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  Drugstore Cowboys (and Cowgirls)

Why do Tennesseeans lead the nation in prescription drug use?

by Joe Tarr

Over the course of the year, Denise will swallow about 6,570 pills.

"I take medicine for rheumatoid arthritis, osteoporosis, congestive heart failure. I think that's about it. That's enough," says the 42-year-old, who started taking drugs for arthritis when she was 16.

"Oh, and my stomach," she adds, a second later, as she sits in her apartment off Sutherland Avenue. The small living room is filled with stuffed clowns and eagles of all sizes, which she collects. Near her stereo is a plastic box with little compartments that divide the medications she takes over the week. "I also take vitamins, calcium and aspirin."

There have been side-effects from much of this medication: ulcers, a torn Achilles tendon, aggravated heart condition.

But Denise (who didn't want her full named used), doesn't have much choice.

"I've had a lot of problems from medicine," she says. "But I kind of got used to it, because my medicine is keeping me going. Without my medicine, I wouldn't make it."

Denise is not alone. Tennesseans, on average, get 14 prescriptions a year. That's the highest rate in the nation, according to Novartis, a pharmaceutical company that tracks the health care industry. The national average is 9.8 prescriptions per person per year. Altogether, Tennessee consumes $2.7 billion of drugs annually—the 12th highest in the country, despite being only the 16th most populous state. The number is not an anomaly; Tennessee has led the nation for some time, and its average keeps climbing apace with a national explosion in pharmaceutical use.

But just what the numbers mean is not clear.

"Statistics don't lie, but statisticians are liars," says Dr. Frank McNiel, a general practitioner who operates a pain clinic in Bearden. "Statistics may not be telling you what you think they're telling you."

Indeed, getting to the bottom of why Tennesseans seemingly pop more pills than most than most Americans is no simple task. Not even the certified experts are certain. "It's a very good question, and...we actually have a research proposal to determine why that is," says Dick Gourley, dean of the University of Tennessee's pharmacy school in Memphis. "We do not have any hard data. Nobody in the state does that I know of.

"A lot of times we try to place blame without having the knowledge, and right now we don't have the knowledge," he adds.

Gourley says it'll take about six months of poring through various studies, surveys and databases to get any conclusive answers. In the meantime, many in the medical field have their own opinions and educated guesses about how Tennessee got so hooked on prescription medicine. There's no question that a sick and aging population, the development of countless new "lifestyle" drugs and a generous TennCare drug plan all play a part. Some argue that increased drug use is a good thing, keeping people out of the hospital and preventing worse problems down the line.

For now, the trend shows no sign of slowing.

Variety drives the market

It's a slow day, but Dianna Drake is making out pretty good. Customers have given the diminutive, chipper pharmacist a couple of sweaters and a home-canned jar of pickles. "They bring us food all the time," laughs Drake, who runs the pharmacy at the Bi-Lo grocery in Bearden. "We must look hungry."

"I try to get to know them because I'm their pharmacist and they like to talk to me," she says.

When Drake was in high school in Kingsport, she worked at a local drug store and enjoyed talking with the customers. So she became a pharmacist.

The business has changed quite a bit since then. "Twenty-five years ago, we didn't have many drugs. We had maybe two heart drugs, insulin and a few antibiotics," Drake says.

Today, doctors have thousands of drugs at their disposal. Last year, Americans and insurance companies spent $112 billion filling 2.7 billion prescriptions, according to Novartis.

Many healthy people have a tough time imagining how so many people could need 14 or more prescriptions in a year, but lots of people surpass that in a month. Many of Drake's customers are getting hundreds.

A person might have diabetes, pulmonary, cerebrovascular and heart ailments, high cholesterol, and a couple of prescriptions to treat each. They might also be on an anti-depressant to treat the malaise and a painkiller to numb the aches that would understandably result from so many problems. Adding it all up, they could easily be on 15 to 20 prescriptions. With monthly refills, that totals 180 to 240 prescriptions a year. The numbers are further stretched when you consider that many doctors will write out unnecessary prescriptions for over-the-counter drugs to get insurance companies to pick up part of the tab.

Nationally, anti-depressants are the most prescribed drug, followed by ACE inhibitors (used for high blood pressure and congestive heart failure) and cholesterol reducers, according to Novartis. The most profitable drug in 1999—at $3.6 billion—was Prilosec, which treats stomach acid problems. The cholesterol drug Lipitor was second at $2.7 billion, and the anti-depressant Prozac was third at $2.4 billion. In Tennessee, specific numbers are harder to come by.

Novartis' figures suggest Tennesseans have bad hearts, lots of infections, are depressed or mentally ill and impotent. Tennessee ranked well above the national average in the use of penicillins, trimethoprims and cephalosporins (all anti-infectives); calcium channel blockers and ACE inhibitors (cardiovascular drugs); anti-depressants, anti-convulsants, anti-psychotics, NSAIDs and anorexiants (central nervous system drugs); H2-antagonists (gastrointestinal agents); and estrogen (used to treat menopause, osteoporosis, atrophic vaginitis and breast cancer) and impotence products, according to Novartis.

Of those, the state led the nation in spending on estrogen, ACE inhibitors, and H2-antagonists.

In 1999, the top five prescribed drugs (excluding mental health prescriptions) for TennCare—which covers a quarter of the population—were, in descending order: Cimetidine (an ulcer medication), Furosemide (for hypertension), Hydrocodone (pain killer), Amoxicillin (antibiotic) and estrogren.

Is pain a Volunteer state?

A number of sources—doctors, MCO managers, pharmacists—suggest that hydrocodone, a narcotic used to treat pain, is the single most prescribed drug in the state, but Metro Pulse could not find any definitive statistics. (Most detailed statistics are proprietary and not released by the drug companies or managed care companies.)

Narcotics are obviously prone to abuse, and many experts say fraud is a big problem.

"It's unbelievable the actual amount of [fraud cases]," says Tim Blackburn of the Knox County Sheriff's Department, who investigates pharmaceutical diversion. "The forgeries are so simple to do. Unless you've got a pharmacist who takes time to verify the prescriptions, we'll never know." Catching and convicting violators is especially hard because it is difficult to get a witness to verify that the suspect actually received the medication, he says.

Mike Arpaio of the federal Drug Enforcement Agency agrees. "We can tell that it's going on quite a bit. A lot of it is inside doctors' offices, where you have a receptionist calling in prescriptions and the doctor doesn't even know about it...I don't have statistics on it. All we know is there is a problem and it's probably nationwide."

"I've worked at clinics, and I was absolutely overwhelmed by requests for narcotics by people who were younger than me and healthy and said they have a pain in their knee," says Dr. Stephanie Hall says, head of the Knox County Health Department. "I can't tell you why that is. I don't know what we've done to get a culture like this, but everybody seems to know that it's out there and it is a problem."

It appears to Hall that there is also a network of users in East Tennessee. The Health Department is fairly strict about prescribing narcotics, but sometimes a new doctor will be more liberal. "It seems like it only takes a week and people are specifically asking for that doctor. That would indicate to me that there's a network out there," Hall says. "We tend to treat people of a lower socio-economic background, but I don't believe it is just a lower socio-economic problem."

The state's Board of Pharmacy—which licenses pharmacists and pharmacies—is working on a computer system that would link pharmacy databases and track who is getting what prescriptions filled and where, a spokeswoman says. This would make it much tougher to get duplicate prescriptions, but the system is nowhere near completion.

Dr. McNiel, who operates a pain clinic, admits that there are a lot of people who abuse pain medication and the medical system. However, he says chronic pain conditions are little understood and frequently go untreated. Many doctors are probably prescribing hydrocodone—which is a schedule III drug—more frequently, because they're afraid to prescribe more regulated schedule II narcotics, even though many of those drugs are more effective, safer, longer-lasting and less prone to abuse, McNiel says.

"The atmosphere for prescribing narcotics has not been friendly or open. There's a lot of fear on the part of physicians that they'll be professionally punished for prescribing narcotics."

The classification system for drugs is somewhat arbitrary, he says. The only thing that makes hydrocodone a schedule III is that it's mixed with either ibuprofen or acetaminophen, two over-the-counter pain killers. Hydrocodone is also cheaper and, as a schedule III, easier to fill and refill.

Another problem is that doctors often prescribe hydrocodone in too small doses, forcing patients to hop from doctor to doctor. "They have pain that's not being relieved so they have to go to several doctors. Which is really taboo, but can you blame them?" McNiel says.

He tries to prevent abuse by making his patients sign contracts agreeing not to abuse the medicine or go behind his back to other doctors. "It allows the patient to understand that if they get narcotics from us, they have to do it in a very responsible way. They can't get them from other doctors," he says. "It gives me a document that allows me to release a patient from my care if they break the agreement."

The equivalent of one and a half staff positions are devoted to investigating patients—calling pharmacists, doing random drug screens—to make sure they're sticking to the agreement. Many of his patients are caught, he admits.

