Q&A with Armond Marcarian
Interviewer: What is prescription drug abuse?
Armond Marcarian: Prescription drug abuse (or sometimes called pharmaceutical abuse) occurs anytime a patient fails to take a medication in the way that it is prescribed. If a physician prescribes a medication to be taken four times a day and a patient takes it three times a day or five times a day, broadly speaking that is abuse – it is misuse. In prescription drug abuse you get into areas where a prescription is prescribed for a patient and the patient is not the ultimate user of the drug. Those drugs find their way onto the streets and fetch quite a few dollars per pill, and then they exchange hands. That is certainly prescription drug abuse. I think the critical issue for pharmacists is: How is the pharmacist to know whether or not a particular prescription is going to change hands on the streets and is not going to be used by the person for whom it was prescribed? When a pharmacist is presented with a prescription, he is required to monitor the patient’s medical history to identify drug-drug interactions and drug-disease interactions and to make a professional judgment whether or not the prescription that patient is presenting is likely to end up on the street. How can you tell that? Well, you look at the patient’s drug usage. If, for instance, the patient is taking a lot of Norco, a very highly abused drug, and is found to be taking it very frequently, that is a red flag for the pharmacist that there could be prescription drug abuse with respect to this Norco. The pharmacist needs to call the prescriber; run a CURES Report; and identify other instances where the patient may have obtained Norco (and the sources of the Norco) in order to determine whether or not there is a case of prescription drug abuse.
Interviewer: Why would someone need an attorney for prescription drug abuse?
Armond Marcarian: If there is a case of prescription drug abuse and the pharmaceuticals involved are controlled substances (such as Valium, Heroin, Morphine, Dilaudid, Vicodin, Vicodin ES, or Soma), once the California State Board of Pharmacy becomes aware that a pharmacist dispensed prescriptions which resulted in prescription drug abuse, the Board does its own investigation, sometimes in collaboration with agents from the DEA. And once they complete their investigation they refer their reports to the California Attorney General’s office. At that point, the Attorney General’s office does its own investigation to determine whether or not there is cause for discipline. If there is, they initiate a lawsuit; they call their lawsuit an “accusation”. They will file an accusation with the Board of Pharmacy – this would be the people of the State of California against the particular pharmacist or pharmacy. At that point, the pharmacy or pharmacist will be well-advised to seek legal help because this is a highly technical area. It would be similar to someone without legal training or experience representing himself when they are criminally charged, or when there is a serious civil lawsuit. The administrative process where a pharmacist’s license is the subject of revocation is a quasi-criminal process, so they are well-advised to seek representation from an attorney who has done these cases and understands the dynamics. In the State of California, I am aware of only maybe three or four other attorneys (other than the Marcarian Law Firm) who do this type of work routinely and, I think three of them are pharmacists. So, there are not too many pharmacist attorneys who do this kind of work. Obviously, we recommend they get their representation from someone who has experience in dealing with this type of case, such as our firm.
Interviewer: How big of a problem is prescription drug abuse, and who does this affect?
Armond Marcarian: Prescription drug abuse and substance abuse is a huge problem nationally. It has resulted in thousands and thousands of cases of death from overdose. Unfortunately, the average age population where you are seeing this happen is with college students and young adults in their late twenties. It affects a lot of people, but in most instances younger individuals.
Interviewer: What are some of the most commonly abused prescription or over-the-counter drugs?
Armond Marcarian: As far as prescription drugs, some of the most commonly abused are Norco, hydrocodone containing products, Soma, Dilaudid, morphine sulfate, various preparations of morphine sulfate, and one in particular that has received tremendous coverage over the years is MS Contin. There is a cough syrup called Promethazine and it is a potentiator. People who take Promethazine typically mix it with morphine sulfate, Dilaudid or Norco to potentiate the drowsiness and grogginess side effects of those drugs. As a result, it is potentially a deadly combination. As far as over the counter drugs that have potential for abuse, Sudafed is a drug that is a decongestant which is sold over the counter. About three or four years ago, all pharmacies in the country were ordered to remove Sudafed from their shelves and place it in the back of the pharmacy because people were buying massive quantities of Sudafed and using it to manufacture speed and crack cocaine. Now, if anyone tries to buy Sudafed, there is a limited supply you can purchase and you need to present the proper identification to the pharmacist. It can only be sold by the pharmacist at the pharmacy counter. OxyContin is a morphine containing product and is by far the most commonly abused controlled substance for the past seven or eight years. Going back about twenty-five or thirty years ago, Quaaludes were very popular and highly abused. Today, OxyContin is today’s equivalent of the Quaaludes of the past. The reason why a lot of pharmacists have had their licenses revoked and their pharmacy permits revoked is because they filled illegitimate prescriptions written by a number of physicians who have been arrested, charged and convicted of second degree murder and manslaughter over the past two years. Nearly all of those cases were related to OxyContin abuse.
Interviewer: Can you tell us a little about California’s Health & Safety Code Section 11153?
Armond Marcarian: Section 11153 of California’s Health & Safety Code is what we call the “corresponding responsibility” statute. Under the corresponding responsibility statute, the pharmacist is required to make sure that a controlled substance prescribed by a prescriber is used for a legitimate medical purpose. There are ways of trying to determine if it is issued for a legitimate medical purpose by going through the patient’s profile; running a CURES Report to identify prior usage of the same drug or similar drugs; finding out whether that patient is obtaining that particular controlled substance from other sources, from other doctors; and if so, how frequently does that patient receive those prescriptions. Those are some of the analyses or work that the pharmacist needs to do under that corresponding responsibility statute in order to formulate a professional judgment before he dispenses a prescription to that patient. In addition, the corresponding responsibility statute was never tested in California, nor to any significant extent anywhere in the country until our office had such a case. We initially lost the case, but the California State Board of Pharmacy determined that that case should have what they call a “precedential value”. It was called the Pacifica Pharmacy Case and is cited now not only in California, but elsewhere in the country. There has been much talk about that case because it was a case which was fully litigated. It did not get to the Court of Appeal, but there was a pretty well-developed record for that case and the main issue there was “corresponding responsibility” under subdivision “a” of California Health & Safety Code Section 11153. The California State Board of Pharmacy is taking this statute and the corresponding responsibility of the pharmacist very seriously. They are very aggressive in their prosecution under this particular statute.
Interviewer: What should a person do if they are accused of violating Health & Safety Code Section 11153?
Armond Marcarian: A person should seek legal assistance from attorneys who have done this type of work – meaning representing health care professionals in the administrative arena. The practice in the administrative arena is a little different than what you do in a criminal setting or a civil setting. Certainly, understanding a little bit about medications, drugs, and prescriptions has advantage to the attorney. To my knowledge, none of the State Attorney General’s deputy attorneys have a background in medicine, so there is tremendous advantage to those licensees and permitees who seek out an attorney who understands the medicine and pharmacy part of it, such as the Marcarian Law Firm.