UPDATED Sept. 22, 2019: We’ve written an editor’s notebook that provides important context for the analysis cited in this post.

Two rural Oregon pharmacies purchased more opioid pills per county resident than 99.9 percent of other pharmacies in the country, recently released federal data show.

Howard’s Drugs, the only pharmacy in Lake County, ordered enough pain pills during a surge in the opioid epidemic for every resident to take 68 doses a year.

That put Howard’s 10th on a list of top sellers nationally in the seven-year period ending in 2012, according to an analysis by The Washington Post. Grant County pharmacy Len’s Drug placed 89th on the list. The Post’s analysis included nearly 83,000 U.S. pharmacies.

Jeffrey Howard, owner of Howard’s Drugs, said he was aware of cases that seemed suspicious but could do nothing about them if the prescription itself followed the letter of the law.

“I’m sure some of our customers sold our pain meds,” Howard said. “We weren’t aware of any that we could do anything about.”

In one case documented in state records, Grant County pharmacy Len’s Drug gave a patient more than 1,000 pills in one month. Owner Greg Armstrong said the error was a product of too much faith in the prescriber, who was addicted at the time and was taking the pills for herself.

“Just because they are hometown providers we can’t just go by trusting them,” he said.

Howard's Drugs pill sales per person per year.

The pharmacists’ views, shared in interviews this week, offer a candid perspective from people on the front lines of the opioid crisis. Pharmacies are usually the last stop before pain pills get to consumers. After that, the meds can treat legitimate needs, feed addictions or get sold on the black market.

Since 2012, substantial state and federal efforts have led to a decline in prescriptions. Pharmacists said they’ve seen that decline first-hand, as well as a dramatic change in the medical culture surrounding pain pills. But the country is still reeling from the decade-old surge in opioid prescriptions, with about 68,000 people dying from opioid overdoses last year alone.

This first public ranking of Oregon pharmacies draws from a recently released database of prescription opioids sales in the United States, tracked by the U.S. Drug Enforcement Administration. The data was made public after a year-long court battle by The Washington Post and the Charleston Gazette-Mail of West Virginia.

The data shows that 76 billion hydrocodone and oxycodone pills flooded the country in the seven-year period ending in 2012. The records are central to a major lawsuit in Ohio accusing manufacturers and distributors of fueling an opioid crisis. Local lawsuits against the companies have been consolidated into the Ohio lawsuit, including those filed by Portland and Multnomah and Washington counties.

The 68 pills per resident that Howard’s purchased annually was an extreme outlier. No one else among Oregon’s 803 pharmacies came close. Only 34 had a rate higher than 10 per person.

The county surrounding Howard’s Drugs encompasses a vast swath of south-central Oregon. It was home to about 7,300 people at the time. Over seven years, the pharmacy filled prescriptions totaling 3.7 million pills. The federal data don’t show who the prescriptions went to and whether or not the patients were Lake County residents.

Unlike opioid manufacturers and distributors, pharmacies don’t have to report suspicious orders or prescriptions. But they still have to use their best judgment before deciding to go through with a prescription, according to Drug Enforcement Administration spokeswoman Barbara Carreno.

“They’re all supposed to have their eyes open and be aware,” Carreno said.

In fact, the agency’s official manual for pharmacists says they can be prosecuted for filling a prescription “when there is reason to believe it was not issued for a legitimate medical purpose.” According to the manual, pharmacists have full discretion when deciding whether or not to go ahead with a prescription.

“The law does not require a pharmacist to dispense a prescription of doubtful, questionable, or suspicious origin,” the guidance document says.

Howard said his drug store had a high rate of opioid orders because it is the only pharmacy in a large county and because the opioid prescription culture in the late 1990s and early 2000s encouraged giving people narcotic pain pills.

Sometimes it was clear that a patient had an addiction of some kind, Howard said, whether it be to methamphetamines or to opioids. Most prescribers knew if their patients were addicted but would keep ordering them more pills, finding that preferable to the patients seeking street drugs, Howard said.

Sometimes, the patients would admit they are addicted.

