In the USA...
February 2, 2013Backstage Glimpses of Clinton as Dogged Diplomat, Win or Lose
By MICHAEL R. GORDON and MARK LANDLER
WASHINGTON — Last summer, as the fighting in Syria raged and questions about the United States’ inaction grew, Secretary of State Hillary Rodham Clinton conferred privately with David H. Petraeus, the director of the C.I.A. The two officials were joining forces on a plan to arm the Syrian resistance.
The idea was to vet the rebel groups and train fighters, who would be supplied with weapons. The plan had risks, but it also offered the potential reward of creating Syrian allies with whom the United States could work, both during the conflict and after President Bashar al-Assad’s eventual removal.
Mrs. Clinton and Mr. Petraeus presented the proposal to the White House, according to administration officials. But with the White House worried about the risks, and with President Obama in the midst of a re-election bid, they were rebuffed.
A year earlier, she had better luck with the White House. Overcoming the administration’s skeptics, she persuaded Mr. Obama to open relations with the military rulers in Myanmar, a reclusive dictatorship eager to emerge from decades of isolation.
As she leaves the State Department, the simplest yardstick for measuring Mrs. Clinton’s legacy has been her tireless travels: 112 countries, nearly a million miles, 401 days on the road. Historians will point to how she expanded the State Department’s agenda to embrace issues like gender violence and the use of social media in diplomacy.
“We do need a new architecture for this new world: more Frank Gehry than formal Greek,” Mrs. Clinton said in a speech last week that served as both a valedictory and a reminder of why she remained the nation’s most potent political figure aside from Mr. Obama.
And yet, interviews with more than a dozen current and former officials also paint a more complex picture: of a dogged diplomat and a sometimes frustrated figure who prized her role as team player, but whose instincts were often more activist than those of a White House that has kept a tight grip on foreign policy.
The disclosures about Mrs. Clinton’s behind-the-scenes role in Syria and Myanmar — one a setback, the other a success — offer a window into her time as a member of Mr. Obama’s cabinet. They may also be a guide to her thinking as she ponders a future run for the presidency with favorability ratings that are the highest of her career, even after her last months at the State Department were marred by the deadly attack on the American Mission in Benghazi, Libya.
“Secretary Clinton has dramatically changed the face of U.S. foreign policy globally for the good,” said Richard L. Armitage, deputy secretary of state during the George W. Bush administration. “But I wish she had been unleashed more by the White House.”
In an administration often faulted for its timidity abroad, “Clinton wanted to lead from the front, not from behind,” said Vali R. Nasr, a former State Department adviser on Afghanistan and Pakistan who is now the dean of the Johns Hopkins School of Advanced International Studies.
Mrs. Clinton made her first official trip to Asia, a choice that spoke to her diplomatic ambitions as well as her recognition from the start that many big-ticket foreign policy issues in the Obama administration — Iraq, Iran and peacemaking in the Middle East — would be controlled by the White House or the Pentagon.
In Afghanistan, several officials said, Mrs. Clinton hungered for a success on the order of the Dayton Accords, which ended the Bosnian War. But when her special representative, Richard C. Holbrooke, who had negotiated that agreement, fell out of favor with the White House and later died, those dreams died with him.
Then came the Arab awakening, a strategic surprise that eclipsed America’s shift to focusing on Asia, and it plunged Mrs. Clinton into a maelstrom. It tested her loyalty to longtime allies like President Hosni Mubarak of Egypt and reinforced her conviction that anger at decades of stagnation, fueled by social media, would sweep aside the old order in the Arab world.
After Britain and France argued for intervening to defend Libya’s rebels against Col. Muammar el-Qaddafi, Mrs. Clinton played an important role in mobilizing a broad international coalition and persuading the White House to join the NATO-led operation.
But it was Syria that proved to be the most difficult test. As that country descended into civil war, the administration provided humanitarian aid to the growing flood of refugees, pushed for sanctions and sought to organize the political opposition. The United States lagged France, Britain and Persian Gulf states in recognizing that opposition as the legitimate representative of the Syria people, but by December, Mr. Obama had taken that step.
Still, rebel fighters were clamoring for weapons and training. The White House has been reluctant to arm them for fear that it would draw the United States into the conflict and raise the risk of the weapons falling into the wrong hands. Rebel extremists affiliated with Al Qaeda had faced no such constraints in securing weapons from their backers.
When Mr. Petraeus was the commander of forces in Iraq and then-Senator Clinton was serving on the Senate Armed Services Committee and preparing for her 2008 presidential bid, she had all but called him a liar for trumpeting the military gains of the troop increase ordered by President Bush. But serving together in the Obama administration, they were allies when it came to Syria, as well as on the debate over how many troops to send to Afghanistan at the beginning of the administration.
Mr. Petraeus had a background in training foreign forces from his years in Iraq, and his C.I.A. job put him in charge of covert operations. The Americans already had experience in providing nonlethal assistance to some of the rebels.
The plan that Mr. Petraeus developed and Mrs. Clinton supported called for vetting rebels and establishing and arming a group of fighters with the assistance of some neighboring states. Defense Secretary Leon E. Panetta was said by some officials to be sympathetic to the idea. Mr. Petraeus and a spokesman for Mr. Panetta declined to comment.
Wary of becoming entangled in the Syria crisis, the White House pushed back, and Mrs. Clinton backed off. Some administration officials expected the issue to be joined again after the election. But when Mr. Petraeus resigned because of an extramarital affair and Mrs. Clinton suffered a concussion, missing weeks of work, the issue was shelved.
In an interview last week, Mrs. Clinton declined to comment on her role in the arms debate and emphasized other steps the United States had taken. “We have worked assiduously, first to create some kind of legitimate opposition,” she said. “We have been the architect and main mover of very tough sanctions against Assad.”
She added: “Having said all that, Assad is still killing. The opposition is increasingly being represented by Al Qaeda extremist elements.” She also said that the opposition was getting messages from the ungoverned areas in Pakistan where some of the Qaeda leadership was believed to be hiding — a development she called “deeply distressing.”
If Syria and Benghazi were low points for Mrs. Clinton, then the diplomatic opening to the military government in Myanmar, also known as Burma, was perhaps the biggest highlight. There, too, she initially met resistance from the White House and Pentagon, as well as the prospect of opposition from the Senate minority leader, Mitch McConnell of Kentucky, a stalwart supporter of Myanmar’s prodemocracy leader, Daw Aung San Suu Kyi.
