Sunday, February 5, 2017

Oxycodone and Pill Mills Again

There have been a multitude of stories in recent years regarding drug death. I have addressed this subject a few times in What Worthwhile can you do in 11.2 Minutes, 2015 Injury and Fatality Study is Interesting, and Dyin' to me don't Sound Like all that Much Fun. I have promoted use of prescription databases, see Maine Makes Opioid Changes. Workers' compensation has collectively wrung its hands and lamented the tens of thousands of Americans that die each year from overdose.

I have attended a variety of workers' compensation conferences. I have been privileged to speak at the largest and some of the smallest, sometimes to diverse and sometimes very specialized audiences. I have heard a great deal about opioids and how we got into this pandemic. A recent poll shows that a majority of respondents think that doctors and their prescribing has played some role in this travesty ("some" = 40% and "most" = 31%). The subject is discussed often, but proposed solutions are not as ready as one might hope. 

Over the past year there has been significant effort invested in discussions of what is wrong and right in workers' compensation generally. The National Conversation has been an amazing experience, illuminating a great many perspectives on what ails workers' compensation and what might remedy it. One of the persistent laments has been "bad actors," and how to deal with them, see What About the Bad Actors.

A news story in January brought these thoughts together for me. The new news service headline was Former Pharmaceutical Salesman Pleads Guilty in $13 Million Money Laundering Conspiracy Involving 2 Million Doses of Oxycodone. The story may begin to clarify (1) how patients accessed opioids inappropriately, (2) and others promoted availability of these drugs. Apparently, a group of Florida clinics distributed oxycodone like they were Skittles. This likely damaged people who were patients, and as likely damaged others to whom pills migrated. It certainly damaged us all in the human cost of addition and death.

Jonathan Sendor, one conspirator, has plead guilty to money laundering charges. Money laundering is not necessarily the charge one hopes to see when the outcome is addiction and death. Of course, we have to remember that Al Capone was convicted of tax evasion, and at least it got him off the streets. It is hard to picture tax evasion as the worst thing Capone did or was responsible for, but we have somewhat accepted this prosecution paradigm in America. 

Mr. Sender and his co-conspirators worked through six pain clinics in southeast Florida, primarily in Broward (Ft. Lauderdale) and Palm Beach (West Palm Beach) counties. The clinics dispensed over two million oxycodone pills, until the clinics were closed in 2011. These were "Pill Mills." 

According to the Florida Attorney General, a "Pill Mill" is "a doctor’s office, clinic, or health care facility that routinely conspires in the prescribing and dispensing of controlled substances outside the scope of the prevailing standards of medical practice." In 2010, Florida was "the ‘epicenter’ of the nation’s ‘pill mill’ epidemic." Then, the Legislature tightened Florida law and made it illegal to "dispense" narcotics from doctors' offices. 

This law change was in part about convenience and in part documentation. Being handed a bottle of oxycodone at the pain clinic is easier than being handed a prescription and having to drive to a local pharmacy. There are less pharmacy locations in Florida than there are physicians (Florida Trend says we have about 45,200 "active" physicians in Florida). As to documentation, with all of the opioids being distributed through pharmacies, a second set of eyes will see each prescription, and a second set of hands will keep a second set of records. It adds inconvenience and perhaps expense. 

When faced with this inconvenience to their drug-dealing, these "pain clinic" conspirators opened two pharmacies of their own to facilitate their trade. Their pharmacy in Boca Raton (Broward County) perhaps comes as no surprise, as it was convenient to the six pill mill clinics in the two counties. But, interestingly, the conspirators also opened a pharmacy in Orlando. That is about 166 miles from West Palm Beach. The purpose of the pharmacies was to fill the pain clinic prescriptions for opioids. The conspirators knew they had patients driving in from central Florida for opioids. They knew that these patients did not want to travel further south to fill their prescriptions in Ft. Lauderdale, so they opened a pharmacy in central Florida. 

Mr. Sendor became a middleman between these "pain clinics" and the distributors of these drugs. He lied to those distributors and instructed the "pain clinics" and doctors to (and perhaps how to) lie to the distributors. The clinic owners "operated the clinics to ensure that the maximum amount of oxycodone would be prescribed without regard to a legitimate medical need, and purely for the sake of profit." Mr. Sendor plead guilty in January. But to "one count of conspiracy to commit money laundering involving criminally derived property." He will be sentenced in March, and faces a maximum penalty of "ten years in prison." 

These clinics and pharmacies dispensed over two million narcotic pills. They "generated approximately $13,466,598 from the unlawful prescribing and dispensing of oxycodone." Credit for the prosecution was given to more than a dozen police agencies. It was an intricate, careful, and thought-through conspiracy. There was deceit, intent, and calculation to both avoid the law and convenience the customers. 

How does a distributor not notice that volume of narcotics? It seems unlikely that such volumes would not be noticed, even when people lie. In an unrelated story, one manufacturer was fined in January 2017. McKesson was hit with a $150M fine according to NBC. And, McKesson sales were suspended in Colorado, Florida, Michigan and Ohio. The article says that the same company was fined $13M in 2008 for similar allegations. Maybe the profit motive that encourages companies to not notice these volumes are simply more than the fines that discourage addicting and killing people? Is it just a matter of fines being a nuisance that can be tolerated in the drug pushing business?

And we are left with other questions. How does this volume of distribution occur and yet there is surprise when it is "discovered" through investigation by dozens of police agencies? How many lives were detrimentally affected, or lost, because of the lies and subterfuge that these clinics committed? What if the physician's penalty for such behavior was to be permanently barred from practicing medicine in any U.S. jurisdiction and forfeiture of all assets related to the practice of medicine? In other words, when these drug dealers are caught, what if the law took away all they own? Would that slow the stream? Could the penalties on manufacturers be raised sufficiently to encourage them to notice? How much in fines to manufacturers or distributors would it take to slow the stream? 

More importantly, why is it that these cases are increasingly footnotes and afterthoughts. Why is more not being done to prosecute those involved for something other than conspiracy or money laundering? And, in the process, why do we not see front-page stories about 100% forfeiture of assets by everyone involved? We will see in March how long Mr. Sendor will spend in prison for his behavior.

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