Ron Januzelli had almost forgotten about the doctor who treated his mother as she battled a heroin addiction. Then, in September, he saw the man’s mugshot next to a story about doctors pushing opioids through shady “pill mills.” And the memories started flooding back.

He remembered his mother’s decades-long struggle with drugs. He remembered taking her to pick up pills Joseph Cipriano prescribed — one call and they were ready at a pharmacy, no exams or consultations needed.

When Marlene Januzelli died of an overdose 14 years ago at age 42, her son didn’t fully grasp, amid his grief, that her easy access to opioid painkillers had almost surely helped kill her.

“My mom was trying to get clean for her kids, and she went to him for help with that,” said Januzelli, 38, a fifth-generation firefighter from Conshohocken. “He took something from me, all that I was trying to work on with my mom.”

Earlier this month, Cipriano pleaded guilty to illegal drug distribution. He is one of five doctors who have been charged in Montgomery County in the last 18 months with improperly prescribing powerful opioid painkillers. Of those, three have already pleaded guilty, and another is expected to admit his guilt. The fifth hasn’t made his plans clear, according to court records.

At a time when the opioid crisis dominates the public conversation, when entire city neighborhoods are besieged by open-air drug markets, suburban prosecutors are turning to what law enforcement sources say is a persistent source for much of the problem, even as regulations improve.

Marlene Januzelli overdosed on opiate medication in 2005. Her son Ron said that she had been getting prescriptions from Joseph Cipriano, a doctor recently prosecuted for improperly prescribing those medicines.
Courtesy Ron Januzelli
Marlene Januzelli overdosed on opiate medication in 2005. Her son Ron said that she had been getting prescriptions from Joseph Cipriano, a doctor recently prosecuted for improperly prescribing those medicines.

“The general course we have seen in overdoses is that this road begins with pills, and then people turn to heroin, and then they’re dying,” District Attorney Kevin Steele said. "The difference between street dealers and these doctors is they’re wearing a white coat.

“They’re certainly not practicing their Hippocratic Oath, and we can see why,” he added. “Greed.”

Steele has made pursuing these doctors a priority. He has an entire unit in his office devoted to it, funded in part by drug forfeiture money and led by Jim Price, an assistant district attorney who helped Steele put away Richard Ruth, a Souderton doctor who wrote scrips for more than 200,000 pills over the course of a year.

For all their similarities to street dealers, doctors who are distributing high volumes of opioids are much more difficult to prosecute, according to Price.

“When you catch a street deal, everything falls in line. There’s no legitimate reason to sell someone heroin," Price said. “And so when we’re seeing a doctor prescribe large amounts of medication, on its face, it’s presumed to be legitimate health care.

“The difference between street dealers and these doctors is they’re wearing a white coat."
Montgomery County District Attorney Kevin Steele

“That’s why it takes a lot of technicality to pierce that veil and prove that, at the core of it, that scrip is not given for medical purposes, and it’s completely unlawfully prescribed,” he added.

Building these cases has more in common with public-corruption prosecution than traditional drug deals. They lean on surveillance and undercover work similar to methods used to take down crooked politicians.

And many start with anonymous tips from former patients, suspicious pharmacists or even fellow doctors.

Steele and his office devoted months to investigating Cipriano, Lawrence Miller, Joseph Rybicki, and Brian Keeley. Steele’s office sent cooperating witnesses to make multiple visits to each practice, each time exchanging cash for prescriptions with very little — or no — discussion about the patient’s health.

In one case, one of the supposed patients working with Steele’s office spent his appointments talking almost exclusively about vacation properties in the Poconos, and left with a scrip for Percocet.

Joseph Cipriano, Joseph Rybicki, and Lawrence Miller were all charged with improperly prescribing opioids.
Courtesy Montgomery County District Attorney's office
Joseph Cipriano, Joseph Rybicki, and Lawrence Miller were all charged with improperly prescribing opioids.

The work uncovered other issues. Cipriano, investigators found, was trading prescriptions for sexually explicit pictures and sexual favors with female patients. Rybicki began abusing the very medicines he was prescribing to others, getting them through phony scrips he wrote out in the name of his daughter, who lives in another part of the country, according to court records.

Prosecutors say Miller was writing prescriptions in volumes so high — sometimes 10 times the recommended dosage — that some of his patients became illegal suppliers of the drugs. Keeley, they said, was taking the lead from his patients, prescribing the types and amounts of medicines they dictated.

None of the four doctors or their attorneys returned requests for comment for this story. Of that group, all but Miller have pleaded guilty. Efforts to reach him and his lawyer were unsuccessful. It could not be learned whether he disputes the allegations.

“The community expects us to go hard after street dealers," Price said. “But how can we say that the criminal justice system is about fairness and not go after people in the medical community that are profiting off it in the same way?"

The trail of that profit often led investigators to tragic stories.

One former patient of Miller’s was a 20-year-old Pennsylvania State University student trying to detox from heroin, court records show. His parents found him dead in his bedroom in September 2016, surrounded by needles. The day before, he had filled a prescription from Miller for codeine-laced cough syrup.

Eight days before his overdose, he wrote a glowing online review for Miller, calling him “phenomenal,” a doctor who “truly cares about each and every one of his patients.”

The man’s family did not return a request for comment.

Another patient, a 58-year-old Lansdale woman who was unable to afford medical insurance, went to Miller for relief from chronic back pain, authorities said. Miller prescribed Oxycodone and other potent painkillers.

She took too many pills in March 2018 and overdosed, according to court records. Her husband told police he believed her death was accidental, but investigators noted that Miller had written her nearly 200 prescriptions for various opiates over the course of five years. The last was for 180 doses of Oxycodone, a quantity “well over” state and federal recommendations, according to the affidavit of probable cause for the doctor’s arrest.

At the time of the woman’s death, authorities said, another prescription was sitting on the couple’s kitchen table, waiting to be filled. The woman’s husband declined to speak with The Inquirer.

The fifth doctor county officials targeted, Spiro Kassis, faces federal drug-distribution charges after Steele’s office referred the matter to the U.S. Attorney’s Office in Philadelphia. Prosecutors have accused Kassis, 66, of running a “pill mill,” serving hundreds of patients in visits that lasted mere minutes and charging them $200 per prescription.

Kassis’ attorney, John McMahon, said Kassis will plead guilty to the federal charges.

Brian Keeley and Spiro Kassis were arrested and charged with improperly prescribing opioids.
Courtesy of Montgomery County District Attorney's office
Brian Keeley and Spiro Kassis were arrested and charged with improperly prescribing opioids.

“He had many, many patients, and these charges involved a smaller percentage of his patients,” McMahon said. “But he will be acknowledging his offenses and taking full responsibility.”

Holding doctors accountable for pushing opiates is not a new phenomenon. The federal Drug Enforcement Administration has been tracking prescriptions since the 1970s, according to Patrick Trainor, a special supervisory agent in the Philadelphia office.

But in recent years, the tools for investigating have become more streamlined. In 2016, the state created a database, the Prescription Drug Monitoring Program, that requires pharmacists to manually input the quantity and type of controlled medicine a doctor is prescribing. Doctors are required to consult the database before writing prescriptions in order to avoid “doctor shopping” — the practice of bouncing between doctors to get duplicate scrips.

High numbers alone don’t always signal fraud, Trainor said. Sometimes, large volumes of opioids are required to treat excruciating or chronic pain, and other times, prescriptions are simply written in error.

But algorithms built into the database help flag cases that, 10 years ago, would have flown under the radar.

“The vast majority of doctors are above board and really practice good-faith medicine, but there are a very small percentage of them that we would refer to as rogue,” Trainor said. “And the scope is that these rogue doctors represent a significant source of diverted pills that turn people toward addiction.”

Maria Zschunke knows that firsthand. For years, she and a loved one went to Joseph Rybicki as their family doctor. When her relative developed nerve damage in his feet, Rybicki started prescribing him Oxycontin, a heavy dose that he started to abuse “almost immediately,” she said.

“He started nodding off while driving, crashing into cars,” said Zschunke, who has since lost contact with her relative. “And then he overdosed. Twice. But nothing was ever done, nothing. Rybicki just kept giving them to him.”

Sometimes, she said, they’d wait for hours in Rybicki’s waiting room, along with dozens of other patients. Sometimes, they’d leave the office at midnight or 2 a.m., she said.

Efforts to reach Zschunke’s relative were unsuccessful. As far as she knows, he’s still dependent on opioids.

“I’m tired of losing friends and family to this epidemic," she said. “This is where it starts.”