A three-part investigation into California’s misguided attempt at tackling the prescription drug epidemic.
This 3-part series was originally published in the Placer Herald on September 25, 2014. It is presented here in its entirety.
Broken CURES for a Broken System
“Steven White” is not your typical drug dealer. “Steven” is not his real name, nor does he put “drug dealer” on his tax returns but rest assured, Steven moves a lot of product throughout the Sacramento region.
Operating out of the Arden-Arcade area of Sacramento, his clientele consists of a segment of society who don’t fit the drug-addict stereotype. They have college degrees, successful careers, and letters after their names.
Steven deals to doctors.
“Crystal Meth,” he states. “I have quite a few doctors who come to me. They say they can’t work without it,” he says, pausing, looking as if contemplating how much more he should say. “They say they got hooked in medical school to stay awake. You’d be surprised, man.”
He reaches into his pocket. “They’ll write me a (prescription) for whatever I want for a few of these,” he says, holding up the drug.
From his backseat he pulls out a newly-received prescription for #360 Norco, a powerful narcotic opioid. “I traded $100 dollars in meth for this,” he explains. “These sell for $4.25 apiece. You do the math.”
“It’s easy, man,” he says, shaking his head. “It’s really easy.”
It’s Not Supposed to Be So Easy
Unscrupulous doctors are nothing new. In January, 2014, Granite Bay doctor Nicholas J. Capos Jr. was charged by federal officials with illegally distributing opiate painkillers and running a criminal enterprise. His practice extended from Grass Valley to Yuba City.
An LA Times investigation in December, 2012 found a disproportionate number of doctors connected to prescription drug overdoses in Southern California, where seventy-one doctors prescribed the medications that caused or contributed to 298 deaths.
Known as “pill-mills,” doctors writing inordinate numbers of prescriptions have gone largely unchecked by any state or law enforcement agency in recent years, with offending physicians and pharmacies, according to the investigation, often being investigated only after a patient overdoses.
To catch doctors and doctor-shoppers—patients who visit multiple doctors for the same prescription—before the patient is found dead is one of the goals of the state’s Controlled Substance Utilization Review and Evaluation System, or CURES.
Having declared prescription drug abuse an “epidemic” in 2012, the Centers for Disease Control (CDC) recommended state participation in a Prescription Drug Monitoring Program (PDMP). While remaining autonomous, each state except for Missouri has independently created a PDMP to meet the objective of curtailing prescription drug abuse and to catch doctors and patients who abuse the system.
Doctors like those who trade prescription drugs for street drugs with Steven White.
Theory vs. Reality
California’s PDMP — CURES—is a good idea in theory. Theoretically CURES should work like this: before writing a prescription for a narcotic, a doctor would check the CURES system to make sure the patient hadn’t visited any other doctor or pharmacy for the prescription he or she is about to write. After writing the prescription, the doctor would put the patient’s name and the drug into the system. After filling the prescription, the pharmacy would do the same thing. The Department of Justice would oversee the entire process, making sure suspicious entries or quantities were investigated properly.
Once again: in theory.
In reality, CURES has proven to be useless to many of the doctors and pharmacists who have tried to use the system.
“It’s notoriously dysfunctional,” said Dr. Ramon Castellblanch, a professor of Health Education at San Francisco State University and Public Member of the California Board of Pharmacy. “(CURES) is cumbersome and error-prone.”
According to Castellblanch, California’s decision to have the Department of Justice run CURES has made the process impossibly difficult. While most states chose to run their PDMP’s through their departments of health, California chose to be one of only seven other states to have it run by their Department of Justice.
“Public Health could handle it better than law enforcement,” said Castellblanch. “But California has gone the other way.”
Under-funded, under-resourced, and under-staffed, the Dept. of Justice, as of 2013, has had only one full-time employee to handle over 100 million prescriptions and 800,000 practitioner inquiries a year.
Ivan Petrzelka, President and General Counsel of NoRxAbuse.org and practicing pharmacist, concurs with Dr. Castellblanch’s findings, having found nothing but frustration when trying to register.