Once she secured Mr. McConnell’s acquiescence, Mrs. Clinton sent her assistant secretary for East Asian affairs, Kurt M. Campbell, to meet the generals. When he returned, persuaded that Myanmar was poised for change, Mrs. Clinton convened a full review of whether to ease American sanctions and establish diplomatic ties.
White House aides remained wary about rewarding a repressive government. So Mrs. Clinton, in effect, made an end run, seeking out Mr. Obama directly and persuading him to send her on a historic visit to Myanmar in December 2011.
“We didn’t know what was going to happen,” she said. “The president basically said, ‘Look, I’m behind you on this.’ ”
While Myanmar’s progress has not been without bumps, things have progressed enough that Mrs. Clinton accompanied Mr. Obama on his own visit last fall. And it was not the only bold move of Mrs. Clinton’s focus on Asia. In July 2010, she provoked a sulfurous reaction from China when she announced that the United States had an interest in helping to resolve territorial disputes between China and its neighbors over the South China Sea.
“There had been a lot of rhetoric about the pivot to Asia, but here was an issue where more U.S. engagement meant a lot to the region,” said Benjamin J. Rhodes, a deputy national security adviser.
And yet Mrs. Clinton’s involvement has done little to quell the tensions. China feuded recently with the Philippines over a rocky shoal claimed by both countries, and farther north, in the East China Sea, it is enmeshed in a dispute with Japan over islands.
Mrs. Clinton insisted that her involvement had put China on notice that it could not brush off international legal norms in pursuing its maritime claims. “There’s still going to be belligerence, and there’s going to be a lot of very hot rhetoric,” she said. “But I think we’ve helped support a strong case for the kind of framework we believe in.”
The fruits of Mrs. Clinton’s work were evident last year in the fraught, but ultimately successful, negotiation over Chen Guangcheng, the dissident who sought refuge in the American Embassy in Beijing. When an initial deal fell apart, she said, she passed a note to China’s senior foreign policy official, Dai Bingguo, that said, “You and I need to talk.”
Huddling in a small room, she persuaded Mr. Dai to order his deputies to go back to the table with her team. “It was incredibly intense,” she said, in an observation that could apply to so many of her days as secretary of state, “but I was always confident.”
February 02, 2013 05:00 PMWeekly Address: 'We Can't Just Cut Our Way to Prosperity'
By Diane Sweet
President Obama used his weekly address to call for a balanced approach to the federal budget. Citing a recent falloff in economic growth attributed to inaction in Washington, Obama called for investments in education and infrastructure and lowering the cost of programs like Medicare -- without passing the expense on to seniors -- as part of a deal to reduce the federal deficit. He said that “2013 can be a year of solid growth, more jobs, and higher wages. But that will only happen if we put a stop to self-inflicted wounds in Washington.”
"We all agree that it’s critical to cut unnecessary spending. But we can’t just cut our way to prosperity. It hasn’t worked in the past, and it won’t work today. It could slow down our recovery. It could weaken our economy. And it could cost us jobs – now, and in the future."
"What we need instead is a balanced approach; an approach that says let’s cut what we can’t afford but let’s make the investments we can’t afford to live without. Investments in education and infrastructure, research and development – the things that will help America compete for the best jobs and new industries."
"Already, Republicans and Democrats have worked together to reduce our deficits by $2.5 trillion. That’s a good start. But to get the rest of the way, we need a balanced set of reforms."
"For example, we need to lower the cost of health care in programs like Medicare that are the biggest drivers of our deficit, without just passing the burden off to seniors. And these reforms must go hand-in-hand with eliminating excess spending in our tax code, so that the wealthiest individuals and biggest corporations can’t take advantage of loopholes and deductions that aren’t available to most Americans."
"2013 can be a year of solid growth, more jobs, and higher wages. But that will only happen if we put a stop to self-inflicted wounds in Washington. Everyone in Washington needs to focus not on politics but on what’s right for the country; on what’s right for you and your families. That’s how we’ll get our economy growing faster. That’s how we’ll strengthen our middle class. And that’s how we’ll build a country that rewards the effort and determination of every single American."
Click to watch: http://www.youtube.com/watch?v=7P_3WDJe5QY&feature=player_embedded
February 2, 2013In Hard Economy for All Ages, Older Isn’t Better ... It’s Brutal
By CATHERINE RAMPELL
Young graduates are in debt, out of work and on their parents’ couches. People in their 30s and 40s can’t afford to buy homes or have children. Retirees are earning near-zero interest on their savings.
In the current listless economy, every generation has a claim to having been most injured. But the Labor Department’s latest jobs snapshot and other recent data reports present a strong case for crowning baby boomers as the greatest victims of the recession and its grim aftermath.
These Americans in their 50s and early 60s — those near retirement age who do not yet have access to Medicare and Social Security — have lost the most earnings power of any age group, with their household incomes 10 percent below what they made when the recovery began three years ago, according to Sentier Research, a data analysis company.
Their retirement savings and home values fell sharply at the worst possible time: just before they needed to cash out. They are supporting both aged parents and unemployed young-adult children, earning them the inauspicious nickname “Generation Squeeze.”
New research suggests that they may die sooner, because their health, income security and mental well-being were battered by recession at a crucial time in their lives. A recent study by economists at Wellesley College found that people who lost their jobs in the few years before becoming eligible for Social Security lost up to three years from their life expectancy, largely because they no longer had access to affordable health care.
“If I break my wrist, I lose my house,” said Susan Zimmerman, 62, a freelance writer in Cleveland, of the distress that a medical emergency would wreak upon her finances and her quality of life. None of the three part-time jobs she has cobbled together pay benefits, and she says she is counting the days until she becomes eligible for Medicare.
In the meantime, Ms. Zimmerman has fashioned her own regimen of home remedies — including eating blue cheese instead of taking penicillin and consuming plenty of orange juice, red wine, coffee and whatever else the latest longevity studies recommend — to maintain her health, which she must do if she wants to continue paying the bills.
“I will probably be working until I’m 100,” she said.
As common as that sentiment is, the job market has been especially unkind to older workers.
Unemployment rates for Americans nearing retirement are far lower than those for young people, who are recently out of school, with fewer skills and a shorter work history. But once out of a job, older workers have a much harder time finding another one. Over the last year, the average duration of unemployment for older people was 53 weeks, compared with 19 weeks for teenagers, according to the Labor Department’s jobs report released on Friday.
