White House Pharmacy Violated DEA Policy

By Pat Anson, PNN Editor

A pharmacy operated by the White House Medical Unit dispensed hundreds of prescriptions for opioids and other controlled substances without keeping proper records, according to a scathing audit released this month by the Office of the Inspector General (OIG) at the Department of Defense.

In many cases, drugs, surgeries and other medical services were provided to ineligible White House staff members at no cost. Over-the-counter medications were also free to be taken from open bins to anyone who wanted them.

The OIG launched an audit of the medical unit in 2018, after receiving complaints that an unnamed senior military medical officer assigned to the White House was acting improperly. Additional complaints received over a hotline questioned procedures at the pharmacy and the eligibility of patients that were being treated.

The resulting audit – which covered the years 2009 to 2020 – found “severe and systematic” problems at the White House pharmacy due to poor oversight that may have resulted in “prescribing errors and inadequate medication management.”

“In our analysis of the White House Medical Unit’s controlled substance records, we found that medications, such as opioids and sleep medications, were not properly accounted for, in violation of (federal law),” the OIG said. “White House Medical Unit medical providers wrote prescriptions for controlled substances that often lacked the medical provider and patient information mandated by DEA policy.”

DEA regulations require that prescriptions for all controlled substances contain the patient’s full name and address, as well as the name, address, and DEA registration number of the prescriber. But when reviewing 11 examples of prescriptions for controlled substances provided by the medical unit, investigators found much of that information was missing.       

The OIG was only able to obtain pharmaceutical records from 2017 to 2019, because the pharmacy kept records for just two years. Investigators found that the pharmacy still used handwritten ledgers to track the inventory of controlled substances. The ledgers frequently contained errors, illegible text, or text was that was crossed out.

A pharmacy ledger from 2019, seen below, shows that prescriptions were dispensed for the opioids morphine, hydrocodone, fentanyl and tramadol, as well as ketamine and diazepam – all controlled substances. Some medications were dispensed in unusually large quantities, such as 2,000 tablets of the sleep aid Ambien.

Names of the prescribers and patients on the ledger were redacted. In some cases, the ledger shows no record of who picked up the medications or if anyone signed a receipt for them.     

WHITE HOUSE MEDICAL UNIT CONTROLLED SUBSTANCE TRACKING FORM

In interviews with 70 former military service members who worked at the White House between 2009 and 2018, the OIG found there was a culture of entitlement. Administration officials and staff members who sought medical treatment were “not normal patients,” as one medical unit member put it.

“We bent knees and we bent the rules to meet this very weird, strange culture that was there, and I think it was really to just impress people,” the service member said. “And so I understand it’s almost like the culture of D.C. and politics, and somehow the Medical Unit got sucked up into that culture as well.”

Another service member highlighted inconsistencies in the medical unit’s practices.

“[There] were several concerns about we’re not accomplishing the mission the right way. Is stuff getting done? Yeah. Is it being done appropriately or legally all the time? No. But, are they going to get to that end result that the bosses want? Yeah.”

Other service members said the medical unit used alias accounts to provide free specialty care and surgery to ineligible White House staff. The alias accounts did not use the patient’s real name or address. When a medical unit staff member expressed alarm about that practice, they were instructed to provide care to the ineligible individual.

“Several former White House Medical Unit staff members stated that they felt unable to act outside of the will of the Physician to the President or the White House Medical Unit Director. One former White House Medical Unit medical provider stated that White House Medical Unit staff members were fearful of ‘making independent decisions’ without the approval of the Physician to the President or the Director of the White House Medical Unit,” the report said.

Dr. Ronny Jackson

The OIG report takes pains not to identify anyone by name or associate them with either the Obama or Trump administrations. But for many of the years covered by the audit, Dr. Ronny Jackson played key roles in the White House medical unit.

A U.S. Navy officer, Jackson joined the medical unit in 2006, and became its director in 2010. In 2013, Jackson was given the additional title of Physician to the President under Obama. In December 2014, Jackson ceased being Director of the White House Medical Unit, but remained as personal physician to Obama and then Trump until 2018. President Trump appointed Jackson as Chief Medical Advisor and Assistant to the President in January 2019.

