'Pharmacy crawl' causes examination of pill mill regulations
TALLAHASSEE, Fla. – Chris Young is a lifelong gun enthusiast, but his wife Lesley got rid of his rifles not long after the couple moved back to Florida nearly two years ago.
She was afraid of what her wheelchair-bound husband might do to himself once the Youngs found themselves among the throng of other patients forced to do the "pharmacy crawl" to get pain medications ordered by doctors.
Chris Young, a former mechanic, was crushed "like an accordion" a decade ago when a car he was standing beneath fell off its lift. Almost completely paralyzed, Young still experiences tremendous pain in his legs, for which his doctors have prescribed a number of narcotic drugs.
Young's struggle to get prescriptions filled, however, is nearly identical to the plight of patients across Florida who need medication to cope with severe pain. The dilemma has reached such proportions that the Florida Board of Pharmacy's Controlled Substances Standards Committee is holding a series of meetings in an attempt to figure out what can be done. The panel will meet Monday in Tallahassee.
With Florida having the dubious distinction of being branded the "pill mill capital" of the country, Florida lawmakers in 2011 --- at the urging of Attorney General Pam Bondi --- imposed strict regulations on doctors and pharmacies about dispensing highly addictive pain medications. The effort was aimed at shutting down rogue clinics that had popped up in areas like South Florida and had drawn addicts and traffickers from states hundreds of miles away.
Around the same time, the U.S. Drug Enforcement Administration targeted pharmacies and distributors that contributed to the problem by allowing powerful narcotics to get into the hands of unscrupulous doctors and dealers.
But now, many doctors, patients and even pharmacists wonder if the pendulum has swung too far in the other direction.
Last year, Lesley Young traveled to more than a dozen Jacksonville-area pharmacies before finding one that would fill her husband's prescriptions.
Suzy Carpenter, diagnosed with Stage IV breast cancer, spent three days pleading with pharmacists at 13 drug stores before she received her pain medication.
And three pharmacies rejected 4-year-old Aiden Lopez's prescriptions for narcotics after the tot underwent surgery for kidney cancer.
A handful of patients have committed suicide because no one would fill their prescriptions, according to doctors who testified at the Board of Pharmacy committee's last meeting.
Other patients have turned to social media to spread the word. Some, like Lesley Young, are showing up at the meetings in tears, begging for help.
They're tired of being treated like drug addicts.
"You try and dress nice. You go into the drug store and speak well, and they look at you and say what do you need all this medication for and fling (the prescription) back at you," Young said. "It's humiliating."
Who's responsible for the problem, and how to fix it, is complicated.
Pharmacists offer a litany of reasons for refusing to fill prescriptions.
They don't have the medicines in stock. They're worried about running out of the medications and leaving their longtime patients empty-handed. They're obeying mandates handed down by corporations like Walgreens and CVS. Or they're afraid of being caught in a net cast by the U.S. Drug Enforcement Agency that has shuttered 13 Florida pharmacies since 2011.
Physicians complain that pharmacists are second-guessing their decisions, demanding that health care professionals provide the results of MRIs or other tests while questioning drug orders.
"You have some pharmacists that are just out of control with their assessment," said Charles Friedman, a Pinellas County physician who is certified with the American Board of Anesthesiology and the American Board of Addiction Medicine.
Friedman said he frequently is grilled by pharmacists, who are required by law to call prescribers if they believe that a prescription may be fraudulent.
"Can you give me his diagnosis? Do you have MRI scans? When was their physical examination? Have you tried other modalities of care?" Friedman said. "It's like a whole laundry list of questions they ask you. They're a pharmacist. They're not really trained in making a clinical assessment. … I think they're really walking outside of the box and stretching out beyond their expertise."
Florida Medical Association General Counsel Jeff Scott, who did the "pharmacy crawl" in Tallahassee in an attempt to locate pain medication for his elderly father, is even more direct.
