The Oxy Express
Pill mills and their role in the opioid epidemic
“This epidemic was caused by the medical community,” Dr. Andrew Kolodny said, looking at Sen. Feinstein. “We [doctors] were responding to a campaign that encouraged long-term use. Minimized risk and maximized comfort,” Instead of lessons about the dangerous, addictive, and deadly qualities of prescription opioids, he got lessons on relieving pain. The result was the over-prescription and over-consumption of prescription opioids that still exists today—or at least that’s how he sees it. “Most patients with chronic pain on long-term opioids… we’re probably harming them,” he said. It was 2017 and Kolodny was speaking at a Senate hearing on America’s opioid epidemic.
To understand how things got so bad you have to go back in time to the early 90’s when the medical and pharmaceutical industries starting focusing on pain - in fact, making it the “5th vital sign” although unlike blood pressure, breathing, pulse and temperature, there’s no test or measurement other than a person’s own personal account that can accurately depict someone’s level of pain.
pain chart introduced in 2001 to assess a patient’s level of pain
Purdue and the FDA
In the early 1990s, a relatively small pharmaceutical company called Purdue Pharma had developed an extended-release morphine drug called OxyContin. Since the pill broke down slowly in the digestive system, the company was allowed to put higher doses of the active ingredient, oxycodone, into each pill — up to 160 milligrams. This was basically synthetic heroin in pill form, oxycodone alters the perception of pain and reduces anxiety while also elevating mood.
The FDA approved a unique warning label allowing Purdue to claim that OxyContin had lower potential for abuse than other oxycodone products due to the time release formula that allowed for delayed absorption of the drug. Oxycontin is the only schedule II drug to get this claim. Purdue added a warning on the label to not crush the drug because it could release ‘a potentially toxic amount of the drug,” which some suggest was more of an instruction to drug abusers than a warning.
After the FDA approved Oxycontin in 1995, the drug manufacturer began highly aggressive marketing tactics to doctors, and not just doctors performing surgery - primary care doctors who were treating people with moderate pain. In 2001, Purdue paid over $40 million in bonuses to its sales reps alone, with a concentration of those reps in Ohio and Eastern Kentucky. Doctors were told there was “no evidence that addiction is a significant issue when persons are given opioids for pain control.” So what had once been a highly potent drug formulated for only the most severe pain (i.e. end-stage cancer and post-operative) was now being marketed as a solution to mild and moderate every-day pain.
The Florida Effect
A few enterprising doctors and run-of-the-mill thugs in Broward County and Palm Beach, FL took advantage of lax prescribing laws and in the mid-2000’s began opening pain clinics. The state had no centralized prescription database. Anyone could open a pain-pill clinic, no license or authorization was required, and doctors were legally permitted to sell drugs directly to patients. A person could visit a pain clinic, pay a couple of hundred dollars in cash (it was a cash-only business) and leave with 200 Oxycontin 30’s and a hundred or so Xanax. No exam, no x-ray or MRI, no questions, just have cash and a desire for pills. Over the course of two years, one group of clinics called “American Pain” prescribed almost 20 million pills to car and van loads of people traveling from Kentucky, Virginia, Ohio, Tennessee and the Carolina’s. Broward County’s population at the time was 1.7 million. That math doesn’t add up.
Wallgreens massive distribution of opioids in Florida
Doctors in Florida were ordering nine times more oxycodone-based pills than doctors in the other 49 states combined — 41.2 million doses to 4.8 million collectively. Of the country’s top 50 oxycodone-dispensing clinics, 49 were in Florida. This flood of opioids raged from 2005-2010 when finally the tide was stemmed after more strict regulations on prescribing went into effect. But the damage was done and states like Ohio and West Virginia were literally awash in pills. Today they’re still referred to as “ground zero” of the epidemic.
Distribution Negligence
You have to ask yourself, where were these clinics getting such massive volumes of drugs? The answer: the distributors — companies that act as middlemen, trucking medications of all kinds from vast warehouses to hospitals, clinics and drugstores.
The industry’s giants, Cardinal Health, McKesson and AmerisourceBergen, are all among the 15 largest American companies by revenue and distribute more than 90% of the nation’s drug and medical supplies. During hearings before Congress, Representative Kathy Castor, a Florida Democrat, picked out a single drugstore in rural West Virginia that had been swamped with opioids — 4,000 pills a day at one point from Cardinal, 5,000 from McKesson. The same companies flooded Kermit, WV with more than 12 million hydrocodone tablets between 2007 and 2012. That’s a staggering 30,000 pills for each Kermit resident. Moving West, between 2006 and 2014, these three companies supplied more than 2 billion opioid pills to Washington State. Clearly, the systems in place to flag suspicious quantities and orders were ignored and the DEA didn’t act on the few alerts they did receive.
McKesson, Cardinal Health and AmerisourceBergen have faced multiple actions by the DEA and others for failing to monitor and stop suspicious orders. McKesson has faced more than $160 million in fines, with the DEA determining that the company filled “hundreds of suspicious orders placed by pharmacies participating in illicit internet schemes, but failed to report the orders to DEA.”
Cardinal has been fined five times for a total of nearly $100 million since 2008, while DEA suspended AmerisourceBergen’s distributor licenses in 2007 for failing to adequately monitor and report suspicious orders. The DEA noted that, between June 2008 and May 2013, one McKesson distribution facility “processed more than 1.6 million orders for controlled substances . . . , but reported just 16 of them as suspicious.”
To gain a deeper understanding of the vicious impact the pill mills, the FDA and the manufacturers and distributors have played in the current epidemic, I would highly recommend reading “American Pain” by Dr. John Temple. You’ll be shocked and offended by the role these organizations played in creating the most devastating health epidemic in American history.