Northern California was enjoying an Indian summer in late October 2003 when Carmen Pack set off with her two young children to find ice cream. Seven-year-old Alana was riding her bike wearing a Halloween costume. Her brother Troy, 10, was on a scooter.
Jimena Barreto’s ageing, gold Mercedes was travelling at 50mph as it veered across two lanes of traffic in Danville, near San Francisco, jumped the curb and plowed into the family.
Alana was killed instantly. Troy was barely alive.
Carmen was injured but managed to grab the car keys to stop Barreto from driving off. Barreto, a 46-year-old nanny who worked for several wealthy families, bolted on foot. She was found a few days later in southern California, by which time Troy had died.
Barreto told the police she’d taken opioid painkiller pills and muscle relaxants, and blacked out at the wheel. Prosecutors suspected she was drinking, too, although she denied it.
As Carmen Pack and her husband, Bob, mourned their children, they made a startling discovery. Barreto had multiple prescriptions for hundreds of opioid pills from six doctors – and they all worked in the same Kaiser Permanente hospital.
The Packs couldn’t believe it. How could the doctors not know about each other’s prescriptions? How could the hospital not know either? Barreto went from one physician to another in the same medical complex collecting prescriptions for the opioid Vicodin and muscle relaxants by faking injuries.
“She would just go to a doctor saying: my back hurts, my arm hurts, or my neck. All these fake things,” said Bob Pack. “She asked for the medication and they just gave it to her. I was incensed. How can these doctors be so irresponsible?”
Pack set out to do something about it. He worked in technology as a former executive at America Online and knew it couldn’t be difficult to set up a database to keep track of opioid dispensing and prevent “doctor shopping” for multiple prescriptions.
Pack was right about that. What he hadn’t counted on were the entrenched financial, medical and political interests that would turn implementation of what he regarded as a simple life-saving measure into a 15-year odyssey that is only now coming to fruition.
Starting this week, doctors in California are obliged to consult a state-run drug monitoring database to check their patients’ prescribing records before giving them opioids and other controlled medicines. It’s a victory for the Packs, but one that came years after other states introduced a similar requirement because, he said, of the power of the medical industry and its lobbying in California.
“I thought this would all be done quickly, like in two years, when I set out. I was just a guy that said: ‘This makes so much common sense and this could have prevented the deaths of my children and others.’ I just kind of figured everybody would be for it. But then I learned the reality of life,” he said.
Carmen Balber, director of Consumer Watchdog, a group that campaigns on healthcare issues which backed Pack’s initiative, said a coalition of medical providers, insurance companies and doctors groups fought hard against obliging physicians to check on the prescription histories of patients not just in California but other states.
“Bob fought for many years to pass legislation requiring the use of this simple tool to identify dangerous prescribing to no avail because of the continued and strident opposition of the California Medical Association, the hospitals and the insurance industry and the political allies they fund in Sacramento,” she said.
While California’s opioid death rate was far below some of the worst hit states, such as West Virginia and Ohio, the total number deaths was significant, running into the tens of thousands over the past 15 years because of its large population.
California’s pharmacy board said that doctor shopping was so easy that one patient visited more than 100 physicians over four years, collected opioid prescriptions from nearly 60 pharmacies and was dispensed 45,000 doses of painkillers worth close to $1m on the street. The lack of prescription monitoring also helped shield those doctors who made huge profits giving large amounts of opioid painkillers to anyone who asked, such as Lisa Tseng, the first physician in the country convicted of murder for prescribing enough to cause at least six deaths and probably more.
Pack was glad to see Barreto convicted of second-degree murder, because she had previous convictions for driving under the influence, and sentenced to 30 years to life in prison. But he thought responsibility for his children’s deaths ran much wider.
“There were six doctors prescribing to her for a long time. They never talked to each other or shared a medical file. She would go in one week, get 60 Vicodin, and a week or two later go in and get another 60 from a different doctor,” he said. “I thought, aren’t they required to share medical files so they know what they’re doing? Isn’t there some kind of computer system where they can look that up or track it? I couldn’t believe that there wasn’t any of that.”
When Pack dug into it he discovered there was already a system in place going back to 1939 requiring California pharmacists to report the narcotics they dispense to the state’s justice department. In 1997, it was turned into a database – the Controlled Substance Utilization Review and Evaluation System, known as Cures. But it was so antiquated that drugstores were still filing reports by fax. It took weeks to enter the data and then it mostly disappeared into computer files, never to be looked at again.
Pack began lobbying members of the California legislature to modernise the system and require doctors and pharmacists to use it. He saw it as working much the same as gun shops carrying out background checks in minutes.
Pack won support from some members of the legislature who sponsored a bill to upgrade the Cures system, but it passed with a rider saying that the improvements must not cost the state of California money. The result was a relatively slow system that was of little practical use to doctors under pressure to cycle through patients every few minutes.
Finally, a decade after the death of Pack’s children and following years of campaigning, the state legislature imposed a levy on on doctors’ and pharmacists’ license fees to upgrade the system.