The lengthy process is partly because older workers are more likely to have been laid off from industries that are downsizing, like manufacturing. Compared with the rest of the population, older people are also more likely to own their own homes and be less mobile than renters, who can move to new job markets.
Older workers are more likely to have a disability of some sort, perhaps limiting the range of jobs that offer realistic choices. They may also be less inclined, at least initially, to take jobs that pay far less than their old positions.
Displaced boomers also believe they are victims of age discrimination, because employers can easily find a young, energetic worker who will accept lower pay and who can potentially stick around for decades rather than a few years.
“When you’re older, they just see gray hair and they write you off,” said Arynita Armstrong, 60, of Willis, Tex. She has been looking for work for five years since losing her job at a mortgage company. “They’re afraid to hire you, because they think you’re a health risk. You know, you might make their premiums go up. They think it’ll cost more money to invest in training you than it’s worth it because you might retire in five years.
“Not that they say any of this to your face,” she added.
When older workers do find re-employment, the compensation is usually not up to the level of their previous jobs, according to data from the Heldrich Center for Workforce Development at Rutgers University.
In a survey by the center of older workers who were laid off during the recession, just one in six had found another job, and half of that group had accepted pay cuts. Fourteen percent of the re-employed said the pay in their new job was less than half what they earned in their previous job.
“I just say to myself: ‘Why me? What have I done to deserve this?’ ” said John Agati, 56, of Norwalk, Conn., whose last full-time job, as a merchandise buyer and product developer, ended four years ago when his employer went out of business.
That position paid $90,000, and his résumé lists stints at companies like American Express, Disney and USA Networks. Since being laid off, though, he has worked a series of part-time, low-wage, temporary positions, including selling shoes at Lord & Taylor and making sales calls for a limo company.
The last few years have taken a toll not only on his family’s finances, but also on his feelings of self-worth.
“You just get sad,” Mr. Agati said. “I see people getting up in the morning, going out to their careers and going home. I just wish I was doing that. Some people don’t like their jobs, or they have problems with their jobs, but at least they’re working. I just wish I was in their shoes.”
He said he cannot afford to go back to school, as many younger people without jobs have done. Even if he could afford it, economists say it is unclear whether older workers like him benefit much from more education.
“It just doesn’t make sense to offer retraining for people 55 and older,” said Daniel Hamermesh, an economics professor at the University of Texas in Austin. “Discrimination by age, long-term unemployment, the fact that they’re now at the end of the hiring queue, the lack of time horizon just does not make it sensible to invest in them.”
Many displaced older workers are taking this message to heart and leaving the labor force entirely.
The share of older people applying for Social Security early spiked during the recession as people sought whatever income they could find. The penalty they will pay is permanent, as retirees who take benefits at age 62 — as Ms. Zimmerman did, to help make her mortgage payments — will receive 30 percent less in each month’s check for the rest of their lives than they would if they had waited until full retirement age (66 for those born after 1942).
Those not yet eligible for Social Security are increasingly applying for another, comparable kind of income support that often goes to people who expect never to work again: disability benefits. More than one in eight people in their late 50s is now on some form of federal disability insurance program, according to Mark Duggan, chairman of the department of business economics and public policy at the University of Pennsylvania’s Wharton School.
The very oldest Americans, of course, were battered by some of the same ill winds that tormented those now nearing retirement, but at least the most senior were cushioned by a more readily available social safety net. More important, in a statistical twist, they may have actually benefited from the financial crisis in the most fundamental way: prolonged lives.
Death rates for people over 65 have historically fallen during recessions, according to a November 2011 study by economists at the University of California, Davis. Why? The researchers argue that weak job markets push more workers into accepting relatively undesirable work at nursing homes, leading to better care for residents.
February 2, 2013Colorado Communities Take On Fight Against Energy Land Leases
By JACK HEALY
PAONIA, Colo. — For a glimpse into the complications of President Obama’s “all of the above” energy policy, follow a curling mountain road through the aspens and into central Colorado’s North Fork Valley, where billboards promote “gently grown” fruits and farmers sell fresh milk and raw honey from pay-what-you-can donation boxes.
Here, amid dozens of organic farms, orchards and ranches, the federal government is opening up thousands of acres of public land for oil and gas drilling, part of its largest energy lease sale in Colorado since Mr. Obama took office.
In all, leases for 114,932 acres of federal land across Colorado are being auctioned off next month — a tiny piece of what Mr. Obama lauded during last year’s campaign as a historic effort to increase domestic natural-gas production. Those holes have to be drilled somewhere, and the move to lease public lands in this valley has stirred a fierce debate, one that has aligned Republican residents more closely to the government’s plans than Democrats.
Coloradans in solidly red cities west of here are the ones who have written letters to the government supporting the lease sale, saying it will bring jobs and tax revenues. In Paonia, where political lines are more evenly split, residents have come out overwhelmingly against the idea of drilling, saying it threatens a new economy rooted in tourism, wineries and organic peaches.
“It’s just this land-grab, rape-and-pillage mentality,” said Landon Deane, who raises 80 cows on a ranch that sits near several federal parcels being put up for lease. Because of the quirks of mineral ownership in the West, which can divide ownership of land and the minerals under it, one parcel up for bid sits directly below Ms. Deane’s fields, where she has recently been thinking of sowing hops for organic beer.
“All it takes is one spill, and we’re toast,” she said.
Paonia takes its environmental debates seriously — so much so that in 2003, someone upset over insecticide spraying set off a bomb in the headquarters of the town’s Mosquito Control District (no one was hurt).
For years, activists in town raged against the century-old coal mines located about 10 miles up the road, before eventually reaching a détente with the industry, which provides hundreds of jobs in the valley. Paonia is also home to an award-winning community radio station and the High Country News, a nonprofit newspaper that covers land and environmental issues across the West.
Last week, the forces of government and upset citizens collided like two weather fronts in a packed, stifling town meeting.
Officials from the Bureau of Land Management explained the situation: Under 90-year-old laws, companies and people can nominate public lands for drilling, and the government is obliged to auction them off after months of review and public comment. The officials explained that they had removed some of the most sensitive and contentious pieces of land from consideration and that they were still reviewing which parcels to lease, but said the auction was happening.
