Vetting the Doc
Nine days after the Bayou Brief published a report documenting that U.S. Rep, Ralph Abraham had owned two rural pharmacies in northeast Louisiana that had received a total of nearly 1.5 million opioid doses between the years 2006-2012, neither the congressman nor anyone formally affiliated with his office or his gubernatorial campaign have issued a single statement or disputed any of the claims in the report.
In assembling the initial report, I relied on public records and documents from a variety of sources: the Drug Enforcement Agency, the Louisiana Department of Health, the Louisiana Secretary of State, and perhaps most importantly, the Securities Litigation and Consulting Group (SLCG), which provides a free and much more comprehensive data set than the one constructed by the Washington Post. (While I had linked to the Washington Post’s data originally, I have subsequently discovered their dataset has some missing information that I accessed through SLCG, which may have created some confusion to those who did not otherwise know how to locate the raw numbers).
SLCG, it should be noted, are working directly on this litigation, which has allowed them access to more data than any news organization. They’re more directly plugged into the database, and it makes a difference.
First and perhaps most importantly, Abraham’s pharmacy in Winnsboro, Adams Clinic Pharmacy, had three different DEA identification numbers; as of this writing, the Washington Post has only uploaded one of those sets.
All told, Adams Clinic Pharmacy ordered 619,970 units of opioids from 2006-2012. At first glance, considering three other pharmacies in Winnsboro ordered double the amount, this may not appear notable, but Abraham had officially gone into business on Sept. 27th, 2006.
In other words, within only a couple of years, his pharmacy (which he co-owned with Kayla Bridges) was already dispensing half as many opioids as the nearby and significantly larger WalMart.
Abraham appears to have served as a shadow partner at the pharmacy in Winnsboro; Bridges and David Doughty of Rayville are listed as the company’s registered agents.
However, at his pharmacy in nearby Mangham, Abraham’s hometown, his involvement was much more public. He was the sole organizer, having established the business in 2003, and he is listed as one of two agents. The other was John Hoychick. Notably, in August of 2018, it appears that Kayla Bridges replaced Abraham as a registered agent, though it is unclear if he relinquished any ownership as well. His recent personal financial disclosure reports indicate he has continued to derive an income from the clinic throughout his time in Congress.
What did Abraham prescribe?
Several readers have inquired about whether it is possible to ascertain if Abraham was the prescribing physician for opioids filled at his own pharmacies. The simple answer is: Yes, it is possible, but currently, that information is not yet available to the public. Or if it is publicly available, I have yet to locate it.
Notably, in a May 2019 profile of Abraham published by the Times-Picayune, he was described as the town’s only doctor. “(Ralph Abraham) was the only doctor practicing in the area, which meant he treated men, women, children – even pets,” the paper reported.
Doc the Vet
Prior to earning his medical degree, Abraham was a veterinarian, a rare feat, and he speaks often about treating animals and people. However, Abraham actually has not been a licensed veterinarian since 2001, eighteen years ago, according to the Louisiana Board of Veterinary Medicine.
While he may have not been a licensed veterinarian, he was, prior to his election to Congress, Mangham’s only doctor. However, he wasn’t the town’s only pharmacy owner, and because of that, it is possible to do an apples to apples comparison of the two pharmacies in order to determine whether one ordered disproportionately more opioids- in a town of 638 residents- than the other.
Location! Location! Location!
Before we evaluate that data, it’s important to dispense, pardon the pun, of one of the primary criticisms I have received from the Republican gubernatorial candidate’s supporters.
In my initial report, I combined the populations of the two small towns, Mangham and Winnsboro, in which Abraham’s pharmacies were located, in order to provide a rough per capita estimate. This misrepresented the daily realities of living in a rural, sparsely populated state, critics said. Their argument goes something like this: If you live out in the country, it’s not unusual at all to have to drive fifteen, twenty, even thirty miles to get to the closest pharmacy.
Different in Richland
It’s a compelling point, and while that may certainly be the case in some areas of the country, in this case, it implicitly exaggerates both the rural populations of Richland and Franklin Parishes and the distances between the cities and towns; it also implies a severe shortage of area pharmacies.
This pocket of northeast Louisiana is definitely rural; Franklin and Richland Parishes have a combined population of slightly more than 40,000 people.
Yet the region has an ample number of pharmacies, fifteen in total (which works out to be one pharmacy per every 2,700 residents). Ten pharmacies in Richland Parish, five in Franklin Parish. And they are distributed throughout the area fairly evenly. You’re likely to encounter at least two pharmacies every fifteen miles.
I applied a 10-mile radius around both of Abraham’s pharmacies, used Census data to determine the population from 2010, and then used data from the annual American Community Survey reports to arrive at a reasonable estimate (6,000 people). At the time, I hadn’t anticipated this would be a point of contention, but after studying the data more closely and considering the legitimate, general criticisms that some have leveled against the DEA for applying this methodology, I believe there is a better approach.
Population has to be considered, of course, but it would be disingenuous to pretend as if every single person who resides in Richland and Franklin Parishes should be counted in order to determine whether a small rural pharmacy is ordering a disproportionate supply of opioids. Regardless of what approach one takes, there will inevitably be those who disagree on what number would qualify as a “disproportionate” supply.
