-profile criminal case in Orange County. A teenager, Raul Laguerre Jr., broke into a home and sexually assaulted a neighbor, bludgeoning her into unconsciousness before he sodomized her. During that trial, Ramirez was said to have improperly prescribed a “pharmacological cocktail” to the teen.

Court records obtained by The Journal News show that despite requests at trial by lawyers, Laguerre’s parents and another doctor to investigate Ramirez’s prescribing habits, no probe resulted by either law enforcement or the state Department of Health in connection to Laguerre’s conviction.

When told about the Laguerre case, Victor Gajdusek, 74, blamed state officials for failing to properly monitor Ramirez and regulate the prescription drugs that killed his son, Daren.

“Doctors like that oughta be in jail,” the father said.

Flawed drug regulations

Michael Milza, the Orange County lead prosecutor in the Laguerre case, reacted with one word — “Wow” — when informed last week by The Journal News that Ramirez faces federal charges of illegally selling pain-pill prescriptions.

Milza couldn’t answer questions about court records showing law enforcement officials ignored requests to review Ramirez’s medical records in 2004 and 2005.

“I don’t remember any investigation like that,” he said.

The Department of Health declined to answer questions about the case. The agency’s press office said, in general, it takes appropriate action when it becomes aware of any potential patient safety issues involving a physician, though investigations are typically prompted by a referral or complaint, such as from police or another doctor.

Paul Kerson, a lawyer who represented Laguerre, addressed how and why concerns about Ramirez raised at the trial should have triggered an investigation by law enforcement, prosecutors and the state health department.

“There is an office of professional discipline. They had a duty to send this case there and they didn’t,” Kerson said in court. “The state frankly has a lot to answer for.”

In addition to missing referrals and complaints, some other doctors and prosecutors say another reason that authorities failed to dig into Ramirez is that prescription drug regulations are flawed.

A doctor working at a major hospital, for example, would have their prescribing monitored closely if a patient died, attempted suicide or attacked someone in connection to medication. An independent physician doesn’t face the same scrutiny because many aren’t controlled by laws that apply to government programs. Hospitals also have internal regulations and oversight related to doctors’ performance.

Oversight gaps are widest for doctors like Ramirez, who police said bounced between at least three health-care offices while supplying an illegal drug ring that spanned Westchester, Orange and Dutchess counties

Some doctors, including Dr. Paul Appelbaum, a psychiatrist and Columbia University Medical Center professor, have raised concerns about lax regulations fueling drug abuse in general, whether illegally selling scripts or simply practicing bad medicine.

They say independent doctors face less scrutiny than physicians affiliated with hospitals and larger clinics.

“There is no question that people in private practice, including the smaller group practices, generally lack the kind of systematic triggers for external reviews,” Appelbaum said.

Meanwhile, prosecutors say they are forced to try to pry doctors’ prescribing records from the state health department after uncovering a crime, such as an overdose death tied to ill-gotten prescription drugs.

The state agency headed by Dr. Howard Zucker, however, has the capability to review narcotics records, identify doctors showing signs of over-prescribing and refer those matters to law enforcement, a request that prosecutors say had been repeatedly ignored prior to an investigation by The Journal News earlier this year.

‘He loved that job’

Daren Gajdusek worked his way through college, mostly tending bar at the Jolly Tinker in the Bronx. He also picked up some cash helping out at St. Barnabas Church, a Bronx congregation that includes his alma mater high school.

His death rocked the working-class Yonkers and Bronx neighborhoods he called home. An online memorial campaign for Gajdusek raised $22,250 from nearly 300 donations.

Family, friends and other teachers posted dozens of comments on the memorial website. Many wrote of their heartbreak at unexpectedly losing a young man with such a bright future. The funeral and wake attracted hundreds.

Like many before him, Gajdusek’s path to pain-pill abuse seems to have been a misguided attempt to self-medicate.

Victor Gajdusek, a retired grocery store butcher who moved from Yonkers to South Carolina, recalled helping his son battle alcohol abuse during their weekly phone calls.

“He didn’t want to drink anymore because he became a school teacher, and one thing I know is that he loved that job,” Victor Gajdusek said.

The father choked up talking about his son’s sudden death, made all the more painful because he had achieved a lifelong goal to become an educator.

“I asked him one time if he had any wise guys in the class, and he said, ‘Yeah, they’re good kids, though,’” the father said, “The kids who didn’t want to do their work were his favorite because he loved getting them to learn.”

In the months before his death, Daren Gajdusek appears to have also visited Quora, a question and answer social media website, seeking help for his drinking and depression. He died after mixing an anti-anxiety drug and opioid pain pills, which have claimed at least 170 lives in Westchester, Rockland and Putnam counties since 2010.

Investigators used phone records to show Gajdusek got the pills from James Cooney of Yonkers, who federal prosecutors charged as Ramirez’s co-conspirator and distributor.

