| Drug Diversion: The Scope of the Problem |
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| Written by Commander John Burke | |
| Monday, 03 July 2006 | |
 Reports of the diversion of prescription drugs have demanded consistent media attention over the past few years. Media types have scrambled to report abuse of OxyContin®, and the personal problems of Rush Limbaugh and his addiction to prescription painkillers. However, the truth of the matter is that prescription drug abuse is nothing new. I have been a law enforcement officer for over 36 years, and during my rookie year quickly discovered that prescription painkillers, tranquilizers, and stimulants, were a large part of the illegal drug market. In fact, conservative estimates are that prescription drug abuse represents approximately 25-30% of the overall drug problem in America, a close rival of cocaine abuse. Obtaining reliable statistics for prescription drug abuse is also difficult, with the most widely used program being that of the Drug Abuse Warning Network (DAWN), which has its own pitfalls. There are reasons why trying to measure pharmaceutical abuse are very difficult, and one of them unfortunately lies at the feet of my peers in law enforcement. In the late 1980’s and into 1990, officers of the Cincinnati Police Division were making only a handful of felony prescription drug arrests. Since over 1,000 sworn members comprised Cincinnati’s law enforcement agency, it would have made an outside observer think that the diversion of prescription drugs was not an important police issue in this Ohio town. However, in late 1990, the Police Division applied for, and received a grant from the state of Ohio, to investigate and prosecute prescription drug offenders. Being fresh from a two year stint in internal affairs and a career background in investigations, I was recruited to command the unit. The grant provided funding for me, four investigators, and a secretary. In less than three years, this unit was investigating over 500 felony prescription drug cases a year, and arresting over 250 prescription drug felons in the process. This ultimately would progress to the unit arresting a health professional every 5.5 days, as part of our aggressive pharmaceutical diversion effort. So was it an incredible coincidence that drug diversion began to become popular in 1990, and the forming of this unit just happened to coincide with this surging problem? This of course was not the case; prescription drug abuse had been maintaining itself quite well in the City of Cincinnati, and law enforcement had no clue of the scope of the problem. This same phenomenon is still true today as many of our largest cities have no law enforcement officers working on the problem of prescription drug abuse. There are many reasons why law enforcement executives across the country have not addressed this issue adequately. One of the biggest reasons is simply the lack of knowledge that this problem exists in their jurisdiction. Prescription drug abuse can remain an almost silent problem, only rearing its ugly head occasionally when someone overdoses and dies, or a pharmacist discovers a bad prescription and calls the police. However, law enforcement officials, like the general public, perceive that prescription drugs are not as addictive or as abused as common street drugs like cocaine, methamphetamine, and heroin. The same violence levels that occur with these drugs are not associated with pharmaceuticals, and with tight budgets, prescription drug abuse takes a back seat in most of their annual fiscal planning. In addition, law enforcement officers are sometimes intimidated by health professionals, and are unwilling to attempt to learn an entirely new set of their state’s criminal code, and/or regulatory sections. Drug diversion investigations are many times somewhat complicated and prolonged, not like the more fast-paced and seemingly glamorous street drug units work. The hardcore facts indicate that prescription drugs are every bit as addictive as the vast majority of street drugs. In fact, many rehabilitation experts across the country advise that prescription drug addicts remain one of the hardest substance abuse problems for them to cure. Over the past 36 years the popular street drugs have changed in the larger cities. Heroin was the number one street drug in the late 1960’s and early 1970’s. Heroin was replaced by powder cocaine, and then “crack” cocaine came on the scene to addict vulnerable people. Currently, methamphetamine is sweeping the country, threatening to overtake and replace the cocaine and “crack” cocaine problems. In many areas this is already a reality, along with heroin, which is making a comeback from decades ago. During each of these times of street drug changes, prescription drugs continued to hang on to second place, making it the most abused drug of the past three or four decades, in my opinion. So let’s look at just a very few of the top prescription drugs of abuse, their street values, and the methods of ingestion by those addicted to these “legal” substances. It is important to remember that street prices vary from jurisdiction to