Pubdate: Sat, 06 Oct 2012
Source: Wall Street Journal (US)
Copyright: 2012 Dow Jones & Company, Inc.
Authors: Thomas Catan, Devlin Barrett and Timothy W. Martin


Jaclyn Kinkade, a 23-year-old doctor's-office receptionist and 
occasional model, was a casualty of America's No. 1 drug menace when 
she overdosed and died, alone, in a tumbledown clapboard house in 
Dunnellon, Fla.

The drugs that killed her didn't come from the Colombian jungles or 
an Afghan poppy field. Two of the three drugs found in her system 
were sold to Ms. Kinkade, legally, at Walgreen Co. WAG -0.66% and CVS 
Caremark CVS -0.04% shops, the two biggest U.S. pharmacies. Both 
prescription drugs found in her body were made in the U.S.-the 
oxycodone in Elizabeth, N.J., by a company being acquired by 
generic-drug giant Watson Pharmaceuticals Inc., WPI +0.77% and the 
methadone in Hobart, N.Y., by Covidien Ltd., COV +0.47% another major 
manufacturer. Every stage of their distribution was 
government-regulated. In addition, Ms. Kinkade had small amounts of 
methamphetamine in her system when she died.

More Americans now die each year from prescription drug overdoses 
than from cocaine, heroin and other illegal drugs. Weekend Review 
editor Gary Rosen discusses the problem with WSJ staff writer Thomas Catan.

The U.S. spends about $15 billion a year fighting illegal drugs, 
often on foreign soil. But America's deadliest drug epidemic begins 
and ends at home. More than 15,000 Americans now die annually after 
overdosing on prescription painkillers called opioids, according to 
the Centers for Disease Control and Prevention-more than from heroin, 
cocaine and all other illegal drugs combined.

Rising opioid abuse means that drug overdoses are now the single 
largest cause of accidental death in America. They surpassed traffic 
accidents in 2009, the most recent CDC data available.

Paradoxically, the legality of prescription painkillers makes their 
abuse harder to tackle. There is no Pablo Escobar to capture or kill. 
Authorities must contend with an influential lobby of industry 
representatives and doctors who argue against more restrictions, 
saying they would harm legitimate patients. And lawmakers have been 
reluctant to have the federal government track Americans' 
prescriptions, leaving states to piece together a patchy, fragmented response.

Ms. Kinkade's final days, and the path of the drugs that killed her, 
were reconstructed from medical and prescription records, police 
files and interviews. Many records were assembled by Ms. Kinkade's 
father and stepmother.

Shuffling through the documents at their living-room table, Bruce 
Kinkade, a garage-door salesman, and his wife, Ann, said they don't 
wish to absolve their daughter of responsibility. "We're not naive 
and want to say she was a perfect angel," said Ann Kinkade, Jaclyn's 

But the Kinkades say the companies and licensed professionals that 
supplied her with the drugs must also bear some responsibility. 
"Jackie didn't wake up one day and say, 'Hey, I'm going to be a drug 
addict today,'" Ann Kinkade said. "Jackie pretty much got sent there 
by a doctor, got hooked and continued to go back."

There are few easy villains in prescription drug abuse. Companies, 
physicians and addicts alike are all pieces in a complex puzzle. For 
some time, regulators have been cracking down on doctors who 
prescribe to addicts for profit. Now, federal and state officials are 
starting to move up the supply chain to pursue pharmacies and distributors.

On Sept. 12, the Drug Enforcement Administration revoked the licenses 
of two Florida CVS stores, which it claims sold excessive amounts of 
oxycodone without ensuring the pills weren't diverted to the black 
market. CVS is fighting the DEA's order in administrative and federal courts.

Two days later, the agency served Walgreen with a suspension order 
halting sales of controlled substances from its Jupiter, Fla., 
distribution center, calling it an "imminent threat to public 
safety." The DEA's regulatory action alleges that the facility-the 
state's largest oxycodone distributor-"failed to maintain effective 
controls" of its narcotic painkillers.