As I mentioned in the first report, Abraham’s single largest, almost exclusive, distributor was the company Morris & Dickson, which controls a massive portion of the marketplace throughout the entire state. Last year, after the DEA investigated the company’s shipments of opioids and discovered around ten pharmacies who had received shipments that, in the agency’s estimation, should have set off some major red flags, they took the unusual and extreme step of suspending the company’s license.
I noted that Abraham had invited Paul Dickson, the company’s president, to be his guest at last year’s State of the Union address, and no matter how you cut it, the decision was highly unusual; this occurred during the investigation but prior to the suspension of the company’s license. Ultimately, Dickson’s company prevailed in court in having their license restored and later agreed to pay a hefty $22 million civil fine.
I bring this subject back up for a reason: During his appeal, which was heard by Federal District Judge Beth Foote, an Obama appointee, Dickson acknowledged the need for improving the company’s internal controls, but he also argued that pharmacies located in areas in which customers were less likely to be insured and therefore more likely to purchase their medications in cash may require maintaining a larger inventory because their customers are also more likely to buy whatever quantity they can afford whenever they can afford it.
The argument did not make any difference in determining the outcome of the case. Judge Foote ruled in favor of Dickson and against the DEA because the government was unwilling to turn over all of the evidence they had collected.
Frankly, I don’t find the argument compelling and Dickson didn’t cite any specific examples; it was a hypothetical. But there will be some who believe it should be a consideration. Similarly, a pharmacist in Baton Rouge attempted to “debunk” my report on Facebook by suggesting that the only way in which one could make a determination about whether a pharmacy had an excessive supply of opioids was by considering their supply of other medications as well. But that approach misapprehends the reality of the epidemic and could obviously be easily gamed by a physician colluding with a pharmacy.
(I should note that the Baton Rouge pharmacist, a man I do not know, was suspicious from the beginning, leaving a long and rambling refutation that sounded an awful lot like campaign double-talk, then falsely claiming his comment had been deleted as a pretense to share screen captures of our exchange. Not surprisingly, after I suggested we speak personally so that I could better understand his argument, he was evasive, and the comment was later used by Scott McKay, a conservative operative paid by the Abraham campaign, to frame a blogpost on his website, the Hayride).
The Mangham Opioid War
With all of that now in mind, let’s look specifically at Abraham’s pharmacy in Mangham, not only because it was the one in which he ostensibly had the most direct involvement but also because we can directly compare it with his one and only competitor in town, Mangham Rx.
Owned by David Paul Gibson of Rayville, Mangham Rx opened four years before Abraham’s pharmacy. Based on the raw data, only one of these men seems to have cornered the local market for opioid prescriptions.
Note the scale may appear to be the same, but look closely: It’s not.
There’s definitely an obvious winner, or, perhaps better put, a biggest loser. During the same seven-year period, Ralph Abraham’s pharmacy ordered more than double the number of opioids as the owner of Mangham Rx.
They ordered roughly the same quantities of OxyContin, but Abraham’s pharmacy dominated the market on hydrocodone.
Exceeded the National Average
In all seven consecutive years, Abraham’s pharmacy’s supply of opioids exceeded the national average, while Mangham Rx consistently ranked under it. To be sure, Abraham never exceeded the state average, but that’s hardly an accomplishment. The state average is already excessive, and remember, Mangham, Louisiana is a town of 638 people. And, for many of those years, Abraham was the only doctor in town.
Winnsboro (population 4,652), with their five pharmacies, is 12 miles south, and Rayville (population 3,574), with their four pharmacies, is 12 miles to the north. But let’s give little ol’ Mangham the benefit of the doubt and draw a ten mile radius around each of its two pharmacies, generously assuming that even if you live closer to a bigger town with more options, you do all of your shopping in Mangham; you simply can’t resist the charm of Mangham.
At the very most, there are 2,274 people living within ten miles of both pharmacies.
In Richland Parish (population 20,411), in a town in which he was its only doctor, Ralph Abraham’s pharmacy, which has slightly more than 10% of the parish’s population living within ten miles (and that’s also being generous, considering the proximity of Franklin Parish), was the fourth-largest purchaser of opioids.
If you’re eagle-eyed, you may note a slight but ultimately insignificant difference between the numbers culled from the Washington Post and those from SLCG. Again, SLCG’s database is more comprehensive, and although I have been using the data they collect directly from the DEA, I directed readers to the Washington Post, which has done an incredible job reporting on the opioid epidemic. I encourage readers to examine both databases; I imagine you’ll reach the same conclusion.
For the purposes of reporting the facts about Ralph Abraham’s pharmacy in Mangham, there are a couple of numbers that need to be corrected. Yesterday, I shared an infograph I created by juxtaposing two screenshots: The Washington Post’s datasheet on Ralph Abraham’s Mangham pharmacy and Mangham Rx’s datasheet.
Both documents contained estimates that undercounted the quantity of opioids the two pharmacies had ordered during the seven-year timeframe.
This is the updated and correct infographic: