Decoding an epidemic

Getting beyond conventional wisdom

 The problem
• Drugs--fueled largely by a surge in
prescription overdoses--kill more people each
year than traffic accidents.

• Prescription drug overdose is one of the few

types of preventable death in the U.S. that are
rising.

• Drugs most commonly involved are opioid

painkillers

• CDC calls it an epidemic

 Physicians:
Healers, pain managers, gatekeepers, highly-trained
professionals
 Conventional wisdom
• The problem is misuse and abuse from a
number of sources:

• "Diversion," pharmacy robberies, internet

• Teenagers/addicts stealing from Grandma's

medicine cabinet

• Teenagers/addicts stealing from medicine

cabinets at open houses

• Teenagers/addicts following old people home

from pharmacy and stealing from their
medicine cabinets
Sources
• News stories

• Medical literature

• Government drug abuse survey

• Mortality studies

• Opioid prescribing guides

 NSDUH
• National Survey on Drug Use and Health:
widely referenced annual query of 70,000
people nationwide.

• More timely and, in some ways, more granular

than other sources, such as CDC mortality
data.

• Focuses on "misuse" and non-medical use.

• Misses some users; dead people don't

answer surveys.
NSDUH: painkillers
• Given by or purchased from friend or relative:
66.4%.

• Took from friend or relative without

asking:4.4%.

• Rx from one doctor: 18.1%

• Rx from more than one doctor:1.9%

• Drug dealer or stranger: 3.9%

• Internet: 0.3%
 Death study

• 2008 study in JAMA looked at about 300

overdose deaths in West Virginia.

• Reported that 63% involved a "diverted" drug,

i.e. the decedent lacked a prescription for at
least one of the implicated meds.

• Did not report % that involved prescribed

drugs.
 Our study
• 3,733 accidental deaths involving prescription
medications from 2006 through 2011 in Los
Angeles, San Diego, Orange and Ventura
counties.
 Our findings
• In 1,762 cases--47%--one or more drugs
prescribed for the deceased caused or
contributed to the death
 The prescribers
• 71 doctors had three or more
patients die of prescription-
involved overdoses.

• All but a handful had clean

records.

• The doctor at the top of the

list had16 patients die of
overdoses.
 The dead
• 71 doctors had total of 298 patients fatally
overdose

• Age range: 21 to 70; average: 48

• They included cops, nurses, teachers, wives,

husbands, mothers and fathers. They lived on
upscale cul-de-sacs, in rural trailer homes and
urban SROs.

• Some took an extra dose because they were

in pain. Many became dependent or addicted
after treatment for real injuries.
 The drugs
• Hydrocodone (Vicodin,
Norco): 362

• Oxycodone (OxyContin,
Percocet): 237

• Alprazolam (Xanax): 211

• Methadone: 201

• Morphine: 191

• Diazepam (Valium): 174

 The sources
• Coroners' reports--including opinion on cause,
investigators' narrative, toxicology results, ID
and demographic info on decedent, prescribed
drugs, prescriber info

• Licensing board records

• National Library of Medicine, U.S. Drug

Enforcement Administration
 The method
• Collected records on accidental deaths
involving prescription overdose; included a few
suffocations and drownings caused by OD.

• Excluded suicides, traffic accidents and other

trauma-related deaths. Also excluded cases in
which the coroner noted the deceased
overdosed on drugs prescribed for someone
else.

• Cleaned up and organized data; sortable by

key variables, i.e. decedent attributes, cause,
toxicology, prescriber, drugs.
 "Dying for Relief"

www.latimes.com/prescriptiondrugs
 Legal Drugs, Deadly Outcomes (/prescription-drugs-part-one) | Part 2: Reckless Prescribing (/prescription-drugs-
wo) | Part 3: Rogue Pharmacists (/prescription-drugs-part-three) | Part 4: An Unused Tool (/prescription-drugs-
ur)

DYING FOR RELIEF | A TIMES IN VESTIGATION

Legal drugs, deadly outcomes
BY SCOTT GLOVER, LISA GIRION. VIDEO AND PHOTOS BY LIZ O. BAYLEN
November 11, 2012

Prescription overdoses kill more people than heroin and cocaine.
An L.A. Times review of coroners’ records finds that drugs prescribed by a 
small number of doctors caused or contributed to a disproportionate number of
deaths.

Terry Smith collapsed face-down in a pool of his own vomit.

Lynn Blunt snored loudly as her lungs slowly filled with fluid.

Summer Ann Burdette was midway through a pear when she stopped breathing.

Larry Carmichael knocked over a lamp as he fell to the floor.

Jennifer Thurber was curled up in bed, pale and still, when her father found her.