Walgreen said it is working with regulators and has tightened its 
procedures. CVS said it was committed to working with regulators "to 
reduce prescription drug abuse and diversion while ensuring access to 
appropriate, effective pain medication for our patients who need them."

Participants in the drug-supply chain acknowledge the problems but 
point to others as the weak link. Doctors involved say pharmacies 
should be able to tell if patients are secretly using several 
physicians to obtain more drugs. Druggists say they can't 
second-guess a valid prescription. Manufacturers and distributors say 
they are simply delivering products ordered by health-care professionals.

What makes this drug scourge different from previous ones, such as 
heroin in the 1970s and cocaine in the 1980s, is that everyone in the 
distribution chain is identifiable. The DEA itself controls the 
supply spigot by setting drug companies' production quotas for 
opioids like oxycodone and hydrocodone.

For years, opioids were reserved mainly for cancer or terminally ill 
patients because of fears over their safety and addictiveness. But 
over the past 15 years, many doctors have come to view them as an 
essential tool to manage chronic pain. Around the same time, drug 
makers began marketing patented, time-release formulations of the 
drugs, making it a lucrative category.

Today, a growing number of doctors say the pendulum has swung too 
far, with powerful narcotics being dispensed for even relatively 
minor complaints. Last year, pharmacies dispensed more than $9 
billion in prescription opioid painkillers, more than twice the 
amount a decade earlier, according to IMS Health, a research firm. 
The number of prescriptions has risen fourfold. The generic version 
of Vicodin, a blend of hydrocodone and acetaminophen, is now the most 
prescribed drug in the country.

Opioids come from the same narcotics family as heroin and can produce 
similar addictions, researchers say. "We're basically talking about 
heroin pills," said Andrew Kolodny, chairman of the psychiatry 
department at Maimonides Medical Center in New York.

Studies show that opioid addicts come from a surprisingly broad swath 
of the population: the middle-age, the elderly and, increasingly, 
young adults. Many U.S. veterans returning from Iraq and Afghanistan 
with physical and mental injuries are also becoming dependent on 
prescription painkillers, researchers say.

In recent decades, researchers have come to view addiction as a 
disease, rather than just a personal failing. Some people are more 
predisposed to becoming addicted because of heredity, experience and 
other factors that have yet to be fully understood. But some drugs 
are simply more addictive than others.

New research suggests that drugs like opioids cause long-lasting 
changes to the brain, rewiring some areas to crave more drugs while 
simultaneously damaging the parts that can control those cravings. 
The drugs can damage the brain's ability to feel pleasure, so regular 
users eventually need to take them not to get high or help with pain, 
but just to feel normal. Avoiding unpleasant withdrawal symptoms end 
up conditioning many drug users' daily lives.

One of the most confounding aspects of this latest epidemic is that 
it blurs the lines between legal and illegal drug use. Some people 
first take drugs from their family medicine cabinets to get high, 
then go to doctors to get more. Others are originally prescribed the 
pills for legitimate reasons, then buy them on the street once they're hooked.

Many, such as Ms. Kinkade, end up mixing legal and illegal drugs in 
ways that can prove lethal.

Ms. Kinkade was a lively, talkative woman with blond hair, a fear of 
caterpillars and a pit-bull terrier, Bentley, that traveled 
everywhere with her.

She was first prescribed an opioid on Oct. 27, 2006, by the doctor 
who employed her as a receptionist, prescription records show. 
According to medical records and an entry from her diary, she had 
been suffering back and neck pain. Thomas Suits, her employer, 
prescribed 20 pills of Endocet, a drug containing oxycodone. "I'd 
never taken opioids before," Ms. Kinkade wrote in a diary entry. "But 
I started the med routine and OMG I felt no pain."

Dr. Suits didn't recall prescribing the medication, said his wife, 
Irene Machel, a doctor who also works at the clinic. She declined to 
discuss the matter further.

