Kaiser pharmacies were the top distributor of opioid tablets containing hydrocodone and oxycodone in Sacramento County for the years 2006 through 2012. This information was brought to light in Drug Enforcement Agency (DEA) data base of controlled substances made available by the Washington Post. However, just because Kaiser pharmacies ordered and distributed more opioids in Sacramento County during this time period then all other pharmacies, it does not mean that Kaiser was a pill mill feeding into the abuse of these narcotics, resulting in addiction in overdose.
As a numbers nerd, I was delighted to see that the Washington Post had published the DEA database of opioid tablets shipped throughout the United States between 2006 and 2012. The Washington Post had to sued to get the database, and then after analyzing it, made it available to the public. I was surprised when I selected California > Sacramento County and saw that Kaiser pharmacies were the top dispenser of opioids.
Kaiser Pharmacy Orders of Opioids in Sacramento County
At first glance, the designation of top dispenser of opioids puts Kaiser in the unfavorable company of doctors and pharmacies who unscrupulously and unethically freely wrote prescriptions for opioids and easily filled the scripts. The Washington Post has shown that there is a causal relationship between counties where opioid pills flooded into pharmacies and deaths attributed to opioid overdoses around those counties.
The linkage between legally prescribed opioids for pain relief and opioid addition and overdose has been described in this manner. The opioid manufacturers, in particular the maker of Oxycontin, claimed to doctors that the pain relievers containing the active ingredients of either hydrocodone or oxycodone, had minimal habit forming or addictive qualities to them. Doctors prescribed the opioids with little concern for the patient to become addicted.
But people who were prescribed these medications for pain relief for a variety of common ailments or work-related injuries did become addicted. When the doctors would no longer prescribe the opioid pain reliever to the individual, they turned to scoring the opioids on the street or turning to heroine. With the addition of fentanyl, which can be lethal in small doses, in illegal street drugs the opioid related deaths skyrocketed in the United States.
Sacramento County was not a hotspot for the sudden increase of opioid pills according to the Washington Post graph that other communities were facing. Plus, the region did not record a spike in opioid related deaths. Sacramento County opioid deaths was trending below the nationwide average per 100,000 population, but slightly above the California average for years 2006 through 2012.
Kaiser Unique Health Care Delivery System
Kaiser is not an independent neighborhood pharmacy that may be susceptible to doctor’s, who they have no relationship with, over prescribing opioids. Kaiser is very structured with lots of controls. I was curious to see what the DEA drug database revealed about the Kaiser pharmacies and their ordering and dispensing of the opioid drugs in question. The overall review showed that Kaiser pharmacies have been regularly ordering opioids for the years 2006 through 2012. There were no sudden spikes for most pharmacies. The one interesting trend was that for some pharmacies the weighted average strength of the opioids increased between 2006 and 2012.
Another point that piqued my interest is that Kaiser is a unique health care system. Whereas most pharmacies (Walgreens, CVS, Costco, Target, etc.) accept and service the prescriptions of a variety of doctors associated with different medical groups and health plans, Kaiser pharmacies, for the most part, are filling prescriptions only from Kaiser doctors for Kaiser members. This gives a little more insight into the prescription habits of at least Kaiser physicians.
Kaiser is made up of three organizations in California. There are the Kaiser Foundation Hospitals, the Kaiser medical group of doctors, and Kaiser Permanente the administrator for the health insurance plans. They are three distinct, but integrated, organizations. With the exclusion of emergency room patients, a person must be a Kaiser member of Kaiser Permanente health plan in order to be seen and treated by a Kaiser physician. One of the benefits of the Kaiser system is that the pharmacy is conveniently located generally in the same office complex or campus of the Kaiser medical group. While Kaiser does contract with a few pharmacies not affiliated with Kaiser in the Sacramento region, it seems like most Kaiser members use the Kaiser pharmacy to fill prescriptions.
