The Poison in the Pill
Pity the poor prescription-drug user - that is, just about every man, woman, and child in these United States. Over the past year or so, we've learned that widely prescribed pain relievers such as Bextra, Celebrex, and Vioxx can do more than take the edge off your discomfort. Depending on how old you are, what ails you, and how long you take them, such "cox-2 inhibitors" can vastly increase your risk of heart attack and stroke. At precisely the moment that pharmaceuticals are becoming ever more integral to the health care system - Americans shelled out $216 billion for prescription drugs in 2003 - it is becoming harder to have faith in the pills, potions, and powders that help us live longer, healthier lives.
If the Celebrex scandal wasn't enough to make you a little queasy about prescription drugs, Katherine Eban's "Dangerous Doses" will certainly make you reach for Maalox or Tums. Ms. Eban's subtitle sums up her topic, but her book is more than just another expose. An investigative reporter who's written about drug fraud for Self and other publications, Ms. Eban has written a riveting tale about an enterprising group of cops, pharmacy inspectors, and state prosecutors who ran Operation Stone Cold, a complicated investigation into a flourishing gray market in prescription drugs.
Set in South Florida during the first few years of this decade - a peculiar yet mesmerizing "Miami Vice"-meets-Rite-Aid world - "Dangerous Doses" is part detective story, part pharmacological primer. Its colorful characters range from the obsessive, foulmouthed special agent Gary Venema ("That's enema with a V in front of it," he says, explaining the pronunciation of his name) to former state assistant prosecutor Stephanie Feldman (a diabetic whose dependence on insulin gave her personal insight into the danger of adulterated drugs) to convicted felon and tax cheat Michael Carlow (who unapologetically ran drug scams while cuckolding business partners and living the high life).
The crooks fouling our drugs are nothing if not inventive. Occasionally, they simply steal shipments of expensive drugs such as NovoSeven, which helps hemophiliacs form blood clots and costs up to $4,000 per vial, then sell them back to shady wholesalers on the hunt for bargains. Sometimes they enlist down-and-out Medicaid patients, who give away their taxpayer-funded prescription drugs for little more than crack cocaine or booze. Then there are good old-fashioned counterfeits: In 2003 fake Lipitor was dispensed to as many as 600,000 people with high cholesterol in the United States.
In one particularly odious scam, called "up-labeling," criminals take a low-dose version of a rare and pricey drug such as Epogen, which boosts red-blood-cell production for cancer and organ-transplant patients, and relabel it as a high-dose version. Such a simple switch, made easier than ever due to cheap, high-quality printing technology, can boost the counterfeiter's take by more than 200%. One especially heartless bastard, who sold vials of Miami tap water as Procrit, another red-blood-cell booster, told the police that the patients hurt by his crimes "were going to die anyway."
What percentage of drugs are somehow counterfeit, adulterated, or otherwise polluted? Though no figures are authoritative, the World Health Organization estimates that between 7% and 10% of the world supply is tainted. In a 2004 report, the Food and Drug Administration pegged the U.S. number at "less than 1 percent." Yet, as Ms. Eban notes, the precise amount needn't be big to cause a huge loss of confidence in the nation's drug supply.
Throughout "Dangerous Doses," she trains much of her ire on drug wholesalers. "Our medicine moves through a gray market of middlemen who trade … drugs as they would any other commodity, seeking profits from ever-fluctuating profits," writes Ms. Eban, who describes a wholesale market "dominated by don't-ask-don't-tell transactions." In Florida, wholesalers' desire to keep costs low, coupled with weak state "pedigree" laws governing the documentation of drug shipments, made it relatively simple for criminals to game the system. In fact, the bad guys took advantage of weak licensing laws and all too easily became, on paper anyway, fully legitimate wholesalers.
It's something of a relief to learn that many of the abuses decried in "Dangerous Doses" have been reduced by reforms passed in the wake of Operation Stone Cold. That investigation, which ended in multiple arrests, indictments, and guilty pleas, helped tighten federal and state laws concerning "pedigree" papers and who could become wholesalers. New inventory-control technologies promise to minimize fraud in the future.
The main weakness of this book is Ms. Eban's nearly relentless castigation of wholesalers and the profit motive in general. The prescription-drug market is immensely lucrative, which means it will inevitably attract a criminal element. At the same time, those profits mean drug manufacturers, wholesalers, and pharmacies all have a vested interest in maintaining the integrity of the drug supply. Just ask Pfizer, the maker of Lipitor, which suffered financial losses and a reputational black eye when fake versions of its anti-cholesterol drug hit the U.S. market. Regardless of any regulatory or legal changes, efforts to reduce or eliminate counterfeit products have to rely first and foremost on the drugmakers, wholesalers, and pharmacies Ms. Eban at times inveighs against.
The sanctity of the system also depends on those of us receiving the more than 3 billion prescriptions that are filled annually. "Patients who understand the hidden dangers can demand the safest drugs possible," writes Ms. Eban, who hopes her "book will help begin that process." To her credit, and despite occasional hyperbole and breathlessness, I think it will.
Nick Gillespie is editor-in-chief of reason. This story originally appeared in The New York Sun and can be viewed in that format here.