About 200 residents sat on the floor, lined the walls and spilled into the hallway, jeering and hooting as officials insisted — sometimes patiently, sometimes brusquely — that hydraulic fracturing was safe, and that there would be little environmental impact on the valley. They applauded as town council members pressed federal officials on drilling’s effect on the town’s air, water and economy — eliciting responses that were as unsatisfactory to the crowd as a bushel of mealy peaches.
“I can’t guarantee you there won’t be a spill,” Lonny Bagley, the land management agency’s deputy state director for energy and minerals, told the audience. “I can’t guarantee there won’t be a blowout.”
Paonia’s mayor, Neal Schwieterman pressed officials on why they had used a 30-year-old resource plan to evaluate whether drilling would mesh with the valley’s lifestyle and growing tourism economy. Why not delay any lease sale, he asked, until the bureau could write a new blueprint for land management in the area?
“People would like it if we said, ‘O.K., we’re just going to stop,’ ” Helen M. Hankins, the bureau’s state director, told the crowd. “We really don’t have that luxury.”
She added: “It’s not the kind of world everybody would like to see.”
Real estate and tourism groups have also spoken against the leases, saying that gas rigs and a torrent of new truck traffic would drive away second-home buyers and hurt a tourist trade that has sprung up from almost nothing in the last 15 to 20 years. Proposed gas leases near Dinosaur National Monument and Mesa Verde National Park were met with howls of protest, and the Bureau of Land Management changed or withdrew several of the parcels from the sale because they were on steep slopes or had qualities of wilderness lands.
Sitting quietly in the crowd was Bruce Bertram, who monitors oil and gas activity here in Delta County on behalf of the county commissioners. There have been 27 wells drilled in the county over the last decade, and only one on federal land. Like it or not, he said, drilling was already at the doorstep to the valley.
“Some of the folks aren’t making a good judgment about what’s good and bad,” he said. “There’s a built-in distrust of government and business. And that permeates through the whole area.”
Even if the land is leased out for drilling, months and years of red tape and public review lie between drillers and the gas-rich rock underneath the tree-covered ridgelines and rolling mesas. Less than one-tenth of the federal lands here in western Colorado leased out for drilling have been developed.
During the presidential campaign, Mitt Romney criticized Mr. Obama’s policies for leading to a drop in drilling on public lands, saying that government regulations had made it too slow and cumbersome for companies to get permits.
But much of the decline in Colorado has been because of rock-bottom natural-gas prices — which fell in part because of abundant new supplies — and a boom in oil drilling on private lands in northern Colorado and western North Dakota. In Colorado, the public acres leased out for energy production have fallen, from 97,232 in 2009 to just 4,393 in 2011 and 64,435 last year. Now, with natural gas prices so low, it is an open question whether any energy companies will risk the money and resources to drill in the valley.
But if next month’s lease sale is a sign of a turn in the industry, small farmers like Wayne Talmage worry about the future of a place nicknamed “The American Provence.” It has been 40 years since Mr. Talmage — a philosophy student — left behind academia to move here to start White Buffalo Farm, which grows organic peaches, apples and pie cherries. One afternoon, as he helped a friend pull crates of cider apples out of cold storage, he pointed to ridgelines towering above his property, where gas wells could one day sit.
“We’re unbelievably blessed by this place here,” he said. “We could be unblessed really quickly.”
February 2, 2013Top G.O.P. Donors Seek Greater Say in Senate Races
By JEFF ZELENY
COUNCIL BLUFFS, Iowa — The biggest donors in the Republican Party are financing a new group to recruit seasoned candidates and protect Senate incumbents from challenges by far-right conservatives and Tea Party enthusiasts who Republican leaders worry could complicate the party’s efforts to win control of the Senate.
The group, the Conservative Victory Project, is intended to counter other organizations that have helped defeat establishment Republican candidates over the last two election cycles. It is the most robust attempt yet by Republicans to impose a new sense of discipline on the party, particularly in primary races.
“There is a broad concern about having blown a significant number of races because the wrong candidates were selected,” said Steven J. Law, the president of American Crossroads, the “super PAC” creating the new project. “We don’t view ourselves as being in the incumbent protection business, but we want to pick the most conservative candidate who can win.”
The effort would put a new twist on the Republican-vs.-Republican warfare that has consumed the party’s primary races in recent years. In effect, the establishment is taking steps to fight back against Tea Party groups and other conservative organizations that have wielded significant influence in backing candidates who ultimately lost seats to Democrats in the general election.
The first test of the group’s effort to influence primary races could come here in Iowa, where some Republicans are already worrying about who will run for the seat being vacated by Senator Tom Harkin, a Democrat. It is the first open Senate seat in Iowa since 1974, and Republicans are fearful of squandering a rare opportunity.
The Conservative Victory Project, which is backed by Karl Rove and his allies who built American Crossroads into the largest Republican super PAC of the 2012 election cycle, will start by intensely vetting prospective contenders for Congressional races to try to weed out candidates who are seen as too flawed to win general elections.
The project is being waged with last year’s Senate contests in mind, particularly the one in Missouri, where Representative Todd Akin’s comment that “legitimate rape” rarely causes pregnancy rippled through races across the country. In Indiana, the Republican candidate, Richard E. Mourdock, lost a race after he said that when a woman became pregnant during a rape it was “something God intended.”
As Republicans rebuild from losing the White House race and seats in the House and Senate last year, party leaders and strategists are placing a heightened focus on taking control of the Senate next year. Republicans must pick up six seats to win a majority.
Representative Steve King, a six-term Iowa Republican, could be among the earliest targets of the Conservative Victory Project. He said he had not decided whether he would run for the Senate, but the leaders of the project in Washington are not waiting to try to steer him away from the race.
The group’s plans, which were outlined for the first time last week in an interview with Mr. Law, call for hard-edge campaign tactics, including television advertising, against candidates whom party leaders see as unelectable and a drag on the efforts to win the Senate. Mr. Law cited Iowa as an example and said Republicans could no longer be squeamish about intervening in primary fights.
“We’re concerned about Steve King’s Todd Akin problem,” Mr. Law said. “This is an example of candidate discipline and how it would play in a general election. All of the things he’s said are going to be hung around his neck.”
Mr. King has compiled a record of incendiary statements during his time in Congress, including comparing illegal immigrants to dogs and likening Capitol Hill maintenance workers to “Stasi troops” after they were ordered to install environmentally friendly light bulbs. But he rejected the suggestion that his voting record or previous remarks would keep him from winning if he decided to run for the Senate.