Finally, Kaiser has a very robust enrollment of households in the Sacramento metropolitan region. They have had some of the lowest health insurance rates in the area for a variety of different groups including individual and family, small group, and large employer groups plans. They also accept limited numbers of Medi-Cal (California’s Medicaid health plan) and Medicare Advantage plans for seniors. Even though the health insurance landscape has changed dramatically since the Affordable Care Act launched in 2014, Kaiser had a diverse demographic group of members between 2006 and 2012, the years covered by the DEA database.
Methodology of Opioid Research
The DEA database is humongous. The Sacramento County database has 669,639 records, each with 42 fields of information. In short, it tracks the flow of opioid orders from the wholesaler to the pharmacy. It lists the manufacturer of the opioid, the transaction date to the buying pharmacy, active opioid ingredient, product name, dosage unit, and strength as measured by milligrams (mg) of active ingredient. The database originally contained all the controlled substances tracked by the DEA. The Washington Post created a revised database that includes only the opioids of hydrocodone and oxycodone.
I sorted the database by pharmacy, address, and transaction date. I then located pharmacies I wanted to review, copied the data and put it into a new Excel workbook. I further sorted the data by hydrocodone and oxycodone orders. I separated the two drugs because they are different and prescribed for different reasons to people with different pain challenges.
The DEA ARCOS (Automation of Reports and Consolidated Orders System) is not perfect. It relies on humans to report the information. This results in some pharmacies having their main address listed under Buyer_Address1 while others are listed under Buyer_Address2. In addition, I did come across some Kaiser doctors who were obviously registered to receive opioids to their practice, but this was rare. There is also the minor complication that Kaiser would add pharmacies at the same location. For example, Kaiser at 6600 Bruceville Rd., has what they title as KFHP #1-New Pharmacy #601 and the South Tower #609 pharmacy at the same location.
Other than sorting the database, I only made a few modifications. First, I included a field to sum the tablet unit count per opioid at each pharmacy by year. Second, the dosage strength was, on occasion, left blank for the drug Percodan. The description under Product_Name included the milligram strength of 4.5, so I transferred that to the dosage strength field. Finally, I added an Average Weighted Strength column to the database.
The average weighted strength is the unit count of the tablets for the specific order multiplied by the dosage strength. I then totaled the weighted strength and divided by the total number of tablets for the year.
Opioid Prescribed Strengths Milligrams
The various brand name and generic opioid drugs come in different mg strengths. Hydrocodone can be ordered in 5, 7.5, and 10 mg tablets. (It is usually combined with acetaminophen. For example, Lortab can be prescribed with a hydrocodone strength of 7.5mg and 500mg of acetaminophen). Oxycodone can be prescribed in mg strengths of 4.5, 4.8355, 5, 5.35, 10, 20, 40, or 80. There are also extended release versions of the drug.
Kaiser pharmacies received hundreds of orders each year for the different opioids. In 2006, the Kaiser pharmacy #601 received 443 orders of hydrocodone and 149 orders of oxycodone drugs. The shipping units could be as small as 100 tablets or as many as 10,000. It was because of the number or orders and the variety of dosage strengths that I created the average weighted strength statistic. The average weighted strength, when graphed, shows if overall orders of either hydrocodone or oxycodone decrease, increase, or are flat.
Kaiser has numerous pharmacies throughout Sacramento County. Some of the pharmacies serve their hospitals and some serve the medical groups. I focused on nine of the pharmacies, seven of which had data for years 2006 through 2012. The other two pharmacies only had data for 2011 and 2012 and were opened to support existing facilities because of population growth. Kaiser also has several pharmacies in the South Placer County area of Roseville that members in northern Sacramento County might visit. Consequently, the Sacramento County numbers don’t capture the full extent of Kaiser’s use of opioid prescriptions to control pain in the Sacramento metropolitan region.
Pharmacy charts below usually include a one chart with the total number of opioids orders with a different color designation for oxycodone and hydrocodone for the reporting years 2006 – 2012. The second chart is the weighted average milligram MG strength of the dosages order for the year.
