Indiana crackdown on opioids sparks more pharmacy robberies

http://www.startribune.com/indiana-crackdown-on-opioids-sparks-more-pharmacy-robberies/430364733/

Newton’s Third Law: As described by the third of Newton’s laws of motion of classical mechanics, all forces occur in pairs such that if one object exerts a force on another object, then the second object exerts an equal and opposite reaction force on the first.

INDIANAPOLIS — As the nation’s opioid epidemic intensified, Indiana cracked down on over-prescribing doctors and “pill mills” catering to people with addictions. The state also took aim at doctor-shopping — the practice of visiting multiple physicians to score more painkillers.

The measures had an impact, but not what officials hoped for.

While making opioid prescriptions harder to get, the crackdown also helped spur a twofold increase in robberies of pharmacies that exacerbated the state’s standing as No. 1 in the nation for those crimes. Between 2009 and 2016, Indiana had 651 pharmacy robberies — the most in the U.S. and more than the 597 recorded by No. 2 California, which has six times the population, U.S. Drug Enforcement Administration records show.

The frequent holdups reflect a grim reality: With each regulation or law enforcement tactic, the opioid crisis quickly shape-shifts to evade new obstacles. Dealers and those struggling with addictions adapt, and the epidemic continues with little interruption.

“They’re always looking for wherever they can get their foothold. And once they do, they’re going to take advantage,” said Tom Prevoznik, a deputy chief of pharmaceutical investigations with the DEA in Arlington, Virginia.

Pharmacies and law enforcement agencies in Indianapolis, where most of the robberies have occurred, are fighting back. Pharmacy chains have installed time-release safes that won’t open for several minutes, forcing robbers to risk arrest by waiting. Signs so far are positive. Robberies in Indianapolis numbered only eight through early June, compared with 55 for all of 2016.

But some criminals responded to those efforts by traveling from Indianapolis to small suburban towns to rob pharmacies, including one in January in Elwood, about 40 miles from Indianapolis, where two robbers herded frantic employees into a bathroom after threatening them with a handgun.

Indiana’s economic makeup has made it a likely breeding ground for opioid addiction for years.

The 2008 financial crisis hit the state’s manufacturing economy hard, causing waves of layoffs. And physically demanding jobs in heavy industry have long left workers prone to injuries that could lead to prescriptions for painkillers.

“They get a legit medical prescription — and then all of a sudden it gets out of control,” said Jason Hockenberry, an Emory University professor of health policy who has studied opioid addiction. He said the state already had outsized opioid woes, related in part to its location along Interstates 65 and 70 — two major corridors for illicit drugs.

Opioid addiction was behind the state’s worst-ever HIV outbreak, in 2015, an epidemic that infected more than 200 people in a rural county north of Louisville, Kentucky. Most had shared needles while injecting a prescription painkiller. That year, Indiana ranked 17th in the nation in heroin and prescription opioid overdose deaths, with 1,245 deaths per 100,000 people.

Four years ago, the Legislature directed the state’s Medical Licensing Board to draft rules requiring patients to visit their doctors periodically to keep getting prescription refills. The changes included requiring doctors to use an online database to check patients’ use of controlled substances.

But stemming easy access to opioids probably contributed to the binge of 168 robberies in 2015, more than twice the previous year’s total, as more people addicted to prescription opioids robbed stores seeking painkillers and other potent drugs, said Greg Zoeller, who was Indiana’s attorney general at the time.

The holdups — sometimes more than five a day in Indianapolis — flooded the black market with nearly 200,000 pills, primarily painkillers.

“We knew full well that if you reduce easy access, you’re going to have these kinds of consequences,” Zoeller said.

Lt. Craig McCartt, who oversees robbery investigations for the Indianapolis Metropolitan Police Department, said 85 percent of Indianapolis’ pharmacy robberies in 2015 were committed by juveniles enlisted by adult dealers offering cash and gifts to rob the stores.

