Putting an End to Pill Mills and the Abuse of Prescription Painkillers

Transcription

1 Moon 1 Augustana College Putting an End to Pill Mills and the Abuse of Prescription Painkillers Kelsey Moon RELG-326 Dr. Daniel E. Lee April 30, 2013

2 Moon 2 There is a doctor s clinic on Main Street in town. It is new to the area but is already attracting a lot of business. Strangely, security guards stand at the entrance to the clinic, and anyone who passes through the doors leaves shortly after holding a bag of prescription medicine (Malbran 3). If one was to enter this establishment, doctors would not even administer a physical exam before handing out powerful prescription painkillers. The clinic runs on a cash-only basis, so that the doctors can make quick easy money that is difficult to trace back to anyone else. This doctor s clinic is, in reality, a pill mill. A pill mills is a doctor s office, clinic, or health care facility that routinely prescribes or dispenses powerful prescription painkillers for illegitimate or non-medical reasons (Bondi 1). While the existence of pill mills hinders today s society economically, by costing insurers money and therefore increasing insurance premiums for innocent Americans, their presence is also unethical in that their business is illegal and can ultimately result in the over-dosage and death of many patients. Walk-in-clinics can be a quick and convenient way to obtain prescription drugs for legitimate causes, which is why the question today is how can we reduce the abuse of prescription painkillers while maintaining access for legitimate users? Selling prescription drugs is a legal business in the United States, subject to regulation and restriction by federal agencies (Gillette 2). These regulations may not always be clear, which can get innocent suppliers into trouble. Clinics may think that they are distributing drugs legally, but if they sell too many pills too fast, or with too much marketing, all of a sudden this legal sale turns illegal and shop owners find themselves with suspended licenses and jail time (Gillette 2). Every year in December, the Drug Enforcement Administration sets a quota of how much controlled substances may be produced and sold in the United States for that coming

3 Moon 3 year. Painkillers such as oxycodone and hydrocodone each have a quota, and if clinics accidentally surpass that amount, they should be prepared to face the consequences (Gillette 1). However, sometimes suppliers knowingly act unethically in order to make a quick and easy profit. Pill mills cause many ethical issues, which demonstrate why these industries should be shut down. Not only are the owners of these shops acting unethical by distributing prescription drugs for illegitimate reasons, but they also drag doctors into the unethical business. Doctors are needed to write out the prescriptions, but according to Christopher and Jeffrey George, owners of a recently busted pill mill pain clinic, doctors are extremely easy to come by (Gillette 3). These two gentlemen obtained doctors for their pill mill by posting ads on Craigslist, and ended up hiring twelve doctors to join their business (Gillette 3). It is against federal law for doctors to prescribe pain medication without a legitimate reason, and considering the pill mills do not perform any sort of physical examination before prescribing the pills, no legitimate reason is formed for the prescription. Because of this, doctors involved in the pill mill industry can be charged with drug trafficking (Malbran 2). Doctors outside of the pill mills still face the issue of prescribing pills for a legitimate reason, considering the fact that even with an exam pain is very difficult to judge and can be faked without much difficulty. The difference here is that doctors outside of the pill mill industry are still examining the patient with the patient s best intentions in mind, whereas doctors within pill mills want to see as many patients as possible without giving physical exams so that they can maximize their profits. Suppliers and doctors are not the only ones in the ethical wrong in this situation. Patients also must act unethically to obtain the high dosage of painkillers. To do this, many