“They kind of just resign themselves. It’s either pain or take these pills,” he said. “Or go through a withdrawal.”

Sometimes, a patient’s friends would call repeatedly about a prescription. That would happen two or three times a month, Howard said.

“That’s when you know that everybody’s waiting for Jane Doe or John Doe to get his pills so we can all share,” Howard said. “Proving it is different.”

He wouldn’t answer their questions, he said, and he would only give the pills to the patient. But beyond that, Howard said he was powerless to act.

Provided no one forged the prescriptions and the patients picked them up themselves, Howard said, he would fill them. He said he never declined to fill a prescription simply on a suspicion that it was being sold or handed off to others, or that the pills weren’t for a legitimate medical need.

“It’s very hard because a person that is seeking narcotics can get really good at portraying their pain and saying the right things,” Howard said. “There’s no blood test, no electrocardiogram test for pain.”

Lake County is only one of many rural Oregon counties that have been hit hard by the opioid epidemic. The top five counties with the highest growth in per-capita rates during the seven-year period ending in 2012 were all in eastern Oregon.

The Grant County pharmacy Len’s Drug had the second-highest rate of opioid pill orders in Oregon. The drugstore bought enough hydrocodone and oxycodone for every resident to take a pill every nine-and-a-half days, or 38 pills per person per year, according to the federal data.

Total sales of opioids at Len's Drug per year.

Armstrong, the owner, said he generally would fill all prescriptions, no matter the volume, provided a doctor gave a valid medical reason. Legally, Armstrong said, he felt he had no choice. And the medical culture at the time was such that a doctor’s word was final. Pharmacists’ concerns were generally dismissed, he said.

But Armstrong said inappropriate prescription patterns likely played a minor role, if any, in driving up Len’s Drug pill order rates. Grant County is home to people who work hazardous jobs, such as cattle farming and timber, and are therefore more likely than urban workers to suffer injuries that require pain meds, Armstrong said.

Armstrong got in trouble with the Oregon Board of Pharmacy 10 years ago for selling huge volumes of pills to one patient. His pharmacy gave a patient 980 opioid pills in January and March 2009, according to state disciplinary records, then 1,120 pills that June. The patient got enough pills to take up to 37 a day, the records say.

Armstrong and other pharmacists at the store filled prescriptions that they “should have known were issued for other than legitimate medical purposes due to excessive amounts prescribed,” the board concluded the following year.

The pharmacy violated state rules of professional conduct, board officials wrote. Armstrong received six hours of continuing education in place of paying a $1,000 fine. The pharmacy paid a fine of $7,000.

According to the federal opioid data, prescription purchase rates at the store leveled off after the board action.

The case was an aberration, Armstrong said. He said he knew and trusted the prescriber, Lindsay Maghan, and called her repeatedly to make sure the pill orders were valid.

According to state disciplinary records, the licensed nurse practitioner was addicted to opioids herself and had arranged for the patient to route the pills back to her.

Maghan pleaded guilty to six drug-related misdemeanors in 2010, entered addiction treatment and surrendered her nurse and nurse practitioner licenses, court and state disciplinary records show.

In an interview, Maghan said her path to addiction started with a combination of traumatic experiences – her infant daughter’s death and her son’s premature birth – and an opioid prescription after a series of intensive surgeries. Over the years that followed, Maghan said, she slid into addiction.

She finally went to get treated in 2010 at a Coburg center for addicted healthcare professionals. Four years of sobriety later, the medical director asked if she wanted to work there, Maghan said, and she accepted.

Being able to now give hope to others that recovery is possible for them, too, “is what my journey was for,” Maghan said.

“I’m doing what I was called to do.”

Armstrong said he respects Maghan for pulling herself out of addiction.

“She could’ve gone in a different direction,” he said.

-- Fedor Zarkhin

fzarkhin@oregonian.com

desk: 503-294-7674|cell: 971-373-2905|@fedorzarkhin

-- Mark Graves

mgraves@oregonian.com

desk: 503-412-7050|@markwgraves

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