This week, the White House unveiled a new national plan to deal with prescription drug abuse, a subject we have devoted considerable time to on our blog. If you haven’t checked out the 2009 CurrentTV short documentary “The OxyContin Express,” it is well worth your time (45 minutes) and really gives the lay of the land in terms of the problem, especially when it comes to pill mills.

What’s a pill mill?

A particular focus of House talks in DC have been pill mills, clinics that dispense a great deal of medication without extensive scrutiny of the patient. How can you tell a pill mill is a pill mill? Well, according to CBS News and the Miami Herald (also worth reading is this Herald piece by Fred Grimm), signs include:

• No physical exam
• No medical records required
• Medical equipment may be limited to non-existent
• Pain is treated by pills alone; no alternative treatments available
• Pharmacy is on-site
• You can select your own medicines
• Large volumes of medications are dispensed
• Medications are dispensed that, when taken together, can cause serious problems or overdose
• Giant crowds
• Many patients are from out-of-state or have otherwise traveled great distances
• Cash only

Or you can tell a pill mill is a pill mill if, as Florida’s new drug czar Dave Aronberg described, “the medical clinic is located between a tattoo parlor and a pawn shop.”

The cons of pill mills

Obviously, there are many disadvantages inherent in the way pill mills conduct business. Law enforcement frequently points to pill mills as a major factor in the prescription drug street trade; you can purchase pills at a $1 price and then sell them on the street for $4 to $10 a pill, or more. At a pill mill you can get enough medication that even if it is needed, you can still turn a profit by selling some of it off. And then there are people who can go into a pain clinic on behalf of someone else and purchase pills for them, for sale or otherwise. As documented by ABC News, the practice is known as “smurfing.” Homeless people are sometimes asked to retrieve the pills from pain clinics in return for cash. A man known as “Bill” interviewed by ABC News claims “he has gone on these types of prescription drug runs upwards of 75 times” and receives about $20 per filled prescription. It is difficult to imagine that “Bill’s” prescription was even remotely legitimate.

In another bizarre turn, until recently almost anyone could operate a pain clinic. Fred Grimm at the Miami Herald in a March 5th article describes the cases of a few ex-cons who have made huge sums by operating pain clinics. In fact, a man convicted of drug trafficking, who could not run a liquor store in Florida, was able to run a series of seven pain pill franchises before being busted on February 23rd of this year. Florida law requires that you must be a licensed doctor to own a pain clinic; that law was in effect when the bust of the former drug trafficker (among other ex-cons) on February 23rd took place. Problems clearly remain.

Another aspect of the pill mill problem is the lack of medical oversight and the damage that can do to patients. Dispensing massive amounts of oxycodone is hardly a good idea, especially when opioid overdose is now the no. 2 cause of accidental death in the United States (see Dr. Jaffe at Psychology Today for more info). But dispensing massive quantities of oxycodone AND Xanax at the same time is an even more terrible idea. Still, it happens. One particular combination has caught on, earning itself the nickname of “the Houston Cocktail.” Combine hydrocodone (the active ingredient in Lorcet, Lortab, Vicodin, Norco, Zydone, and others) with the muscle relaxer soma and Valium or Xanax and obtain a “heroin-like” high.  (See Houston-based Bacoda Blogs for more detail).  You can easily fill prescriptions for at least two of these three drugs from the same pill mill at the same time. According to a doctor interviewed by Dallas News, there is “no legitimate medical reason for a doctor to prescribe all three together.”  And yet a pain clinic director in Houston prescribed this combination 3,800 times between 2006-2007.  On Jan 18th of 2011, this man, Dr. Maurice Conte, was forced to pay millions of damages to the family of a man who died from taking this combination of drugs.

The pros of pill mills

Yes, there are in fact “pros” to pill mills.  Although tons of dealers and scammers rely upon pill mills to conduct their trade, legitimate patients in actual pain need pill mills too.  Crackdowns on the pill trade have made it harder for people to obtain the pain pills they need, and made the price per pill balloon from $1 to $6.  Maintaining supplies has also been difficult for some pharmacies.  One Florida woman with debilitating back pain and a legitimate prescription had to phone 26 area pharmacies before she could finally fill her prescription (St. Petersburg Times).  Patrick Coyne MSN, APN, FAAN, testified at a House hearing last week on the behalf of the Oncology Nursing Society on the already burdensome difficulties many of his patients face in dealing with chronic pain.  You can read his 2 1/2 page testimony here (PDF).

The solution to pill mills

As of this writing, Florida does not appear to have solved its pill mill problem.  Florida is one of the few states that have held out from creating a prescription drug database that would track prescriptions and patients, and flag people whose use signals illegal trade or abuse.  Florida’s database was authorized two years ago, but has never received the funding it requires to actually be established.  Such drug databases are not unusual; at least 38 other states have them, according to Time Magazine.  These databases, known as Prescription Drug Monitoring Programs (or PDMPs), will be playing a greater role in national efforts to combat prescription drug abuse announced yesterday by the White House Office of National Drug Policy (PDF here), although no national database has been established as yet and national agencies do not have oversight over any state PDMP, according to the DEA.  The extent to which this helps a state like Florida, still fighting over how and whether or not to fund its own PDMP, is unclear.

Clearly, in combating prescription drug abuse, states and the nation at large must be mindful of the needs of those in chronic pain.  If some in chronic pain are finding it possible to address their needs only through pill mills, that should be addressed so as to increase their access to pills and ensure they remain affordable.  Lower-income patients, for example, may find it necessary to pay for pills with cash, and their needs should not be neglected.  However, pill mills as they stand, in Florida and in a few remaining states like Texas, are a national scandal, that waste valuable law enforcement resources and contribute to the destruction of thousands of American lives.

– article by Robyn Schelenz