Court records show Cooney sold pain pills and other drugs using a variety of schemes. He would fill Ramirez’s scripts at pharmacies, including several written to a police informant. Occasionally, Cooney took pain pills as payment to fulfill the bogus scripts. He typically charged $25 per pill on the street, court records show.

“He didn’t want to drink anymore because he became a school teacher, and one thing I know is that he loved that job.”
Victor Gajdusek

Cooney seems to have taken a cab ride to deliver drugs to Gajdusek, court records show, after they exchanged text messages on cellphones three days before the teacher’s death.

“Hey you don’t have anything right,” Gajdusek wrote. Cooney replied: “Yeah I’m good. Got 30s now and I have a few zannys. But I’ll have a bunch of zannys manana.” Police said “30s” is slang for oxycodone 30 milligram pills and “zannys” refers to Xanax or Alprazolam, the anti-anxiety drugs.

Cooney and Ramirez each face up to 20 years in prison on federal charges related to illegally selling thousands of pain pills from 2012 to 2015, which should have had alarms ringing for Health Department officials tasked with monitoring narcotics data.

Court records, however, suggest Ramirez’s troubling prescribing patterns went unnoticed or ignored until this March, when one of his empty pain-pill bottles showed up near Gajdusek’s body. The patient’s name was scratched off, but federal agents said Cooney illegally obtained the script from Ramirez.

Joshua Povill, a Goshen lawyer representing Ramirez, did not respond to a request for comment. The case is on hold until Nov.11 while preliminary legal discussions focus on reaching an agreement to avoid trial, court records show.

While Health Department records eventually played a role in arresting Ramirez and Cooney, law enforcement’s investigation included informants, undercover officers, stakeouts and a routine traffic stop on the Palisades Parkway in Alpine, New Jersey.
‘Dr. Kookoo’

From May to August, law enforcement officials watched Ramirez while he worked at Middletown medical offices about 60 miles northwest of White Plains. At one point, authorities said they saw Ramirez selling scripts out of his gold Lexus.

One “customer” picking up a script in the parking lot gave police another name for Ramirez: “Dr. Kookoo.”

Many of the deals happened at night, as late as 10 p.m. Sometimes, Ramirez had people waiting in line on benches and in other cars. During one stakeout, police said at least seven people appeared to be buying scripts from Ramirez as he sat in the Lexus. Court records show he charged police informants and undercover officers between $150 and $420 for illegal scripts.

In September, police pulled over a vehicle driving from Queens to Middletown. They arrested three people on marijuana charges. One of them told police the reason for the 80-mile trip: buying scripts from Ramirez. It was their third such drug run, court records show.

Police informants and undercover officers, court records show, also illegally bought scripts for pain-pills and other drugs from Ramirez during staged visits inside his medical office. They recorded audio during some meetings and also provided incorrect medical records to get the illegal scripts. One informant gave Ramirez a blank disc falsely labeled and described as test results from a nearby hospital.

“If I gave you the money that you would be able to give me a month’s script, so I don’t have to come back,” one police informant asked Ramirez in an effort to get pain pills and other drugs. Ramirez replied: “You want to give me 180 I’ll be glad to do it.”

Court records show each of the drug buys shared a critical element: Ramirez didn’t conduct physical examinations of the supposed patients to determine if they legitimately needed pain pills and other drugs, which is a breakdown of basic medical standards.

Ramirez graduated in 1961 from the University of Philippines, College of Medicine in Manila, and received his New York physician license in 1967. The Department of Health Office of Professional Misconduct, which is tasked with physician oversight and investigating complaints, hasn’t taken disciplinary action against Ramirez during the past 25 years, state records show.

Doctor advocacy groups, medical boards and insurance companies worried about insufficient government oversight have started a push to limit their liability and improve public safety, said Appelbaum, the psychiatrist and Columbia University professor. They have essentially sought to self-police the profession to reduce the risk of lawsuits and other problems, he said.

“They have begun to require a process of self-assessment by physician and identification of gaps in knowledge and training, with plans designed to fill those gaps,” Appelbaum said.

The solution includes amending state laws to close oversight gaps for independent physicians, while improving regulations related to medical licensing and certification.

In New York, an e-prescribing regulation law is set to take effect in March 2016, after being delayed this year. The mandate to eliminate paper scripts, such as those police say Ramirez sold illegally, is part of a 2012 law seeking to curb doctor shopping and prescription drug abuse.

The U.S. Centers for Disease Control and Prevention has declared pain-pill abuse alone an epidemic, killing 16,000 people nationally each year.

Thousands of people misusing pain pills have also turned to the cheaper and more easily accessible street drug heroin, which has killed 230 people in Westchester, Rockland and Putnam counties since 2010.

Still, law enforcement and public health officials seem to have missed repeated warning signs related to Ramirez’s prescribing, beginning with the Laguerre case in 2003 and ending with Gajdusek’s death 12 years later.

‘The case of Raul Laguerre Jr.’

