Pharmacists Struggle on Fraud’s Front Lines

A generation ago, local 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% 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 on the up and up.

Last month, Noelle Bush, the daughter of Florida Gov. Jeb Bush and niece of President Bush, was arrested on prescription fraud charges for allegedly trying to buy the anti-anxiety drug Xanax without a prescription. Authorities say 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; countless others obtain drugs from the Internet.

The agency 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 this country, 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 Assn., the national trade group for pharmacists. “We have to figure out how to stop what we can and identify what we can’t.” Even now, those seeking prescription drugs may use multiple phone lines, computerized prescription forms and other sophisticated methods.

The Bush arrest, pharmacists say, highlights not only the problem 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, especially when medications with addictive potential are involved, said John Tilley, owner of 14 pharmacies in Southern California. He said the two hottest prescription drugs of abuse right now are the painkillers Vicodin and OxyContin.

If a prescription for such a drug is telephoned in, the pharmacist may ask questions to filter out phony prescriptions. 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, Winckler said. Physicians typically use Latin abbreviations and other shorthand, so a doctor would convey a need for 30 tablets by writing “#30.” The forger might write “30 tablets.”

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 furnish the medications.

Some of the red flags that traditionally tipped pharmacists off in the past may not be valid today. Ira Freeman, the pharmacist-owner of Key Pharmacy in North Hollywood, 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.

When pharmacists detect fraud, they share that information with regulatory and law enforcement agencies and with one another.

Sometimes that can create other problems. Carmen Catizone, executive director of the National Assn. of Boards of Pharmacy in Illinois, cited a case in Washington state in which a pharmacy suspected someone of pharmacy shopping. The pharmacy gave the person’s name to the state’s pharmacy board, but the person proved he had legitimate prescriptions and won a multimillion-dollar judgment against the board for invasion of privacy, Catizone said.

Despite that incident, he said, “we’re telling the boards again to be vigilant and continue to do these types of things when they suspect there’s a problem. Sometimes they’re going to win; sometimes they will bear the consequences.”

Many pharmacists have set up networks to alert colleagues to prescription fraud. When a member of the Pharmacists’ Professional Society of the San Fernando Valley gets a phony prescription, he or she will fax an alert to a pharmacy in Northridge that then faxes the alert to nearly 400 other pharmacists.

Still, pharmacists say, the gatekeeper role puts them in a difficult position.

“Detecting fraud is not the pharmacist’s primary duty. It’s clearly a secondary duty,” Vivian said. “The problem is, do we want to train pharmacists to be health-care providers first, or train them to be policemen first? Our first obligation is to the patient.”