Amid that crime spree, Indianapolis police teamed up with the DEA, FBI and federal prosecutors for a multi-agency approach that’s led to the indictments of 35 people, including six juveniles, in 62 of the robberies.

The state’s two largest drugstore operators, Walgreens and CVS, have also installed time-release safes at their roughly 180 Indianapolis pharmacies and added armed guards at some stores in recent years.

Indiana’s pharmacy robberies dropped to 78 in 2016, but the state still ranked second in the U.S., behind California. The latest effort targeting the robberies is a law taking effect in July that will lead to longer sentences for people who threaten violence or injure anyone during pharmacy robberies.

Ken Fagerman, a former South Bend pharmacist who wrote a book about the robberies, said the pharmacy industry should not have tolerated the heists for years and shares some blame.

“It’s regrettable that more wasn’t done sooner,” he said.

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1. I had my 6mo checkup with PCP.  He quit Rxing my pain meds July 2015.

 2.   Discussion of current meds led to him basically telling me all the CME he is getting locally is discouraging any use of opioids.  His wisdom, “yup, the momentum swings too far in one  direction when these things come about.”

3.  Had my 1 month visit with pain management.  He said he just returned from a 3-day pain mgt. conference at Harvard. He said in 3 days of talks, only one physician spoke on how the  pendulum has swung too far in the other direction and patients are being adversely affected.
4.  A friend of mine in Spokane, Wa (which I have heard has no pain management physicians and they have to travel to West side Washington for evaluation) is having a total knee replacement

     in Sept.   My friend was told by the surgeon his post op pain medications are,   wait for it……

     ta da,  Celebrex and Lyrica !    Really !

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CBS DFW, a local television station covering the Dallas-Fort Worth (Texas) metro area, has documented yet another example of PBM clawback practices that are negatively impacting community pharmacy patients. One local pharmacist says he see examples on a daily basis of customers with insurance being charged a higher price for a prescription drug than those with no insurance at all, and he can’t recommend lower-priced alternatives because of contractual confidentially clauses that would prevent him from telling customers their copay is more than the drug price. In one example, a customer with insurance purchased a common generic drug. His copay for that drug was $125, but had the customer paid with no insurance the cost would have been just $55—a difference of $65. The station did point out that if patients bring up the question unprompted about how much a prescription would cost if they didn’t use their insurance, the pharmacist can tell them.

https://www.goodrx.com/

https://www.blinkhealth.com/

If you have Medicare part D and by checking the price of your prescription on the above two websites and ask the pharmacist before you get it filled the cash price and use your prescription insurance card.. Could both save you money and keep you from going into the “donut hole”  and save you more money.

Some PBM (Prescription Benefit Managers) apparently are charging pts a SURCHARGE for using their prescription insurance.  Just like auto insurers raise your premium if you have a accident and have to use your insurance.

They have “gagged” the Pharmacists from telling you about this form of ROBBERY.. unless you ask…

By checking your cash prescription prices with the above two websites.. you can beat the PBM at their own game 🙂

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The prescriber himself is against this . He apologizes constantly but tells me because the fact that the office he works for made every doctor implement the guidelines to new and old patients , that his hands are tied because he doesn’t want to loose his job. Myself and 79 other patients all with different doctors but the same office have all been lowered to the CDC guidelines . The problem is that doctors offices and doctors themselves are reading the guidelines as law . Their afraid that if they don’t follow the recommendations ,that they will get into trouble and loose their jobs . That’s what I’m finding also with pain patients across the country. Patients are being lowered to the CDC recommended morphine equivalents or their being forced off their medications altogether . So it’s not been 
That their following the standard of care , their following the recommend highest dose or morphine equivalents even though they’ve been on higher doses that have worked for them for many many years

This is what I believe is a good example where a class action lawsuit would come into play. The corporation that employs these prescribers and claiming that they are going to follow the CDC guidelines for all 80 pts.  So they are basically stating that the CDC guidelines are the standard of care and best practices for all the employed prescribers.  Apparently this prescriber is not happy about the edicts from the corporation in how he is being FORCED to mistreat or under treat pts against what his experience and training guides him to how pts should be treated.

