A Case Against Controlled Drugs

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A Case Against Controlled Drugs [

By DANIEL T. WAGNER

On September 2, 1980, a gunman bolted into my newly established pharmacy located in an attractive J middle-class suburb of Pittsburgh. He yelled for everyone to freeze. His frigid voice momentarily stunned us all. My father and mother, who were visiting me at the time, were seated on stools behind the prescription counter and I was typing a prescription label. My father instinctively jumped up from the stool and braced himself against the prescription counter. The gunman held high

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Daniel T. Wagner is a community pharmacist in Gibsonia, PA.

a .38 caliber midnight special and maliciously-without hesitationshot him. As my mother moved to cover my father's fallen body, bleeding profusely from the gunshot wound, the gunman walked over my father as though he were part of the carpet and ordered me to the floor. He warned that if I tried to press any buzzers he would shoot me too. Then he demanded Dilaudid. I told him honestly that I didn't stock Dilaudid. He called me a liar, then demanded all Schedule II narcotic drugs. I abided. When he could not locate the drugs where I pointed to the shelf, he ordered me to get up and get the drugs and place them on the checkout counter. As he proceeded to empty the money from the cash register, he lowered the gun long enough for me to jump him. I was able to release

the gun from his hand. The fight ensued throughout the front of the store and we crashed through the aisles, knocking down merchandise all over the store. We wrestled out the front door and into the parking lot. At that point, his accomplice jumped from the getaway car and assisted his partner in the struggle. Within seconds they had escaped without an eyewitness in the vicinity. My father died 10 days later.

A Profession Endangered I relate this story not to foster a personal tragedy, but to point out what can happen-and is happening-to pharmacists everywhere. Between 1976 and 1978, thefts of controlled substances increased 225% in the United States. In 1979 alone more than 8,100 pharmacy robberies were reported and, most

~---------------------------------------------Pharmacy Crime Requires an All..out Effort [

By W. JAMES BICKET

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1 he incidence of pharmacy crime J involving

controlled substances is increasing, and the pharmacist must become more vigilant in the control, storage and dispensing of these drugs. Every pharmacist, whether practicing in a community pharmacy or in a hospital, faces the daily possibility of a holdup, burglary or forged prescription. The Drug Enforcement Administration (DEA) reports that drug thefts from DEA registrants have doubled since 1976 and that the number of reported annual rob~es of DEA registrants has in-

W. James Bicket is director of ambuIlatory care at North Carolina Memorial

Hospital, Chapel Hill, NC 27514. 'encan Pharmacy

Vol. NS21, No. 12, December 1981 /691

creased 33 % from 1978 to 1979. This increase was for all DEA registrants including hospitals and wholesalers, so the problem is not limited to community pharmacies. The issue of pharmacy crime was a major topic of the 1981 APhA annual meeting in St. Louis. The House of Delegates voted to urge the 1981-82 Policy Committee on Public Affairs to consider innovative approaches to the problem of pharmacy crime. The fact that pharmacies are extremely vulnerable to criminal forces cannot be denied. The issue to be resolved is how pharmacists can best protect themselves and still meet the time-honored tradition of the pharmacist as the purveyor of all the drug needs of the public.

Schedule II Issues Pharmacist Wagner proposes the removal of all Schedule II sub-

stances from the inventories of community pharmacies. That proposal raises several issues of importance to pharmacists. First, the scheduling of drugs .is the responsibility of the DEA, and pharmacy's influence on the federal government's drug scheduling decisions has been historically ineffective. An administrative decision by the DEA to schedule or reschedule a drug seldom can be successfully opposed by any group . Pharmacist Wagner suggests that Schedule II drugs have "little or no use in community pharmacies." Wagner has assumed the list of drugs currently in Schedule II will remain constant. A review of the record will show that DEA has continually scheduled new drugs and rescheduled older drugs. There is no assurance that drugs needed in community pharmacies would not be placed in Schedule II at some 11

-~-----------------------------------------------------~~ tragically, more than 50 pharmacists were killed during robberies in the same year. An alarming increase in pharmacy robberies and holdups is endangering the profession on a grand scale. As drug addiction reaches epidemic proportions in our nation, and while the street value of Schedule II and other controlled drugs skyrockets, pharmacists must logically look for alternatives. These decisions must be forthright to help salvage rising insurance rates and losses of merchandise and property, and most realistically, to save lives. Crime against pharmacies is becoming much too common; we have reached a point where we must find a solution. Legislators make the rules of our land, but the profession must, through national, state and local organizations, provoke the need for reform. If we analyze three important aspects of pharmacy crime, we can ascertain what can best be done to

combat it. • First, what are the gains for the pharmacy criminal-why do it at all? • Second, what are the existing laws and penalties tied to this crime? • Third, how can we best diminish the frequency of this crime?