"They still filter through the cracks because you have to trust people. You really can't have a good doctor-patient relationship if you don't trust people.

"We have hundreds and hundreds of patients leading productive lives, working, who would not be able to if they weren't receiving pain medication," he adds. Some patients can't afford more permanent fixes such as an operation, so in the meantime drugs are their only option to keep working.

"You can literally give a patient's life back to them if you treat them successfully."

Sicknesses thrive here

An obvious reason Tennesseans take so many pills is that we're quite ill, statistically speaking.

According to the National Center for Health Statistics, Tennessee has one of the highest death rates in several disease categories (which would presumably indicate a higher disease incidence). The death rate is the number of people who die from a certain cause for every 100,000 people. Of all 50 states, Tennessee ranks third in heart disease, third in pneumonia and flu, fifth in strokes, fifth in cancer, ninth in pulmonary disease, 12th in liver disease, and 16th in diabetes. About a quarter of the adult population smokes, and although that number has declined in recent years, Tennessee consistently ranks among the dozen states with the most smokers, according to the Centers for Disease Control.

The state also ranks eighth in accidental deaths, which would presumably indicate a corresponding high number of accident survivors who would go on to need medical care and pills.

Overall, Tennessee has the fourth highest death rate in the nation. (Mississippi, Louisiana and Alabama are first, second and third, respectively.)

Another factor, both in Tennessee and around the country, is that the population is aging, and as people get older they tend to need more medication to maintain their health.

None of this is very surprising to Dr. Rob McDonald of the Interfaith Health Clinic. Running a health clinic for the working poor who don't qualify for TennCare, McDonald sees some of the sickest, poorest patients in the state. "It's not unusual for my patients to be on 10 prescriptions," he says. "But these are folks with multiple problems. They're diabetic, overweight, they have high cholesterol, heart problems. And yes, they smoke. They're being treated [for] each problem with one or two or three drugs."

"I've kind of got blinders on here at the Interfaith Health Clinic. I take care of a very sick population, but they've been without health care for so long," he adds.

Systemic problems

Another possible culprit to the escalating drug use is TennCare, the state's health insurance system for low-income people who have no other insurance options. TennCare enrollees are lucky in one respect. The state program pays the entire cost of all prescriptions, with no limits or co-payments required—a benefit that beats out many private insurance plans. These are people who wouldn't otherwise have access to health care or free medicine, thus pushing the number of prescriptions way up.

"Because of our TennCare program, we have a large percent of our population covered by an insurance program that has a prescription benefit," says Baeteena Black, executive director of the Tennessee Pharmacists Association. And, logically, that population needs a lot of medication. "Uninsurable folks are uninsurable because they have some medical condition that makes them uninsurable."

According to Novartis, 78.2 percent of all prescriptions in Tennessee were covered by insurance companies or public programs in 1999. Only Nevada, Pennsylvania, Maryland and Michigan have a larger percentage of residents covered.

"If you offer a benefit, you're going to get utilization," TennCare's pharmacy director, Leo Sullivan, says dryly.

As of October, 1.38 million people—about a quarter of the state's population—were enrolled in TennCare, including 500,000 women older than 21 and 600,000 children under 19, says Lola Potter, TennCare spokeswoman. Last year, the program spent $451 million on 20 million prescriptions (not including behavioral health drugs).

According to Potter, Tennessee is one of only five states without a limit on prescriptions for their Medicaid programs. Gov. Don Sundquist has asked the federal Health Care Financing Administration—TennCare's oversight agency—for permission to limit prescriptions to seven a month, with exceptions for the chronically ill. "We have not yet received a response to this repeated request," Potter says.

TennCare's drug costs are likely to keep climbing after a court ruling that took effect this November. Doctors are supposed to prescribe from a list of drugs that favors generic prescriptions when treating TennCare patients. Exceptions can be made by filing an appeal. The court ruling last year requires pharmacists to give patients a minimum 14-day supply of drugs that aren't on TennCare's approved list while an appeal is filed. Before the ruling, patients were only entitled to a three-day supply.

Even if TennCare is pushing up the number of prescriptions in the state, many people caution against using it as a convenient scapegoat. It's only part of the reason, albeit probably a large one. TennCare is likely mirroring patterns among the privately insured.

"I don't think it's TennCare driving it," Drake says. "What's driving it is there are so many new medications out there and doctors are not looking at somebody's total picture."

