New data points to which Delaware pharmacies dispensed the most oxycodone
When national pharmacy chains began limiting the amount of opioids they dispensed to customers in the last couple years, smaller independent pharmacies began filling the void for those with high-dose prescriptions.
In Delaware, three of the top 4 pharmacies that received millions of the oxycodone and hydrocodone pills that flooded Delaware from 2006 to 2014 are or were independently owned, according to newly released data collected by the U.S. Drug Enforcement Administration.
It's been long questioned whether pharmacies should be held accountable for their role in the opioid and subsequent heroin and fentanyl epidemic. The Delaware Department of Justice named numerous chain pharmacies as plaintiffs in a lawsuit when it sued Big Pharma in January 2018. Many have since been removed or dismissed by a judge.
Those three independent pharmacies, of the top four, are in New Castle County, and all are located near or along a major roadway.
Disciplinary action was taken against at least one pharmacist working at one of the independently owned pharmacies, according to publicly available licensing records. The pharmacist and owner, Leonard Bronstein, said he closed Stanton Discount Pharmacy Inc., the third-highest pharmacy for opioid shipments, in 2013 – before his license was suspended.
And despite years of data, these pills still legally come into Delaware, continually leaving the state ranked highest in the country for prescriptions of long-acting and high-dose opioids.
In 2019, enough oxycodone pills were prescribed here to give every Delaware resident 16 tablets apiece, according to data from the Delaware Division of Professional Regulation.
But the pharmacy data, made public by plaintiffs' attorneys in the National Prescription Opiate Litigation, sheds light on how these drugs made their way from manufacturers to distributors – and pharmacies – across the country, leaving a trail of overdoses in their wake.
"Obviously, there is more scrutiny on the prescribing and dispensing of opioids," said Hooshang Shanehsaz, a licensed pharmacist who serves as the president of the Delaware Board of Pharmacy. "That has created a situation where quite often the pharmacist finds themselves being asked to be police and that is not what their function is."
Where Delaware got its pain pills
Situated between a liquor store and a vacant storefront in a strip mall along U.S. 13, Manor Pharmacy topped Delaware's opioid list from 2006 to 2014.
The drugstore received nearly 12 million oxycodone and hydrocodone pills, which found their way into Delaware communities during the nine-year span – nearly 4 million more pills than the next highest-distributing pharmacy in the state.
A handwritten sign on neon green paper hangs by the checkout counter, noting the store's requirement for a valid ID in order to drop off or pick up narcotics. It is a reflection of a growing epidemic that has changed Delaware's landscape and arguably made the work of a pharmacist even harder.
That's what Manor Pharmacy owner Jeffrey Smith told Delaware Online/The News Journal in a 2011 interview about the difficulties facing pharmacies as those looking to get their hands on prescription painkillers turned to more sophisticated means. He said at the time that he had been threatened, robbed and offered bribes to fill prescriptions.
Smith did not return messages to comment on this story.
Smith said one man threw a punch at him after he refused to full his opioid prescription, according to the News Journal archives. Another put $5,000 cash on the counter in an attempt to persuade Smith to fill a prescription.
At the time, Smith said he considered bringing a gun to work given the armed robberies and break-ins the pharmacy had experienced in 2010.
"After many weeks of thinking, I decided it could go from bad to worse," he told The News Journal, "if, God forbid, I actually pulled it."
The privately owned business sits in one of Delaware's most deadly ZIP codes for drug overdoses, where about 53 people per every 100,000 died in 2018, according to the age-adjusted death rate. That's 57% higher than the state average of about 34 deaths per 100,000 people.
The 19720 ZIP code encompasses much of the New Castle and Wilmington Manor area, as well as a swath of waterfront land that reaches down to Delaware City. The area covers the U.S. 13 corridor, which is dotted with motels and neighborhoods greatly impacted by the opioid epidemic.
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About 60 miles south, Pill Box Pharmacy is nestled at the Del. 1 and U.S. 113 split in Milford – the second-highest pharmacy for opioid sales in Delaware.
The independently owned pharmacy handled more than 8 million oxycodone and hydrocodone pills over nine years.
In 2014, the last year for which there is publicly available data on prescriptions in Delaware, the Census tract in which Pill Box is located had one of the highest overdose rates – nearly three times the state average.
While it is impossible to say exactly where these drugs ended up in the community, some of the surrounding Census tracts reported high overdose rates, as well – especially during a time when more people were dying from prescription drug overdoses than the heroin and fentanyl overdoses seen today.
That movement from prescription painkillers to synthetic opioids like heroin and fentanyl came as the result of the crackdown on pills nationwide, which drove up the street price for legal medications and made heroin much more convenient for the user.
The rest of the top five opioid pharmacies are as follows, according to data ranking the pharmacies by the number of oxycodone and hydrocodone pills handled from 2006 to 2014:
- Stanton Discount Pharmacy Inc., 2006 W. Newport Pike, Wilmington – 6,418,600 pills distributed
- Happy Harry's Inc. (now known as Walgreens), 1120 Pulaski Highway, Bear – 5,385,370 pills distributed
- Happy Harry's Inc. (now Walgreens), 22898 Sussex Highway, Seaford – 5,133,030 pills distributed
How did this happen?
