After writing the following, I was reminded of a lyric from Karn Evil First Impression, Part Two (1973), by Emerson, Lake, and Palmer: "Welcome back my friends to the show that never ends."
There has been a great deal written about pill mills and the distribution of opioids in America. See The Hot Seat, Opioids, Marijuana and More (September 2017); Florida's 2018 Session - Opioids (March 2018)(including a list of all the prior opioid posts dating back to 2013). America has been fighting opioid addiction for decades, and though there have been victories the challenges remain.
A November 2020 press release from the United States Attorney in New York announced the filing of charges against a New York physician and his employee. It stresses that these are only charges or allegations and that everyone involved is presumed innocent. The physician operated a clinic for pain management in Manhattan. It is alleged that he accepted "cash payments" for writing "thousands of prescriptions for large quantities of oxycodone." Furthermore, the authorities allege that those scripts were for individuals that the doctor "knew did not need the pills for any legitimate medical purpose." This, the release states, demonstrates the doctor "betrayed his profession."
The process that authorities have alleged is not unfamiliar. We have all heard of and lamented the "pill mill" practice that exploded over the first decades of the twenty-first century. The authorities claim that clinic patients in this instance referred and recruited new patients to the clinic. The recruiters are labeled "gatekeeper patients" and one of those at this clinic was allegedly later hired to participate in "managing the (clinic) operations." The authorities allege that the clinic was open "only a few hours per day," perhaps only between "2:00 p.m. and 5:00 p.m." Despite these allegedly limited hours, it is alleged that the doctor ran a "grotesquely lucrative pill mill."
The authorities allege that oxycodone prescriptions were written for patients that the physician "knew did not need the pills," and that many of those patients "were addicted to opioids," "failed drug test administered by the clinic," and some "traveled long distances to obtain the illicit oxycodone." They allege that some patients "sold oxycodone pills on the street to drug users."
In about three years, between "November 2017 and in or about September 2020" the authorities allege that the physician "prescribed more than 1.3 million oxycodone pills," "generally . . . after conducting limited or no examination of the patient."
The magnitude of this struck my interest. One way to appreciate this is by discussing the sheer pill volume. Between November 1, 2017, and September 30, 2020, there were 1,066 days; without Saturdays and Sundays there were 761 days; removing the federal holidays leaves 732 days. the 1.3 million pills divided by 732 days yields 1,776 pills per day; at the three hours per day the clinic was allegedly open, that is 591 pills per hour, or about 10 pills per minute.
That is an incredible volume of pills. One study suggests that patient consumption of such pills is about three pills daily, so a thirty-day supply might be 90 pills. The 591 each hour might represent 7 patients per hour receiving a 30-day supply. Statistics support that doctors average about 20 patients per 8-hour day (2-3 per hour). The physician in New York was perhaps prescribing enough Oxy to suggest a much higher patient-per-hour ratio or prescriptions for more than a 30-day supply.
Another way to appreciate the magnitude might be financial. Addiction Center reports that Oxycodone has a prescription price (without insurance) of $.33 per pill, but the "street price" is $20.00 each. The "street value" of the pills dispensed according to the allegations in this case equates to a total of $26,000,000. That is a significant markup that could be profitable even after costs such as travel and doctor fees are considered. Profitable, that is, to those who might visit such a clinic, obtain these medications, and then resell them elsewhere rather than consume them in palliation of symptoms or complaints.
Based on these allegations, the U.S. Attorney has charged the physician and the clinic manager "each with one count of conspiracy to distribute oxycodone illegally. The allegations are that over one million pills were involved throughout hundreds of days of clinic operation. The allegation is of "thousands of medically unnecessary opioid prescriptions." And yet, each is charged "with one count of conspiracy." It is worth considering that the charges could result in "a maximum sentence of 20 years in prison," which the press release stresses remains discretionary, to "be determined by the judge." One may wonder whether it would be more productive to pursue multiple charges against those who engage in such activity thousands of times?
An FBI official quoted in the press release contends that pill distribution such as this is detrimental to communities, to those "struggling to overcome (the) addiction," and is "an offense against all of society." The import of those comments seems critical of these two defendants, but more a broad indictment of the type of behavior alleged. That such activity may occur, the release noted such a "greed-fueled" and "callous" "scheme" places "an immense burden on communities." The significance they state is, however, perhaps undermined by the filing of only one criminal count against each despite the implication of millions of pills and dollars?
As noted, these kind of drug distribution allegations are not new. There are reports of prescription medications dispersing into communities, from person to person. Years ago, I heard a presentation in which a police officer referred to the manner in which students in his community shared illicit drugs; he referred to gatherings as "skittle parties," a label I have seen repeated in various publications. And yet, in 2021, we continue to see news about the operation of clinics in the manner described above. One wonders why it is so difficult to identify and deter such "grotesquely lucrative" activity and its "immense burden on communities?"
Drugs like this do not come from back alleys or illicit producers. These are manufactured by pharmaceutical companies, distributed through pharmacies, and prescribed by doctors. The medical profession is highly regulated, as is the distribution of medication. And yet, we persistently see these stories about fantastic numbers over long periods. It seems that statistically spotting such "medical practices" would be reasonably simple? How do these volumes rise into the millions of pills over hundreds of days? There is no debating the existence of a problem or its seriousness.
Despite that, here we are in the third decade of the new century facing the same old problem of prescription opioids and "grotesquely lucrative pill mill(s)." One wonders whether it will ever end, and perhaps whether society really cares enough about it to want it to end? The lyrics from Karn Evil return us to reality with the refrain "right before your eyes, we pull laughter from the skies, and he laughs until he cries, then he dies, then he dies." How many Americans have to die from the opioids being distributed? How many is enough?