4 Moon 4 patients bring self-altered MRI s to the pain clinics as proof that they have a pathological and painful problem that can be solved by painkillers (Bandell 4). Selling prescription painkillers for illegitimate purposes just to make a profit is unethical in itself, but the dire consequences that these sales can cause are even worse than the act of breaking the law. Oftentimes, the easy access to prescription drugs made available by pill mills can lead to a sale and/or overconsumption of these medications to those who clearly have no medical need for the prescription, which can ultimately lead to death of the consumer. According to the CDC, nearly three out of four prescription drug overdoses are caused by prescription painkillers (Policy Impact 2). Furthermore, the rise in overdose deaths parallels a 300% increase in the sale of the painkillers, most likely from a pain clinic pill mill (Policy Impact 2). Just how many deaths are occurring from prescription painkillers? According to the Center for Disease Control and Prevention (CDC), in the year 2008 approximately 26,000 Americans died from overdosing on drugs. 14,800 of these Americans died from overdosing on painkillers alone. This number accounts for more than half of the deaths caused by overdosing, and it is greater than the amount of deaths from overdosing on both heroin and cocaine, two of the most common and fatal street drugs (Gillette 4). This painkiller overdose problem is mirrored all over the country, especially in states where pill mills are the most prominent, such as Florida and Texas. To illustrate this point one can look at Palm Beach County, Florida. In this county alone, not even the entire state, 365 prescription drug-related deaths occurred in the year 2010 (Trim 1). That evens out to one overdose death each day for a year! Not all of the patients who obtain the painkillers mean to

5 Moon 5 overdose on them, but the very nature of the pill makes it almost inevitable. Once a patient consumes the pill, chemicals from the painkiller bind to receptors in the brain that decrease the consumer s perception of pain. These drugs can cause feelings of euphoria, leading to physical dependence which can cause addiction. With the easy access to prescription painkillers that pain clinics offer, patients find it incredibly simple to obtain more drugs to feed that dependence. Patients who are addicted start taking larger and larger doses of the medicine and start needing more and more of the pills to reach that euphoric feeling. However other side effects of the medications, such as a slower breathing rate, are occurring simultaneously. Due to the large and multiple doses that patients are taking, breathing rates can slow down so much that breathing actually stops, causing death (Policy Impact 3). One last ethical concern of the pill mills is that since no background check is done on the patients that walk in expecting pills, the painkillers can often end up in the wrong hands. There is evidence that many of the pills that are prescribed and sold at pain clinics are sold to drug dealers. These individuals take this opportunity to purchase a lot of the easily accessible pills, only to turn around and sell the painkillers on the street to other drug addicts (Cullen 1). Not only is this act illegal, but as the number of addicts climbs in a society, so does the incidence rates of crime, such as theft and robbery (Cullen 2). Doctors and suppliers don t think of these risks when prescribing and selling the painkillers. According to the George twins, the largest illegal dispensers of oxycodone in the United States, the business is about the quick profit from the pills, not about the patients (Gillette 3). Since patients are only in the pain clinics for a short while and don t receive any

6 Moon 6 kind of testing or examinations, neither the doctors nor the suppliers really get to know and care about the patients like in hospitals or other areas of healthcare. According to one of the George twins, Jeffrey George, they continued their business regardless of the consequences because People don t just suddenly stop doing something they are doing really well at. Besides, I liked the work and the challenge of it all (Gillette 4). The doctors, on the other hand, are also in it for the employment and quick profit. They don t consider the consequences that could occur if one of their patients dies, which is ultimately worse than if one of their normal, non-pill mill patients dies. Doctors in the pill mill industry can be held liable for wrongful death arising from a prescription drug overdose if they were the ones that prescribed the medications. While painkillers are quite often prescribed for legitimate purposes, a panel would examine the case to see if there truly was a legitimate reason for the prescription. If it can be shown that a reasonable physician would not have prescribed that large of an amount of medication to the patient, the doctor can be held liable for the death of that patient (Cullen 1). Not only that, but doctors can also be held liable for prescription drug suicides if it can be proven that there was forewarning that the patient exhibited suicidal tendencies (Cullen 1). Even with all these ethical implications that accompany pill mills, doctors and suppliers just can t seem to pass up the economical benefits that arise from such an industry. Doctors at clinics such as the George twins were paid a flat fee for every painkiller prescription that they wrote. This fee was normally in the range of 75 to 100 dollars per prescription (Gillette 5). In order for doctors to fill as many prescriptions per day as possible, they were supplied with prescription stamps so that they could stamp one patient out and bring the next right in. In a successful pill mill, doctors may see up to 100 patients per day. If one were to calculate such an