“You mail the (notarized) application, wait two months, and no response. Send email inquiry—no response. Call the number on the website—no answer or pre-recorded message saying there is a backlog of several months. Send a certified mail inquiry—they tell you your application was not received and to start over again. You go to the site to start over again—it tells you your log-in already exists, that you cannot submit again.”
Mike Small, the DOJ Administrator tasked with handling these issues, has, according to Castellblanch, made no secret about his inability to work with individual doctors or pharmacists who encounter problems. Castellblanch recalls Small, whom the DOJ refused to allow to be interviewed for this story, speaking at a joint Pharmaceutical Board-Medical Board Forum in February, 2013, telling the group that he would not return any phone calls, and that he would only meet with groups of 20 or more to explain the registration process.
Further exacerbating the frustration, says Petrzelka, is the ease with which doctors and pharmacists in neighboring states have signed up for their respective PDMPs. “Contrast (CURES) with Nevada, where access is granted within a week of submitting the application.”
Leticia Tanner, a Department of Justice data analyst, defends the DOJ handling of CURES and its implementation.
“We do return emails and field replies,” said Tanner. “But the funding has been gradual. Since Senate Bill 809, the system has begun to work more smoothly.”
Senate Bill 809 (SB 809), the legislature’s latest patch for CURES, mandates an annual $6 dollar fee to all doctors and pharmacists to fund CURES. That funding, according to Tanner, has helped ease the congestion of the current system.
Petrzelka’s experience, however, has been different.
“My personal signup for California took about three months to complete,” he explained. “(And that was) without technical difficulties.”
As for the DOJ’s claims of improvements since the passing of SB 809, Petrzelka is skeptical.
“Given that it is largely manual process at the DOJ and the mandate for all providers to sign up by 2016, it is hard to imagine that it has improved much.”
More Money, More Problems
CURES’ flaws extend beyond its registration process. There is a three-week lag time between when information is put into the system and when it is viewable. Often times, data put into the system is never seen again, leaving the pharmacist or doctor to either try and get ahold of someone at the DOJ to fix the problem, or simply let it go.
SB 809 may have thrown more money at CURES, but its ambiguous language leads to even more questions.
According to the bill, the deadline for doctors and pharmacists to “obtain approval to access information stored” regarding controlled substance history of a patient is January 1, 2016.
SB 809 mandates that doctors and pharmacists register with the Dept. of Justice to have access to the information in the system.
Nowhere is there a mandate for a doctor or pharmacist to actually view or use the patient information in the system prior to writing prescriptions for narcotics; they are only required to have access, not to use it.
California Proposition 46, on the ballot this November, would, among other things, mandate all doctors and pharmacists to consult the CURES system prior to authorizing or dispensing controlled substances.
Bob Pack, author of Prop 46, says it’s only logical for practitioners to use the information being provided to them.
“In the past ten years, the sheer number of prescriptions has skyrocketed,” said Pack. “We’ve gone from 3 million in 2002 to 50 million last year. But the pharmaceutical lobby is fighting this hard.”
Prop 46 is facing coordinated resistance from “Vote No on 46,” who argue CURES could not handle the burden of being accessed by every doctor and pharmacist in the state.
“The infrastructure is not robust enough to handle it,” said Tom Sugarman, former president of the California American College of Emergency Physicians and opponent of Prop 46. “It’d be too much on the system and would overload the database. It’s not ready.”
Business as Usual
As for drug dealer Steven White, he doesn’t seem too concerned with the state politics surrounding the product he sells. As far as he’s concerned, his business will be booming regardless of any new regulations.
No laws are going to stop doctors looking for a fix, according to White, nor will they curb the public’s appetite for prescription narcotics.
“Best-case scenario—nothing changes and the pill game stays hot,” he explains.
When pressed for a worst-case-scenario, he pauses, thinking long about the question.
“Worst-case scenario—this pill game dries up,” he says, holding up a different prescription than the one he flashed before, “and this (stuff) gets more expensive.”
