Local pharmacists on front line

PEOPLE'S PHARMACY

Medicine: Fraud case involving President Bush's niece points up crucial role of druggists.

Health & Fitness

February 24, 2002|By Jane E. Allen | Jane E. Allen,Special to the Sun

A generation ago, neighborhood pharmacists knew all the doctors in town and remembered each customer by name -- making it difficult to obtain prescription drugs, especially potentially addictive ones, without a doctor's order.

But Americans became increasingly mobile, switching communities, doctors, insurance companies and drug plans on a regular basis. And the number of prescriptions soared, from 1.87 billion in 1992 to 2.98 billion in 2000, a nearly 60 percent increase in just eight years, according to the Kaiser Family Foundation.

As a result, pharmacists now are finding it difficult, some say impossible, to ensure that every prescription they fill is legitimate.

In late January, Noelle Bush, the daughter of Florida Gov. Jeb Bush and niece of President Bush, was arrested on charges of trying to buy the anti-anxiety drug Xanax without a prescription. Authorities say that she posed as a doctor to call in an order and that a pharmacist, who suspected something was amiss, contacted police.

Pharmacists and the federal Drug Enforcement Administration say there's no way to determine how many Americans obtain prescription medications illegally. Some fake written or verbal prescriptions, some seek multiple prescriptions for the same drug from several doctors, others obtain drugs from the Internet.

The DEA in the last five years has increased the number of "tactical diversion squads," dedicated to curbing the problem, from just two in early 1997 to seven scattered around the country today; it also has investigators working at more than 70 sites nationwide, an agency official said.

Drug officials acknowledge that little can be done about drugs purchased overseas or shipped by overseas Internet sites without a prescription. But, in the United States, the agency is pushing for a system in which doctors would use a digital signature that must be validated before a drug is dispensed. Pharmacists would be able to tell if the prescription was altered after it was entered into the computer. The agency hopes to have regulations for the system finalized in October 2003.

Even with that system, "we won't know how secure it is until someone tries to beat it," said Susan Winckler, group director of policy and advocacy for the American Pharmaceutical Association, the national trade group for pharmacists.

The Bush arrest, pharmacists say, highlights the problem not only of prescription drug abuse, but of a system that relies on them to find it.

Those who dispense the drugs are the first line of defense, and law enforcement depends on their tips. They have a professional and regulatory responsibility to ensure they're dispensing medications from a legitimate prescription.

When a local pharmacist suspects a prescription has been forged or altered, he or she has the choice "to fill or not to fill," said Jesse Vivian, a professor of pharmacy law and ethics at Wayne State University in Michigan. When there's some doubt, the pharmacist must decide whether to fill the prescription and potentially put medications into the hands of a drug abuser, or hold back the prescription and potentially deny a sick person the relief they need.

Many pharmacists rely on gut instincts to determine if something is awry, said John Tilley, owner of 14 pharmacies in Southern California. He said the two hottest prescription drugs of abuse now are the painkillers Vicodin and OxyContin.

If a prescription for such a drug is telephoned in, the pharmacist may ask questions. The pharmacist also listens for "the cadence of the prescribing physician or nurse. Are they hesitating with answers?" Winckler said.

With written or faxed prescriptions, pharmacists will examine the writing style, she said. Physicians typically use Latin abbreviations and other shorthand.

Forgers might alter the number of pills or refills, while others "pharmacy shop" by going to several pharmacists to see who is most likely to fill the phony prescription.

Some of the red flags that tipped pharmacists off in the past may not be valid today.

Ira Freeman, the pharmacist-owner of Key Pharmacy in Los Angeles, said his radar used to go up if a patient came in with a prescription for 100 Vicodin pills.

But today, with more doctors attending to chronic pain, pharmacists are scrutinizing those prescriptions more on the basis of whether they appear appropriate. For example, they'd be more likely to furnish large quantities of painkillers prescribed by a cancer specialist than a dentist.

Freeman has established his own policy about frequently abused drugs: "If I don't know the patient and the physician is outside of my area, I don't fill it," he said.

Jane E. Allen is a reporter for the Los Angeles Times, a Tribune Publishing newspaper.

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