The High Profits There is little doubt that the gains from breaking into and/or holding up a pharmacy are very fruitful. The street value of controlled drugs is incredibly high . For example, a controlled substance like Dilaudid, with an average wholesale price of $20 per hundred, can sell for $15-$20 each on the street. That adds up to a whopping $2,000 per bottle. Another popular street drug is Percodan; each tablet can sellfor $5-$10. This means that more than $5,000 can be made by stealing and selling one bottle of 1,000 Percodan, an amount stored in most pharmacies. Amphatamines can also bring a hefty price on the

illicit market. If a criminal ever stops to assess the aspect of risk vs. profit in his demented mind, he will readily justify the profit alternative, for the risk of getting caught is quite low and the risk of going to jail is even much less. The percentage of bandits that carry a loaded gun into a holdup is assuredly high. The felon may be under the influence of drugs when he attempts the robbery, but even if he is not, it is obvious that anyone who carries a loaded gun into a pharmacy is prepared to use it. That there are high profits in illicit drugs simply proves the fact that pharmacists practice one of the most life-threatening professions in this country.

The Lax Laws One need only scrutinize the established laws that are designed to prosecute the felon and protect the pharmacist to find that they are, in a word, lax. Last year, the U.S. Senate failed to

(C~'J)ll~---------------------fu ture time. Wagner further states that patients requiring Schedule II drugs for terminal cancer or other painful conditions could "just as easily get the drug from the hospital where they are surely being treated .. .. The inconvenience would be small for them; the resulting safety factor to the pharmacist would be immeasurably large." Large teaching hospital medical centers are very complex organizations, and obtaining prescription drugs through these outpatient facilities can be a time-consuming task. For example, in our outpatient clinic, the patient must find a parking space, which may be a couple of blocks away, wait to see a physician, who must wait to get the patient's chart, and then the patient may wait for up to an hour at the outpatient pharmacy-total time may exceed three hours. One can suggest that this is citing the worst case as the rule, but unfortunately it may be close to the 12

truth . Furthermore, hospitals-large or small-tend to restrict their outpatient services to daytime hours, thus eliminating evenings and weekends for patients to procure their medications. Physicians recognize these problems and tend to prescribe larger amounts of drugs to tide the patient over between office visits, a tendency that leads to larger supplies of controlled drugs in the home, a solution which is not acceptable. In the more rural areas of the country, the local pharmacist may be the only source of medical help, with patients having to travel many miles to both physician and hospital. Clearly, shunting all patients to hospital pharmacies is not in the best interest of the patients. Further, hospital pharmacy personnel would lead a tentative existence at best if they had to maintain even larger stockpiles of controlled substances. Closely associated with the issue

of the scheduling of drugs and the limiting of their distribution to hospitals is the issue of methadone. Pharmacy has been responsible for drug distribution since the separation of medicine and pharmacy and traditionally has resisted attempts to dilute that responsibility. Only a few years ago, APhA sued the federal government because the government restricted methadone dispensing to hospital pharmacies. APhA won that suit and it was a major victory for all pharmacies, not because they could dispense methadone, but because the federal government was prohibited from restricting the distribution of methadone based on the practice setting of the pharmacist. It is not hard to imagine the development of new drugs that will require special knowledge or equipment. While the use of the drug, the cost of the equipment, and the time commitment for the advanced training may cause some community pharmacists to step aside in favor of

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pass a bill that would make robberies of controlled substances a federal crime. This was a clear insult to the profession. Currently, a provision in the Senate's version of the Criminal Code Reform Bill would make robbery of more than $500 of controlled substances a federal crime. Sen. Roger Jepsen (R-IA) thinks this dollar minimum should be eliminated. "Your head hurts just the same and you're shot dead just the same whether the thief gets $490 or $510, " Jepsen said. Local and state laws dealing with pharmacy robberies are just as fragile as federal ones. In most states, when a pharmacy is robbed for controlled drugs, the local township or city magistrate handles the case. If the criminal is caught and charged and the judge decides to put him in jail, the thief often walks because the closest county jail is most likely filled. If there is room in the jail, the criminal is likely to be out in a day or two on bail. The bails most judges set are ridiculously low

-$1,000 cash or $10,000 property, a figure that anyone can attain. In a case near Pittsburgh recently, a man was arrested on a Sunday for armed robbery of drugs and money from a neighborhood pharmacy. The robber made bail on Monday, and on Tuesday he shot and killed a pharmacist in another holdup only five miles from the first pharmacy. It has gotten to the point where it may not be worth an investment for a pharmacist to install a burglar alarm system and a panic button alert. Chances are that even if the robber is caught, he will be back out on the street soon enough . The other disconcerting fact about pharmacy crime is that when these criminals stand trial or are facing a hearing, the criminal, not the victim, has all the rights. This sad truth is attested to by policemen, lawyers and criminals alike. Until recently, the Drug Enforcement Agency has steadfastly opposed making pharmacy crime a federal offense. That indirectly helped make pharmacies more at-

Looking at the scope of the entire problem-the increased frequency of pharmacy robberies, the stealing of cODtrolled drugs and cash, and the likelihood of bodily injury sustained by the pharmacist-a logical analysis predicates only four possible solutions: 1) Isolate the criminal from society, an obvious impossibility at best. Only after the criminal commits a crime can he be locked away, and then he rarely stays locked up long. 2) Protect the pharmacist by putting him behind bars or bulletproof glass. This would be damaging to the practice of the profession for it would divorce the pharmacist from patient contact, a vital function of his or her job. 3) Legislate and enforce more stringent laws. This appears to be an immediate answer, but passing new legislation is an extraordinarily slow process and the means to enforce

( hospital pharmacists as a practical matter, community pharmacists should not be prohibited from distributing a drug per se. Further, patients have the right to expect their \ pharmacist to stock all the drugs ( they may need. Each and every pharmacist has the right to refuse to serve a patient or to stock any drug. This right is an \ independent professional decision, but this decision-making responsibility must not be denied other \ pharmacists.

and national levels to win the war against crime. Pharmacists must be willing to spend their money, give their time and forego some of their individual autonomy for the common good of the profession. There are several things that pharmacists can do now that will have an impact on the pharmacy crime problem; some of these are obvious, such as installing or improving security systems, reducing controlled drug inventories, joining cooperative crime prevention programs, and promoting local, state and national legislation. Security systems may be the best deterrent to crime . Some of this equipment is very sophisticated and therefore expensive; others, such as the installation of better locking mechanisms, can be effective at minimal expense. Pharmacists should install the best equipment they can afford. This expense could be amortized by adding a few cents to each prescription dispensed over the life of

the equipment. The prescription department should be well lighted and clearly visible to cruising police patrol cars and the public. Store fixtures and displays should be arranged to facilitate a continued monitoring. Local police can be contacted for their suggestions and support. An "open" coffee pot will bring policemen into the pharmacy as a deterrent, particularly if the visits are at random times. Efforts to reduce the number of forged prescriptions also can be effective in communities when the criminals know that the pharmacists and police are working closely together, in which case criminals tend to go elsewhere. Many pharmacists could reduce their stock of Schedule II drugs. The bother of completing DEA Schedule II order forms tends to cause infrequent and larger orders than necessary. Some hospitals have eliminated or are planning to eliminate cocaine

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Pharmacist Responsibilities

The 1981-82 APhA Policy Committee on Public Affairs has been ( charged with the responsibility of determining innovative methods for dealing with pharmacy crime. In the meantime, we must unify ourselves and pit our combined strength against the criminal element. No single answer is best, nor is one solution the panacea for this complex set of problems. Pharmacists must unite at the local, state

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tractive to traffickers and addicts than ever before.

A Logical Answer

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-~ the laws are becoming scarcer. There simply is no cohesion between lawmakers, law enforcers and the judicial system. 4) Eiminate the source of the crime-controlled drugs--from community pharmacies. If we closely scrutinize the list of drugs labeled Schedule II, we find many potent and addictive drugs. In all practicality, most of these drugs have little or no use in community pharmacies. Most narcotic drugs have no rational therapeutic use for persons outside a hospital setting or institutional environment. If a patient needs a potent narcotic, he or she should either be in a hospital or under close physician supervision. A law should be created to allow Schedule II drugs to be dispensed only at hospitals or authorized clinics. In most cases a criminal will not hold up a pharmacy just to steal the money. He is after the drugs first and usually steals the money because it is there. Eliminate the controlled substances and we will vastly reduce this crime and the great,

great risk of loss of life. Such a law would work in two ways to eliminate another crime that confronts the profession: passing forged prescri ptions. All forged prescriptions are for controlled drugs; eliminate the source and you eliminate the problem.

A Plausible Change There always will be an argument · for considering those chronically ill but ambulatory persons who need potent controlled drugs, patients with terminal cancer or persons recovering from accidents. It is my contention that these patients would just as easily get the product from the hospital where they are surely being treated as either an inpatient or an outpatient. The inconvenience would be small for them; the resulting safety factor to the pharmacist would be immeasurably large. As intelligent professionals, we must all weigh the merit of such a plausible change. The manufacturers of some controlled pharma-

ceuticals may strongly disapprove of such action. But we are not debating a matter of lost profits or personal inconvenience. We are proposing a solution to a problem that could reduce addiction, reduce crime and save the lives of many pharmacists. It will take a strong grassroots commitment to this approach to convince the lawmakers to eliminate controlled drugs from the community pharmacy. It will require convincing our state and national pharmaceutical organizations that such a change is in the best interest of the profession. But if we are concerned about ensuring a safe working environment for ourselves, our fellow professionals, and the employees and patients in our pharmacies, we must reach a working solution to this growing epidemic of pharmacy crime. We all agree that something must be done; I hope this approach will be considered. 0

-~------------------------------------from their formularies, citing drugs of equal anesthetic value without the associated potential for abuse. Community pharmacists can meet with ther local physician groups to make an equally compelling case for discontinuing the prescribing of certain drugs or limiting the quantities prescribed-both of which will help reduce controlled drug stock levels. The DEA Pharmacy Theft Prevention (PTP) programs have been effective nationwide. Fourteen programs have shown that where pharmacists and law enforcement agencies work together in a planned manner, they can reduce pharmacy crime. Yet in California, where pharmacy crime has reached all but epidemic proportions, only the San Diego area has initiated a program.

A Law and a Goal

gates that the DEA now favors federal legislation covering pharmacy crime. That legislation should provide a mandatory minimum sentence for persons convicted of crimes against all DEA registrants. Further, the sentence should be stronger for injury to or murder of registrants, and no jurisdictional minimum should protect the criminal. This law and punishment must be so powerful that even the most desperate criminal will not risk the penalty. Further, the jurisdictional and parole systems need reform. Convicted criminals get off with a minimum sentence or are paroled at the earliest moment, only to repeat the offense. And, it should be a federal offense: after all, federal law prohibits dispensing without a prescription." No, Pharmacist Wagner, throwing out the baby with the bathwater is not the solution. First and foremost we are professional pharmacists. Our patients should expect us /I

Yes, "there ought to be a law," and the political climate in Washington appears to be favorable. Gene R. Haislip, director of DEA's office of compliance and ~egulatory affairs, told the 1981 APhA House of Dele14

to dispense any and all legal drug products that they need to get healthy and stay that way. What we need is for pharmacists to get off their backsides and put their shoulders to the wheel. Collectively, we can go a long way toward solving the pharmacy crime problem. But we cannot simply wait for federal legislation; nor can we individually attack this nationwide ' epidemic. It will, instead, require that APhA and other pharmacy organizations , assume leadership positions in the fight to stop pharmacy crime. We must have a flag around which to rally, and attainable goals, both legislatively and professionally. I challenge APhA leadership to lead-and pharmacists to supportan all-out campaign to stop the senseless killing of pharmacists, their families, their employees, their I patients, and their friends . That should be a primary goal of this decade-one that all pharmacists I can support. D

American Pharmacy Vol. NS21 , No. 12, December 1981/694 /