Asked what that will mean for his business long-term, he smiles.
“All those addicts aren’t just going to just disappear. They’re still going to need something.”
It just wasn’t Robert Rothman’s year in 2011. Rothman’s pharmacy popped up on the radar of the Bureau of Narcotics Enforcement (BNE), implicating him in a complicated prescription drug ring.
Rothman filled large quantities of narcotics, often, according to the Department of Consumer Affairs and California Board of Pharmacy’s accusation, without doctor approval.
The prescription narcotics were then transported to San Diego before being smuggled into Tijuana, according to court documents and the official accusation.
Pills were sold in bulk to various Tijuana pharmacies for around $3.50 apiece, with the pharmacy then reselling the pills to American addicts who crossed the border for around $6 dollars apiece.
This was not Rothman’s first brush with the law. According to documents obtained in this investigation, Rothman had his license revoked in 1987 after being convicted of dispensing drugs without a prescription. The Board of Pharmacy, Case Number 1217, suspended his license for 90 days, and placed him on three years of probation.
As of April 8, 2011, Rothman had gone 18 months without a single report to CURES. Analyzing the data, the BNE—the primary agency used by the Department of Justice (DOJ) to investigate suspicious data found by CURES — found this, in combination with his past conviction, suspicious.
Mining the little data Rothman and his pharmacy did provide proved to be enough for the BNE to launch an investigation.
Spearheading the investigation, the BNE took the lead, coordinating with local law enforcement and U.S. Immigration and Customs Enforcement (ICE) to shut down the prescription drug ring. The primary doctor involved, Carlos Estiandan, was convicted of 13 felony counts of illegally prescribing controlled substances, and sentenced to five years in prison.
Rothman’s hearing before the Board of Pharmacy and Department of Consumer Affairs is scheduled for next month.
With prescription drug abuse in the state of California mirroring the rise throughout the rest of the country, the BNE was busy. Al Cardwood, the President of the Association of Special Agents for the Department of Justice, worked narcotics for the BNE for 20 years.
“We used CURES to track and monitor suspicious activity,” said Cardwood. “It was a great tool for investigation.”
Law enforcement works within their respective jurisdictions. Drug smuggling does not. The most valuable serviced provided by the BNE was their ability to form task forces comprised of multiple agents in multiple jurisdictions, tracking, following, and ultimately shutting down drug rings like the one in which Rothman finds himself implicated.
According to Cardwood, agents gained a certain satisfaction taking down corrupted doctors, more so than busting the dealer on the corner.
“Doctors are trusted members of society. They took an oath. There’s no excuse for that.”
When legislative Democrats pushed forward a plan in 2009 to close a $24 billion budget gap by cutting the BNE by one-third, then-Attorney General Jerry Brown called it a “terrible budgetary decision.”
Brown was a strong advocate of CURES. In 2009, his office worked closely with Prop 46 author Bob Pack, an advocate for tighter prescription controls and whose seven-year-old daughter and ten-year-old son were killed by a hit and run driver high on prescription medication.
Founder of the Troy and Alana Pack Foundation, Pack worked directly with then-Attorney General Brown’s office, using Pack’s background in technology to help design the current CURES system.
“I brought the idea of an electronic version of CURES, with information available in real time,” said Pack. “We brought it to the (medical) Board and the legislature, and it was approved.”
With CURES having been updated and the BNE using the real-time data to shut down doctors, pharmacists, and patients who were abusing the system, the outlook, according to Pack, was good.
The gubernatorial election of 2011 would change all of that.
It All Falls Apart
Candidate Brown’s opponent in that election was Meg Whitman, and she was making big promises. Whitman promised that her plans for pension-reform would not apply to law enforcement.
Candidate Brown would not make that promise.
As a result, the California Statewide Law Enforcement Association (CSLEA), which includes the BNE, officially endorsed Meg Whitman, giving $500,000 dollars to her campaign and spending millions on media spots.
This was seen as politics.
