A recent headline in my neighborhood newspaper read, “A Dentist Became a Top Opioid Buyer in W. Va. Now a Drug Firm Faces Penalty for Ignoring Red Flags.” The drug firm sent 25,400 hydrocodone pills and 3,600 Xanax to one Huntington, WV area dentist. The DEA raided the dentist’s office and shut it down. The dentist admitted to ordering the pills for personal use.

This summer, also right here in my West Virginia neighborhood, a landmark bellwether trial took place against the three largest medical distributors. The aim of the trial was to force the drug distributors to pay money to help correct the damages done by the opioid epidemic they fostered.

As a physician, when I think of drug distributors, catalogs of medical wares come to mind. I think of ordering Band-Aids for my husband’s surgery office. Medical distributor firms provide these bandages, syringes, gloves, gowns, lidocaine, and the like. I never thought of the companies behind these catalogs as major players in propagating an opioid epidemic. I thought, “What would distributors have to do with anything? They just send what is ordered.” How on earth could a distributor play a causal role in this opioid epidemic catastrophe? I wondered. To flat-out blame them for the opioid epidemic seemed like a stretch to me. I learned differently.

A lawyer explained it to me. It’s green. It’s tempting. It’s called money. Now I understand.

Not only did the opioid manufacturers profit billions from the opioid epidemic, but the medical distributors that delivered the pills into the front lines also profited billions as well. The distributors were definitely part of the grand scheme of the opioid epidemic. How so? They had an obligation to uphold. They were obligated by the Controlled Substance Act (CSA) to red flag any suspicious orders and notify the DEA. The purpose of this was to monitor for and mitigate illegitimate opioid use. Distributors were under the DEA’s domain and were to stop sending pills when told to do so, and in response to red flags. Time and time again, distributors ignored this.

They knew it, too, as of 2005, the DEA told them as much. In fact, this liaison was so key to the opioid profit motif that between 2014 and 2016, the drug industry spent $102 million lobbying Congress to pass a bill that weakened the DEA’s power over distributors. In our WV trial this summer, the distributors blamed us—doctors—and WV’s poor economy and the DEA for the opioid epidemic that racked up billions of dollars of profit.

A 2018 Congressional Report, titled “Red Flags and Warning Signs Ignored,” explains that in 2005, indeed, the DEA realized that policing doctors and pharmacies one by one was an inefficient way of getting a handle on the overwhelming opioid problem. The deluge was too much. So the DEA changed its focus to policing the distributors. The top three controlled 85 percent of the drug supply. The DEA started meeting with the companies in 2004, reminding them of their legal responsibilities to report suspicious orders and prevent excessive, problematic drug distribution. The drug industry pushed back.

The “Red Flags” Congressional Report focuses on my home state of WV and the exorbitant amount of pills pouring into here, stating, “the investigation… of distributors and the DEA’s oversight thereof was primarily limited to the state of West Virginia, with a specific focus on the southwestern part of the state hardest hit by the opioid epidemic.” I’m from there, the southern coalfields. I’ve witnessed the epidemic at street level.

The Congressional Report noted these companies sent over 900 million hydrocodone and oxycodone pills to West Virginia between 2005 and 2016. The population of West Virginia is 1.79 million. It has the highest rate of overdose deaths and the fastest growing rate of overdoses in the country. In the face of these trends, these distributors flooded our country roads with more pain pills. With a duty to red-flag suspicious orders to the DEA, the companies did not stop these orders. To temper the problem would temper the bottom line.

Congress’ Report showed how some of the top prescribing doctors for WV pharmacies were located far away from the pharmacies; one was an eleven-and-a-half-hour round trip drive away from the particular pharmacy. Large numbers of prescriptions were paid with cash. Some prescriptions were not verifiable. The list of issues continues for pages.

In a five-year span, one distributor sent twenty million doses of opioids to pharmacies around Mingo County, West Virginia, population 25,000. It sent around five million doses of opioids in two years to one pharmacy in a West Virginia town with a population of 406. That pharmacy received 13 million doses over six years. That’s thirteen million doses for four-hundred-six people. The small pharmacy owner ultimately went to jail for operating a pill mill. Comparably sized pharmacies in the same region received frankly lower doses. Yet the giant orders did not trigger scrutiny? Instead of also going to jail, the distributors continued sending pills, continued profiting.

Cha-ching.

They made fun of us, too. Various emails showed how distributors mocked the Appalachian places they dumped pills and profited. One circulated, “To the tune of Beverly Hillbillies … poor mountaineer … Pillbillies!”

The drug distributors, in the face of their federally mandated duty, had the wherewithal to give the run-around to the DEA and the Congressional Committee. The Congressional Report states, “at times the information produced by the distributors seemed to be incomplete, causing the Committee to request additional explanation or documentation …” Committee Chairman Walden referred to such delays in the midst of a live epidemic when he said, “My patience is wearing thin… delay, excuses and, frankly, inadequate response. People are dying, lives and families are ruined.”

The Committee noted the declining number of enforcement actions by the DEA and asked for an explanation of it. The DEA, by then deflated from the drug industry’s punches, stalled and deferred.

This kind of run-around was part of the master plan. The drug firms wore down the DEA. The DEA was increasingly deluged with
excessive administrative costs due to higher and higher restrictions placed on the DEA when trying to sanction drug companies. The DEA’s power was weakened against them. This no doubt contributed to declining numbers of sanctions against drug firms.

The drug distributors had a legal obligation to report these red flags to the DEA amidst a rampant epidemic, yet what they did was they kept pouring pills into these pharmacies, despite the red flags. They did nothing even though their role in the process was a safeguard as set forth by law. They were entrusted with the responsibility to report suspicious orders and to curb the sizzling opioid epidemic, not fuel it.

To me, that’s like being a school safety patrol and pushing people in front of cars.

Greed.

Meanwhile, what was the cost to West Virginia’s economy? A WVU economist estimated $1 billion. One billion. The same number of zeros as the drug firms’ profits.

Rebecca Thaxton is a family physician.

Image credit: Shutterstock.com