Over the summer, a federal appeals court in Washington state ruled that pharmacies do not have a right to refuse to fill a patient’s prescription on moral grounds. The plaintiffs in the case, Stormans v. Wiesman, were three pharmacists who denied emergency contraceptives to dozens of female customers, saying that doing otherwise would violate their Christian principles.
While the ruling served as an important test case for the Religious Freedom Restoration Act, the likelihood of a religious fanatic trying to come between you and your medication is minuscule compared with the threat posed by well-meaning public officials who think the best way to prevent people from getting addicted to prescription drugs is to make them harder to get for everyone.
I wrote about the ancillary impact the war on drugs is having on patients back in 2013. We now have a clearer picture of the scope of that collateral damage, and it’s worse than even I expected.
Over the past four years, reports of pharmacists refusing to honor valid prescriptions for controlled substances have grown considerably as blame for America’s opioid addiction crisis has fallen increasingly on health care providers.
Media reports such as the recent “60 Minutes” segment “Heroin in the Heartland” have helped stoke the hype against narcotic medications without adding necessary context. But federal drug policy has done the most damage. For the past five years, the Drug Enforcement Administration has been orchestrating a high-stakes proxy war between physicians and pharmacists, creating tens of thousands of opioid refugees in the process.
“Opioid refugee” is the term doctors, pharmacists and patient advocates use when referring to pain patients who have been left adrift by physicians who no longer want to deal with the hassle of writing prescriptions for narcotic pain medication and by pharmacies so fearful of sanction that they will use any excuse they can not to fill them.
As usual, poor, minority and elderly patients, many of whom already suffer from inadequate access to opioid analgesics, have been the hardest hit. An investigative report that an Orlando, Florida, news station aired this year determined that some pharmacists now go so far as to flag prescriptions for controlled substances by ZIP code — the equivalent of medical redlining. Many of these patients are now forced to travel miles and visit multiple pharmacies each month is search of medication. Others are subjected to regular trips to hospital emergency rooms during gaps in medication availability.
From patient to ‘drug seeker’
The opening salvo in the DEA’s campaign can be traced to 2010, when it issued a decision that greatly expanded the guidelines for corresponding responsibility — a decades-old federal mandate that requires drug dispensers to ensure that prescriptions for controlled substances be issued for a “legitimate medical purpose.”
Connecting the dots between federal drug enforcement efforts and the opioid refugee problem is easy.
The decision codified a list of red flags that pharmacists dispensing controlled substances could be held responsible for ignoring. One of these red flags vaguely targets medication orders that include “combinations generally known in the medical and pharmacy profession as being favored by drug-seeking individuals.”
In theory, the policy is designed to add another check in the process of preventing drug abuse and diversion. In practice, it means that after your physician diagnoses your condition and writes you an order for medication, you may be subject to a second diagnosis delivered across a counter by a virtual stranger who won’t so much as take your pulse before determining the validity of your prescription.
Since instituting its crackdown on pharmacies, the DEA has filed actions against hundreds of retail and wholesale drug dispensaries. In some cases, they shut down legitimate pill mills that were operating virtual narcotics drive-throughs. But in most cases, pharmacies and wholesalers are targeted for exceeding what the DEA considers average dispensing numbers for certain types of drugs.
Exactly how these averages are determined and what it takes to show up on the DEA’s radar are unclear. (I’ve filed a Freedom of Information Act request in an attempt to find out.) But the bulk of federal efforts have focused on the Deep South — which has suffered from an epidemic of opioid abuse but also happens to account for among the highest rates of cancer diagnoses, cancer deaths and hospice patients in the nation. In other words, these states are home to an above-average number of sick people.
Meanwhile, at least three major drug wholesalers have responded to aggressive federal enforcement efforts by establishing arbitrary monthly rations that limit the amounts of controlled medications that each pharmacy may purchase. According to one survey from 2013, three-quarters of pharmacies experienced three or more delays or issues caused by stopped shipments of their controlled substances over the past 18 months. In more than two-thirds of those cases, pharmacists could not obtain replacements from alternative suppliers.
Stunningly, the DEA has repeatedly gone on record denying that it is part of the problem.
But connecting the dots between federal drug enforcement efforts and the opioid refugee problem is easy. For example, in 2014 — less than a year after Walgreens was fined a record $80 million by the DEA over accusations it overdispensed painkillers, including oxycodone and hydrocodone — a concerned Walgreens pharmacist leaked a secret internal checklist the company had begun using that included exceedingly strict guidelines for dispensing.
Among other things, the rules required pharmacists to deny prescriptions if the person filling it was on their medication for more than six months, had never been to the store before or paid cash for their medicine (which, as a freelance writer, I did for years before acquiring health insurance this year under the Affordable Care Act).
A recent federal audit further undermines the DEA’s claim that it’s not getting in the way of legitimate patients and their medicine. In July the Government Accountability Office issued a report on DEA policies on prescription drug abuse and found that while the agency’s enforcement actions have helped decrease prescription drug abuse and diversion, they have also helped decrease actual medical treatment.
How many more innocent people need to suffer before we realize that the war on drugs is a failed strategy, no matter where we choose to point the cannon?
“Over half of DEA registrants have changed certain business practices as a result of DEA enforcement actions or the business climate these actions may have created,” the report stated, adding that these changes have “affected their ability to supply drugs to those with legitimate needs.”
Rationing of care
The blowback has been devastating. Scores of local and national media reports over the last 18 months have described the living hell that patients are being subjected to as a result of artificial drug shortages facilitated by federal policy.
One pharmacist from Jacksonville, Florida, told a reporter for Kaiser Health News in August that he sometimes turns away 20 patients a day because of dispensing thresholds imposed on him by the DEA. “We’re being asked to act as quasi-law-enforcement people to ration medications,” he said. “I have not had training in the rationing of medications.”
Some states now appear ready to double down on the war on patients. In October, Massachusetts Gov. Charlie Baker proposed a bill to the legislature that would prohibit physicians from prescribing more than 72 hours’ worth of pain medication. Doctors and patient advocates have blasted the measure, and the American Medical Association has warned it could have “unintentional consequences to the patient-physician relationship.”
That plan may be terrible policy, but it addresses what by all accounts is a legitimate issue. More people are abusing narcotic painkillers, and more people are dying from them. But fundamental misunderstandings of the nature of the problem are leading us down a path we can’t afford to take.
One of the biggest is the all-too-common myth that drug dependency, a physical condition, is the same as drug addiction, an obsessive-compulsive disorder that may or may not include physical dependency. All patients who receive regular doses of opioid painkillers will become physically dependent over time; only a minority will ever fit the diagnostic criteria for addiction.
Unfortunately, to get to that minority, we’re forcing more and more people into real danger. Sick people denied proper care are inclined to self-medicate. In the case of opioid refugees, this frequently means turning to adulterated street heroin — a far more nefarious substance than prescription pharmaceuticals. We have a better chance of saving their lives if we let doctors take the lead rather than armed federal agents.
We are currently in the midst of one of the most conscientious dialogues in decades about the sensibility of U.S. drug control policy. Yet instead of a real shift in strategy, there is ample evidence that we’re simply diverting resources to another front. How many more innocent people need to suffer before we realize that the war on drugs is a failed strategy, no matter where we choose to point the cannon?