Cowboy’s Drugstore 

Prescription drug addiction—and the crime it spawns—is on the rise in Montana, even as the state falls behind in efforts to curb abuse. How late is too late?

On July 29, 2005, at 7:30 p.m., Chad Lewis, a 32-year-old Kalispell man with no criminal history, allegedly walked into the Evergreen Kmart with a .357 revolver, showed it to a pharmacist and demanded bottles of Norco and Percocet, two synthetic opiate prescription painkillers.

The pharmacist handed over about 500 pills. Lewis took the drugs and left, beginning an 11-day run from the law.

Flathead County Sheriff Detective Bruce Parrish says it’s exceedingly rare for someone’s first crime to be armed robbery.

And, according to Kimberly Lewis, Chad’s 29-year-old wife who teaches high school English in Kalispell, her husband’s act was completely uncharacteristic.

The road to robbery started four years ago, when Chad fell to his knees with overwhelming back pain while working a construction job. Kimberly says she’s unsure exactly what caused the injury, but they eventually discovered that Chad had fractured three discs in his back. The fractures caused Chad constant pain. He tried several surgical procedures but, Kimberly says, “Nothing helped.”

The couple was waiting for the FDA to approve prosthetic discs, but in the meantime, Chad had to take prescription painkillers. Even that, according to Kimberly, didn’t stop the pain, only dulling it enough so he could function. He remained unable to sit for long periods of time, or lie on his back. He also had to quit his construction job and take a job as a real estate agent.

After trying a few different prescriptions, Chad started taking Lortab.

THE WILD WEST
Lortab, Percocet, Norco and prescription drugs in general are still in a wild west stage of oversight and regulation in Montana, with addicts often able to obtain these drugs for years before being caught, and with virtually no programs in place to help patients legitimately using addictive drugs to get off them.

Chad’s was not the first prescription drug-related crime this year in the Flathead Valley. In late February, a Columbia Falls man tossed a cinder block through the window of a Whitefish pharmacy and stole more than 18,000 milligrams of Lortab, with a street value of $1 per milligram. He, like Chad Lewis, was considered by law enforcement to be an addict.

According to Flathead County Sheriff’s Detective Kevin Burns, director of the Kalispell-based Northwest Drug Task Force, there has been a steady increase in prescription drug-related crimes over the last 10 years in his jurisdiction, which encompasses Flathead, Lake and Lincoln counties, and the Salish-Kootenai reservation. To combat crime and abuse, in May 2004 the task force added a full-time officer to work prescription drug crimes. That officer handled about 60 prescription-related cases last year, Burns says, up about 75 percent from 10 years ago and 30 percent from five years ago. The Flathead County prescription drug officer was promoted a few months ago and replaced last week with a new officer, Jeff Middleton.

Middleton says he still has a lot to learn about the job, but adds, “The more I dig into it, the bigger the problem appears to be.” His job, he says, entails investigating all prescription fraud and trying to build working realtionships with doctors, pharmacists and law enforcement personnel.

According to Flathead County Under Sheriff Mike Meehan, there have been 18 prescription drug overdoses in Flathead County this year alone. Recently, a 52-year-old Kalispell woman died by overdosing on fentanyl, a synthetic narcotic pain killer, after altering several fentanyl patches to increase the drug’s potency.

Mike Cummins, director of the Flathead Valley Chemical Dependency Clinic, says he also has noticed a steady rise in the number of patients he sees addicted to prescription drugs. He says he really noticed an uptick in the last five years with the development of oxycodone, a synthetic opiate better known by the brand name OxyContin, which is effective for pain, but has a potential for addiction comparable to heroin if crushed and injected or snorted.

The Flathead’s prescription drug problem is part of an overall state and national trend. According to the Montana Department of Public Health and Human Services, the number of people admitted to state-approved chemical dependency programs has climbed steadily from 478 in 2002 to 659 in 2004. Prescription drug abuse has recently come into the national limelight, thanks in no small part to the parade of celebrities, including Green Bay Packers quarterback Brett Favre, talk-show host Rush Limbaugh, rapper Eminem and Wilco vocalist Jeff Tweedy, who lately became addicted to narcotics and other drugs originally prescribed by doctors. Nationwide, the National Center on Addiction and Substance Abuse (CASA) estimates that between 1992 and 2003, prescription drug abuse jumped 212 percent among 12- to 17-year-olds and 81 percent among adults. Nationwide, prescription overdoses account for 44 percent of all overdoses.

