Addicts are infiltrating our pharmacies, placing themselves and everyone else in danger. Is it time for the man in the white coat to don the white hat?
RYAN DONNELLY HAD IT DOWN COLD. THREE years ago he was a 25-year-old Navy vet who had been booted from the service for a failed drug test, cycled through cocaine to alcohol, and finally landed on a 560-milligram-a-day oxycodone addiction. To maintain his habit, Donnelly stole prescription pads. When those ran out, he dipped legitimate scrips in nail polish remover to strip away the physicians’ scribblings. He then took his forgeries to more than 20 pharmacies in and around his hometown of Toms River, New Jersey.
Today when the clean and sober Donnelly looks back on those years, he knows there were obvious signs of his addiction that anyone, especially an experienced pharmacist, could have picked up on.
“When you’re withdrawing, your upper lip and your forehead sweat; you look like you have the flu,” says Donnelly, who now runs FreeFromHell.com, a social support website for recovering addicts. He says sometimes he’d even put on a suit in an effort to look normal. “You try to pull it together, but you end up looking like a hoodlum.”
If the red flags were there for all behind the counter to see, why didn’t anyone turn Donnelly away—or better yet, turn him in? Fortunately, a family intervention finally pushed the pillhead to rehab before he could hurt himself or anyone else.
Things ended more tragically in the case of David Laffer. In June 2011, Laffer walked into a Long Island pharmacy and shot the pharmacist, a 17-year-old employee, and two customers while stealing hydrocodone, a semisynthetic opioid derived from codeine. In the 12 days before the killings, he had filled six prescriptions from five different doctors for a total of more than 400 pills, according to one Long Island newspaper.
“We sometimes lose sight of the fact that pharmacists are trained to spot drug-seeking behavior,” says Luis Bauza, director of investigations at RxPatrol, an alliance formed between local law enforcement and the drug company Purdue Pharma, which makes OxyContin, to track pharmacy fraud and thefts across the country. “I see pharmacists as our last line of defense.”
OPIUM FROM AFGHANISTAN’S POPPY FIELDS helps fund the Taliban, but you could argue that it’s the synthetic stuff that poses the most immediate threat to U.S. national security. In 2008 alone, 14,800 people died after taking opioid painkillers like oxycodone, according to the CDC. More recently, a 2010 survey by the Substance Abuse and Mental Health Services Administration found that an estimated 1.9 million people had abused or been dependent on prescription painkillers in the past year. And increasingly, the addicts who don’t kill themselves are becoming desperate enough to endanger others. The U.S. Drug Enforcement Administration reports that 686 armed pharmacy robberies took place in 2010, an 81 percent increase from just 4 years earlier. (Sure medicines are made for you to feel better, but some are no joke. Make sure you are aware of The 3 Meds with the Craziest Side Effects Ever.)
Pharmacist Mike Donohue has witnessed the change firsthand. In 2009, a man walked into Donohue’s Seattle pharmacy and slipped the technician on duty a piece of paper that read, “Give me your OxyContin. I have a gun.” Luckily for the people in the store that afternoon, Donohue noticed what was going on, pulled out his own gun, a Glock 19 loaded with hollow-point bullets, and chased the would-be robber out the door.
Donohue, 55, has been working behind a drugstore counter for more than two decades. He remembers a time not so long ago when a holster wasn’t part of his uniform. In fact, in the late 1990s, medical boards across the nation were chiding doctors for often under-treating patients’ pain and recommended the increased use of opioids for difficult-to-manage cases. According to Donohue, pharmacy boards encouraged reluctant pharmacists to dispense narcotics in such situations, in amounts that were significantly larger than what the pharmacists were used to doling out.
“They said people were suffering needlessly,” he recalls. “We were told that with proper documentation and a legitimate prescription, dispensing these narcotics was appropriate. The word out then was ‘Pharmacists are not police officers!'”
They’re not physicians either, but if pharmacists don’t intervene when suspicious customers proffer scrips, they expose themselves to as much liability as doctors do when they prescribe drugs inappropriately. Under the Controlled Substances Act, a clause commonly known as “corresponding responsibility” stipulates that a pharmacist who fills a prescription when there’s reason to doubt its intent for legitimate medical use can lose his or her license and even be prosecuted for a felony.
