Strong Medicine

The Drug Enforcement Administration is cracking down on prescription drug abuse.

Cultural anthropologists might debate the role of shame in instilling social values, but federal officials have long known that there's nothing like bad publicity to force individuals, corporations and even entire professions to make good on their taxes, stop polluting, start self-policing and otherwise clean up their act in the public sphere. Thus, it's no surprise that the Drug Enforcement Administration has begun publicizing the egregious behavior of physicians who violate drug laws.

Last month DEA launched a new page on its Web site (www.dea.gov) called "Cases Against Doctors" that details the circumstances surrounding the arrest and prosecution of doctors who have violated drug laws since 2003. It's the latest salvo in the agency's battle against prescription drug abuse and marks the first time a law enforcement agency has publicly posted the reasons for initiating investigations, says DEA Administrator Karen P. Tandy.

The point of the Web page is to "increase the comfort level" of the majority of doctors operating in good faith by detailing the egregious behavior of their colleagues, Tandy says. "Law-abiding physicians will see that doctors on this Web page engaged in criminal activity that 99 percent of doctors wouldn't even dream of committing," she says.

Among the physicians profiled are:

• Dr. Fred Williams, a Panama City, Fla., physician who wrote multiple prescriptions for a single patient on the same day, wrote prescriptions for more than 100 patients for whom he maintained no medical charts, and frequently replaced "lost" prescriptions. During his trial, he conceded prescribing OxyContin to one of his daughters who had a crack cocaine habit. He was convicted in June 2004 on 94 counts ranging from unlawfully dispersing controlled substances to health care fraud, wire fraud and firearms violations.
• Dr. Callie Herpin, a Houston physician, wrote prescriptions using a list of names lifted from the phone book. She pleaded guilty to conspiracy to illegally distribute more than 1.7 million doses of hydrocodone and 2,500 gallons of promethazine with codeine. She was convicted in June and sentenced to 120 months in prison and ordered to pay $12.9 million in restitution to Medicare.
• Dr. Sidney S. Loxley from Chesapeake, Va., was investigated for excessive prescribing of powerful painkillers and for the overdose deaths of four patients. He pleaded guilty to one count of drug trafficking and was sentenced to 87 months in prison last December.

The availability of powerful new painkillers in the last decade has provided dramatic medical benefits, but also has created a massive public health problem, says Dr. Robert L. DuPont, a specialist in drug abuse prevention and treatment and a clinical professor of psychiatry at Georgetown University School of Medicine. This "new reality" requires new tools for combating abuse, and he supports the DEA Web page as a valuable means of informing doctors about what some in their profession are doing.

Federal researchers at the Health and Human Services Department estimate that more than 6 million Americans are abusing prescription drugs-that's more than the number of Americans who abuse cocaine, heroin, hallucinogens and inhalants combined. Or, as Tandy points out, it's the equivalent of the combined populations of Chicago, Houston and Philadelphia. What's more, nearly one in 10 high school seniors admit to abusing prescription painkillers, especially Vicodin.

Abusers get their drugs in a number of ways: stealing from family medicine cabinets or directly from pharmacies, doctor shopping (when one doctor wises up to a drug habit, a resourceful patient can always find another doctor willing to write a new prescription), by forging prescriptions and, increasingly, through pharmacies that dispense drugs over the Internet.

Rogue doctors are rare, but they do tremendous damage, Tandy says. Last year DEA revoked the registrations of less than one-tenth of 1 percent of the 720,000 physicians in the country for drug violations. DEA agents arrested 67 doctors in 2005, the largest number of doctors arrested in any year. So far in 2006, the agency has arrested 31 doctors. Most cases are initiated when the agency is alerted to a problem by a state medical board, other physicians or patients, Tandy says.

DEA also has issued a new rule and policy statement that aim to explain the agency's law enforcement role and clarify for doctors the requirements for dispensing Schedule II prescriptions-a category of powerful narcotic pain relievers, sedatives and stimulants.

Federal law prohibits doctors from issuing refillable Schedule II prescriptions because of the abuse potential for those drugs, which are often highly addictive and have a street value as high as $100 a pill. But the law does not address whether doctors can issue multiple prescriptions, thus allowing patients suffering from chronic conditions to continue a drug regimen for more than 30 days without having to revisit their doctor for a new prescription.

The rule allows doctors to prescribe up to a 90-day supply of drugs by issuing multiple, post-dated prescriptions during a single office visit.

Dr. William S. Jacobs Jr., co-founder and president of NexStep Integrated Pain Care, a medical practice in Jacksonville, Fla., devoted to treating patients with chronic pain, says the new rule "is a big deal" because it reduces legal ambiguity. While overprescribing pain medicine is a problem in some cases, more often doctors underprescribe pain medicine for fear of running afoul of the law, something the new rule should help alleviate, he says.

Congress also is looking to crack down on prescription drug abuse by going after online pharmacies that provide drugs to users without valid prescriptions. In August, Sens. Jeff Sessions, R-Ala., and Dianne Feinstein, D-Calif., both on the Senate Judiciary Committee, introduced legislation designed to regulate the online sale of prescription drugs and controlled substances. According to the senators, the most abused drugs dispensed without a prescription include the painkillers hydrocodone, OxyContin and Vicodin, along with depressants Valium and Xanax.

The 2006 Online Pharmacy Consumer Protection Act would prohibit the distribution of controlled substances and prescription drugs via the Internet without a valid prescription, hold violators criminally liable and allow the federal government to take possession of property used illegally by online pharmacies. Online pharmacies would have to file an additional registration statement with the attorney general and report all controlled substances and prescription drugs dispensed over the Internet.

Feinstein said she was motivated in part by the experience of La Mesa, Calif., teen Ryan Haight, a high school honors student and athlete who died in 2001 from an overdose of the painkiller hydrocodone, the generic version of Vicodin. He bought the drug from an online pharmacy using a debit card his parents had given him to buy baseball cards. When he filled out the pharmacy's online questionnaire, he described himself as a 25-year-old man with chronic pain. The prescribing doctor never met him.

"Dangerous narcotics are just a click away on the Internet," Feinstein said. "You don't need a prescription, a physical examination or a legitimate reason. All you need is a credit card."

House Calls

Since 2003, DEA has arrested nearly 200 doctors for violating federal drug laws.

Source: Drug Enforcement Administration

Poppers

Self-reported drug misuse among people age 12 and older shows more Americans abuse prescription drugs than cocaine, heroin, hallucinogens and inhalants combined.

Source: 2004 National Survey on Drug Use and Health, Substance Abuse and Mental Health Services Administration.