Despite these numbers, little has been done in Montana to curb abuse, or to make addictive prescription drugs more difficult to obtain.

DOCTOR SHOPPING
By early 2005, according to Kimberly, Chad’s use of Lortab had become something more than a means of alleviating pain. In February Chad told Kimberly and his father that he had a problem with painkillers, and that he was considering going to Pathways Treatment Center in Kalispell to try to get off them.

At the time, Kimberly and Chad’s father questioned whether that was a good idea.

“[Treatment centers] don’t teach you how to take five painkillers a day, they teach you how to take zero,” Kimberly says.

Chad’s family didn’t think he would be able to function without something to alleviate the pain, though in hindsight, Kimberly says, they should have encouraged him to go.

Instead, they tried several methods to curb his use. At one point, they set up a plan with the Rosauers pharmacy in Kalispell that allowed Chad to come in once a day and get his pills for that day only.

Kimberly also tried taking control of his pills herself, locking them in a box and giving them to Chad only when he was supposed to take them.

“It’s hard to do that between husband and wife. It was hard to say ‘no’ when he said ‘Can I have just one extra here and there?’”

Eventually, according to Detective Parrish, Chad began getting his prescriptions through a practice known as doctor shopping. Doctor shopping, in states like Montana with no program or central database for monitoring prescriptions, is fairly easy, even though it is illegal. A person makes appointments with several doctors, fakes symptoms that would merit their prescription of choice, then goes to multiple pharmacies to get those prescriptions filled.

“It’s amazing how much of a prescription you can get by doctor shopping,” says detective Burns. That, he says, is one of the reasons prescription drug abuse has increased in recent years.

Paul Brand, chairman of the Montana Pharmacy Association and a pharmacist in Florence, has seen doctor shopping first hand.

“We’ve seen people who use multiple names and multiple dates of birth,” he says. “Its pretty hard to catch someone like that.”

The only way they do get caught, he says, is when a pharmacist happens to work at more than one pharmacy, and notices the same person using two names.

In Chad’s case, doctors and pharmacists did eventually catch up with him.

On July 28, Chad became desperate and went to several area doctors, hoping to get a painkiller prescription. But Chad had worn out his welcome with local doctors, was refused more painkillers and advised to seek counselling.

On July 29, he and Kimberly were supposed to go on a camping trip together. But just before they left, Chad told her that he was out of Lortab, was unable to get anymore and would have to go through withdrawal. He told Kimberly to go camping alone so she wouldn’t have to watch him struggle, and she did.

“I think that was a moment of desperation for him,” says detective Parrish. “I think it was his inability to get those prescriptions on the 28th that caused him to commit robbery on the 29th.”

THE DARK AGES
On Aug. 11, 2005, President Bush endorsed what many states have already pursued as a solution to prescription drug abuse. Bush signed a law that would make $60 million available to states to kick-start prescription drug monitoring programs. A monitoring program creates a database for physician and law enforcement use that shows a patient’s prescription history within the state. A doctor in Hamilton could see, for example, if a patient had an OxyContin prescription filled in Whitefish the day before, and could either talk to him about abuse counselling or, depending on the state, refer the matter to law enforcement. One of the requirements for receiving the federal money is that the states would eventually have to connect to a nationwide system to prevent doctor shopping across state lines.

Twenty-one states already had monitoring programs in place before the federal bill was signed. In the northwestern United States, Washington, North and South Dakota, Idaho and Wyoming all either have a prescription drug monitoring program in place or are in the process of creating one.

Brand, Cummins and detectives Burns and Parrish all agree that a monitoring program would help curb abuse of addictive drugs in Montana. So does Rebecca Deschamps, executive director of the Montana Board of Pharmacy.