But Drake isn't blaming the doctors either. "The reimbursements are lower, so doctors are having to spend less and less time with patients. A lot of times, patients will see a nurse practitioner," she says. "If I call a doctor, most of the time I get a voice mail and maybe they'll call me back the same day. Sometimes it's 48 hours later."

Ad campaigns at work

It seems clear that more and more people are leaning on medication—not doctors—to feel better. The drugs themselves are being pitched to patients, and doctors have simply become the middlemen. Companies advertise their wonder drugs for allergies, stomach problems and all stripes of stress and anxiety on television and magazines. Although anti-depressants are a life-saver to many, critics say they're increasingly being marketed for vague problems that could apply to almost anyone (e.g. PMS, social-anxiety disorder).

"Advertising is incredible. You've got companies marketing direct to the consumer," Potter says. "If you watch TV, you've got those allergy medicines, Bob Dole hawking Viagra, medicines for ulcers."

According to the National Institute for Health Care Management, pharmaceutical companies spent $1.8 billion advertising their products directly to consumers last year. This included $1.1 billion in television ads.

The ads appear to be effective. Drug manufacturer Schering-Plough spent $137 million advertising the allergy drug Claritin to consumers in 1999. Claritin sales rose 21 percent, to $2.6 billion. Similarly, sales of the cholesterol drug Lipitor jumped 56 percent billion after its manufacturer spent $55.4 million on direct advertising. Meanwhile, sales of a competitor, Pravachol, rose a more modest 8.7 percent after its maker only spent $100,000 on ads.

However, Dr. Charlie Barnett, a Farragut family doctor, doubts that direct advertising is having too big an impact. "Whether they'll admit this or not, their drug sells itself," he says. "If it's not a good drug, it won't sell.

"We're using more drugs because we have great drugs we didn't used to have. Drugs for cholesterol, allergies, stomach trouble—just the whole bit," Barnett says.

Mark Grayson, spokesman for the Pharmaceutical Research and Manufacturers of America, a pharmacy industry lobbying group, agrees, saying that hundreds of new medications were developed in the '90s. He adds that direct advertising is making people more aware of their health, not turning them into pill poppers.

"Direct to consumer marketing gives people information. It's not like marketing other products. They still have to go to doctor," Grayson says. "So basically they're realizing they can be treated rather than suffering. It's brought people into doctors offices who hadn't been there in a while. So we think it's a boon to the health-care system."

McNiel doubts that the 14-prescription average means much in itself. He says many doctors in this region will prescribe smaller amounts of medication in each prescription. "Many doctors in the Knoxville area will give patients, 12, 16, 30 tablets and make them come back in 15 days. So they can accumulate a large number of prescriptions in a short period of time."

Spread that trend out over thousands of patients, and Tennessee might be dispensing many more prescriptions, but the same amount of medicine, he says.

His point might be supported by Novartis' figures. Although Tennessee ranks number one in the number of prescriptions per person, it's only sixth when it comes to money. The average Tennessean gets $497.90 worth of medicine each year. That's still above the $412.48 national average, but less than New Jersey's high of $533.25 a person.

Chemicals have pluses, too

As the doctors, pharmacists, bureaucrats, insurance agents, and HMO managers try to get a handle on and control drug use in Tennessee, there's an important point to keep in mind: in many cases, increased use of pharmaceuticals may not be such a bad thing.

If done properly, medicating health problems early can help people live longer and better. High cholesterol is a perfect example, Dr. Barnett says. Patients' best efforts through diet and exercise will cut their cholesterol levels only about 10 percent, he says. Drugs can lower it by half.

Properly used medications can also lower health costs in other areas, keeping people out of the hospital and preventing surgery. It allows some people to work, and it keeps others alive.

Gary Robinson knows that lesson well. The 56-year-old has been on heart medication since he was 26. He had open-heart surgery at 39 and has had two heart attacks and a stroke in the past three years. Retired now, he used to be a technician at Lakeshore.

He's on 11 different prescriptions which over the course of the year will tally up to more than 130, to regulate his heart, breathing and nerves. Every Sunday night, he'll fill up his plastic organizer with the pills he'll take over the next week. "That lets me know if I've missed medication. I don't try to keep it all in my head," he says.

"My medication, when I'm taking it, I think, 'Gosh, that seems like a lot.' But it's checked by three doctors, so I'm not taking the same [type of medication] twice," Robinson says. "I don't want to take what I don't need, but I do want to take what I do need."

"Without this medication, I'd be dead. I know that in my mind."

November 30, 2000 * Vol. 10, No. 48
© 2000 Metro Pulse