7 Moon 7 income they would find that these doctors at the pill mills make around $37,500 a week, which is equivalent to $1.95 million a year! The pill suppliers make an even larger profit than the doctors they employ. At the George twins clinic, the brothers charged walk-in patients $200 for the first visit and a discounted rate of $150 every time they come in after that (Gilette 5). This cost covers consultation fees, even though patients are not examined or tested for any sort of illness or pain. The rest of their profit comes from buying generic painkillers in bulk and reselling them at a higher price. A normal prescription includes 180 pills, which are sold to the patients at $2 per pill. The twins only purchased the pills for 70 cents apiece, meaning that they earned a profit of $1.30 per pill. This gives them a net profit gain of $235 for each prescription that is filled (Gillette 5). Those purchasers who don t consume the pills but instead sell them on the streets make an even larger profit than the pill suppliers! The price of a single tablet of a generic prescription pill, such as oxycodone, is sold on the streets for anywhere from twelve to forty dollars for a single pill (Kavilanz 1). How is it possible that pill mills can buy pills at a cheap price and sell them at a much higher cost? For the suppliers, it is quite easy to obtain large numbers of painkillers. Pain clinics are known to prescribe painkillers, and so pill producers don t find it strange when pain clinics order the pills in bulk. For the consumers of the pills, the demand is extremely inelastic. Although there may be a certain price at which consumers are no longer willing to purchase the painkillers, for the most part these patients will keep returning to the clinic no matter what the cost. This is mainly due to the addictive quality of the medications. Once a consumer increases

8 Moon 8 their consumption of the pills, they will find themselves needing to continually return to the clinics for more, finding no issue in paying $150 for a consultation and another $360 for the next prescription. While this sets the demander into a vicious spending cycle, it racks up profits for the supplier. This type of success is not just found in the twins clinic. There are thousands of businesses in India, Turkey, and Australia that produce the pills and distribute the generic painkillers to the United States. Companies in the United States purchase these generic pills in bulk and resell them to individuals. This business is extremely profitable wherever pill mills happen to spring up. In the year 2011 alone, the sales of prescription drugs in the United States surpassed nine billion dollars (Gillette 5). While these pill mills are extremely profitable for the doctors and owners of the pain clinics, the clinics have a very negative effect on the rest of the economy. The average overall cost of painkiller abuse to insurance companies is over $70 billion each year (O Toole 1). A small fraction of this cost, consisting of about thousand dollars, arises from the process of shopping around for doctors in order to get prescriptions. While patients may be required to pay an out-of-pocket co-pay or deductible, the insurance companies cover the rest of the visit cost. This expense is only a small fraction of the total cost to insurance companies. A large percentage of the expense comes from actual treatment (O Toole 1). While it is true that patients do not get examined or tested in the pain clinics before receiving their prescription medications, one must think of the future and any problems that may arise. Since so many of the patients that purchase prescription medication from pain clinics end up

9 Moon 9 overdosing or having other health issues as a result of taking the painkillers without a legitimate reason, they soon find themselves facing all kinds of doctors visits. If consumers overdose on the pain medications, they might need emergency assistance. A trip to the emergency room can accumulate a large bill if one includes the cost of transport via ambulance, the cost of any testing or medical procedures that may be done in the emergency room, as well as the cost for any newly prescribed medications to treat symptoms. Once consumers become addicted to the prescription painkillers, another cost to think about is the cost of rehabilitation. If a consumer reaches out for help, or if a friend realizes that the consumer is addicted to painkillers, rehabilitation is the next step in eliminating the problem. While the cost of rehabilitation may be high, if the rehab is successful it will ultimately lower costs in the future. Finally, one must think of the path a consumer would take if rehabilitation either is not successful or does not occur. If this is the case, more and more medical bills pile up because the addicted consumer will continue to shop around at different pill mills and will continually purchase more and more prescription painkillers. An example of this cost of treatment can be seen in Broward County, Florida, where hospitals are constantly treating patients who have overdosed on prescription painkillers (Bandell 3). These patients are either suffering from drug overdose or are experiencing severe painkiller withdrawals. A majority of the time, the patients who overdose on prescription painkillers are not likely to have insurance. However, hospitals are still mandated to perform life-saving procedures on any patients who enter the hospital. Procedures are carried out and tests are run, and since the patient doesn t have insurance the costs of these procedures are absorbed by the health system s taxpayer-supported hospital (Bandell 3). Adding to the cost of