Deschamps recounts a recent phone call she received from a doctor in Idaho. The doctor had a Montana patient in his office asking for “fairly heavy-duty narcotics,” and was hoping to have Deschamps check the Montana monitoring program to see if the patient had a legimate need.

“Well,” Deschamps told the doctor, “Montana’s still in kind of the Dark Ages, but we hope to be coming up into the 21st century soon.”

Deschamps says she gets similar calls several times each month.

She says she hoped to have a monitoring program passed during the 2005 legislative session but was unable to coordinate efforts with various interests, including associations for dentists, physicians, hospitals, nurses and law enforcement, in time to make it happen.

She has continued her work to bring these groups together, though, and has set her sights on the 2007 session. So far, she says, she has not come across any opposition to a monitoring program. The one hang-up she forsees is the privacy issue, but she expects to address that in any law.

“It’s not a fishing expedition,” Deschamps stresses, saying that police won’t be able to check to see who is using what drugs on a whim. In fact, she says, she wants felony penalties mandated in the bill for anyone who misuses prescription information.

Deschamps isn’t exactly excited about the bill Bush recently signed. She points out that there are already $350,000 grants that states can apply for to help pay for monitoring programs. If any good does come out of the bill, she says, it will be the attention it directs toward the problem, which could help legitimize the issue with state legislators.

By the 2007 session, she says the state must enact a monitoring program.

“We are soon to be surrounded by states that have this...we’re going to kind of force people into [Montana],” she warns.

PUZZLE PIECES
While monitoring programs appear to have strong support as a way of curbing prescription drug abuse, they do have limitations. For one thing, none requires patients to show identification to either doctors or pharmacists. A person could presumably use a false name to go doctor shopping, as Brand points out they are already doing. Also, states have not yet linked their monitoring programs, so a person could travel to several different states to fill prescriptions, or come to states without monitoring programs, like Montana, and get as much as they want.

And then there’s the Internet. According to CASA, a one-week study in 2004 found nearly 500 websites selling prescription drugs. Only 6 percent of those required a prescription, and none verified age of the buyer.

“The Internet has a larger effect than we’d like to see,” Deschamps says. “It’s hard to get your arms around it.”

Because the prescription websites can be based anywhere in the world, and can set up and tear down quickly, Deschamps says they are hard to handle on the state level.

“Any true answer is going to come from the federal government,” she says.

Even if all the loopholes are closed, prescription drugs could do what all other illicit drugs have done—go on the black market. And even now, with prescription drugs easily attainable through fraud, the street markup on them is high. A 25-30-pill count bottle of Lortab, also known as Vicodin, sells for $8 at the pharmacy and $250-$300 on the black market, according to detective Burns. Likewise, a 30-pill count bottle of oxycodone costs about $173 at a pharmacy, but goes for around $1,200 on the black market.

“People always find a way to get them,” says Jim Pittaway, an addiction counsellor at Community Medical Center’s Bridges program, where he specializes in helping brain injury patients battle addiction to painkillers.

Pittaway is a contrarian when it comes to monitoring programs. He says they approach addiction from the wrong angle. Pittaway would rather see more pressure put on doctors to prevent their patients from becoming addicts in the first place.

“They are the responsible adults in this equation,” he says.

He says he sees a constant flow of patients who, because of an injury, were given addictive painkillers for as as long as six weeks at a time.

“They get addicted,” Pittaway says, “and then the docs go, ‘Oh jeez... That’s your character.’ And the patients are on their own.”

After losing their legitimate prescription, he says, some patients suffer through their withdrawals; others, like Chad Lewis, Limbaugh, Favre and Tweedy, find a way to keep getting their drug of choice.

“Right now it’s anarchy,” Pittaway continues. “Physicians need to take initiative to restore some sanity to the whole process. [Addiction] is a medical problem, and doctors need to stop pretending that it’s not.”

Even detective Parrish subscribes to the view that prescription addiction is often a medical, not criminal problem. The best solution for many addicts, Parrish says, would be getting them help in the form of counselling rather than sending them to prison.

“[Chad Lewis] commited a crime, but he wasn’t selling drugs,” Parrish says. “He was doing it solely for his own purpose. Counselling would have been the answer.”