They are also just implementing small portions of the CDC guidelines… the most limiting part that INTENTIONALLY limits a pt receiving optimum care and quality of life. That would be the 90 mg/day ME.  IMO.. they are violating their own standard of care and best practices which meaning that they are in the malpractice arena, pt/senior abuse and discriminating against pts that are suffering from subjective disease which could be a violation/civil rights discrimination under the Americans with Disability Act and Civil Rights Act.

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Doctors ‘gun shy’ to prescribe opioids hurting those in pain, say experts

http://www.cbc.ca/news/canada/windsor/doctors-gun-shy-to-prescribe-opioids-hurting-those-in-pain-say-experts-1.4163563

A Windsor, Ont. woman who relies on prescribed narcotics to help with chronic pain believes “responsible” opioid users are being unfairly victimized in the government crackdown on drugs like Fentanyl. 

• Ontario overhauling the way it collects data on opioid deaths, overdoses
• Pain expert says Ontario opioid strategy demonizes people

Jennifer Butcher has been unable to find a physician who will refill her prescriptions ever since her family doctor retired last month. She’s not alone, according to medical professionals and other patients in Windsor who say a spike in deaths across the region and province has doctors reluctant to prescribe opioids.

“I don’t feel like a functioning, productive member of society anymore,” said Butcher. “I am looked down upon by 90 per cent of the people I talk to, including doctors and pharmacists, because of the types of drugs I’ve been prescribed.”

Jennifer Butcher struggles to stand on her own without her pain medication. (Aadel Haleem/CBC)

Butcher, 46, suffers from fibromyalgia, carpal tunnel syndrome and arthritis. She has neck and back pain from a car accident when she was a teen and has difficulty standing for long periods of time.

She relies on her walker to get around and has been using pain medication for more than 20 years. Her pain has been compounded in recent weeks by the gnawing pangs of withdrawal.

“People like me are slipping through the cracks. I’ve talked to a few people in my situation that really feel there’s going to be an uprise in suicides because of this,” she said. “People don’t want to live in pain and suffering every day — it’s no way to live. If I had cancer, they wouldn’t say, ‘We’re not going to give you chemo because it might kill you.'”

‘Distinct shift’

Angela Lambing has seen a “distinct shift” in how pain management is being addressed. The nurse practitioner believes physicians have become “gun shy” when it comes to prescribing opioids. She’d like to see medical professionals receive more pain management training.

“It’s like anything else, you have one patient that misused, you worry that another patient is going to do it too,” said Lambing. “Physicians are saying there’s going to be a higher rate of suicide because patients aren’t going to get what they need and they’re going to have significant pain, which is difficult to live with.”

Angela Lambing has seen a ‘distinct shift’ in how pain management is being addressed. The nurse practicioner believes providers are ‘very gun shy’ when it comes to prescribing opioids. (Aadel Haleem/CBC)

Reluctance on the part of physicians is no surprise, considering the provincial government in October announced what it called its first comprehensive opioid strategy.

The moves comes after a steady increase in opioid-related deaths and injuries for more than a decade, according to Public Health Ontario. The latest available statistics are for 2015, when the province recorded more than 730 opioid-related deaths, which is a 99 per cent jump from 2003 figures.

Numbers for emergency room visits are a little more up to date, with 4,420 patients showing up at ERs with opioid-related problems, compared to 1,858 in 2003. Those figures represent a whopping 137 per cent increase.

But as prescription medication dries up, Lambing, who has worked at Detroit’s Henry Ford hospital for 25 years, fears people in pain will turn to the streets.