“This is a decision for Iowans to make and should not be guided by some political staffers in Washington,” Mr. King said in an interview, pointing out that he won his Congressional race last year even though President Obama easily defeated Mitt Romney in Iowa. “The last election, they said I couldn’t win that, either, and the entire machine was against me.”
The Conservative Victory Project will be a super PAC operating independently of the National Republican Senatorial Committee. It will disclose the names of donors and raise money separately from American Crossroads, officials said, because some donors were uncomfortable about aggressively weighing in on Republican-vs.-Republican fights.
“It is a delicate and sensitive undertaking,” Mr. Law said. “Our approach will be to institutionalize the Buckley rule: Support the most conservative candidate who can win.”
But by imposing the rule of the conservative leader William F. Buckley, the group could run afoul of Ronald Reagan’s “11th Commandment” to not speak ill of a fellow Republican.
In Iowa, Cory Adams, the chairman of the Story County Republican Party, said the criticism aimed at Mr. King was unfair and misdirected. He warned of resistance from conservative activists if outside groups tried to interfere in the Senate race.
“If he wants to run for the Senate, he should be allowed to run,” Mr. Adams said of Mr. King, whose Congressional district includes Story County. “The more people get to know him, the more they will like him.”
The retirement announcements last month from Mr. Harkin and Senator Saxby Chambliss, Republican of Georgia, have created wide-open Senate races that are expected to attract several prospective candidates. The Conservative Victory Project is working to build a consensus with other groups on candidates who have the strongest chance of winning.
Grover Norquist, who leads Americans for Tax Reform, a fiscally conservative advocacy group that plays a role in Republican primary races, said he welcomed a pragmatic sense of discipline in recruiting candidates. But he said it was incorrect to suggest that candidates backed by Tea Party groups were the only ones to lose, pointing to establishment Republicans in North Dakota and Montana who also lost their races last year.
“People are imagining a problem that doesn’t exist,” Mr. Norquist said. “We’ve had people challenge the establishment guy and do swimmingly.”
Sue Everhart, the head of the Georgia Republican Party, said she did not object to outside intervention. But because open Senate seats do not come along very often, she said,“we have six congressmen who want the job,” which could create a messy and divisive primary regardless of the efforts to control the race.
“The primary has to sort itself out in Georgia,” Ms. Everhart said. “That’s what primaries are for. But we cannot afford to take our eye off the ball. This is going to be a very important election, and it’s paramount that Georgia keeps its Senate seat in Republican hands.”
February 2, 2013Drowned in a Stream of Prescriptions
By ALAN SCHWARZ
VIRGINIA BEACH — Every morning on her way to work, Kathy Fee holds her breath as she drives past the squat brick building that houses Dominion Psychiatric Associates.
It was there that her son, Richard, visited a doctor and received prescriptions for Adderall, an amphetamine-based medication for attention deficit hyperactivity disorder. It was in the parking lot that she insisted to Richard that he did not have A.D.H.D., not as a child and not now as a 24-year-old college graduate, and that he was getting dangerously addicted to the medication. It was inside the building that her husband, Rick, implored Richard’s doctor to stop prescribing him Adderall, warning, “You’re going to kill him.”
It was where, after becoming violently delusional and spending a week in a psychiatric hospital in 2011, Richard met with his doctor and received prescriptions for 90 more days of Adderall. He hanged himself in his bedroom closet two weeks after they expired.
The story of Richard Fee, an athletic, personable college class president and aspiring medical student, highlights widespread failings in the system through which five million Americans take medication for A.D.H.D., doctors and other experts said.
Medications like Adderall can markedly improve the lives of children and others with the disorder. But the tunnel-like focus the medicines provide has led growing numbers of teenagers and young adults to fake symptoms to obtain steady prescriptions for highly addictive medications that carry serious psychological dangers. These efforts are facilitated by a segment of doctors who skip established diagnostic procedures, renew prescriptions reflexively and spend too little time with patients to accurately monitor side effects.
Richard Fee’s experience included it all. Conversations with friends and family members and a review of detailed medical records depict an intelligent and articulate young man lying to doctor after doctor, physicians issuing hasty diagnoses, and psychiatrists continuing to prescribe medication — even increasing dosages — despite evidence of his growing addiction and psychiatric breakdown.
Very few people who misuse stimulants devolve into psychotic or suicidal addicts. But even one of Richard’s own physicians, Dr. Charles Parker, characterized his case as a virtual textbook for ways that A.D.H.D. practices can fail patients, particularly young adults. “We have a significant travesty being done in this country with how the diagnosis is being made and the meds are being administered,” said Dr. Parker, a psychiatrist in Virginia Beach. “I think it’s an abnegation of trust. The public needs to say this is totally unacceptable and walk out.”
Young adults are by far the fastest-growing segment of people taking A.D.H.D medications. Nearly 14 million monthly prescriptions for the condition were written for Americans ages 20 to 39 in 2011, two and a half times the 5.6 million just four years before, according to the data company I.M.S. Health. While this rise is generally attributed to the maturing of adolescents who have A.D.H.D. into young adults — combined with a greater recognition of adult A.D.H.D. in general — many experts caution that savvy college graduates, freed of parental oversight, can legally and easily obtain stimulant prescriptions from obliging doctors.
“Any step along the way, someone could have helped him — they were just handing out drugs,” said Richard’s father. Emphasizing that he had no intention of bringing legal action against any of the doctors involved, Mr. Fee said: “People have to know that kids are out there getting these drugs and getting addicted to them. And doctors are helping them do it.”
“...when he was in elementary school he fidgeted, daydreamed and got A’s. he has been an A-B student until mid college when he became scattered and he wandered while reading He never had to study. Presently without medication, his mind thinks most of the time, he procrastinated, he multitasks not finishing in a timely manner.”
Dr. Waldo M. Ellison
Richard Fee initial evaluation
Feb. 5, 2010
Richard began acting strangely soon after moving back home in late 2009, his parents said. He stayed up for days at a time, went from gregarious to grumpy and back, and scrawled compulsively in notebooks. His father, while trying to add Richard to his health insurance policy, learned that he was taking Vyvanse for A.D.H.D.
Richard explained to him that he had been having trouble concentrating while studying for medical school entrance exams the previous year and that he had seen a doctor and received a diagnosis. His father reacted with surprise. Richard had never shown any A.D.H.D. symptoms his entire life, from nursery school through high school, when he was awarded a full academic scholarship to Greensboro College in North Carolina. Mr. Fee also expressed concerns about the safety of his son’s taking daily amphetamines for a condition he might not have.