Karl Finnila sat down on a curb to rest and never got up.

hics.latimes.com/prescription-drugs-part-one/ 1/10
 1: Legal Drugs, Deadly Outcomes (/prescription-drugs-part-one) | Part 2: Reckless Prescribing (/prescription-drugs-
-two) | Part 3: Rogue Pharmacists (/prescription-drugs-part-three) | Part 4: An Unused Tool (/prescription-drugs-
3/29/2018 Dying for Relief: Rogue pharmacists feed addiction - Los Angeles Times

-four)

DYING FOR RELIEF | A TIMES INVESTIGATION

JOEY ROVERO'S QUEST

FOR PI LLS EN DED AT
PACI FI CA PHARMACY. ll four died of drug overdoses after filling

It was the same for Naythan Kenney,

Matt Stavron and Joseph Gomez.
A prescriptions at the tiny pharmacy in Huntington
Beach, court and coroners' records show.

Pacifica's owner, Thang Q. "Frank" Tran, sold pain

All four were patients of a Rowland Heights
physician who was a prolific prescriber of narcotic
painkillers and other addictive drugs. To get their fix,
they needed more than a piece of paper.
They needed a pharmacist willing to dispense the drugs,
and at Pacifica they found one.
BY SCOTT GLOVER, LISA GIRION A ND HAILEY BRANSON­PO TTS
VIDEO AND PHOTOS BY LIZ O . BAYLEN
December 20, 2012
medications in large quantities. Particularly popular with his
customers were high-dose, 80-milligram tablets of OxyContin.
Tran filled nearly twice as many of those prescriptions as did
nearby Walgreens, CVS and Sav-On pharmacies combined,
according to state records.
ADVERTISEMENT
Many of his customers traveled long distances and paid cash.
Rovero drove more than 350 miles from Arizona State University in Tempe to get his
prescriptions in Rowland Heights and then 33 more miles to the pharmacy.
"I thought to myself, 'Why in the world would these kids go that much farther out of
their way?' " said April Rovero, whose son was 21 when he died. "Someone must have
told them to go there."

Pharmacists are supposed to be a last line of defense against misuse of prescription

medications. By law, they are required to scrutinize prescriptions, size up customers
and refuse to dispense a drug when they suspect the patient has no medical need for it.

Some, however, provide massive

amounts of painkillers and anti-
anxiety drugs to addicts and
dealers with no questions asked,
aphics.latimes.com/prescription-drugs-part-three/ 1/9
according to state records,
regulators and law enforcement
officials.

Rogue pharmacists are key

enablers of drug abuse and an
important source of supply for
the illegal market.

State officials who license and

oversee pharmacies are
Thang Q. Tran is appealing the revocation of his license. The state Board of Pharmacy
overmatched by the scale of the found in April that he had improperly dispensed narcotics at Pacifica Pharmacy in
problem. Huntington Beach. (Liz O. Baylen / Los Angeles Times)

Prescription drug abuse has

increased sharply over the last decade, fueling a doubling of drug fatalities nationwide.
http://graphics.latimes.com/prescription-drugs-part-three/ 2/9
egal Drugs, Deadly Outcomes (/prescription-drugs-part-one) | Part 2: Reckless Prescribing (/prescription-drugs-
) | Part 3: Rogue Pharmacists (/prescription-drugs-part-three) | Part 4: An Unused Tool (/prescription-drugs-
3/29/2018 Dying for Relief: Reckless doctors go unchecked - Los Angeles Times
r)

DYING FOR RELIEF | A TIMES IN VESTIGATION

KAMALA HARRI S HAS

A POW ERFUL TOOL
FOR I DEN TI FYI NG he system, known as CURES, was created so

RECKLESS DOCTORS, T physicians and pharmacists could check to see

whether patients were obtaining drugs from
multiple providers.

BUT SHE DOESN 'T USE I T. Law enforcement officials and medical regulators could mine
the data for a different purpose: To draw a bead on rogue
doctors.
As California's attorney general, Harris controls a database
that tracks prescriptions for painkillers and other commonly abused drugs But they don't, and that has allowed corrupt or negligent
from doctors' offices to pharmacy counters physicians to prescribe narcotics recklessly for years before ADVERTISEMENT

and into patients' hands. authorities learned about their conduct through other means,
a Times investigation found.
BY LISA GIRION AND SCOTT GLOVER
VIDEO AN D PHOTOS BY LIZ O . BAYLEN Prescription drug overdoses have increased sharply over the last decade, fueling a
December 30, 2012 doubling of drug fatalities in the U.S. To help stem the loss of life, the federal Centers
for Disease Control and Prevention recommends that states use prescription data to
spot signs of irresponsible prescribing, and at least six states do.

California is not one of them.

By monitoring the flow of prescriptions, authorities can get an early jump on illegal or
dangerous conduct by a doctor. Among the telltale signs: writing an inordinate number
of prescriptions for addictive medications or for combinations of drugs popular among
addicts.

s.latimes.com/prescription-drugs-part-four/ 1/9 Harris' office keeps CURES off-limits to the public and the news media. But information
from a commercial database containing the same kind of data illustrates how valuable
CURES could be as an investigative tool.

