June 11, 2012 7:34 pm Dr. Webster 2 Comments (Edit)
Bloomberg Businessweek recently published an article detailing the takedown of what is described as “the largest U.S. pill mill.” Florida-based twin brothers, Christopher and Jeffrey George presided over a collection of so-called pain clinics that dispensed the most illegal oxycodone of anyone in the United States, according to federal agents.
The key word in the previous sentence is “illegal.” The George facilities had several hallmarks of true pill mills, such as: 1) non-physician owners who retained physicians for their federally-granted registrations to prescribe strong analgesics, 2) onsite dispensing of pills, 3) fake appointments at which no real medical assessment or follow-up took place, 4) a cash-only basis, meaning no insurance was billed, and 5) one form of treatment — pills. It is clear that what the George brothers were doing had nothing to do with medicine.
What emerges is a strong cautionary tale of unethical activity and preying on the vulnerable. If the facts of the Businessweek story are correct, the George twins represent the true definition of pill mill. The important thing is not to call every clinic that prescribes opioids, even in larger-than-average quantities, a “pill mill.” That would be an error.
Doctors who prescribe opioids to treat chronic, intractable pain – particularly if there is no malignancy involved – often fear for their licenses and their freedom. They fear the enforcement centrism of recent official conversations centered on opioid prescribing. And they fear that their patients may suffer as a result.
These perspectives are not represented in the Businessweek story. That is because these are indeed two separate worlds. Physicians who prescribe opioids are charged with thoroughly assessing and monitoring their patients and with keeping clear, complete medical records. Pain relief, not profit, is the motivating force.
Not so at true pill mills as described in Businessweek. At one point, Christopher George describes the most common pill he dispensed — a form of roxy, labeled “M/30.” The Businessweek story recounts, “George suspects customers liked them the most because they were the easiest to crush up, mix with water, and inject.” This is as far from legitimate medicine as one can get.
The lack of a prescription-monitoring database is one reason pill mills were able to flourish in Florida. The state finally adopted legislation to enact prescription monitoring in 2009 and made the system operational in 2011. However, it is still unclear whether the new monitoring system might have the unintended consequence of reducing access for legitimate patients in Florida’s aging population. This danger is particularly acute if only opioid quantities are considered without context or analysis.
Overall, media reports are spending more time on such distribution news. The Businessweek article contains a graphic showing that the kilograms of opioids sold per 10,000 people correspond to the parts of the country with the worst abuse and illegal distribution problems (e.g., Florida, Maine, Appalachia). Some outlets are even promoting a meme that “X” quantity of opioids equates to a specific milligram dose for every man, woman and child in the United States. The lapse in logic, of course, is that patients with chronic pain consume disproportionate amounts of opioid analgesics compared to the rest of the population just as diabetics consume more of the medication formulated to treat their disease.
High prescribing and consumption patterns do not always signal illegal activity. Prescription monitoring may help make these distinctions clear as long as the databases are used to help inform good medical decisions, not merely chase down “high prescribers.” Remember, oxycodone is also a legitimate medication, not just a drug of abuse.
Time will tell whether the genuine problem of pill mills – for which Florida became the poster state – will be wiped out by renewed and vigorous efforts to take them down. Meanwhile, the patients who depend on strong analgesics to control daily severe and intractable pain are praying that the enforcers will know a true pill mill when they see it.
Lynn Webster, MD
@LynnRWebsterMD
www.facebook.com/lynnwebstermd
Filed Under: Pain Medication Abuse