Endo Health Solutions, ENDP -1.21% which made the pills, declined to 
comment on Ms. Kinkade. "These types of stories are tragic and we 
obviously take them seriously," said Endo spokesman Blaine Davis. 
"Our responsibility, as a company that is very dedicated to the field 
of pain management, is to educate both physicians and patients about 
appropriate use."

Soon Ms. Kinkade was seeking more drugs. On Jan. 5, 2007, she saw 
Bruce Kammerman, a family practitioner at a clinic in Stuart, Fla., 
and came away with a generic blend of oxycodone and acetaminophen. A 
scan taken a month later showed no problems with her spine, according 
to the medical report. Through his lawyer, Dr. Kammerman declined to 
say why he wrote the prescription. "That's a sad case," said his 
attorney, Lance Richard. "Maybe she didn't have justifiable pain but 
she certainly came in and made complaints about it. At some point the 
doctor just has go on the patient's word."

Dr. Kammerman was arrested in July at a pain clinic in Vero Beach, 
Fla., charged with drug trafficking, racketeering and illegally 
selling controlled substances. The DEA said in a news conference he 
was prescribing an average of 1,700 oxycodone tablets a day. Dr. 
Kammerman's lawyer said his client has done nothing wrong and pleaded 
not guilty.

Ms. Kinkade broke up with her boyfriend. She began missing work. One 
day she was found curled up under her desk, crying. "She always used 
to be clean-cut, nice makeup," said Susan Cochran, a former 
colleague. Then "she would come in in sweatpants and it was like: 
'Who is this person?'"

Ms. Kinkade changed jobs to work at a radiologist's office. There, 
she had two other scans, in April and July 2008. Neither showed 
significant spine problems, according to the medical reports. Ms. 
Kinkade started seeking clinics that asked fewer questions. "Family 
practitioners hate writing narcotics," she wrote in her diary. 
"Nowadays-I'll just go str8 to pain docs."

During that period, she was prescribed large amounts of oxycodone, 
her records show, combined with antianxiety drugs and powerful muscle 
relaxants. Her parents grew increasingly alarmed. "Sometimes you'd be 
having a conversation with her and her head would just drop," Mr. 
Kinkade said. "And she'd say: 'Oh, I'm just tired; I was out late.'"

After reviewing her records, he said, "We estimated that at one point 
she was taking 13.4 pills per day, for nothing wrong with her."

In May 2009, Mr. Kinkade and his wife asked a judge to have their 
daughter forcibly admitted to drug treatment under a Florida law. 
Their request was initially denied because she wasn't a minor. 
Angered by their efforts, Ms. Kinkade moved out of their home and 
drove across the state to her biological mother's house. She crashed 
her car and was found wandering along the highway in a drug-induced 
daze, her parents said, searching for her pills.

Legal records show she was arrested several times for minor crimes 
such as possessing controlled drugs without a prescription and 
shoplifting small items, including makeup and cake topping. In each 
case, she was released and the charges dropped.

She started visiting a pain clinic in Tampa called Doctors Rx Us, 
where she was prescribed oxycodone, methadone, alprazolam and 
gabapentin, an antiseizure medication, according to records her 
parents collected. Housed in a rundown strip mall, the clinic today 
is called Palm Medical Group after a name change in 2011, according 
to its state records.

Ms. Kinkade was prescribed the drugs by two physicians at Doctors Rx 
Us: Richard Smith and William Crumbley. Dr. Crumbley was arrested in 
December and charged with operating a nonregistered pain clinic at 
another location. He has pleaded not guilty.

Dr. Smith and the clinic declined repeated interview requests. A 
lawyer for Dr. Crumbley said he was innocent of any wrongdoing.

On May 3, 2010, Ms. Kinkade stopped at a CVS in Crystal River, Fla., 
and picked up a prescription written by Dr. Smith for 90 tablets of 
10mg methadone, along with 90 tablets of alprazolam, an antianxiety drug.