“The doctor wouldn’t give me anything that’s bad for me,” Mr. Fee recalled his son saying that day. “I’m not buying it on the street corner.”
Richard’s first experience with A.D.H.D. pills, like so many others’, had come in college. Friends said he was a typical undergraduate user — when he needed to finish a paper or cram for exams, one Adderall capsule would jolt him with focus and purpose for six to eight hours, repeat as necessary.
So many fellow students had prescriptions or stashes to share, friends of Richard recalled in interviews, that guessing where he got his was futile. He was popular enough on campus — he was sophomore class president and played first base on the baseball team — that they doubted he even had to pay the typical $5 or $10 per pill.
“He would just procrastinate, wait till the last minute and then take a pill to study for tests,” said Ryan Sykes, a friend. “It got to the point where he’d say he couldn’t get anything done if he didn’t have the Adderall.”
Various studies have estimated that 8 percent to 35 percent of college students take stimulant pills to enhance school performance. Few students realize that giving or accepting even one Adderall pill from a friend with a prescription is a federal crime. Adderall and its stimulant siblings are classified by the Drug Enforcement Administration as Schedule II drugs, in the same category as cocaine, because of their highly addictive properties.
“It’s incredibly nonchalant,” Chris Hewitt, a friend of Richard, said of students’ attitudes to the drug. “It’s: ‘Anyone have any Adderall? I want to study tonight,’ ” said Mr. Hewitt, now an elementary school teacher in Greensboro.
After graduating with honors in 2008 with a degree in biology, Richard planned to apply to medical schools and stayed in Greensboro to study for the entrance exams. He remembered how Adderall had helped him concentrate so well as an undergraduate, friends said, and he made an appointment at the nearby Triad Psychiatric and Counseling Center.
According to records obtained by Richard’s parents after his death, a nurse practitioner at Triad detailed his unremarkable medical and psychiatric history before recording his complaints about “organization, memory, attention to detail.” She characterized his speech as “clear,” his thought process “goal directed” and his concentration “attentive.”
Richard filled out an 18-question survey on which he rated various symptoms on a 0-to-3 scale. His total score of 29 led the nurse practitioner to make a diagnosis of “A.D.H.D., inattentive-type” — a type of A.D.H.D. without hyperactivity. She recommended Vyvanse, 30 milligrams a day, for three weeks.
Phone and fax requests to Triad officials for comment were not returned.
Some doctors worry that A.D.H.D. questionnaires, designed to assist and standardize the gathering of a patient’s symptoms, are being used as a shortcut to diagnosis. C. Keith Conners, a longtime child psychologist who developed a popular scale similar to the one used with Richard, said in an interview that scales like his “have reinforced this tendency for quick and dirty practice.”
Dr. Conners, an emeritus professor of psychiatry and behavioral sciences at Duke University Medical Center, emphasized that a detailed life history must be taken and other sources of information — such as a parent, teacher or friend — must be pursued to learn the nuances of a patient’s difficulties and to rule out other maladies before making a proper diagnosis of A.D.H.D. Other doctors interviewed said they would not prescribe medications on a patient’s first visit, specifically to deter the faking of symptoms.
According to his parents, Richard had no psychiatric history, or even suspicion of problems, through college. None of his dozen high school and college acquaintances interviewed for this article said he had ever shown or mentioned behaviors related to A.D.H.D. — certainly not the “losing things” and “difficulty awaiting turn” he reported on the Triad questionnaire — suggesting that he probably faked or at least exaggerated his symptoms to get his diagnosis.
That is neither uncommon nor difficult, said David Berry, a professor and researcher at the University of Kentucky. He is a co-author of a 2010 study that compared two groups of college students — those with diagnoses of A.D.H.D. and others who were asked to fake symptoms — to see whether standard symptom questionnaires could tell them apart. They were indistinguishable.
“With college students,” Dr. Berry said in an interview, “it’s clear that it doesn’t take much information for someone who wants to feign A.D.H.D. to do so.”
Richard Fee filled his prescription for Vyvanse within hours at a local Rite Aid. He returned to see the nurse three weeks later and reported excellent concentration: “reading books — read 10!” her notes indicate. She increased his dose to 50 milligrams a day. Three weeks later, after Richard left a message for her asking for the dose to go up to 60, which is on the high end of normal adult doses, she wrote on his chart, “Okay rewrite.”
Richard filled that prescription later that afternoon. It was his third month’s worth of medication in 43 days.
“The patient is a 23-year-old Caucasian male who presents for refill of vyvanse — recently started on this while in NC b/c of lack of motivation/ loss of drive. Has moved here and wants refill”
Dr. Robert M. Woodard
Notes on Richard Fee
Nov. 11, 2009
Richard scored too low on the MCAT in 2009 to qualify for a top medical school. Although he had started taking Vyvanse for its jolts of focus and purpose, their side effects began to take hold. His sleep patterns increasingly scrambled and his mood darkening, he moved back in with his parents in Virginia Beach and sought a local physician to renew his prescriptions.
A friend recommended a family physician, Dr. Robert M. Woodard. Dr. Woodard heard Richard describe how well Vyvanse was working for his A.D.H.D., made a diagnosis of “other malaise and fatigue” and renewed his prescription for one month. He suggested that Richard thereafter see a trained psychiatrist at Dominion Psychiatric Associates — only a five-minute walk from the Fees’ house.
With eight psychiatrists and almost 20 therapists on staff, Dominion Psychiatric is one of the better-known practices in Virginia Beach, residents said. One of its better-known doctors is Dr. Waldo M. Ellison, a practicing psychiatrist since 1974.
In interviews, some patients and parents of patients of Dr. Ellison’s described him as very quick to identify A.D.H.D. and prescribe medication for it. Sandy Paxson of nearby Norfolk said she took her 15-year-old son to see Dr. Ellison for anxiety in 2008; within a few minutes, Mrs. Paxson recalled, Dr. Ellison said her son had A.D.H.D. and prescribed him Adderall.
“My son said: ‘I love the way this makes me feel. It helps me focus for school, but it’s not getting rid of my anxiety, and that’s what I need,’ ” Mrs. Paxson recalled. “So we went back to Dr. Ellison and told him that it wasn’t working properly, what else could he give us, and he basically told me that I was wrong. He basically told me that I was incorrect.”