Yet even at the risk of possible legal ramifications, many pharmacists don’t step in early on. This is despite the fact that in a 2005 report from the National Center on Addiction and Substance Abuse at Columbia University, 52 percent of pharmacists said the patients—not physicians or drug companies—were mostly to blame for the problem of unlawful prescription drug use.
One reason for their reticence is that pharmacists don’t feel adequately prepared to spot patients with problems. A study of Florida pharmacists found that less than a third of those surveyed had more than 2 hours of addiction and substance-abuse training in school. Worse, nearly 30 percent said they’d received no training at all.
“It’s not something you can really teach in a classroom,” says Lauren Schlesselman, Pharm.D., an assistant clinical professor at the University of Connecticut’s school of pharmacy. She estimates that less than 1 percent of the UConn curriculum is dedicated to spotting signs of addiction in customers. That course work includes students viewing mock patient profiles, looking for signs of doctor shopping (trying to fill multiple scrips from different physicians) and pharmacy hopping (trying to fill the same scrip at different places), and noting the numbers of attempts at early refills. But the best lesson—witnessing the physical signs of a customer who’s slipping into addiction—isn’t found in a textbook. That’s why Dr. Schlesselman believes pharmacists should be honing their observational skills on the job during their internships. (For secrets on how to sharpen your memory, boost your creativity and strengthen your mental muscles, discover 27 Ways to Power Up Your Brain.)
That said, she also admits that pharmacists and pharmacy techs would be able to spend more time evaluating the legitimacy of a prescription held by, say, the fifth customer in a 10-person line if they weren’t stretched so thin already. With much of the population aging into a medication-reliant culture, pharmacists are in high demand. Adding to their work stress is the fact that they now often provide immunizations, and Medicare is requiring them to become more involved in counseling patients. And while enrollment in pharmacy schools is up, most stores can’t afford to hire enough pharmacists, says Dr. Schlesselman. She also points out that just about every transaction—even the basic ones handled by technicians, like counting pills—must be overseen and approved by the pharmacist.
“With chain stores, frankly, they are trying to move you through the line as fast as possible,” she says. “And the small shops are also trying to fill as many scrips as fast as they can so they can afford to stay in business.”
A possible compromise between classroom education and hands-on prescribing would be to train pharmacists in the virtual world. When researchers from the Philadelphia College of Pharmacy recently tested a Web-based learning program on second-year pharmacy students, the results were encouraging. The study, published in the American Journal of Pharmaceutical Education in 2010, found that after answering a series of questions on addiction and then sitting through a Web-based tutorial, students’ scores on the questions improved by 30 percentage points.
Of course, it isn’t enough simply to spot an addict—the hard part is stopping one. “Pharmacists have only a few options,” says Dr. Schlesselman. “They can approach the pre-scriber with their suspicions in an effort to obtain confirmation, they can confront the patient, they can warn other pharmacists in the area, or they can call the police.”
RYAN DONNELLY DOESN’T KNOW HOW MANY of the pharmacists who filled his scrips suspected he was hooked, but he believes they all acted appropriately by not challenging him. “I don’t think it’s worth it for them to get involved,” he says. “The longer you use and the more desperate you get, eventually you’ll end up doing something stupid.”
“Pharmacists are positioned at a critical intervention point,” says Sherry Green, CEO of the National Alliance for Model State Drug Laws. “But we can’t expect them to be the sole gatekeepers, to take all this on themselves. That burden has to be shared.”
To that end, Green’s organization has been pushing state governments to institute prescription drug monitoring programs (PDMPs), computer databases that are set up to track and share information on prescriptions as those scrips flow from doctor to patient to pharmacy. With access to such data, a pharmacist can run the details of a prescription through the system and look for suspicious activity. The database can then reveal whether a patient is doctor shopping or pharmacy hopping, for example, or whether specific physicians are prescribing inordinate amounts of painkillers to many different patients. (Prescriptions may not be the only thing you visit the drugstore to buy. With our list of the The Best Over-the-Counter Medicines for Men you may be able to avoid the pharmacy counter altogether.)
