By: Alisha Kuriakose, PharmD Candidate c/o 2022

“The Pharmacist” is a Netflix documentary that showcases pharmacist Dr. Daniel Schneider’s crusade against OxyContin® abuse. It highlights his discovery of a corrupt doctor who exploited her medical license and destroyed communities in Louisiana. It also illustrates his fight to expose Purdue Pharma of falsely reporting the addictive properties of OxyContin® and marketing it under false pretenses. Be aware this article does contain spoilers.

In 2001, Dr. Daniel Schneider began noticing that his pharmacy was receiving a suspicious number of OxyContin® prescriptions for young adults, thus, he speculated opioid abuse. He started questioning patients why they were started on high doses of OxyContin®, about their doctor, what pain they were feeling etc. To his surprise, many patients admitted that they had no pain, no recent surgeries, or accidents. He began counseling his patients in hopes of dissuading them from using OxyContin® with alternative suggestions of Tylenol® or Motrin®. He saw that he was often unsuccessful, and patients were still demanding their prescriptions be filled. Dr. Schneider informed the pharmacy owner of the influx of OxyContin® users in their community and his suspicions of doctors who were abusing their medical license to write scripts for patients who were clearly misdiagnosed or selling the pills for profit. He was told to stop harassing the patients as all the prescriptions were legal and the questioning would hurt business.

Dr. Schneider kept these instructions in mind, but knew he had to take action. He began collecting evidence for his theory by secretly recording conversations and maintaining copies of the prescriptions. The pharmacy kept a “dead list”, this tracked patients that were suspected to die soon due to the progression of their illness. Dr. Schneider compared this list to those he had suspected of abusing OxyContin® and local obituaries and found they often overlapped.

As time passed, Dr. Schneider noticed that most of the prescriptions were coming from the same pediatrician, Dr. Jacqueline Cleggett, who had opened a pain management clinic. When questioning mutual patients, one said, Dr. Cleggett, “once tried to pay [me] for [printer repair] services in prescriptions. The bill came to about $300 or $400, and Cleggett handed [me] prescriptions. When [I] said [I] needed cash to bring back to [my] employer, a police officer returned carrying the prescriptions…the officer told [me] it was in [my] best interest to leave with the prescriptions”.¹

This patient and Schneider began collecting information which they presented to the FBI and DEA. These agencies had known about Dr. Cleggett’s corrupt business and had an ongoing investigation, but they could not disclose information to Dr. Schneider. A DEA agent stated that Clegget had written 182,723 prescriptions distributed among ten pharmacies over the course of one year. ² They discovered that Dr. Cleggett did not examine her patients before prescribing them painkillers, and treated as high as 76 patients per day, predominantly overnight. The DEA had sent undercover agents as patients to confirm the legitimacy of the clinic and they observed that the parking lot of her practice was always crowded especially overnight. Investigators reported seeing license plates from Mississippi, Georgia, Alabama, and Tennessee. There were patients who often waited days for an appointment, some even camped out in their cars. Most of the patients received identical prescriptions and paid in cash. Cleggett deposited her profits of $2 million in one year.² It was evident that Cleggett was not practicing medicine; she was running a pill mill.

During this time, when receiving complaints about the number of Oxycontin® related overdoses, deaths, and addiction, Purdue Pharma, the manufacturers of OxyContin®, were calling the problem “pseudo addiction”. Alan Spanos, MD., MA., the Purdue spokesperson reported, “when a patient is looking like a drug addict it is because they were pursuing pain relief”, which Purdue claimed was different from an addiction, “because there was no physical addiction”.³

Schneider was told that he needed to present solid evidence to the medical board to catch Dr. Cleggett and Purdue Pharma. Schneider got the smoking gun he needed when a girl was prescribed Soma®, Valium®, Roxicodone®, and OxyContin®. The combination which was commonly known as the “holy trinity”, was a definite overdose for a child of her weight. To catch Dr. Cleggett in the act, Schneider called her to confirm that she had prescribed the combination, to which she admitted. Schneider talked to the doctor who had discharged the patient from the hospital and deduced that the patient was discharged on Tylenol® and that Dr. Cleggett was in the wrong. When presented with the case, the medical board took action, which prompted the DEA to take action. Many boxes of prescriptions that were already signed and awaiting to be dated were found in her clinic and taken as evidence against her malpractice.

Although Cleggett denies her charges, she was convicted under a theory of “willful blindness”. This means that, “the mental state of the offender is equated to “knowing” because the physician intentionally buried her head in the sand to avoid knowing (it is also known as the “ostrich instruction”) …in other words, it took a knowing act to avoid learning that a prescription would be improper, and that knowing act substitutes for actual knowledge of the criminal endeavor”.³

Having Dr. Cleggett arrested and the termination of her medical license aided Dr. Schneiders fight against Purdue’s mis-marketing of OxyContin’s® addictive properties. Schneider’s small victory in putting away Dr. Cleggett aided in dismantling a pill mill that was destroying communities throughout the southern United States.

