ROCHESTER, Minn. — In late 2016, Minnesota’s office of the attorney general released an exhaustive, 67-page report on the opioid crisis in the state. Though Minnesota had been spared the worst of the epidemic — the pill mills and soaring death rates in Appalachian states, southeastern US and Ohio River Valley — opioid deaths had risen five-fold in Minnesota since 1999, and Native American communities in the state were experiencing five times the death rate of the state’s white residents.
Having been promoted as medically sound and non-addicting, painkillers were suddenly in the spotlight. In March of that year, the Center for Disease Control warned doctors to stop prescribing opioids for chronic pain. A month later, opioids took the life of the musician Prince. The AG’s report in the fall of 2016 called on Minnesota lawmakers to fund treatment, rescue drugs, prescription monitoring and more. It was thorough and comprehensive and missing critical information: Someone had to have counted, shipped and sold all of those pills. What did they see?
Shouldn’t they have known something was amiss?
The answer emerged last month in a courtroom in Ohio, as a three-judge panel forced the release of ARCOS (Automation of Reports and Consolidated Orders System), the Drug Enforcement Administration’s closely-guarded database detailing the hard numbers reported to the DEA from industry sources in accordance with the controlled substances statute, granular numbers revealing the daily workings of the pipeline feeding the nation's rising numbers of prescriptions.
The release of the ARCOS data, made possible thanks to legal action and subsequent publication by the Washington Post, offers a first-hand look at a mundane but ultimately deadly pipeline through which the drugs moved across the country between 2006-2012, a period when, as the Post reported last month, 76 billion pills were shipped, and 100,000 Americans died of overdose.
Millions of pills moved through Minnesota pharmacies large and small during this period, the height of the opioid epidemic.
The pharmacy receiving the most pills in the state was Omnicare-Minnesota of Brooklyn Center. A closed-door facility owned by CVS, it provides opioids to nursing homes and assisted living centers, and received 12.6 million pills. Omnicare was followed by Pharmerica of Fridely, a similar institutional dispensary, followed by Hennepin County Medical Center, which received over 6 million of the highly addictive pills, or a million each year.
The next two pharmacies receiving the most opioids in the state suggest numbers appearing to conflict with the surrounding population. At 14.3 million pills over six years, for example, just five Walgreens stores in Duluth, a city with a population of 86,000, received nearly as many opioids as the six Mayo Clinic pharmacies in Rochester, which received nearly the same number of opioids (14.4 million), while treating hundreds of thousands of patients annually.
Observers say those numbers should have been hard to square.
"If in fact the Walgreens stores in Duluth dispensed almost as many opioids as all of Mayo Clinic,” said Cody Wiberg, Executive Director of the Minnesota Board of Pharmacy, “yeah that would seem a bit odd."
In an effort to change practices, starting in 2014, Walgreens ceased to provide controlled substances to its customers.
“Seeing this, it is shocking to know just how long the distributors have been a part of this problem and really have turned a blind eye,” said Rep. Liz Olson, who serves Duluth in the Minnesota House of Representatives and recently co-authored the omnibus opioid legislation which passed in the 2019 session. “So I’m surprised and not surprised.
“We knew this problem was coming from everybody that was touching the opioids, from the prescribers, to the manufacturers, to the distributors. But to see how much this has been impacted by the distributors themselves is really quite striking.”
Olson believes the opioids in her district likely served patients from within and outside of Duluth. “We have a large medical community here. A lot of people come here from throughout the region for their medical care. We have two large hospital systems within our community, so there is a lot or demand...which is part of it.”
At 50 pills per person annually, Mille Lacs County received the most pills per capita in Minnesota on a countywide basis. Pharmacy-specific numbers in the county draw out what would have been an out-of-proportion pill-to-population ratio. A small drug store in Onamia, for example, a town of 861 residents, received 1.6 million pills over six year — a sum equal to 22,000 opioids a month, or very likely enough opioids to fill a pair of large packing crates.