10 Moon 10 health care is that many of the patients entering these hospitals are medical tourists (Bandell 3). Medical tourists are those patients who travel from highly developed areas of the country to lesser developed areas in order to get cheaper health care and more readily-available drugs (Bandell 3). Many of the patients are medical tourists because pill mills aren t found in all parts of the country. A majority of the clinics are found in Florida and in Texas, and so patients flock to these states from all across the country to obtain the pills in an easy, convenient fashion. It is oftentimes too difficult to acquire drugs in other home states, and so people travel across the country to get the pills more easily. The fact that Florida hospitals are having to treat so many extra patients that are not even residents of the state leads to the idea that there is a finite amount of health care available, and with every extra medical tourist that needs treatment, the cost of health care rises (Bandell 3). Florida is a huge medical tourist area because the regulations and laws that exist in Florida make it the easiest state in the nation to operate pill mills without getting busted (Florida 2). The law used to allow any civilian, not just doctors, to run a Florida pill mill. Even convicted felons that were no longer incarcerated could obtain a license to run a pain clinic (Florida 2). Another regulation that made Florida such a target was the fact that the Florida clinics could dispense prescription painkillers directly to the public, rather than have their patients take prescriptions to the drugstore. This bypasses the new computerized prescription drug monitoring program that tracks all prescriptions that go through drugstores (Florida 2). Even further expenses are derived from lost productivity as well as criminal justice costs (O Toole 1). The time, energy, and money that is spent on obtaining these painkillers for

11 Moon 11 patients and treating them after the effects take place could be spent elsewhere to achieve a much more productive end product. All of the time, energy and money spent are put into a vicious cycle one that continually eats time and money yet only produces more costs to the economy. Criminal justice costs can also add to the equation. Some demanders who obtain the prescription painkillers do not take the drugs themselves. Instead, they receive the pills at the clinic and then resell them on the street for a much higher price. While the sale of pills in the pain clinic can be legitimate at times, the sale of pills on the street is almost never legitimate. The demanders who are purchasing pills off the street are those who are most likely to abuse the drugs. Prescription drug abuse, besides causing physical harm, can also lead to a higher crime rate. This is another cost to the economy because taxpayers have to pay money to incarcerate prisoners (O Toole 1). All of these extra costs to the insurance company ultimately end in higher insurance premiums for average, innocent Americans. If insurance companies are having to spend more money on these overdose patients who don t have insurance to begin with, or are overusing their insurance in order to continually have a supply of prescription painkillers, then the only way the company will profit is if they cover the extra expenses by raising costs of premiums. While the demand for insurance is fairly elastic, insurance companies still are able to raise their premiums quite a bit and still have demanders purchase the product. All of these ethical and economical implications make pain clinics sound all negative with no benefits. It is important to keep in mind, however, that while all pill mills are pain clinics, not all pain clinics are pill mills (Cullen 3). This is why it is a complicated situation to

12 Moon 12 completely remove pain clinics from today s society. A pain clinic s main goal should be to ease the suffering and distress of those people who experience pain. In theory, pain clinics are a good idea. They are a quick and easy way to alleviate some painful symptoms, by quickly obtaining a readily-made prescription of generic painkillers. However, one must also accommodate for those who will abuse the system. Millions of Americans actually suffer from chronic pain and need the prescription pain killers, so unfortunately pain clinics can t be removed entirely, because there are some patients actually in need of prescription painkillers (O Toole 4). There are three different solutions that could work to solve the problem of the abuse of prescription painkillers. The first option for a solution is that all the ownership of pain management clinics should be restricted to licensed physicians. A licensed physician is a lot less likely to fall under the lure of pill mills than a physician who is not licensed. Along with this, law enforcement should have easier access to the state s prescription drug database in order to better indentify those patients who are addicts, those who are dealers, and even those doctors who don t seem to be acting completely legal and professional. However, there are a few problems with this solution. One problem is that some people may think that giving the government a larger oversight of the prescription drug informational database is a violation of personal privacy. Many people are opposed to big government, especially when it comes to healthcare, so this may be a bigger issue. One other problem with this solution is that the federal government would have a lot of issues pinpointing the illegality of the situation. Unlike importers and dealers of illicit drugs such as cocaine, the supply chain for prescription painkillers is entirely legal. None of the components of the pills are illegal, and oftentimes those who are in charge or