Dr. Ellison met with Richard in his office for the first time on Feb. 5, 2010. He took a medical history, heard Richard’s complaints regarding concentration, noted how he was drumming his fingers and made a diagnosis of A.D.H.D. with “moderate symptoms or difficulty functioning.” Dominion Psychiatric records of that visit do not mention the use of any A.D.H.D. symptom questionnaire to identify particular areas of difficulty or strategies for treatment.
As the 47-minute session ended, Dr. Ellison prescribed a common starting dose of Adderall: 30 milligrams daily for 21 days. Eight days later, while Richard still had 13 pills remaining, his prescription was renewed for 30 more days at 50 milligrams.
Through the remainder of 2010, in appointments with Dr. Ellison that usually lasted under five minutes, Richard returned for refills of Adderall. Records indicate that he received only what was consistently coded as “pharmacologic management” — the official term for quick appraisals of medication effects — and none of the more conventional talk-based therapy that experts generally consider an important component of A.D.H.D. treatment.
His Adderall prescriptions were always for the fast-acting variety, rather than the extended-release formula that is less prone to abuse.
“PATIENT DOING WELL WITH THE MEDICATION, IS CALM, FOCUSED AND ON TASK, AND WILL RETURN TO OFFICE IN 3 MONTHS”
Dr. Waldo M. Ellison
Notes on Richard Fee
Dec. 11, 2010
Regardless of what he might have told his doctor, Richard Fee was anything but well or calm during his first year back home, his father said.
Blowing through a month’s worth of Adderall in a few weeks, Richard stayed up all night reading and scribbling in notebooks, occasionally climbing out of his bedroom window and on to the roof to converse with the moon and stars. When the pills ran out, he would sleep for 48 hours straight and not leave his room for 72. He got so hot during the day that he walked around the house with ice packs around his neck — and in frigid weather, he would cool off by jumping into the 52-degree backyard pool.
As Richard lost a series of jobs and tensions in the house ran higher — particularly when talk turned to his Adderall — Rick and Kathy Fee continued to research the side effects of A.D.H.D. medication. They learned that stimulants are exceptionally successful at mollifying the impulsivity and distractibility that characterize classic A.D.H.D., but that they can cause insomnia, increased blood pressure and elevated body temperature. Food and Drug Administration warnings on packaging also note “high potential for abuse,” as well as psychiatric side effects such as aggression, hallucinations and paranoia.
A 2006 study in the journal Drug and Alcohol Dependence claimed that about 10 percent of adolescents and young adults who misused A.D.H.D. stimulants became addicted to them. Even proper, doctor-supervised use of the medications can trigger psychotic behavior or suicidal thoughts in about 1 in 400 patients, according to a 2006 study in The American Journal of Psychiatry. So while a vast majority of stimulant users will not experience psychosis — and a doctor may never encounter it in decades of careful practice — the sheer volume of prescriptions leads to thousands of cases every year, experts acknowledged.
When Mrs. Fee noticed Richard putting tape over his computer’s camera, he told her that people were spying on him. (He put tape on his fingers, too, to avoid leaving fingerprints.) He cut himself out of family pictures, talked to the television and became increasingly violent when agitated.
In late December, Mr. Fee drove to Dominion Psychiatric and asked to see Dr. Ellison, who explained that federal privacy laws forbade any discussion of an adult patient, even with the patient’s father. Mr. Fee said he had tried unsuccessfully to detail Richard’s bizarre behavior, assuming that Richard had not shared such details with his doctor.
“I can’t talk to you,” Mr. Fee recalled Dr. Ellison telling him. “I did this one time with another family, sat down and talked with them, and I ended up getting sued. I can’t talk with you unless your son comes with you.”
Mr. Fee said he had turned to leave but distinctly recalls warning Dr. Ellison, “You keep giving Adderall to my son, you’re going to kill him.”
Dr. Ellison declined repeated requests for comment on Richard Fee’s case. His office records, like those of other doctors involved, were obtained by Mr. Fee under Virginia and federal law, which allow the legal representative of a deceased patient to obtain medical records as if he were the patient himself.
As 2011 began, the Fees persuaded Richard to see a psychologist, Scott W. Sautter, whose records note Richard’s delusions, paranoia and “severe and pervasive mental disorder.” Dr. Sautter recommended that Adderall either be stopped or be paired with a sleep aid “if not medically contraindicated.”
Mr. Fee did not trust his son to share this report with Dr. Ellison, so he drove back to Dominion Psychiatric and, he recalled, was told by a receptionist that he could leave the information with her. Mr. Fee said he had demanded to put it in Dr. Ellison’s hands himself and threatened to break down his door in order to do so.
Mr. Fee said that Dr. Ellison had then come out, read the report and, appreciating the gravity of the situation, spoken with him about Richard for 45 minutes. They scheduled an appointment for the entire family.
“meeting with parents — concern with ‘metaphoric’ speaking that appears to be outside the realm of appropriated one to one conversation. Richard says he does it on purpose — to me some of it sounds like pre-psychotic thinking.”
Dr. Waldo M. Ellison
Notes on Richard Fee
Feb. 23, 2011
Dr. Ellison stopped Richard Fee’s prescription — he wrote “no Adderall for now” on his chart and the next day refused Richard’s phone request for more. Instead he prescribed Abilify and Seroquel, antipsychotics for schizophrenia that do not provide the bursts of focus and purpose that stimulants do. Richard became enraged, his parents recalled. He tried to back up over his father in the Dominion Psychiatric parking lot and threatened to burn the house down. At home, he took a baseball bat from the garage, smashed flower pots and screamed, “You’re taking my medicine!”
Richard disappeared for a few weeks. He returned to the house when he learned of his grandmother’s death, the Fees said.
The morning after the funeral, Richard walked down Potters Road to what became a nine-minute visit with Dr. Ellison. He left with two prescriptions: one for Abilify, and another for 50 milligrams a day of Adderall.
According to Mr. Fee, Richard later told him that he had lied to Dr. Ellison — he told the doctor he was feeling great, life was back on track and he had found a job in Greensboro that he would lose without Adderall. Dr. Ellison’s notes do not say why he agreed to start Adderall again.
Richard’s delusions and mood swings only got worse, his parents said. They would lock their bedroom door when they went to sleep because of his unpredictable rages. “We were scared of our own son,” Mr. Fee said. Richard would blow through his monthly prescriptions in 10 to 15 days and then go through hideous withdrawals. A friend said that he would occasionally get Richard some extra pills during the worst of it, but that “it wasn’t enough because he would take four or five at a time.”