Twenty miles to the south, a pharmacy in Milaca, population 2,890, received nearly 1.3 million pills between 2006 and 2012, or 18,000 pills a month on average. Ten miles to the east, a pharmacy in Isle, population 751, received over a million pills. Following Mille Lacs County on the list of hardest hit counties in the state were 40 pills received per capita annually in Carlton County, 39 in Saint Louis County, 37 in Pennington County and 33 in both Isanti and Cook County.
Though it is only part of the picture, Wiberg notes, all of the five counties in Minnesota receiving the highest numbers of opioids per capita either served as the home to or bordered tribal lands.
“Our prescription monitoring program data tracks the next step, where drugs are actually being dispensed to patients,” he said. “You would expect similarities between those two data sets, because most of the opiates that are (received) do end up getting dispensed... and that is exactly what I found... every one of the highest counties in our prescription monitoring program data either has tribal land within the county or in the next adjacent county.”
Though the number of pills received by each county does not necessarily mean the pills remained in that county, Wiberg said the shipments underscored the depth of the crisis experienced on tribal lands in the state. “Three of the northern tribes declared public health emergencies on opioid abuse several years ago, leading then-Gov. Dayton to organize a conference at the request of tribal officials to formulate ways to combat the problem.”
"For those who live here, and fight daily to combat the devastating effects of drug addiction in our communities, it comes as no surprise to learn that this area is ground zero for commercial opioid distribution,” said Melanie Benjamin, chief executive of the Mille Lacs Band of Ojibwe in a statement. “The system is flawed when it allows such high quantities of addictive prescription drugs to flood into our streets unchecked."
'You feel a bit betrayed'
For all of its out sized shipments, the highest-receiving Minnesota county numbers fall those of below regions hardest hit elsewhere in the country. Rural counties in Virginia, South Carolina and West Virginia all received shipments surpassing 200 opioid pills per person annually. Wealthy enclaves like Palm Beach County, Florida (43 pills per person annually), and Clark County, Nevada (56 pills per person annually), even received more opioids per capita than four of the five hardest hit counties within Minnesota.
But the shipments of opioids to rural regions of northern Minnesota approached a doubling of the 24 pills per person shipped to Hennepin and Ramsey counties. Wiberg said pharmacists were operating on a distorted view of the drugs that was shaped by pharmaceutical marketing efforts. He said pharmacists, who have a dual responsibility by statute to fill legitimate prescriptions and to not provide pills which may be prescribed for illegitimate uses, were manipulated.
“As some of these internal documents come out and you realize this was a well-organized scheme, yeah, you feel a bit betrayed," Wiberg said. "Even the regulatory agencies got hoodwinked. Under my predecessor, the Boards of Pharmacy, Medical Practice and Nursing put out a joint statement on pain which pretty much catered to what we were being told by the industry.”
Joseph Rannazzisi, a former DEA official for diversion control and agency whistle-blower who testified at the Minnesota legislature in 2018, said that the DEA, while it knew prescribing numbers were rising, were forced to follow the lead of prescribers. The pharmaceutical distribution industry places blame on the DEA and doctors. Olson said distributors remain the lone participant in the epidemic to fail to accept responsibility.
“When we had the distributors at the testifiers table for this legislation, they still denied that they were anything more than someone who was essentially a go-between, someone that moved the pills. But we’re seeing they knew the pills were going into these communities, with some of them being very few people living in these communities, and the number of pills that were being sent in, and that didn’t sound any alarm bells. These pills were essentially making them a lot of money so it’s easy to not have to dig too deep if your pockets are getting thicker from these pills. So they can no longer deny the role they’ve played in this, and it’s time they step up to the plate, as every person in this chain has started to do.”
Though prescribing has dropped, Benjamin said the work of repairing the problem is only beginning.
"While we continue fighting the addiction and related criminal activity here in our communities that comes from drug abuse," Benjamin continued in her statement, "other government agencies are failing to carefully control access to the prescription opioids that are the source of so much abuse and the gateway to a lifetime of addiction. This is not an issue of race or color or cultural heritage — this is a human issue, and we all should be outraged and demand accountability.”