But Pittaway has come up with his own plan for administering addictive drugs and preempting counselling. His plan is designed from the addiction counsellors’ perspective, and tries to medically treat addiction before it wrecks a patient’s life. He says patients should not become addicted to prescription drugs, especially opiates, in the first place. People who need to be on an addictive drug for an extended period of time, he says, should sign a contract with their doctor that sets rules for how the drug will be used and dispensed. Patients should be required, by the contract, to use only one pharmacist and one doctor. And, most importantly, just before the time they would become physically or mentally dependent on a particular drug, they would either go without it or switch to another drug based on a different chemical. Once they have cleared the potentially addictive drug out of their systems, patients would be able to start using it again. This way, Pittaway says, addiction could be short circuited. As of now, Pittaway says he has not been able to persuade any doctors to try this method.

Dr. Richard Wise is uniquely suited to evaluate the various proposed solutions, such as monitoring programs and Pittaway’s ideas. He works as medical director of chemical dependency services at Pathways Treatment Center in Kalispell, and as a pain management specialist at Big Sky Family Medical, also in Kalispell.

Wise believes that he, as a doctor, is responsible for helping prevent patients from becoming addicts, is a fan of Pittaway’s contract idea and in fact uses contracts in his own practice. Wise’s contracts limit the number of times patients can get an early refill on their medication and limits them to getting their prescriptions only through him. His contract also states that patients may have to submit to urine tests and have their pills counted on a regular basis, to see if they are using other substances with their medication, and to make sure they are not giving pills away or using more than prescribed. If the contract is broken, the patient is barred from coming to Wise’s practice. With these rules in place, Wise says he has been able to keep patients on pain medications for long periods of time without having them abuse the drug by taking more than what was prescribed.

Wise says he isn’t familiar with montoring programs, but from what he’s heard, they haven’t been successful. Wise is not a fan of Pittaway’s plan for taking patients off of drugs temporarily to prevent addiction, either.

“That’s an old idea, called a ‘drug holiday,’” Wise says. “All that does is make you sick, make you go into pain and go through withdrawl, and you feel like crap. Drug holidays don’t really work.”

When he can, Wise likes to put his patients at the treatment center and pain clinic on a drug called Suvoxone, which has some of the narcotic effects of an opiate and can ease withdrawl symptoms. But unlike other drugs, Suvoxone stops working once a patient takes more than 32 milligrams. The problem with Suvoxone, Wise says, is that it is expensive, $6 to $7 per pill, and difficult to get. According to him, only a “handful” of doctors in Montana are allowed to prescribe it, and those doctors are only allowed to have 30 patients on it at any one time. Wise says he always has a Suvoxone waiting list.

For the majority of his patients, Wise prefers to lower a patient’s dosage slowly when it’s time for them to stop using, and eventually, after the lowest dose possible is administered, cut them off. Physical dependence and withdrawal is a normal part of taking opiates, Wise says, but is not the same thing as addiction.

“Addiction is compulsion, loss of control and continued use despite adverse consequences,” Wise says. “Opiate withdrawl is like a bad case of the flu. You think you’re gonna die, but you’re afraid you’re not. You’re lying on the couch, you’ve got diarrhea, you’ve got vomitting. But what can you do about it? You tough it out.”

According to Wise, one in 10 people who use prescription pain killers are addicts. That, in his view, is an acceptable number.

Unlike Wise, Cummins likes Pittaway’s idea about avoiding addiction in the first place, but thinks any real fix for the prescription problem is going to involve a multifaceted approach. “Not just any one thing is going to be a silver bullet,” he says. He proposes using Pittaway’s methods, as well as monitoring and continued law enforcement efforts, such as those of Flathead County’s task force.

In addition to these approaches, Cummins also thinks changes in society’s relationship with prescription drugs need to be considered.

“Ten years ago, you never saw a prescription drug ad,” he says. “The marketing angle goes right to the patient. But they still have to go through a doctor.”

This works against what Cummins sees as a need to “slowly try to change our propensity to take a pill every time we have a problem, physical or emotional.”

“We tend to jump too quickly toward the medical route,” Cummins says.

