Drug wholesalers choking pain-pill supply in Tennessee

May 19--A Middle Tennessee pain clinic doctor, targeted last month in a Drug Enforcement Administration investigation into overprescribing, says restrictions are strangling supplies of pain medications in rural communities and are causing misguided investigations of some pain management doctors.

Dr. Councill C. Rudolph, of Winchester, Tenn., said limits on independent pharmacies that many of his patients use are harming care. For such pharmacies, controlled substances can comprise no more than 20 percent of their total filled prescriptions.

"Community pharmacies before this had in their storerooms just what the community needed. [The limitation] is ruining this country," Rudolph said.

The DEA and Franklin County, Tenn., authorities said Rudolph's clinics in Decherd and Manchester were raided in connection with suspected overprescribing and "a number" of possible overdose deaths.

Rudolph denies wrongdoing and hasn't been charged in the DEA investigation, but authorities have said the case will be presented to a federal grand jury.

Rudolph is not alone in complaining about recent changes.

Self-imposed restrictions on opioid-based pain medications by drug wholesalers limit the supply chain from the top down, according to Santa Maria, Calif., pharmacist K. Scott Guess.

In many cases, legitimate chronic pain patients feel the pinch.

Because of increasing pressure from the DEA and lawmakers, "pharmacy suppliers are severely restricting the available quantities of opioids that are most-commonly prescribed," Guess wrote in the trade publication Practical Pain Management. "[T]he authorities have come perilously close to throwing the pain management baby out with the drug abuse bathwater."

Guess said in an interview Friday that the nation's largest wholesalers have become "de facto deputies" in the war on pain medication diversion and abuse.

Corporate pharmacies and those in larger, metropolitan areas deal in enough volume that the limitations have little impact, "but independent pharmacies specialize," said Guess, whose own pharmacy specializes in pain management.

"Diversion" refers to the act of using or redirecting prescribed medicine or other chemicals for anything other than that their legitimate, intended use, according to the DEA's Office of Diversion Control website. The federal agency is focused on the problem.

Jasper, Tenn., physician Charles Michael Howe, 72, who pleaded guilty to 14 counts of illegally prescribing pain pills from his women's clinic over the past three years, was sentenced in Chattanooga last week to three years in federal prison.

Federal charges filed in November said Howe prescribed hydrocodone, oxycodone and methadone "not for a legitimate medical purpose" at least 14 times between October 2011 and June 2013.

The DEA's 2013 National Drug Threat Assessment says controlled prescription drug abuse "continues to be the nation's fastest growing drug problem ... with individuals abusing controlled prescription drugs at a higher prevalence rate than any illicit drug except marijuana."

Guess contends the crackdown from suppliers is linked at least partially to an $80 million settlement by the Walgreen Co. to resolve federal charges that it failed to control sales of narcotic painkillers at some outlets. As part of the settlement, the license of a Florida facility used by Walgreen to distribute controlled drugs was revoked for two years, according to reports in The New York Times. DEA officials said last year that the fine was the largest ever paid by a pharmacy chain.

Dr. Baeteena M. Black, executive director of the Tennessee Pharmacists Association, said the restrictions Walgreen and most other large wholesalers have felt pressure to initiate don't apply well across the board.

"One size doesn't fit all," Black said. "We're very concerned about legitimate patients with legitimate needs."

Some pharmacies serve nursing homes, assisted-living facilities and hospice patients, all of whom require a greater number of controlled substances. And many employers' insurance plans require patients to get their maintenance drugs from mail-order pharmacies while medications they might need for a broken bone or tooth extraction demand immediate attention from the local pharmacy, she said.

Those situations work against percentage-based restrictions, she said, noting she had heard "all kinds of percentages" and "many different formulas."

Independent and small-town pharmacies are more susceptible to problems from the restrictions, she said.

"We are seeking some reasonable solution," said Black, who spent last week discussing the topic with lawmakers in Washington, D.C. "It's an item of ongoing concern."

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Contact staff writer Ben Benton at [email protected] or 423-757-6569.

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