When his family moved from the Bronx to Orange County, Raul Laguerre Jr. liked having barbecues and a small pool in their yard. His parents spent their life savings to buy the house on a dead-end street in a rural neighborhood, just outside the city of Newburgh.

Laguerre also struggled to fit in as the new eighth-grader in Wallkill Central School District. He was teased and bullied, his parents said. When Laguerre threw a chair in class, the district required a psychiatric evaluation before he could return the next school year.

His parents picked Ramirez from a list of doctors within their health insurance network. At the first visit in June 2003, Ramirez prescribed three drugs, including an anti-depressant, for the 15-year-old boy.

A family photo of Raul Laguerre, Jr. and his younger brother Zachary. The photo was taken in 2002, when Raul was 14-years old and Zachary was six. Raul Jr., has been in prison for thirteen years after beating and sexually assaulting a neighbor when he was fifteen years old in 2003. His parents blame their son’s behavior on the fact that he was on several prescription drugs that were prescribed by a doctor who has now been charged for illegally prescribing pain medications.

Laguerre had negative reactions to the drugs almost immediately, the parents said. The mother, Mirna, who worked as a phlebotomist, collecting blood samples at Arden Hill Hospital in Goshen, complained about her son’s headaches, agitation and other symptoms to Ramirez, who replied that the medication needed more time to work properly and increased the dosage.

Seven weeks after starting the drugs, Laguerre, who didn’t have any prior criminal record, broke into a neighbor’s house and assaulted and sodomized a woman, court records show.

Dr. Lawson Bernstein, a psychiatrist and assistant professor at University of Pittsburgh Medical School, testified at trial that the teen had an adverse reaction to the “pharmacological cocktail” of drugs – Zoloft, an anti-depressant; Strattera, which is used to treat attention deficit hyperactivity disorder; and Risperdal, an anti-psychotic.

A list pf prescriptions for Raul Laguerre, Jr. when he was under the care of Dr. Alfred Ramirez. Raul Jr., has been in prison for thirteen years after beating and sexually assaulting a neighbor when he was fifteen years old in 2003. His parents blame their son’s behavior on the fact that he was on several prescription drugs that were prescribed by Ramirez, who has now been charged for illegally prescribing pain medications.

Bernstein, who Laguerre’s parents paid as an expert witness, also raised concerns in his testimony about Ramirez failing to meet basic medical standards, including recordkeeping that plays a critical role in regulating prescription drugs.

“The records are very, very brief, so brief that they are really – they don’t fulfill the standard for a medical record,” Bernstein said at trial.

He continued in a signed court statement: “It is my professional opinion that (Laguerre) suffers from neurotoxicity because of the wrongful administration of Zoloft, Strattera and Risperdal, highly toxic drugs wrongfully prescribed for him by his treating psychiatrist, Dr. Alfred Ramirez.”

While the jury convicted Laguerre, questions aired at trial about Ramirez should have warranted further review of his prescribing. His arrest this year, which is also related to mishandling prescription drugs, underscores concerns about lax oversight of drugs.

Reached by phone this month, Bernstein declined to discuss the case, saying the court records speak for themselves.

The state Department of Health’s press office noted, in general, physicians have a duty to make a complaint when they suspect peers pose a public health risk. The agency added it relies on referrals because “it is impossible to monitor all testimony rendered in all courts.”

Milza, the Orange County prosecutor, noted the jury convicted Laguerre, who remains in prison beyond his 10-year sentence based on a civil confinement law related to sex offenses and mental health issues.

At trial, a prosecution witness, Dr. Alan Tuckman, a psychiatrist and assistant professor at several colleges in New York, including New York Medical College in Valhalla, refuted some statements by Bernstein as to the drugs’ role in the crime.

Dr. James Knoll, a psychiatrist and SUNY Upstate Medical University professor, who is unaffiliated with the Laguerre case, raised concerns about the situation. He said the matter may prompt civil lawsuits because Ramirez has been charged with illegally selling scripts after having his prescribing questioned in court previously.

Mirna and Raul Laguerre, along with their son Zachary, 18, in their home in Newburgh Oct. 8, 2015. Raul Jr., has been in prison for thirteen years after beating and sexually assaulting a neighbor when he was fifteen years old in August of 2003. His parents blame their son’s behavior on the fact that he was on several prescription drugs that were prescribed by a doctor who has now been charged for illegally prescribing pain medications. The photo that she is holding was taken when Raul Jr. was 14-years old, and Zachary was six.

“I can see the lawyers bringing that up trying to show that this doctor is a loose cannon and doesn’t know what he is doing and shoots from the hip,” Knoll said.

Still, Laguerre’s lawyer warned law enforcement and public health officials about the public safety risk at the 2005 trial, court records show.

“(Dr. Ramirez) is out there right now,” Kerson said. “Someone else is getting a pharmacological cocktail. How many? They chose no investigation of Dr. Ramirez.”