During the election, Candidate Brown, after leaving a message for CSLEA President Alan Barcelona, forgot to hang up the phone. While unknowingly being recorded on voicemail, someone in the room called Meg Whitman a “whore.” Barcelona released this recording to the media.
This was seen as personal.
The CSLEA backed the wrong horse in what proved a consequential race. Brown won the election and did an about-face on both CURES and the BNE. Newly-elected Governor Brown did what then-Attorney General Brown had warned against: going after who he called “some of the best-trained agents in the world.”
When reached for comment, J.D. Palmer, spokesman for the Dept. of Finance, said budget cuts were not Brown’s decision. The legislature, according to Palmer, handed Brown the budget. He just signed it.
Regardless of the reasons for the cuts, or whose decision the cuts were, the Bureau of Narcotics Enforcement was slashed in half to less than 200 agents.
“Bottom line was, Governor Brown was handed a financial mess,” said Pack. “BNE was cut by $70 million, and 200 narcotics officers were taken off of the street at the peak of the prescription drug epidemic.”
The 52 drug task forces throughout the state of California, comprised of local law enforcement and lead by BNE agents — tasked with everything from shutting down unscrupulous doctors to the chemical clean-up of meth labs—were slashed.
Currently only 17 remain task forces remain, statewide.
The remaining 200 BNE agents were reassigned to other areas, according to Cardwood. “We literally at this moment have agents who worked their whole careers fighting narcotics, assigned to aluminum can theft, elder abuse, and internet crimes.”
Cardwood can speak personally to this. He has been taken off of narcotics, where he spent his career on the meth-lab team, special operations team, and where he ran a task force.
Today he works for the Bureau of Gambling Control in Fresno.
“Brown believes narcotics enforcement is a local law enforcement issue,” said Cardwood. “Here in Fresno, we have cases that are not being worked because there is nobody to work them. There’s nobody to coordinate across the various departments and jurisdictions.”
Governor Brown’s office did not respond to a request for interview on this issue.
In October, 2012, a Rocklin CVS pharmacy on Granite Drive was found to be missing over 20,000 prescription narcotics. Search warrants were also issued for Fairfield, Dixon, Turlock, and Modesto CVS pharmacies.
Tens of thousands of pills were taken over the course of a year, with no state law enforcement agency catching the discrepancy between prescribed pills and inventory.
“Now they have civilian data analysts looking at all of the information provided by CURES,” said Cardwood, “where before you had the BNE analyzing it.”
“What good is a collection of data if you don’t know what to do with it?”
Aaron Fechter is an ‘ideas guy.’ He’s an engineer, an entrepreneur. He’s an inventor.
In 1973 he founded Creative Engineering, his best-known invention being one that most Americans would at some point play in their lives. It’s nearly impossible to go into an arcade, Chuck-E-Cheese, or any other place where adults take children to run around, eat pizza, and play video games, and not see his creation.
But never could he have envisioned how the Drug Enforcement Agency (DEA), the US government, state legislatures, and local law enforcement would one day play his game on perpetual rotation, since the day Richard Nixon declared a “war on drugs” in 1971.
Aaron Rechter invented the game “Whack-a-Mole.”
The Law of Unintended Consequences
Adhering to the Centers for Disease Control’s (CDC) recommendation of creating a Prescription Drug Management Program, or PDMP, to curtail prescription drug abuse, California has created the Controlled Substance Utilization Review and Evaluation System, or CURES.
One of the goals of CURES is to get prescription drugs off the street and away from people who abuse controlled substances. Whether bought off the street or obtained by going to multiple doctors for the same prescription, the California Department of Justice’s aim is to cut off the supply of those who use prescription drugs illicitly.
And if history is any indication, this could have potentially dire consequences.
Everything changed in 2010. Purdue Pharmaceutical had been selling OxyContin since 1996, and, according to a Therapeutics and Clinical Risk Management report from 2005, was being abused rampantly from the late 1990s through the early 2000s. It was in October of 2010 that Purdue, after receiving pressure from the Drug Enforcement Agency (DEA), changed the make-up of the tablet to combat those who were abusing the drug. When crushed, the new tablet turned into a gummy-like ball instead of a powder, making snorting, smoking, or injecting, nearly impossible.