It also helped establish a prescription monitoring program (PMP) in Louisiana. This helped monitor drugs being sold by making all records electronic. In 2017, Governor John Bel Edwards mandated the use of the Louisiana’s PMP for opioids making it a statewide comprehensive platform for healthcare professionals to review each patients’ controlled substance prescription history efficiently and quickly. The PMP is an electronic database run by the Louisiana Board of Pharmacy. It monitors controlled substances by compiling data on controlled substances dispensed in Louisiana and distributes this information to authorized individuals such as prescribers and pharmacists. Act 76 requires prescribers to consult the PMP before prescribing opioids, this effort to combat Louisiana’s opioid epidemic helps verify whether the patient has other active opioid prescriptions. This electronic database works to, “minimize any workflow disruption by providing near-instant and seamless access to critical controlled substance prescription history information to both prescribers and pharmacists. This platform utilizes current PMP prescription data and transfers it into electronic health records and pharmacy management systems”. ⁴

Using a PMP enables prescribers to verify prescriptions, identify potential substance abuse disorders and provide these patients with the necessary support, verify the controlled substance prescriptions associated with prescribers’ DEA registration numbers to identify potential fraud, correct errors and identify trends, and reduce potential adverse reactions.⁵ Although Louisiana has made many changes to prevent substance abuse, the state still has a long way to go. In 2018, the National Institute on Drug Abuse reported 79.4 opioid prescriptions for every 100 persons were written in Louisiana. This is higher than the national average rate of 51.4 prescriptions. Louisiana was among the top five states in the country for highest rates in 2018. Almost 40% of the reported drug overdose fatalities (1,140) in Louisiana involved opioids in 2018 totaling 444 deaths. ⁶

Data collected by New York State suggests that, “more than 500,000 people in the United States have died from drug overdoses since 2000-nearly 91 people a day. An average of one call every 45 minutes was reported to Poison Control Centers for pediatric opioid exposures from 2000-2015”. ⁷ Like Louisiana, New York State is also taking similar steps in its crusade against the opioid epidemic. New York State Department of Health is working to identify and share data between various healthcare, government agencies and affected communities, make New York’s PMP easier for providers to access and use, provide resources such as overdose treatment (Naloxone) and medication assisted treatments (Buprenorphine etc.), offer overdose prevention classes, provide more medication drop off boxes and develop training for healthcare providers on addiction, pain management and treatment. ⁷ Governor Cuomo has initiated the New York State Addiction and Substance Use Disorder Resource flash drive program in which flash drives are distributed to coaches, school administrators and teachers for instruction targeted for school aged children and athletes to make them aware of what to do in the case of an overdose and the dangers of addiction and substance abuse. ¹ The Bureau of Narcotic Enforcement, the Office of Alcoholism and Substance Abuse Services, and the Education Department worked to prepare the materials on the flash drive so that they can be distributed at no charge to New York State Schools to address substance abuse in young kids at the community level. New York State also initiated the Naloxone Co-payment Assistance Program (N-CAP) which can cover up to $40 in prescription copayments to reduce or eliminate out of pocket expenses when purchasing naloxone at a participating pharmacy. This overdose campaign helps people proactively educate themselves and others and allows them to be prepared in case of an overdose.⁷

Dr. Daniel Schneider’s story proves that if one person speaks up, a whole system can change.

References

1. ChoiniereA. Jacqueline Cleggett: 5 Fast Facts You Need to Know. https://heavy.com/entertainment/2020/02/jacqueline-cleggett/. Published February 7,2020. Accessed August 28, 2020
2. Dineen KK, DuBois JM. BETWEEN A ROCK AND A HARD PLACE: CANPHYSICIANS PRESCRIBE OPIOIDS TO TREAT PAIN ADEQUATELY WHILEAVOIDING LEGAL SANCTION?. Am J Law Med. 2016;42(1)
3. The Pharmacist. Feb. 2020. [Video] Directed by J. Furst and J. Nason. Netflix: TheCinemart
4. Connect LH. How To Use The PMP-And Why You Should. How To Use The PMP – And Why You Should | Louisiana Healthcare Connections.
5. State of Louisiana. Louisiana Board of Pharmacy.http://www.pharmacy.la.gov/index.cfm?md=pagebuilder. Accessed November 13, 2020.
6. National Institute on Drug Abuse. Louisiana: Opioid-Involved Deaths and Related Harms. National Institute on Drug Abuse.https://www.drugabuse.gov/drug-topics/opioids/opioid-summaries-by-state/louisiana-opioid-involved-deaths-related-harms. Published September 13, 2020. Accessed November 13, 2020
7. Governor Cuomo Announces New Initiatives to Combat Substance Abuse Among School-Aged Children and Student Athletes.https://www.governor.ny.gov/news/governor-cuomo-announces-new-initiatives-combat-substance-abuse-among-school-aged-children-an-0. Published April 5, 2018. Accessed November 13, 2020