In an email to PNN, a spokesperson for Jackson said that he only had a policy role in the medical unit after 2014, and had no association or involvement with the unit’s delivery of care.

In 2018, allegations of drunkenness, misconduct and mismanagement arose about Jackson’s service. Jackson called the allegations a “political hit job.” In December 2019, he retired from the Navy as a Rear Admiral, left the White House, and was elected a Republican congressman in Texas, a position Jackson still holds.   

In 2021, a seperate OIG investigation of Jackson found that he disparaged and bullied subordinates, created a hostile work environment, and engaged in “inappropriate conduct” involving his use of alcohol. Jackson was also found to have used Ambien to help him sleep on long overseas flights on Air Force One, “raising concerns about his potential incapacity to provide proper medical care during this travel.”  

(3/7/24 Update: The Washington Post reported that Jackson was demoted to the rank of captain in 2022 after the OIG report on his conduct. The demotion had not previously been reported and has not been acknowledged by Jackson.)

Opioid Prescriptions Down Sharply for Medicare Patients

By Pat Anson, PNN Editor

The number of Medicare beneficiaries receiving opioid prescriptions has declined significantly since 2016, according to a new government report that also found steep declines in the number of beneficiaries receiving high doses or who appear to be doctor shopping.

The report by the Department of Health and Human Service’s Office of Inspector General found that over 21 million people -- 23% of Medicare Part D beneficiaries -- received at least one opioid prescription in 2021, down from 33% of beneficiaries in 2016. Over 51 million people are currently enrolled in Part D.

The Centers for Medicare and Medicaid Services (CMS) adopted new safety rules in 2018 that discourage high dose prescribing and limit the initial supply of opioids to 7 days. The rules also allowed pharmacists and insurers to flag Medicare patients deemed to be at high risk, as well as their prescribers.

The rules appear to have had a major impact on prescribing. In 2016, over half a million Medicare beneficiaries received a daily opioid dose of at least 120 MED (morphine milligram equivalent). By 2021, that fell to less than 200,000 patients, a 60 percent decrease in high dose prescribing.   

MEDICARE PATIENTS RECEIVING HIGH DOSE OPIOIDS

HHS Office of Inspector General

Since 2016, the number of Medicare beneficiaries who appeared to be doctor shopping dropped from 22,300 to 1,800; while the number of doctors with “questionable” prescribing patterns fell from 401 to just 98.  Patients were flagged for doctor shopping if they were on high doses and received opioids from four or more prescribers or four or more pharmacists.

“The opioid epidemic continues to grip the nation. There is clearly still cause for concern and vigilance, even as some positive trends emerge,” the OIG report found. “The number of Medicare Part D beneficiaries who received opioids in 2021 decreased to approximately a quarter of a million beneficiaries, extending a downward trend from prior years. Further, fewer Part D beneficiaries were identified as receiving high amounts of opioids or at serious risk of misuse or overdose. The number of prescribers ordering opioids for large numbers of beneficiaries at serious risk was steady.”

But there is little evidence that less prescribing is reducing addiction and overdoses.  The Centers for Disease Control and Prevention estimates there were nearly 81,000 opioid-related deaths in 2021, nearly twice the number reported in 2016, when the CDC’s opioid guideline was released. The vast majority of deaths involved illicit fentanyl and other street drugs, not prescription opioids.

The OIG report found that 50,391 Part D beneficiaries experienced an opioid overdose (either fatal or non-fatal) in 2021, but did not break down how many were linked to illicit or prescription opioids.

Over one million Medicare beneficiaries were diagnosed with opioid use disorder (OUD) last year, but only one in five received a medication like Suboxone or methadone to treat their condition. Medicare patients were far more likely to receive naloxone, an overdose reversal drug. Over 445,000 beneficiaries received a prescription for naloxone, an 18% increase from 2020.