Sacramento
Kaiser pharmacy at 1650 Response Road serves the medical group offices at that location along with an urgent care center. This was the only Kaiser pharmacy where the weighted average MG dosage strength for hydrocodone was consistently higher than for oxycodone. But like the other pharmacies, the trend line for hydrocodone strength increased over the years
Kaiser pharmacy at 2025 Morse Avenue has a variety of specialists, hospital, and emergency room facilities. This pharmacy on Bruceville Road, also associated with a Kaiser hospital, had some of the largest orders for opioids.
Kaiser pharmacy at 2345 Fair Oaks Blvd. serves various specialist including cancer care.
South Sacramento
Kaiser pharmacy at 6600 Bruceville Road serves the hospital, emergency room trauma specialist, general surgery, and other specialty health care services.
Kaiser pharmacy 6600 Bruceville South Tower designation seems to have been opened to support the older pharmacy.
Kaiser pharmacy at 7300 Wyndham Drive is right around the corner from the hospital on Bruceville Road. It serves the medical group at that location that have various specialties including head and neck surgery.
Elk Grove
Kaiser pharmacy at 9201 Big Horn Blvd. serves the medical group focusing on primary care services for adults and children. This pharmacy had 12 orders of oxycodone tablets with a strength of 80mg in 2006. This spiked the weighted average MG dosage up to 15.83 In subsequent years the orders dropped down to three or six for 80mg tablets, lowering the overall weighted average.
Kaiser pharmacy at 10305 Promenade Parkway also serves the medical group at that location that also includes sports medicine specialist.
Rancho Cordova
Kaiser pharmacy at 10725 International Drive serves the medical group primary care and specialists in cancer care, eye surgery, and radiation oncology.
General observations
- Some Kaiser pharmacies realized a sharp increase in the weighted average MG dosage strength for oxycodone. Most of these spikes occurred before 2010. It only takes a few patients requiring the higher dosage prescription to create a marked increase in the weighted average.
- With the exception of Kaiser on Big Horn Road, and to a lesser extent the pharmacy on International Drive, oxycodone weighted average MG dosage levels dropped from 2006 to 2012.
- Every Kaiser pharmacy realized an increasing trend of increased weighted average MG dosage strength for hydrocodone over the seven year reporting period. In other words, they were ordering more 7.5mg and 10mg tablets over time. Over the reporting period, the weighted average of hydrocodone generally increased 2mg from the 6mg range up to 8mg per dose.
- Many of the Kaiser pharmacies saw a drop in all opioid orders in years 2007 and 2008. This was most likely because of the recession and many people lost employer based health insurance.
Comparing Kaiser To Other Pharmacies
Because the Kaiser health care system is relatively unique in its delivery of care and pharmacy services it is difficult to compare it to other pharmacies that serve multiple medical groups and health plans. One that I thought might come close was the pharmacy that serves the UC Davis Medical Center – but I was wrong. This pharmacy at 4501 X Street would be the closest for patients of the UC Davis Medical Group and the UC Davis Trauma Center. It is also next to the Shriners Hospital who serves children with severe burns and spinal cord injuries.
Compared to Kaiser, even the pharmacies serving Kaiser hospitals, the UC Davis pharmacy ordered a far higher percentage of oxycodone relative to hydrocodone. The weighted average MG dosage per tablet, between 17mg and 34mg, was also higher than the Kaiser pharmacies. It’s possible the nature of the illnesses and injuries (cancer and burn victims) accounts for the higher utilization of oxycodone. Similar to Kaiser, the UC Davis pharmacy showed a trend of increasing hydrocodone strength over the reporting period. It would appear that the nature of patients and care at UC Davis is very different from Kaiser and not necessarily a good comparison.
I also researched a few other pharmacies for comparisons. Costco pharmacies have contracts with a variety of different health plans to fill prescriptions.