It worked. But there were consequences.
In July, 2012, the New England Journal of Medicine documented an immediate rise in heroin use, with an inverse correlation between OxyContin and heroin abuse. Documenting 2500 dependent users, they found that between March 2009 and July 2012, OxyContin abuse dropped 17% while heroin use doubled.
A Journal of American Medical Association (JAMA) study from July 2014 surveyed 2800 addicts entering treatment. The study found that of addicts who began using in the 2000s, 75% started with prescription drugs before moving to heroin. Of those, 94% said they switched to heroin because prescription drugs became more expensive to buy on the street and more difficult to find.
Both studies proved that cutting off the supply of a widely abused prescription narcotic like OxyContin did not stop addicts from using. Instead, it simply forced addicts of a prescription narcotic like OxyContin to use a street narcotic like heroin.
Lead researcher of the JAMA study, Theodore Cicero, told ABC News, “Substance abuse is like a balloon: If you press in one spot, it bulges in another.”
Should CURES be successful, California will once again hit the supply side of prescription drug abuse with force, pressing on the metaphorical balloon described by Cicero. And once again, if the OxyContin-to-heroin model holds true, there will be consequences—consequences the California Department of Justice is not prepared to handle outside of more law enforcement and more incarceration.
Nicholas Pacilio, spokesperson for the California Department of Justice (DOJ), is unaware of any plan in-place to catch the addicts whose supply will be cut off by CURES data. “It’s a database,” explained Pacilio. “I’m not sure I even understand what one has to do with the other.”
When pressed further as to what will happen with the millions of prescription drug addicts once CURES data is used to cut off their supply, Pacilio responded, “I’ll have to get back to you on that.”
Despite repeated attempts, Pacilio has not returned with a comment on this issue.
Different State, Different Approach
Not all states are preparing to use law enforcement to treat the potential health crisis.
Chris Baumgartner is the head of the Prescription Drug Management Program for the state of Washington, which runs its PDMP through the Department of Health. Believing in a proactive approach, Washington has created the Unintentional Poison Workgroup, tasked with creating a strategic plan to deal with the addicts who will maintain their demand for narcotics despite the PDMP’s cut into the supply.
“The PDMP is important, but it’s not the only tool,” said Baumgartner. “We have to take a holistic approach. There is no ‘silver bullet’ to combat prescription drug abuse.”
Washington’s Unintentional Poison Workgroup works directly with the state’s PDMP, offering patients addicted to prescription drugs treatment options and doctor support, in an attempt to keep them from simply turning to street drugs like heroin as a replacement.
Washington has also created pain management guidelines for physicians – written by physicians, not law enforcement – that guide prescribers on how to treat chronic pain, give dosing guidelines, and notify practitioners whose scope of practice does not include treating chronic pain, when to refer a patient to pain management.
“So far we’ve seen tremendous success,” says Baumgartner. “The PDMP is just a database. You have to have something in place to treat patients based on that data with patient health being the primary focus.”
At the moment, California has no such plan in place.
DOJ Approach Short-Sighted
Neither Ivan Petrzelka, President and General Counsel of NoRxAbuse.org and practicing pharmacist, or Ramon Castellblanch, Public Member of the California Board of Pharmacy, are aware of any DOJ directive on what to do when a doctor-shopper is identified, other than refuse to fill their prescription and send them on their way.
“To the best of my knowledge,” said Petrzelka, “there is no hard and fast standard for this decision making process.”
Both are unaware of any DOJ effort to combat the demand that will remain in-tact in a post-CURES California.
Leticia Tanner, a DOJ analyst for CURES, is also uncertain as to what to do.
“The DOJ role is not fully developed,” she explained.
When pressed as to how the Department of Justice cannot have a fully-developed role when they are the ones who are creating the roles, she responded: