Rogue Pharmacists Jesse C. Vivian, RPh, JD Professor, Department of Pharmacy Practice College of Pharmacy and Health Sciences Wayne State University Detroit, Michigan 10/20/2010 US Pharm. 2010;35(10):120-123. The profession of pharmacy is a noble one. Everyone entering the field for the past few years comes in with a doctorate-level degree, and before that a 5-year Bachelor of Science (BS) in pharmacy was required. Pharmacists subscribe to a code of ethics and take an oath to ensure the best outcomes for the patients we serve. But, as the saying goes, “it only takes one bad apple to spoil the barrel.” Every time a pharmacist does something illegal or unethical, that action reflects negatively on the rest of us. Keeping our fellow pharmacists acting within the law and following ethical standards is the best approach to protecting our status as one of the top professionals for honesty and ethical behavior and the best way to ensure our public image. But rogue pharmacists do exist, and we as a profession need to condemn their unacceptable actions and do everything we can to make sure our patients, other health care professionals, and lawmakers do not perceive the bad actors as a reflection of the whole. This month, a few recent stories about pharmacists who acted outside professional norms should serve as a reminder of why the rest of us adhere to high standards of care. Case 1 On April 10, 2010, a 59-year-old pharmacist pled guilty in a federal court in New Hampshire to unlawfully dispensing and misbranding controlled substances. The former Wal-Mart managing pharmacist knowingly dispensed Schedule III drugs, including Vicodin (hydrocodone and acetaminophen), to an individual on four separate occasions in 2005 and 2006 without a valid prescription. After the conviction, the pharmacist voluntarily surrendered his license to the state. He could have faced up to 5 years’ imprisonment for unlawfully dispensing the drugs and 1 year for misbranding. He was sentenced to 14 months in a federal penitentiary.1 Case 2 On July 7, 2010, two pharmacists who were owners of the Patterson Family Pharmacy in Sacramento, California, admitted to dispensing Schedule III and IV controlled substances on over 2,000 occasions. These were Internet prescriptions that were not valid because no patient-physician relationship existed. The pharmacists have agreed to pay $500,000 in civil fines.2 Case 3 The Primary Care Center Pharmacy, also in Sacramento, agreed to pay $250,000 in penalties and enter into a 5-year compliance plan to settle federal charges that the pharmacy illegally dispensed controlled substances over 175 times.3 Case 4 On September 3, 2010, an optometrist and a pharmacist were arrested in Kokomo, Indiana, on prescription fraud charges. The optometrist, who was not licensed to prescribe drugs, went into a K-Mart pharmacy several times and wrote controlled substances prescriptions in the names of different patients, always using the Drug Enforcement Agency (DEA) numbers assigned to other physicians and the pharmacist who filled them. Apparently, on at least one occasion, the optometrist had a legitimate prescription for OxyContin (oxycodone), but after it was filled, he traded the medication with a woman for other drugs. An undercover officer bought the oxycodone from that woman.4 Case 5 A prominent 63-year-old pharmacist in Madison, Wisconsin, was arrested with an alleged coconspirator, the 55-year-old founder of the Women’s Health Center and a member of the University of Wisconsin Foundation’s Board of Directors. On September 3, 2010, the two were charged with two counts each of conspiring to deliver counterfeit prescription drugs, including controlled substances in New York. According to the complaint, an FBI informant, who was running an illegal online pharmacy, ordered millions of the antianxiety drug alprazolam and the appetite suppressant phentermine during 2008 and 2009 from the pharmacy, even though the informant did not have a license to purchase drugs. The drugs were delivered to the pharmacy from India. Some of the medications contained broken tablets and several bottles were not properly labeled. During the spring of 2010, another FBI informant ordered oxycodone, hydrocodone, and Viagra (sildenafil) from the same pharmacy. The complaint states that the pharmacist offered to sell generic Viagra to the informant. Generic Viagra is not available in the United States because Pfizer holds an exclusive patent. Investigators intercepted five packages sent to the informant by the pharmacist. Two of the packages, both from India, contained counterfeit oxycodone tablets. Another package contained about 1,000 tablets of what appeared to be Viagra, complete with the Pfizer monogram in an unlabeled container. Assays showed that the tablets did not contain any Viagra.5 Case 6 A 61-year-old pharmacist working for the Pennsylvania Department of Public Welfare’s Office of Mental Health, Substance and Abuse Services—who was also secretary of a committee that approved Medicaid-paid drugs in state hospitals, prisons, and juvenile centers—was convicted on two felony charges of conflict of interest for taking payments from drug manufacturers and pocketing money for supervising pharmacy interns from Duquesne University. He could face up to 5 years in prison and $10,000 in fines. Interestingly enough, he paid more than $27,000 in civil fines after the Pennsylvania Ethics Commission cited him for state ethics violations in connection with the same allegations in 2005. The criminal complaint said the pharmacist accepted perks from Pfizer and Johnson & Johnson’s Janssen, which were promoting the use of psychiatric drugs in state hospitals. Prosecutors said he used his position to pocket $2,400 from Duquesne University for supervising pharmacy interns at state hospitals between 2000 and 2003. The pharmacist was convicted on a third misdemeanor count for failing to file a full accounting of his outside income on his state ethics disclosure forms.6 Case 7 On June 4, 2010, a 53-year-old pharmacist from Elizabeth, New Jersey, pled guilty to insurance fraud and agreed to make restitution payments of more that $235,000. This leader in the Sierra Leonean community and patriarch in a fast-growing church may face up to 10 years in prison when sentenced. He was charged with pocketing money from at least 290 insurance claims billed to Medco for nonexistent prescriptions between 2008 and 2009. The father of four children immigrated to the U.S. from Sierra Leone in 1981 and graduated with a pharmacy degree from Rutgers University. He had been featured in local media for his extensive work in helping fellow immigrants adapt to life in this country.7 Case 8 On August 13, 2010, a federal judge sentenced a 44-year-old pharmacist to 4 years in prison for participating in a nationwide conspiracy to sell anabolic steroids compounded at Applied Pharmacy Services located in Mobile, Alabama. He is the first of a group of five men to be sentenced and could have faced imprisonment for up to 7 years. Two of the other men convicted, who were also owners of the pharmacy, are expected to be sentenced in the near future. According to court records, Applied Pharmacy Services shipped 762,388 dosages to 17 doctors and clinics from April 4, 2004, until August 30, 2006.8 Case 9 On July 1, 2010, police arrested a 61-year-old pharmacist in a Modesto, California, Rite Aid. He was described as a “traveling pharmacist,” someone who works in one location for only a few days before moving on to another one. He was observed by company loss-prevention officers as leaving the pharmacy several times during the day, going to his car, smoking cigarettes, and drinking from a mug. After the pharmacist left his car, the loss-prevention officers looked through the windows and noticed an accumulation of pills and bottles. After being seen stealing a bottle of alcohol and heading toward his car, the pharmacist was detained by the officers. Upon inspecting the car, the officers found 350 tablets of diazepam, acetaminophen with codeine, alprazolam, and several bottles of promethazine codeine syrup. The mug he had been drinking from was filled with alcohol.9 Case 10 On August 12, 2010, a 37-year-old pharmacist was arrested in Vincennes, Indiana, following an investigation alleging he stole over 900 Schedule III controlled substances from a Walgreens pharmacy where he was employed in 2009. At the time of the arrest, however, he was no longer employed there.10 Case 11 During a routine traffic stop on February 15, 2010, police arrested a 51-year-old pharmacist who worked at the Jasper, Texas, Wal-Mart after noticing he was driving his truck erratically. Police found a large quantity of prescription drugs in his pockets and in the truck. The drugs included hydrocodone, Vicodin, Tylenol 3 and Tylenol 4 (acetaminophen/codeine), tramadol, butalbital, codeine, ibuprofen, Xanax (alprazolam), Provigil (modafinil), bupropion, ranitidine, Viagra, Cialis (tadalafil), and Levitra (vardenafil)—all of which were allegedly stolen from Wal-Mart. When questioned, the man had no explanation for why he was in possession of the prescription medications. His bond was set at $13,500, and he was not immediately able to post bail. The police had been investigating the pharmacist after Wal-Mart officials informed them of suspicions that he was involved in the theft of drugs.11 Case 12 On January 14, 2010, a 44-year-old pharmacist was arrested in Citronelle, Alabama, on charges of selling and distributing controlled substances. He was stopped as he was leaving the pharmacy where he was employed. At the time of his arrest, he was in possession of 1,000 hydrocodone tablets and 1,400 mL of codeine syrup. He is suspected of stealing at least 4,000 controlled substances and 2,000 mL of codeine syrup.12 Case 13 In Plainview, New York, police arrested a 53-year-old pharmacist after they overheard what sounded like a drug deal while he was talking on his cell phone as he sat in his parked car in a gas station at 3:45 pm. Moments later a minivan arrived, and the driver got into the pharmacist’s car. The police observed what looked like an exchange of a bag of pills for cash. The minivan driver was found to have 15 Cialis pills in his possession. The pharmacist was in possession of more than 400 oxycodone tablets. While the investigation was ongoing, another vehicle pulled up. As its driver walked up to the phamacist’s car, police apprehended him. He was carrying several doses of oxycodone and methadone and was in possession of $17,000 cash. All three individuals were charged with illegal possession and distribution of drugs.13 Case 14 This case is somewhat different from the others because the articles allegedly stolen by the pharmacist do not involve controlled substances. On June 9, 2010, a female pharmacist working at the University of North Carolina (UNC) Student Health Center was arrested on two counts of felony embezzlement for stealing $4,000 worth of drugs and other items including blood pressure medicines, bone loss medication, a pulmonary drug, antiaging cream, flaxseed oil, grape seed extract, and deodorant. She had been employed by UNC since 1999. Her employment was terminated on May 18 for “personal reasons,” according to university records. An anonymous tip was called into the UNC police department on April 23, 2010.14 Case 15 A 50-year-old pharmacy owner in Edison, New Jersey, was arrested in July 2010 when federal marshals searched his home and several businesses he owns and found thousands of oxycodone tablets, anabolic steroids, fraudulent and blank prescription pads, three guns, and $500,000 in cash. Dubbed “Operation Oxymoron,” federal and local police agencies began investigating the pharmacist in October 2007. He allegedly filled more than 45,000 prescriptions for oxycodone that were not issued by legitimate prescribers. In all, 19 people were arrested in the sting operation, which was said to be generating about $1 million per month. Eleven other individuals are also being sought in connection with the investigation. The pharmacist faces 20 years to life in prison if convicted of all charges.15 REFERENCES 1. Former Wal-Mart pharmacist pleads guilty to unlawfully dispensing and misbranding controlled substances. U.S. Department of Justice. Media release. April 12, 2010. www.justice.gov/usao/nh/press/april10/MI_Reilly.html. Accessed September 14, 2010. 2. Robertson K. Sacramento pharmacies settle over illegal drug sales. Sacramento Business Journal. July 8, 2010. http://sacramento.bizjournals.com/sacramento/stories/2010/07/05/daily45.html. Accessed September 14, 2010. 3. See Note 2, supra. 4. McAnnally D. Optometrist, pharmacist arrested on fraud, drug charges. WTHR Eyewitness News. September 3, 2010. www.wthr.com/global/story.asp?s=13100717. Accessed September 14, 2010. 5. Richmond T. Wisconsin pharmacist accused of selling fake drugs. Forbes. September 3, 2010. www.forbes.com/feeds/ap/2010/09/03/business-health-care-us-counterfeit-drugs-wisconsin_7901993.html?boxes=Homepagebusinessnews. Accessed September 14, 2010. 6. Erdley D. State pharmacist convicted of conflict of interest. Pittsburgh Tribune-Review. December 24, 2008. www.pittsburghlive.com/x/pittsburghtrib/s_604288.html. Accessed September 14, 2010. 7. O’Connor J. Elizabeth pharmacist convicted of insurance fraud is leader of Franklin Township church. Star-Ledger. June 4, 2010. www.nj.com/news/index.ssf/2010/06/pharmacist_convicted_of_insura.html. Accessed September 14, 2010. 8. Kirby B. Steroids case pharmacist gets 4 years in prison in Mobile case with ties to pro sports, wrestling. Alabama Live LLC. August 13, 2010. http://blog.al.com/live/2010/08/pharmacist_in_mobile_ala_stero.html. Accessed September 14, 2010. 9. Clark B. Pharmacist arrested on suspicion of pill theft at Modesto Rite Aid. Modesto Bee. July 1, 2010. www.modbee.com/2010/07/01/1235291/pharmacist-arrested-on-suspicion.html. Accessed September 15, 2010. 10. Scott M. Former pharmacist arrested for stealing medication. Wish TV8. August 12, 2010. www.wishtv.com/dpps/news/indiana/former-pharmacist-arrested-for-stealing-pain-medication-share_3543393. Accessed September 15, 2010. 11. Lawrence S. Pharmacist arrested on drug, other charges. KFDM News. February 15, 2010. www.kfdm.com/articles/hasewinkle-36612-pharmacist-drugs.html. Accessed September 15, 2010. 12. Kramer J. Citronelle pharmacist arrested for stealing prescription drugs. Alabama Live LLC. January 15, 2010. http://blog.al.com/live/2010/01/citronelle_pharmacist_arrested.html. Accessed September 15, 2010. 13. Bolger T. Pharmacist among 3 arrested in Plainview drug deal. Long Island Press. February 14, 2010. www.longislandpress.com/2010/02/14/pharmacist-among-3-arrested-in-plainview-drug-deal/. Accessed September 15, 2010. 14. Dunn A. UNCW pharmacy looks at security after employee’s embezzlement charges. Star-News. June 16, 2010. www.allbusiness.com/crime-law-enforcement-corrections/law-arrests/14643893-1.html. Accessed September 15, 2010. 15. Cruz A. Flemington pharmacist arrested in ‘Operation Oxymoron.’ Black Urban Times. April 8, 2010. www.theblackurbantimes.com/2010/04/flemington-pharmacist-arrested-in.html. Accessed September 15, 2010. 16. Bureau of Labor Statistics. U.S. Department of Labor. Occupational Outlook Handbook, 2010-11 Edition. Pharmacists. www.bls.gov/oco/ocos079.htm. Accessed September 15, 2010.

Why, BigPharma? Why?

This list is comprised of what I feel to be the most useless, non-essential drugs on the market today. I got the idea from The Red Headed Pharmacist's Blog. In no particular order, they are:

1) Tribenzor - This "new" drug has 3 ingredients: olmesartan, amlodipine, and hydrochlorothiazide. Drug companies constantly whine that medications cost so much so that they can afford research and developement for new, innovative (key word there) medications. However, the geniuses at Daiichi Sankyo have combined 3 old drugs into 1! No need to pay generic prices for amlodipine and HCTZ, and your Tier 2 price for Benicar! Just try to get a PA on Tribenzor and (if the PA goes through) pay your Tier 3 co-pay. And those of you without insurance, just, please, don't bother.

2) Solodyn - Have you ever heard of Minocin? No, because it went generic YEARS ago and is now known as minocycline. Usually people take it twice a day and it's on $4 lists in some places. But this "brand name" drug is extended release--you just have to take it once a day! But it's near $500. Good luck.

3) Doryx - This falls into the same category as Solodyn. This is just an extended release form of doxycycline hyclate. Want it for $4 and take it twice a day? Go to Giant Eagle. Want to have your PA denied and pay $500 just to take it once a day? Go ahead and try.

4) Oracea - Oracea is right in line with Solodyn and is almost exactly the same as Doryx! It's an extended release version of doxycycline! What a joke.

5) Jalyn - OK, you want to make purple paint. If a can of blue paint costs $10 and a can of red paint costs $10, you can spend $20 and mix them. Or, you can buy the can of purple paint for +$500. That's what this is. Avodart (dutasteride) and Flomax (tamsulosin) in one can.

6) Oleptro - Oh this is a good one. Trazodone HCl was first introduced as Desyrel so long ago, that the FDA doesn't even have it in the Orange Book anymore. It was first used to treat depression. Now, it's mainly used to help people sleep. Well, now Angelini Labopharm wants to bring it back and make it extended release for depression again. Why? Why would anyone (in their right mind) take this medication. It's going to cost a fortune and there are already enough generic antidepressants on the market, I've got them falling out of my ass.

7) Silenor - This is doxepin. Why does doxepin sound familiar? Because it was already introduced as Sinequan years ago. Now it's generic and cheap for the people who need it. It comes in a capsule form. Silenor, on the other hand, is in tablet form and comes in two lower strengths. Apparently this is consider a good innovation by the FDA.

8) Suboxone - Before you start yelling at me about how this medication may have helped you, let me point something out. Suboxone is a sublingual tablet. That means you stick it under your tongue and it dissolves. Now Reckitt Benckiser decided to reformulate the damn thing into a sublingual film! So now in stead of putting a little pill under your tongue, you put a little film strip under your tongue! It's so innovative! It's just a Listerine Pocketpaks breath strip. By the way, if you go to the Suboxone site, the home page is overrun with ads for the soluable films now. It doesn't even mention the sublingual tablets. There is also a link for a coupon for $75 off your prescription. If the drug company will give you $75 off a single prescription, that should tell you how expensive this redundant medication really is.

9) Vimovo - Another great innovation from BigPharma. Take 1 generic drug, now available over the counter, and another generic drug ALSO available over the counter, and what do you get? Basically an Aleve/Prilosec combo. Now you need a prescription for this +$300 medication instead of just taking 2 things at once. Naproxen/esomeprazole. Just...why?

10) Zuplenz - Zofran is indicated for nausea associated with cancer patients/chemotherapy. it is available in generic form as ondansetron. Then Zofran ODT was released. ODT stand for orally disintegrating tablet. The ODT drugs melt in your mouth, not in your hand. Well, the makers of Zuplenz pulled a Suboxone move. They reformulated it (innovative, huh?) and now have approval for a "brand only" ondansetron film.

11) Caduet - Amlodipine and atorvastatin...Norvasc and Lipitor. Way to go combining two of your own previous drugs into one, Pfizer. Real innovative.

Another thing that pisses me off is metabolites. Medline Plus defines a metabolite as: "any substance produced during metabolism...in terms of medications, a metabolite usually refers to the product that remains after the drug is broken down by the body." Understanding this, let's look at some current BRAND NAME medications with their relative chemical name.

Xyzal - levocetirizine

Clarinex - desloratidine

Nexium - esomeprazole

Kapidex - dexlansoprazole

Lexapro - escitalopram

Focalin - dexmethylphenidate

Levaquin - levofloxacin

Do any of these sound or look familiar? You've probably seen or heard ads for them somewhere. Now, let's look at another list and try to find the similar items.

Zyrtec - certirizine

Claritin - loratidine

Prilosec - omeprazole

Prevacid - lansoprazole

Celexa - citalopram

Ritalin - methylphenidate

Floxin - ofloxacin

Do you see the difference? The first list is made up of metabolites from the second list. After being metabolized, a medication changes chemical make-up. After being metabolized, Zyrtec (certirizine) turns to LEVOcertirizine. After being metabolized, Claritin (loratidine) turns to DESloratidine. The drug companies took one step out of our bodies' process and patented the metabolized version of the chemical JUST TO MAKE MORE MONEY.

Let me make it simple. Metabolized means swallowed. Here's another example: after being swallowed, Ritalin (methylphenidate) changes to DEXmethylphenidate. In essence, these ARE NOT new, innovative drugs and insurance companies hate paying for them because they know there is a cheaper, possibly OTC item, that will work just as well.

This kind of nonsense pisses me off, it pisses my co-workers off, it pisses the entire medical field off...except for BigPharma. They just keep making money hand over fist at the general public's expense.