Forty-one states have already installed and launched PDMPs, and all other states except Missouri and New Hampshire have enacted legislation to do so. Reluctance in the two holdout states, Green says, is due to privacy concerns about the government maintaining a database of personal prescription information. Nevertheless, she believes that the benefits of the monitoring program will outweigh any negatives. “With early detection, the appropriate professionals can intervene early and help resolve potential problems.”
So far the implementation of these systems has been problematic. Because each state decides how to set up its database, each system is different. That means communication among state databases is difficult if not impossible, resulting in loopholes that border-hopping pill poppers can exploit. As of February 2012, only 24 states have begun sharing data with the PDMPs of other states.
Another issue, Green says, is that the laws surrounding each state’s system differ; in some states, pharmacists can only enter information—they aren’t allowed to access it. That’s currently the case in New York, at least for now. The Laffer shooting has helped spur legislation that could change that and open the database door to pharmacists.
Mike Donohue, for one, is willing to give this technology a chance. He has recently installed new software in his Seattle pharmacy that will pipe him into Washington State’s PDMP, which allows full access to pharmacists. But while he appreciates the convenience of the new system, he feels it’s no replacement for a pharmacist’s intuition.
“We do this all day,” Donohue says. “We know when we should say no to a customer and when we should say yes. If you use common sense and good judgment, you’ll be okay.”
AS A BANKER ON WALL STREET, MICHAEL Altman dealt with risk all the time. So it didn’t surprise anyone when 9 years ago, at the age of 36, he left the stress of the Street to take a chance on starting his own business: a pharmacy in the small village of Hastings-on-Hudson, less than 20 miles from Manhattan.
The gamble paid off, at least financially. But as the decade passed, an unexpected problem emerged. Altman began to notice unfamiliar faces infiltrating his closely knit core of local customers. People came bearing prescriptions from doctors in the Bronx or Brooklyn. Many of the scrips being presented were on photocopied paper, some obviously altered with an extra digit penned in to change, say, 20 pills to 120. Some of these customers insisted on paying cash. And all of the prescriptions were for painkillers—usually oxycodone.
“I had a guy come in with a falsified scrip on a stolen prescription pad,” says Altman in a thick New York accent. “I called the doctor, turned the guy away. He came in again; I called the cops. He was arrested right outside the store, right in front of his friend, who was waiting in the car.” Then Altman delivers the punch line: “The next week, the friend comes in with the same pad. It’s a game to them.”
If there’s a lesson in Altman’s experience, it’s that now it’s more critical than ever for pharmacists to stay connected to the communities they serve.
“The pharmacist needs to know the patients who come into the pharmacy,” says Bauza from RxPatrol, “and he or she should also have relationships with the doctors in the area.” When these connections are made, the pharmacist not only comes to trust the prescription, adds Bauza, but also becomes familiar with the circumstances surrounding treatment and can possibly even provide the customer with useful advice.
“I want my pharmacist to call my doctor if any questions arise about a medication I’m supposed to be taking,” says Bauza. “It’s like getting a second opinion.”
John Burke, president of the National Association of Drug Diversion Investigators, recommends that a pharmacist extend that same familiarity to local law enforcement.
“Don’t wait until there’s a robbery to meet the cop on the beat,” he says.
WHETHER IT’S THE NATIONWIDE ADOPTION of PDMPs, a renewed focus on adequately educating pharmacists to spot addiction, or a conscious move toward building stronger and more personal customer relationships, no single prescription can cure the problem of painkiller abuse everywhere. Each individual pharmacy needs to figure out a combination of strategies that works best for the particular community it serves.
There is, however, one last-resort measure that no pharmacist wants to implement. Altman eventually saw it as his only option for protecting himself, his staff members, and his customers. He printed up signs and then taped them to the windows of his pharmacy. They read: WE ARE NO LONGER CARRYING OXYCODONE.
“It’s worked,” he says. “The calls for the drug have largely stopped.”
Altman doesn’t relish the idea of denying people with real medical needs—his neighbors—access to pain relief, nor does he look forward to the inevitable hit to his bottom line. But he also knew he had to do something.
“Everybody should take the situation into their own hands as part of our civic responsibility,” says Altman. “If we allow these people to become junkies just so we can make a profit, we’re no better than the people selling on the street.”