Deschamps, like Cummins, is a believer in a versatile approach to curbing prescription abuse. In addition to monitoring, she also believes strongly in doctor responsiblilty, although it is her belief that doctors already try hard, through contracts like Wise’s, to keep patients from becoming addicts. She says education is another big component in beating prescription drug abuse, including teaching doctors and pharmacists what to look for, explaining what privacy laws allow them to do and getting the message out to the general public that prescription drugs can be dangerous, and even lethal.

Kimberly, for her part, thinks something needs to change.

“The first doctor he went to should have been the only doctor he was allowed to go to,” she says. And, she adds, he should have had only one place to get his prescriptions from.

“If [appropriate oversight] had started way in the beginning, I don’t think it would have gotten so bad,” she says.

AN UNNECESSARY DEATH
For a few days after the Kmart pharmacy was robbed, Flathead County Sheriff officers didn’t have a suspect. The doctors Chad visited on the 28th finally tipped them off a few days later. Parrish was then able to call Chad’s cell phone. Over the course of several calls, he tried to convince Chad to turn himself in. At one point, Chad agreed to surrender in Lewistown, but changed his mind and kept fleeing.

Parrish had begun to worry that Chad would harm himself. On Aug. 8, he tracked Chad down to a hotel in Chinook and had Blaine County sheriff’s deputies sent there. When they arrived, they found Chad’s body. He had committed suicide, shooting himself with the same gun he allegedly used to rob the pharmacy.

In a suicide note, Chad apologized to his wife, to the pharmacist for the robbery and to Parrish.

“He apologized to me for not turning himself in,” Parrish says. “I think he had a heck of a conscience and didn’t like what he had become. He’s certainly one of the nicest criminals I’ve ever dealt with.”

“What I regret,” says Kimberly, “is my fear. I was afraid to find out the depth of what he was doing.”

“I loved Chad so much,” she continues, “so I think it’s important for people to know, just don’t give up on them.”

ppeters@missoulanews.comGeneration Rx

As Roy Bostock, chairman of The Partner for a Drug-Free America, quipped in a recent study, “generation Rx has arrived.”

The cute phrase downplays a serious issue. Between 1992 and 2003, the number of 12–17-year-olds abusing prescription drugs jumped 212 percent, to 2.3 million, according to The National Center on Addiction and Substance Abuse. That’s nearly one in 10 U.S. teenagers. Bostock notes that teens are now more likely to abuse prescription drugs than LSD, heroin, crack and ecstacy combined.

Scott Boyles, a program administrator for the Montana State Chemical Dependency Bureau, says that teens have gotten “incredibly wise” to the availability of prescription medications.

“Kids have really learned to search medicine cabinets,” he says. “There’s a readily available supply of mood enhancers in every medicine cabinet across the country.”

Lance Isaak, director of the Flathead Attention Home, a short-term care facility positioned as an alternative to incarceration for Flathead youths, has seen the results of that increased awareness in four incidents at the home in just the last six months.

In one of these incidents, a 17-year-old girl was able to get a prescription to OxyContin while on break from her job outside the home. Later, she overdosed and had to be hospitalized.

The other three incidents ended up with teens from the home being detained by police for felony drug distribution. Isaak says teens have suddenly begun trying to hide their prescribed pills in their cheeks so they can take them later in a way that increases the drug’s potency—such as snorting—or distribute them to other teens.

Pat Warneke, chief probation officer for the Flathead County Youth Court, notes two ways that teens are accessing prescription drugs: medicine cabinets and other teens. He says that oftentimes teenagers on various prescription drugs, including attention deficit hyperactivity disorder drugs like Ritalin, will sell them to other teens.

Warneke recommends parents be especially careful with prescription drugs at home.

“Anyone that has a kid should keep these drugs under a watchful eye, or under a lock and key,” he says.

The Partnership for a Drug-Free America recommends two ways to keep teens from abusing prescription drugs. Keep them inaccessible, and explain to kids that they can be just as addictive as illicit drugs, and just as dangerous—43 percent of all overdoses treated in emergency rooms are the result of prescription drugs. —Paul Peters

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