But then the real battle began. Cures would only be effective if doctors were obliged to consult it, and the California Medical Association (CMA) was among the most vocal opponents. It told legislators that mandatory prescription monitoring would impose “an unnecessary bureaucratic burden” on physicians and prevent pain patients from getting the medicine they need. At the same time, the association also claimed that there was no need to make the system compulsory because its members would sign up in droves.
Pack met repeatedly with the CMA to try to get it on board.
“They said in three years, 90% of doctors will be enrolled in checking Cures and so you don’t need a mandatory bill to do that. It never happened. The percentage of doctors using the Cures system was really low. It only reached a peak of about 15% of doctors in California while it was voluntary,” he said. “There’s very big money in opioid prescribing.”
Pack joined others to push a California ballot measure in 2014 requiring doctors to use Cures. The CMA and other medical groups spent $92m to defeat the measure. They placed adverts claiming that Cures was “a vulnerable government-run database containing your personal prescription drug history, open to law enforcement, hackers, identity thieves or simply accidents”.
The San Jose Mercury News described the adverts as “shamelessly deceptive”, noting that the Cures database had been around since 1997 and never been breached. The Sacramento Bee called the advert “an outright lie” and the Los Angeles Times described the claims as “baloney”.
The issue returned to the California legislature in 2015, by which time increased public awareness of the opioid epidemic was shifting. But at a state senate hearing, the CMA again objected to a law making Cures compulsory by saying it “will create an unnecessary regulatory burden to prescribing and increase the threat of litigation, both of which would have a detrimental impact on patient care while adding limited value to addressing prescription drug abuse”.
Pack was incredulous. California had prescription monitoring before any other state, yet it was being left behind by similar programs in other parts of the country that were clearly effective.
Kentucky, Tennessee and New York all saw a significant drop in opioid prescriptions after they required compulsory checks. The US department of health called Kentucky’s program, launched in 1999 and made mandatory six years ago, the “gold standard” for prescription monitoring.
“Kentucky has seen its ranking among states with the highest non-medical use of prescription painkillers drop from second to 31st place, reflecting a drop that officials attribute largely to its monitoring program,” a report by the Substance Abuse and Mental Health Services Administration said last year.
The position of the CMA and other medical institutions finally shifted in 2016 in the face of public pressure. Politicians who had overwhelmingly sided with the industry, and more often than not received large campaign contributions, abruptly changed their positions and Cures was made mandatory – although it would take more than two years for the requirement to be put into effect because of the CMA’s resistance.
“The political reality of the opioid crisis, the thousands of people who are dying every year, became overwhelming. It was impossible to ignore,” said Balber. “But the CMA never removed their opposition to the mandatory use of Cures. We never saw the medical association reversing position and saying: ‘You’re right. Cures should be mandatory.”
The CMA sidestepped a series of questions about its long opposition to the legal requirement for doctors to consult Cures, including its claims that the system would created regulatory burdens and increase the threat of litigation even though that was not the experience in other states. It also did not directly address a question as to whether the association now supports mandatory consultation of Cures by doctors.
The association claimed that the questions were “outdated” because, in effect, they have been overtaken by the law. It also maintained that its opposition was largely driven by concerns about the operational shortcoming of Cures even though the objections made to the state legislature went much wider.
The CMA’s president, Dr Theodore Mazer, issued a brief statement in response to questions.
“The California Medical Association has been actively engaged in addressing opioid abuse and overdose while ensuring patient access to appropriate care. While more work is needed, even before the duty to consult Cures, our efforts have helped California lead the nation in reducing opioid prescriptions by over 24%. After working with the state to ensure adequate support for physicians who will have to rely on Cures, CMA is optimistic that the system is ready for statewide use, and we will continue to monitor implementation,” he said.
The number of opioid prescriptions has been falling across the country, in part because of greater doctor awareness of the epidemic and new guidelines from the Centers for Disease Control and Prevention (CDC). But Pack and others wonder how many of those now dying amid the surge in lives claimed by heroin and a synthetic opioid, fentanyl, were drawn into the epidemic by the unrestrained prescribing of painkillers.
Pack is glad to see the measure he fought so long and hard for finally introduced, but the struggle took its toll.
“Early on, I was working out of anger and frustration because of the deaths of my kids. But over the years, just for my own emotional sake, I had to calm down because I would get so impatient over the fighting. With politics, a year or two is nothing. They have tricks in their bag where they can delay and delay and delay,” he said.
Pack is glad to see the measure he fought so long and hard for finally introduced. The couple rebuilt their lives and have another daughter now, Noelle. But the struggle took its toll.
“I couldn’t fight it out of anger any longer,” he said. “I had to keep at it with an attitude of just commonsense persistence and the fact that if I keep at it, it’ll save other lives. I had to take a much calmer approach because it was hard on me too.”
Chris McGreal’s book American Overdose: The Opioid Tragedy in Three Acts is published in November