One night during an argument, after Richard became particularly threatening and pushed him over a chair, Mr. Fee called the police. They arrested Richard for domestic violence. The episode persuaded Richard to see another local psychiatrist, Dr. Charles Parker.
Mrs. Fee said she attended Richard’s initial consultation on June 3 with Dr. Parker’s clinician, Renee Strelitz, and emphasized his abuse of Adderall. Richard “kept giving me dirty looks,” Mrs. Fee recalled. She said she had later left a detailed message on Ms. Strelitz’s voice mail, urging her and Dr. Parker not to prescribe stimulants under any circumstances when Richard came in the next day.
Dr. Parker met with Richard alone. The doctor noted depression, anxiety and suicidal ideas. He wrote “no meds” with a box around it — an indication, he explained later, that he was aware of the parents’ concerns regarding A.D.H.D. stimulants.
Dr. Parker wrote three 30-day prescriptions: Clonidine (a sleep aid), Venlafaxine (an antidepressant) and Adderall, 60 milligrams a day.
In an interview last November, Dr. Parker said he did not recall the details of Richard’s case but reviewed his notes and tried to recreate his mind-set during that appointment. He said he must have trusted Richard’s assertions that medication was not an issue, and must have figured that his parents were just philosophically anti-medication. Dr. Parker recalled that he had been reassured by Richard’s intelligent discussions of the ins and outs of stimulants and his desire to pursue medicine himself.
“He was smart and he was quick and he had A’s and B’s and wanted to go to medical school — and he had all the deportment of a guy that had the potential to do that,” Dr. Parker said. “He didn’t seem like he was a drug person at all, but rather a person that was misunderstood, really desirous of becoming a physician. He was very slick and smooth. He convinced me there was a benefit.”
Mrs. Fee was outraged. Over the next several days, she recalled, she repeatedly spoke with Ms. Strelitz over the phone to detail Richard’s continued abuse of the medication (she found nine pills gone after 48 hours) and hand-delivered Dr. Sautter’s appraisal of his recent psychosis. Dr. Parker confirmed that he had received this information.
Richard next saw Dr. Parker on June 27. Mrs. Fee drove him to the clinic and waited in the parking lot. Soon afterward, Richard returned and asked to head to the pharmacy to fill a prescription. Dr. Parker had raised his Adderall to 80 milligrams a day.
Dr. Parker recalled that the appointment had been a 15-minute “med check” that left little time for careful assessment of any Adderall addiction. Once again, Dr. Parker said, he must have believed Richard’s assertions that he needed additional medicine more than the family’s pleas that it be stopped.
“He was pitching me very well — I was asking him very specific questions, and he was very good at telling me the answers in a very specific way,” Dr. Parker recalled. He added later, “I do feel partially responsible for what happened to this kid.”
“Paranoid and psychotic ... thinking that the computer is spying on him. He has also been receiving messages from stars at night and he is unable to be talked to in a reasonable fashion ... The patient denies any mental health problems ... fairly high risk for suicide.”
Dr. John Riedler
Admission note for Richard Fee
Virginia Beach Psychiatric Center
July 8, 2011
The 911 operator answered the call and heard a young man screaming on the other end. His parents would not give him his pills. With the man’s language scattered and increasingly threatening, the police were sent to the home of Rick and Kathy Fee.
The Fees told officers that Richard was addicted to Adderall, and that after he had received his most recent prescription, they allowed him to fill it through his mother’s insurance plan on the condition that they hold it and dispense it appropriately. Richard was now demanding his next day’s pills early.
Richard denied his addiction and threats. So the police, noting that Richard was an adult, instructed the Fees to give him the bottle. They said they would comply only if he left the house for good. Officers escorted Richard off the property.
A few hours later Richard called his parents, threatening to stab himself in the head with a knife. The police found him and took him to the Virginia Beach Psychiatric Center.
Described as “paranoid and psychotic” by the admitting physician, Dr. John Riedler, Richard spent one week in the hospital denying that he had any psychiatric or addiction issues. He was placed on two medications: Seroquel and the antidepressant Wellbutrin, no stimulants. In his discharge report, Dr. Riedler noted that Richard had stabilized but remained severely depressed and dependent on both amphetamines and marijuana, which he would smoke in part to counter the buzz of Adderall and the depression from withdrawal.
(Marijuana is known to increase the risk for schizophrenia, psychosis and memory problems, but Richard had smoked pot in high school and college with no such effects, several friends recalled. If that was the case, “in all likelihood the stimulants were the primary issue here,” said Dr. Wesley Boyd, a psychiatrist at Children’s Hospital Boston and Cambridge Health Alliance who specializes in adolescent substance abuse.)
Unwelcome at home after his discharge from the psychiatric hospital, Richard stayed in cheap motels for a few weeks. His Adderall prescription from Dr. Parker expired on July 26, leaving him eligible for a renewal. He phoned the office of Dr. Ellison, who had not seen him in four months.
“moved out of the house — doesn’t feel paranoid or delusional. Hasn’t been on meds for a while — working with a friend wiring houses rto 3 months — doesn’t feel he needs the abilify or seroquel for sleep.”
Dr. Waldo M. Ellison
Notes on Richard Fee
July 25, 2011
The 2:15 p.m. appointment went better than Richard could have hoped. He told Dr. Ellison that the pre-psychotic and metaphoric thinking back in March had receded, and that all that remained was his A.D.H.D. He said nothing of his visits to Dr. Parker, his recent prescriptions or his week in the psychiatric hospital.
At 2:21 p.m., according to Dr. Ellison’s records, he prescribed Richard 30 days’ worth of Adderall at 50 milligrams a day. He also gave him prescriptions postdated for Aug. 23 and Sept. 21, presumably to allow him to get pills into late October without the need for follow-up appointments. (Virginia state law forbids the dispensation of 90 days of a controlled substance at one time, but does allow doctors to write two 30-day prescriptions in advance.)
Virginia is one of 43 states with a formal Prescription Drug Monitoring Program, an online database that lets doctors check a patient’s one-year prescription history, partly to see if he or she is getting medication elsewhere. Although pharmacies are required to enter all prescriptions for controlled substances into the system, Virginia law does not require doctors to consult it.
Dr. Ellison’s notes suggest that he did not check the program before issuing the three prescriptions to Richard, who filled the first within hours.
The next morning, during a scheduled appoi