The increase in opioid prescribing dates back more than two decades and follows the national trend of using pain as a diagnostic tool and symptom – one that was treated largely with highly addictive painkillers.
As addiction and overdoses started signaling problems with these medications, eventually reaching the height of the opioid epidemic, doctors and pharmacies were tasked with rolling back these measures.
"In the beginning ... these were legitimate prescriptions written for legitimate reasons," Shanehsaz said. "They [pharmacists] were feeling that their mission was to take care of the patient, and if they have a legitimate prescription, you have to dispense it."
Because the medications come directly from the hands of pharmacists, many national chains instituted policies around prescribing – as did states and other government agencies.
Take CVS Caremark, which in 2018 rolled out limits for opioid prescriptions based on the Centers for Disease Control and Prevention’s Guidelines released in 2016. This included a seven-day limit for new opioid prescriptions and maximum quantity limits unless a prior authorization is obtained.
Those looking to get their prescriptions filled turned to smaller, private pharmacies without those more-stringent regulations, Shanehsaz said.
In some cases, patients were successful at circumventing the system through these means.
Bronstein, owner and pharmacist at Stanton Discount Pharmacy Inc., was found at a hearing in 2015 to have "filled hundreds of invalid prescriptions" over the course of three years and missed red flags like a patient paying in cash for her prescriptions, according to public records.
"Given his many years in the profession, Mr. Bronstein should have known better," wrote a Division of Professional Regulation investigator in hearing documents.
He told the board he had known the patient for a long time and that she "fooled him," according to hearing documents.
The behavior resulted in a suspension of his license for five years and a $2,000 fine.
Bronstein claimed Wednesday that his license had not been suspended and that he had only one patient who presented fake prescriptions.
Pharmacists have the professional ability to deny a prescription if they believe it's fraudulent.
If pharmacists believe they've been given a fake or altered prescription, guidelines instruct them to contact the prescriber, confirm the prescription and the dosage, and review the Prescription Monitoring Program, which allows medical professionals to see how many prescriptions a patient is receiving.
"Traditionally, pharmacists have always been called the gatekeepers because they are the last points of contact between prescriber and patient," Shanehsaz said. "It's a huge responsibility and one that you have to truly try to balance between professionalism, and for lack of better word, policing."
Other factors like the push for mail-order prescriptions mean people are coming to their pharmacies largely for drugs that can't be mailed, like narcotics, and they're often going to their local pharmacy to do it, Shanehsaz said.
Independent pharmacies also benefit from buying large quantities of medications in bulk in order to get a better price and ensure they don't run out of stock by the end of the year.
The data doesn't take into account where these prescriptions were written and who they were prescribed by – pharmacists don't determine who needs what medication; they only serve as distributors.
"Really, the biggest change came from prescribing and more education on the prescribing side," Shanehsaz said. "This was started because there was the overprescribing of opioids."
Can pharmacies be held accountable?
In a lawsuit filed by the state in early 2018, attorneys argued that pharmacies had a direct role in the opioid epidemic when they filled large opioid prescriptions "despite having reason to believe it was not being filled for a legitimate medical purpose."
Reasons cited by the state in the lawsuit included the patient being a drug dealer or opioid-dependent, as well as failing to recognize red-flag behavior including filling multiple prescriptions from different doctors or traveling great distances to fill prescriptions.
The state also cited a study that estimated as many as 110,000 prescriptions of the 860,000 opioid prescriptions filled yearly in Delaware are "diverted to non-medical uses," according to the complaint.
At the time, attorneys reiterated that pharmacists, as distributors, have legal obligations to "refuse to fill suspicious orders and to conduct due diligence of customers submitting such orders," according to the complaint.
And in many cases, pharmacists say they do – and they take great precautions to avoid putting medications in the wrong hands.
The Prescription Monitoring Program was signed into effect here in 2010 specifically for medical professionals to call upon when both writing and filling prescriptions.
By granting a doctor or pharmacist a patient's controlled substance prescription history at their fingertips, officials hoped to better monitor those filling multiple prescriptions for the same medication and become aware of problematic dosages.
The judge overseeing Delaware's case against Big Pharma ruled that pharmacies were largely off the hook for their prescribing practices, as prosecutors didn't provide enough evidence that the prescriptions were not "for a legitimate medical purpose," according to court documents.
The state would need different documentation to substantiate such a claim, according to the judge.
This lawsuit, which names Purdue Pharma, Endo Health Solutions and a number of other big-name drug manufacturers and distributors, is on hold until April 30, according to court records. This comes largely because Purdue Pharma declared bankruptcy and now may need to be dealt with in a separate proceeding, court records say.
Have you or your family been impacted by the opioid epidemic? Share your story with investigative reporter Brittany Horn at (302) 324-2771 or firstname.lastname@example.org. Follow her on Twitter at @brittanyhorn.