The Costco pharmacy at 1600 Expo Parkway showed a marked increase in both hydrocodone and oxycodone orders in 2007 and 2008. One explanation might be the potentially lower cost of drugs at Costco. If an individual has lost Kaiser health insurance, they can’t use a Kaiser pharmacy, but they still have prescription medication requirements. The increase in Costco orders may be a consumer shift in purchasing habits as a result of the recession and loss of health insurance. Orders for opioids dropped back down after 2008 and remained relatively constant thereafter. Like the other pharmacies, Costco on Expo Parkway reflected an increase in hydrocodone strength from 2006 to 2012.
The Costco pharmacy at 11260 White Rock Road in Rancho Cordova also showed a small bump in orders in 2007 and 2008, like Expo Parkway pharmacy. Similar to the Kaiser pharmacies, the strength of the oxycodone orders decreased while the MG strength of hydrocodone increased slightly. The weighted average MG dosage strength for hydrocodone in 2006 was 8.07 and went up from there. Most Kaiser pharmacies never hit an 8mg hydrocodone strength level, and if they did, it did not happen until 2011 or 2012.
Blue Star Pharmacy at 3811 Florin Road is in South Sacramento in a lower income community. A cynical perspective would assume that this is where you would see an opioid pill mill. This was not the case with the Blue Star orders. They ordered no oxycodone and the weighted average strength of the hydrocodone never went above 5.71.
The pharmacy at Folsom Prison in Repressa had a spike in opioid orders that would most resemble some pharmacies filling lots of orders from unscrupulous doctors. The hydrocodone orders went from 3200 in 2010 to 20,460 in 2011. The strength went from 5.31mg to 8.45mg of hydrocodone. This does not mean that Folsom Prison all of the sudden started feeding the inmates hydrocodone. There may be administrative reasons for the sudden increase in hydrocodone orders such as moving from off-site pharmacies filling prescriptions to in-house dispensing to save money.
Kaiser, A Responsible Actor In Opioid Prescriptions
From my limited review of the data I don’t see any indication that, even though they there were the number one distributor of opioids in Sacramento County, Kaiser was intentionally profiting from the prescription of either hydrocodone or oxycodone. Their designation of largest distributor of opioids was most likely influenced by having a large Kaiser Permanente membership during the reporting period of 2006 to 2012.
Kaiser is unique in that because they manage their own pharmacies, we can get a look at the ordering habits of opioids, and by extension, the prescribing of those opioids by Kaiser doctors. With a pharmacy like Costco, that has a higher ordering rate for higher strength doses of hydrocodone, it is hard to pinpoint which doctors or medical groups are prescribing the stronger drugs. It may not even be a doctor in Sacramento County.
The Washington Post analysis calculated that for the reporting years of 2006 – 2012, there were 45.5 opioid pills prescribed per person per year in Sacramento County, based on population figures. By comparison, Lake County had rate of 97.3 opioid pills prescribed per person.
For the most part, Kaiser orders of the opioids remained constant. The dosage strength of the oxycodone usually dropped over time. The pharmacy orders are in direct relationship to what the doctors are prescribing. It is interesting that the weighted average strength of hydrocodone increased for all pharmacies, not just Kaiser. Only the doctors involved with those prescriptions can tell us why oxycodone strengths dropped while hydrocodone crept upwards.
Sacramento is dominated by large medical groups such as Kaiser, Mercy Medical Group, UC Davis, Hill Physicians, and Sutter Medical Group. Most people, regardless of their health plan type, visit a doctor affiliated with one of the large medical groups. Because of the structure, controls, and oversight at large medical groups such as Kaiser, there is much less room for a doctor to unethically over prescribe opioids to their patients. This does not mean there is not abuse of prescribed opioids.
However, compared to other counties not dominated by large medical groups and saw a notable influx of opioids, Sacramento was fortunate to have health care systems monitoring the use of opioids among their patients during this reporting period. This is reflected in the lower opioid death rates for Sacramento County compared to the state statistics and the lower opioid pill prescriptions per person in the total population. Overall, it looks like Kaiser was one of the good actors in a nasty national tragedy where easy access to opioids led to addiction, overdose, and in too many instances, death.