“They’re going to be taking medicines off the street that are cut with who knows what, and then we’re going to have the same issue that we’re already seeing with that fentanyl,” she said.

Doctors are ‘being cautious’

Dr. Amit Bagga, the president of the Essex County Medical Society, acknowledged doctors are now more “cautious” about prescribing high-dosage opioids to patients with non-cancer pain.

“There are guidelines, and the College [of Physicians and Surgeons] is watching physicians and supervising the dosages that are being used,” said Bagga. “So one is being cautious, one is being careful.”

Dr.Amit Bagga admits doctors are now more ‘cautious’ to prescribe high-dosage opioids in non-cancer pain. (Aadel Haleem/CBC)

He said doctors need to balance their responsibility to manage pain with the havoc being wrought on the streets by powerful opioids, which is being described by officials across the country as an epidemic. 

“There is appropriate use, but there is misuse. There’s people selling it on the streets, there are people using high doses getting into accidents,” said Bagga. “So at the societal level, physicians are a bit of a gate-keeper, and we have to kind of respect that they are in a tough position.”

Like Butcher, Marcie Porter feels like collateral damage in the battle against the opioid epidemic. She suffers from fibromyalgia and has been taking fentanyl patches and Percocets to ease the pain. Her family doctor shuttered his practice two months ago and now Porter only has enough medication to last another month. 

She said she has called 12 doctors, many of whom are taking new patients, but none will see new patients looking for pain medication. 

Marcie Porter is wearing two fentanyl patches. She returns used patches to the pharmacy before receiving next prescription. (Aadel Haleem/CBC)

“I feel like we’re being discriminated against because they don’t know us as a person,” said an exasperated Porter. “We’re being looked at as a different person because of the epidemic — and I get the epidemic — but it’s not fair to us that need [opioids] and actually don’t abuse it.”

Porter stressed she is a responsible opioid user in desperate need of pain medication.

“I would like to see doctors looking at people who are in pain more, not to look at us as a druggie or somebody that’s taking them on the streets because that’s not true,” she said. “I take mine back to the pharmacy every time that is needed and I’ve been tested every time when I go to the doctors.”

Refusals must be ‘in good faith’

In an email to CBC, the College of Physicians and Surgeons of Ontario says its Accepting New Patients policy states doctors must accept new patients “on a first-come, first-served basis.”

However, there are exceptions “if a patient’s medical needs don’t align with the physician’s clinical competence or scope of practice. This type of situation would be grounds for refusing a prospective patient. The policy also says that such decisions to refuse must be made in good faith.”

Butcher has been taking pain management drugs for more than two decades now, starting with Tylenol 3s and moving on to Percocets, Oxycontin and finally fentanyl patches. 

She has gone through five physicians since her family doctor retired and none of them will refill her prescription. She is living in pain and fears what may happen to others who may seek solace in the streets. 

“The people that are getting addicted now and that are dying, a lot of times it’s because they can’t get what they’re used to being prescribed,” she said. “Then they turn to the streets and they either go towards heroin, which can be cut with anything, or these new fentanyl patches. They don’t realize that the liquid inside — you cannot drink, lick, smoke or shoot. You have to wear the patch.”

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People protesting outside Mitch McConnell’s office, some in wheelchairs, removed by police

http://wsbt.com/news/connect-to-congress/people-protesting-outside-mitch-mcconnells-office-some-in-wheelchairs-removed-by-police

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Robert D. Rose Jr.‎ to Vets Fight Back

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I recently saw your website and read your views on how to file a complaint. However, Im in Louisiana and have a friend that was denied a narcotic medication refill because it was after 2 days since it was prescribed from the emergency room. She  was still in pain and wasn’t able to get it filled because she had not received her paycheck. She also did not have insurance to pay for it. What are we supposed to do or can we do about this?

This was an interaction at the local large chain pharmacy – one that has their “good faith filling policy”

Part of that policy is that the pharmacist is not suppose to fill controlled prescriptions for pts wishing to pay CASH..