"(Pharmacists) need to fill the damn prescription," Scott, whose father was diagnosed with cancer, said. "If a doctor orders it, they need to fill it. Period. Unless they have reason to believe it's fraudulent."
At a meeting of the pharmacy board committee last month, Susan Langston, the Drug Enforcement Administration's divergent program manager for the Miami Field Division, called 4-year-old Aiden Lopez's story "deeply troubling."
The DEA's Miami staff "is horrified to hear the heartbreaking stories of cancer patients, hospice patients, surgery patients and legitimate pain patients being forced to endure needless suffering," Langston said. "This has to stop, and it has to stop now."
Langston, who delivered lengthy prepared remarks, insisted that her agency isn't trying to keep pharmacists from doling out medicines to legitimate patients.
"In watching for suspicious activities we are not asking pharmacists to be medical doctors. We are not asking them to review medical records, MRI reports or to diagnose a patient. We simply want pharmacists to be aware that there is an epidemic of pharmaceutical drug abuse in this country and to use their education, experience, professional judgment, ethics and common sense to not knowingly participate in this national health crisis," she said.
But, three years after Walgreens agreed to pay an $80 million fine for violations regarding distribution and dispensing of highly addictive narcotics, Florida Pharmacy Association Executive Director Michael Jackson acknowledged that pharmacists are scared.
Pharmacists are experiencing "some real, real fear," Jackson, a member of the controlled substances committee, said at a meeting in June. "We need to find ways of overcoming that fear and fixing that anxiety."
Two months later, the DEA's Langston tried to quell those concerns.
"I want to make myself perfectly clear. Pharmacists do not need to fear the DEA when they use their professional judgment, experience, education, training and common sense to fill legitimate prescriptions," she said at the August meeting.
Part of the problem may rest in Florida's history as the country's "pill mill capital."
"Addicts have brought us to this point," Melissa Ramba, a lobbyist for the Florida Retail Federation, which represents pharmacy chains like Walgreens, told the panel in June.
Doctors aren't required to consult the state's prescription-drug monitoring program, the database that contains all of the prescriptions for controlled substances. About 10 percent of physicians use the program, according to the latest data provided by the Department of Health. Nearly half of the state's pharmacists have consulted the database, the records show.
Florida's law should require doctors to check the database prior to writing prescriptions, Ramba said. That would give pharmacists "some comfort" in filling the orders and "help move the needle on this issue," she said.
But the Florida Medical Association vehemently opposed forcing doctors to use the database, and it is unlikely that lawmakers will approve such a requirement without the support of the powerful lobbying group.
In the meantime, Jackson's association, which represents independent pharmacies, held a summit last weekend to educate about 150 pharmacists and pharmacy technicians about state laws and rules regarding controlled substances.
The Board of Pharmacy's committee agreed last month to open up the 2002 "Standards of Practice for Dispensing of Controlled Substances for the Treatment of Pain" for possible revision.
That's the first step in addressing the problem, according to Jackson.
The rule contains "red flags" for pharmacists, including whether a patient frequently "loses" drugs; only has prescriptions for controlled substances; has more than one name; has the same drug prescribed by two or more doctors at the same time; and pays only in cash.
Also of concern is a state law that includes a trigger for distributors to examine retailers who order more than 5,000 dosage units per month of controlled substances. While the 5,000 dosage units are only a trigger, some pharmacies may be treating it as a cap, according to testimony from the committee's previous two meetings.
Bondi, who has made prescription drug abuse a signature issue since taking office in 2011, called the plight of legitimate patients heartbreaking. But she balked at the idea of eliminating the 5,000 dosage unit trigger.
"If they're not doing anything wrong, they shouldn't have a concern about it," she said. "What I know is that we cannot return to the days when seven Floridians were dying each day due to prescription drug overdoses. I also know there are credible reports of people with legitimate pain who aren't able to get their prescriptions filled. My heart goes out to them."
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