13 Moon 13 prescribing or selling the pills act incredibly professional. It is hard to determine which doctors are legitimate and which ones are acting shady when the product that they are prescribing is 100% legal. Another similar solution is that all pain management clinics, rather than the actual doctors themselves, should be required to be licensed by a state or federal medical board each year. If the pain clinic is operating without obtaining a license, then those owners and doctors are able to be charged with a felony (Gillette 3). This solution would also allow for more government regulation, and panels would be able to analyze the pain management clinics to ensure that they were valid and legitimate. These two similar solutions would help to eliminate the illegitimate pill mills, leaving only the legitimate pain clinics behind. A second solution that focuses more on solving the problem of those consumers who choose to overdose or resell the drugs on the street would be to enact a new program entitled the Prescription Drug Monitoring Program, or PDMP. This program tracks the distribution of prescription drugs to individuals (O Toole 2). By keeping a record of which patients are receiving which pain medications, authorized professionals like doctors and law enforcement workers would be able to identify those patients who are potentially abusing the prescription painkillers. According to the Jeffrey George, one of the twins that owned the most infamous pill mill in Florida, a solution like this one would have stopped his business from the start. George claims that there was no way that he and his employees should be held responsible for failing to differentiate between patients who actually needed the pills and those who were only

14 Moon 14 purchasing them for recreational purposes or to resell them on the streets (Gillette 5). If a PDMP had been in working order, the George twins would have been able to track which patients of theirs actually needed the medicine and which were taking advantage of the system. The twins were also angry that the wholesalers who sold their clinics the pills were not getting into any trouble. Without a PDMP in order, the George twins had just as little idea as the wholesalers as to who should or should not receive a prescription (Gillette 5). One last potential solution to the problem of pill mills is for pain clinics to either perform more physical examinations and tests, or for the clinics to require a referral from another doctor s office before patients can get medication. This would truly solve the problem of overdosing on the painkillers. For example, if doctors were to perform more tests in the pain clinic, they would be able to tell for themselves whether or not that patient needed a prescription. While pain clinics are meant to be quick and easy, there are many quick tests that doctors can run on the patient that would help avoid overdosing. For example, all patients could be required to submit to a urine test before receiving their prescription. If the urinalysis comes back abnormal, this means that the patient has been taking more than what was prescribed and should not be given a refill on the prescription. If one wanted to avoid performing any extra tests at pain clinics, the primary care physician could act as a gatekeeper when it comes to entering the pain clinic. Just like one would have to get referred to a specialist by a primary care physician, patients would have to get referred to a pain clinic by their primary care physician before being able to enter the clinic and get a prescription. This way, the primary care physician could make an unbiased analysis of the patient condition before sending them to the pain clinic. If these tests were run at the pain clinic the results may be biased if an unethical

15 Moon 15 doctor is working, because the more prescription painkillers the clinic sells, the more money the doctor makes. If the primary care physician acted as a gatekeeper, hopefully that would eliminate the problem of both unethical pain clinic workers as well as unethical patients hoping to get some free prescription painkillers. The fact of the matter is that it is extremely difficult to reduce the abuse of prescription painkillers while at the same time maintaining access for legitimate users. While all pill mills are pain clinics, not all pain clinics are pill mills and it can be extremely hard to differentiate between the two. The best way to reduce the existence of pill mills while maintaining the presence of helpful pain management clinics is to use the success seen in Florida as a model. Because Florida s loose regulation was causing so many problems, tougher laws were created just a year ago to help shut down pill mills. Due to such legislation, over 400 clinics were shut down and over 80 doctors got their license suspended for working in these illegal facilities (Alvarez 4). The new laws were effective in cutting off distribution of painkillers. The legislation banned doctors from dispensing prescription pills in their own offices or clinics. As a result, the amount of painkillers purchased by doctors declined by a whopping 97% in one year (Alvarez 3). The new legislation also kept a watchful eye on the activity of pharmacies. In order to solve the former issue of anyone, even convicts, being able to open clinics, the new laws now require background checks for owners and employees of pharmacies and pain clinics (Alvarez 4). The penalty for prescribing drugs without a legitimate reason for the prescription also becomes much steeper with the new legislation (Alvarez 4).