"Jaclyn Kinkade's death is a terrible tragedy that highlights the 
need for a comprehensive national effort to prevent prescription drug 
abuse," CVS said in a statement.

Information provided by the manufacturer suggests that the methadone 
dispensed to Ms. Kinkade was likely supplied to CVS by Cardinal 
Health Inc. CAH -0.32% Cardinal was the only distributor to have sold 
that particular drug to that CVS branch during that period, according 
to the manufacturer's records. CVS and Cardinal declined to comment.

Last year, the DEA launched a probe of the Florida-based operations 
of Cardinal Health and CVS Caremark. The agency alleged they 
dispensed "extremely large amounts" of oxycodone with signs that the 
drugs were "diverted from legitimate channels."

CVS said it has "responded to the DEA's concerns, including 
implementing enhancements to our policies and procedures for filling 
controlled substance prescriptions." Cardinal settled with the DEA in 
May, agreeing to suspend sales for two years at one of its key 
distribution facilities in Lakeland, Fla.

The methadone Ms. Kinkade picked up at the end of her life was made 
in Hobart, N.Y., by Mallinckrodt, a unit of health-care giant 
Covidien. "Any death from abuse or misuse of prescription drugs is 
tragic," Covidien said. "That's why we believe that, as a nation, 
ending the abuse, diversion and misuse of powerful pain medications 
is necessary to ensure adequate treatment of pain and access to that 
treatment for legitimate pain patients."

On May 10, 2010, Ms. Kinkade was stopped by police in Levy County, 
Fla., for having an expired registration. A drug-sniffing dog reacted 
to her car and she was arrested for possessing a generic form of 
Xanax without the correct prescription. This time, her parents let 
her sit in jail for a couple of weeks while they organized a place 
for her in a rehabilitation program. They bailed her out May 25 and 
enrolled her in drug treatment.

Over the next month, Ms. Kinkade went to the treatment program during 
the day and seemed to improve, her parents said. Then, the evening of 
June 24, she climbed out the window at her parents' house.

A few days later, on the other side of Florida, she met up with a 
boyfriend, according to a statement he later gave police. She 
returned to Doctors Rx Us, where Dr. Smith wrote a prescription for 
90 tablets of 30mg oxycodone, according to prescription records. It 
would be her last.

The next day, Ms. Kinkade filled the prescription at a Walgreens in 
Beverly Hills, Fla. The oxycodone would have come from Walgreen's 
Jupiter, Fla., distribution center, a company spokesman said. On 
Sept. 14, the DEA barred that facility from selling controlled 
substances, alleging that it failed to maintain effective controls to 
stop large amounts of oxycodone from reaching the black market. "When 
[companies] choose to look the other way, patients suffer and drug 
dealers prosper," Mark Trouville, the DEA special agent in charge, 
said at the time. Walgreen said in a statement it is cooperating with the DEA.

The oxycodone came from the New Jersey plant of Actavis, a Swiss 
pharmaceutical company. In April, Actavis was bought by Watson 
Pharmaceutical in a $5.8 billion deal awaiting regulatory approval. 
An Actavis spokesman described Ms. Kinkade's situation as a "tragic 
occurrence" and called for discussion on "how to prevent such cases 
in the future." A Watson spokesman cautioned against action that 
would make it harder to treat legitimate patients. He said the 
company supported educating patients about the drugs' proper use.

The morning of July 4, Ms. Kinkade's boyfriend found her sitting 
cross-legged and slumped in his room at a white, low-slung house 
tucked behind a trailer park. The medical examiner said she died from 
a drug cocktail including oxycodone, methadone and methamphetamine.

Ms. Kinkade's physical decline made such an impression on the 
detective who investigated the case that, two years later, he still 
recalls the scene. In the living room, he noticed a poster of Ms. 
Kinkade modeling for a biker magazine.

"Wow, she's a beautiful young lady," Detective Matthew Taylor 
remembered thinking. "When I actually saw her, it was as different as 
night and day." -Evan Perez contributed to this article.
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