Private firms purchase Pills collected at death scenes await destruction in a coroner’s

prescription data from
pharmacies and sell it to drug
companies for use in marketing
their products. The Times
obtained a list from such a
database ranking the most
prolific prescribers of narcotic painkillers in the Los Angeles area for June 2008.
property room. Prescription overdoses have fueled a doubling of
U.S. drug fatalities in the last decade. (Liz O. Baylen / Los Angeles
Times)
Pills collected at death scenes await destruction in a coroner’s property room.
Prescription overdoses have fueled a doubling of U.S. drug fatalities in the last decade.
(Liz O. Baylen / Los Angeles Times)

Of the top 10 doctors on the list, six were eventually convicted of drug dealing or similar
crimes or were sanctioned by medical regulators. One of them was a cocaine addict.
Some had been prescribing narcotics in high volume for years before authorities caught
up with them.
http://graphics.latimes.com/prescription-drugs-part-four/ 2/9
REPORTING ON OPIOIDS

April 2018
Kristina Davis, reporter
The San Diego Union-Tribune
 DEATH DIARIES

• 254 opioid deaths in 2013

• 186 (73 percent) had filled prescriptions in
past year
• CURES database – tracks patient
prescription history, doctors, pharmacies
 THE FINDINGS

• No. 1 killer: hydrocodone

• 48 deaths (tied with oxycodone),
990 prescriptions
• Chronic users
• 70 percent who overdosed were
prescribed the same medication
for three months or more
 THE FINDINGS

• Deadly cocktails: 80 percent had a

combination of substances
• Opioids and benzodiazepines fatal
combo – both suppress breathing and
sedate user
 THE FINDINGS

• Doctor shoppers (four doctors, four pharmacies in

same year)
• More than half of all prescriptions written

• Ignoring CURES
• Prescribing doctors weren’t checking history
• Shouldn’t prescribe, period
• Opportunity to warn patients about drug combos
• Counsel about addiction
 CASE STUDIES

• Male, Navy, clean cut, well-dressed • Female, 34

• ER asks for Ambien to help sleep on
business trip
• CURES shows 17 doctors and 42
prescriptions in past year
• 75 Ambien pills filled that month by five
doctors
• 54 prescriptions by 36 doctors and 21
pharmacies
• More than 1,300 pills – oxycodone,
hydrocodone, codeine, Ambien,
lorazepam, Soma
• Overdosed in 2013 five days after filling
oxy prescription
THE EXPERIMENT

• Doctors can write warnings to

other doctors but no good
unless already using CURES
• Letters to doctors: “Your
patient died…"
• Send to half (400) and monitor
prescribing habits to see if
made a difference
 MAT
(MEDICATION-ASSISTED TREATMENT)

METHADONE SUBOXONE

• Started in NYC criminal justice system • Higher functioning addict

• Completely covers the receptor, can use • Convenient: Primary doctor prescription
right away
• Goal: Steady state dose, no high • Reduces stigma

• Inconvenient: It’s so potent, must go daily, • Safer: Combined with naloxone

use as directed under supervision
• Must be somewhat detoxed or get sick
• Can use in detox
• Doesn’t cover receptor completely
• High number of deaths: No. 1 killer in 2013
of single substances • Metabolizes differently
• Painkiller use, black market, Mexico
 CULTURAL SHIFT

NEW EMPHASIS ON MAT TENSION

• Call for wider access to Suboxone • 12-step, abstinence-based vs. MAT

• Vermont Hub and Spoke model • Replacing drug with another drug
• Hub: Treatment center as regional • Public programs control access
resource
• Blend both programs, tailor treatment
• Spokes: Doctors’ offices, smaller
treatment centers
• Once on, can you really get off?
 PROSECUTING OVERDOSES
THE LAW
• Federal law: Distribution causing death
• California law: Murder
• Evidence: Text messages, crime scene
investigation, toxicology
• Key elements: Level of deception,
rendering aid, number of overdoses
• Is this a real solution?
CASES
• Google exec and the escort
• 23-year-old: Sober for year, friend sold
him heroin, dead on bathroom floor
• 34-year-old: Dealer warned him that
“China” (pure heroin laced with fentanyl)
was “a ton stronger”
• Dealer presented fentanyl as Percocet,
bragged that he knew how powerful the
pills were. Murder prosecution
 PURER, POTENT

NEARLY PURE, AND BLACK TAR BEING PRODUCTION UP,

REPLACED BY WHITE PRICES DOWN
CHEAP POWDER, CHINA
 30,000 pills
140 lbs powder

THE SUPPLY
DEADLY STUFF
 FENTANYL PIPELINE

MEXICO CHINA

• Cartels control fentanyl production and
distribution
• Made in labs like meth
• Typically less pure (4-6 percent)
• Blue M30s or laced into street drugs
• Smuggled through border, distributed
through typical networks
• Through the mail system to smaller
operators in U.S.
• Purer form (90 percent) or precursors
(4ANPP)
• Extremely easy to make, unlike meth
• Varying levels of experience, equipment
• Hotspots
• Dark web
 DATA

• DEA National Drug Threat Assessment

reports
• CBP/DEA seizure stats
• CONTACT:
• Medical Examiner
• kristina.davis@sduniontribune.com
• CDC/Emergency room admissions
• (619) 293-1391
• Use surveys, treatment admissions
• Jail surveys
• PDMP
• Board of Medicine