16 Moon 16 This decline in the purchase of prescription painkillers by doctors has, in the long run, saved addicts health and money. Because doctors are no longer able to distribute the pills, the street price of generic painkillers such as oxycodone has more than doubled in cost (Alvarez 3). This increase in price is inversely related to the number of pain clinics present in the Florida area, which fell in the course of one year from 29 to one pain clinic on a large street in Broward County, Florida (Alvarez 3). A benefit of such high prices for street drugs is that many addicts are seeking help instead of pills. Since they no longer can afford prescription drugs off of the street, addicts are turning to rehabilitation clinics so that they no longer need to purchase such painkillers (Alvarez 3). Finally, the new Florida legislation creates a prescription drug monitoring system, which requires pharmacies to record the sale of each prescription drug in a database. This allows pharmacists to access the database and view just how often a patient is prescribed and is sold the prescription drugs (Alvarez 4). This system should help prevent patients from jumping around pharmacies in order to maximize their purchases. This would help solve the problem of people purchasing the prescription painkillers for illegitimate purposes. If pharmacies are able to track how often patients come in and buy prescription medications, they should be able to limit the amount of painkillers that each patient can receive in a certain amount of time. However, Florida is still experiencing problems with pill mills in central and northern areas of the state, areas in which the strictness of the legislation has been less intense (Alvarez 2). This instance demonstrates the need for a federal law to control the outbreak of pill mills. If a federal law were implemented that matches the new legislation being enacted in Florida, the

17 Moon 17 use of pill mills and the number of deaths or hospitalizations due to overdosing on prescription medications would steadily decline. It is important that all areas of the nation have laws that prohibit doctors from handing out their own prescription pills, and it is also important that all areas of the nation require background checks for pain clinic and pharmaceutical owners and employees. If these regulations were made into federal law, the prescription drug monitoring system would also be nationwide. This would help solve the problem of pharmacy-hopping, considering all pharmacies in the nation would be logged under the same database. It is important to put an end to the existing pill mills because they are both economically hindering and extremely unethical. While the owners and doctors involved in a pill mill can make millions of dollars per year in profits, the pill mills can actually cost insurance companies billions of dollars per year in medical bills. The easy accessibility of prescription painkillers from the clinics oftentimes leads to overdosing on painkillers, which can lead to death of the individual. Eliminating pill mills would improve the ethical standards of pain clinics across the country as well as improve the economy by saving time, money, and energy that can be used towards a more productive goal. For these reasons, America should keep the clinics but cut the pill mills.

18 Moon 18 Works Cited Alvarez, Lizette. Florida Shutting Pill Mill Clinics. August 31, Web. The New York Times. < Bandell, Brian. "Pill mill practices savage lives, economy." February Web. < Bondi, Pam. "Pill Mill Initiative: Florida's Prescription Drug Diversion and Abuse Roadmap " 2011.Web. < Cullen, Kim, and Bob Hemphill. "Prescription Drug Overdoses Are Never Far Behind Pill Mills Here s What You Need To Know." Prescription Drug Overdoses Web. < Florida Pill Mills Contribute to Oxycodone Addiction Web. Novus Medical Detox Center. < Gillette, Felix. "American Pain: The Largest U.S. Pill Mill's Rise and Fall." 6/6/2012Web. Bloomberg Business Week: Companies & Industry. <

19 Moon 19 Harris, Kay. " Pill Mill Legislation Passes." The Valdosta Daily Times, sec. Local News: 1. March 24, 2013 Print. Kavilanz, Parija. Prescription drugs worth millions to dealers. June 1, Web. m>. < _ html>. O'Toole, James. "How prescription drug abuse costs you money." February Web. < >. "Policy Impact: Prescription Painkiller Overdoses." November 29, 2012.Web. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. < Malbran, Pia. "What's a Pill Mill?" May 31, Web. < Trim, Mike. "Pharmaceutical drug overdoses steady as pill mill crackdowns continue." 2011.Web. WPTV News. <