It is reported that some 30 million Americans DO HAVE HEALTH INSURANCE… so it would appear that those 30 million pts  ( close to 10% of the USA population ) need not come to this chain pharmacy if they need a controlled prescription filled…

Once again my recommendation to pts in need of getting controlled prescriptions filled is DUMP THE CHAINS !!!

Here is a link to help you find a independent pharmacy by zip code http://www.ncpanet.org/home/find-your-local-pharmacy 

The chain store pharmacist gets paid every week … regardless if they fill your prescription(s) or not… at a independent pharmacy you will – most likely – be dealing with the Pharmacist/owner who only gets paid if they fill legit/on time/medically necessary prescriptions.. They typically understand that the world is not perfect and some people can’t afford insurance and or that don’t have the money to get prescriptions filled when they need them.

The money you spend in a locally owned independent pharmacy STAYS IN YOUR COMMUNITY.. profits aren’t sent off to some corporate HQ in another state or another country.. It is one way to BUY USA !

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Well I’ve been going to the same PM Dr for the past 8 years.

Always had a good relationship.

I’ve used only the same pharmacy for well over 15 years.

Always took my meds as prescribed.

2 oxycodone 5/325 per day.

Never had them lost or stolen.

No matter how unbearable at times, I’ve never called in between appts.

Just one of the most honest/compliant patients she’s had IMO.

Anyway the bottom line is she alleged me to be negative on my urine 3 times so she cut me off last month.

She said I’m still a patient for now and can go back for injections if I wish.

I have access to my records via the Patient Portal and for every accused negative it shows positive and I know I was positive because I certainly took them.

I’m assuming this positive is from the cup.

They then send the urine to a lab.

Because the lab shows negative, I guess that’s all that matters to her.

I could see if I was negative on the cup AND the lab I wouldn’t have much of an argument, even though I took them as prescribed. But I’m positive and negative which makes no sense to me.

At my last appt, I called her out on this and told her to “stop trying to convince me that I was negative, it’s like me trying to tell you that you didn’t wear shoes to work this morning, sounds silly doesn’t it?”

She said she believes me but can no longer prescribe because of the lab results.

She printed out the lab results and gave me copies.

As you’ll see, it was collected the day of my appt. 

The lab receives it 3 days later and possibly didn’t test it for yet another week.

I do believe I have a fast metabolism because I’m 56 and weigh the same as I did in high school. I’ve never been able to gain weight.

So my questions are:

1) did the time it took for the lab to process the urine have any effect on the outcome?

2) do you feel she should have based her decision on the fact that the cup was positive for every one?

I will leave it as this for now although as you can imagine I have a ton of questions.

I feel completely blindsided and this couldn’t have happened at a worse time as on top of my chronic pain I’m also in a bad flare of diverticulitis and scheduled for a colectomy on July 10.

Thank you very much for your input and time!

It seems strange to me that a physician would send out a urine sample to a outside lab when the office’s testing shows the medication that the pt is prescribed shows up in the test…

I am not very knowledgeable on urine testing procedures, but common sense would suggest that tests on a sample that is not stored properly or mishandled.. could allow the medication being tested for to deteriorate until it was at such a level that it could not be detected.

I found this website that discusses mishandling and other issues effecting false urine test outcomes http://www.brighthub.com/science/medical/articles/71492.aspx

I also find it strange that the physician is willing to continue treating the pt with ESI’s… it is common knowledge that ESI’s are MUCH MORE PROFITABLE for a practice than getting a office visit charge for writing a prescription.

For a pt to have their pain managed on such a low dose of Oxycodone  – a total of 10 mg/day – seems so benign. Could this physician have figured out how to improperly store or mishandle urine samples being sent to outside labs so that the sample will deteriorate to a point that it will test negative for the medication that the pt is on .. so that there is “proof” of a negative test ?

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