jurisdiction, and that the prices mentioned here only reflect an average across the United States. PAIN RELIEVERS Hydrocodone (Vicodin®, Lortab®, Lorcet®) products continue to be the #1 prescription drugs of abuse in this country. Almost always taken orally, this drug can demand $6-$8 per pill on the street, with common addiction levels being 15-20 tablets a day. Addiction levels can be much higher, with rates as high as 75-100 pills per day. Many of these hydrocodone products contain acetaminophen (Tylenol®), with excessive amounts providing potential damage to a person’s liver long before the narcotic affects their bodies. Abusers are also prone to combining hydrocodone products with carisoprodol, commonly known as the muscle relaxant Soma®. Oxycodone (Percodan®, Percocet®, Tylox®) have long been a major source of prescription drug abuse in this country. These drugs are also frequently sold for $6-$8 per pill, but taking these drugs orally is only one method of ingestion. They can also be melted down for injection, and/or crushed and snorted like cocaine. Those injecting oxycodone products have been known to reach 50-60 pills per day. OxyContin®, which contains only oxycodone, and is designed to be a long-acting drug, is not popular for abusers in its intended form. However, the drug is altered by chewing it up and swallowing the pieces, melting it down for injection, or crushing the product and snorting like a person would cocaine. Therefore, taking an OxyContin® 80 milligram tablet in the aforementioned ways, is like ingesting 16 Percocet® at one time. Street values range from $.50 to $1 per milligram, and most abusers have experienced long-time addiction to a multitude of drugs. Methadone, which is usually associated with being a narcotic maintenance drug, is also widely used today for pain management. The drug is somewhat long-acting, and can be challenging for the inexperienced practitioner to prescribe. In addition, abusers who may not receive their high as quickly as expected may increase their intake of the drug until they overdose and die. Street prices may reach $10 per pill on the illegal market. Fentanyl patches (Duragesic®) are also the target of abuse and diversion. The drug is designed to be placed on the pain patient’s body and the potent narcotic releases over a three day period. Abusers may slit the patch open and put the drug under their tongue, use it as a suppository, chew it up and swallow the contents, or apply a heat source to the patch on their body to increase the delivery of the fentanyl. Since fentanyl is an extremely potent synthetic opiate, overdose death is possible, especially when attempts are made to inject the drug. Street values can range from $10-$40 per patch. BENZODIAZEPINES (Tranquilizers) Benzodiazepines have seen a sharp rise in prescribing and dispensing since September 11, 2001, for obvious reasons. They are generally used to treat anxiety, insomnia, and other related problems. It also appears that a younger patient is being prescribed these drugs, causing increased diversion issues in middle and senior high schools. Benzodiazepines are commonly combined with many other drugs, including alcohol, to enhance the feeling of sedation. Alprazolam (Xanax® ) appears to be the most abused drug in its class currently, and is one of the top prescription drugs of abuse overall. The reason it has gained such popularity is that this drug rushes through the bloodstream faster than its well known counterpart, diazepam (Valium®). This creates the “high” that drug abusers and addicts are seeking when they use their substance of choice. Street prices for Xanax® are generally close to $3 per pill, depending on strength. Valium® (diazepam) still remains a strong prescription drug of abuse, with street values usually ranging between $1 and $2 per pill. Abusers can reach addiction levels of 20-30 pills per day, and even more in extreme cases. FORGED/ALTERED PRESCRIPTIONS Forged, altered, and bogus prescriptions continue to be a popular source of diversion for the prescription drug abuser. For many years forgers have used correction fluid to blot out the ink on prescriptions they wanted to change. They would then take this piece of paper to a photocopier, and produce what appears to be a blank prescription. The problem with this method is that it requires the forger to write and entirely new prescription. The more popular method today is to use fingernail polish remover for the acetone it contains. Acetone will remove ballpoint pen from paper. Those involved in criminal drug diversion will use acetone to “wash” the prescription. This means the chemical is only used to eliminate the drug they want to change, leaving the doctor’s signature intact. The sought after drug is then written on the altered prescription, often with no one the wiser, including the pharmacist who ultimately dispenses the drugs. DOCTOR SHOPPERS Law enforcement agencies who concentrate on prescription drug diversion on a full time basis are likely spending over 40% of their time investigating doctor shopping cases. Doctor shoppers typically are visiting multiple practitioners that can be physicians, dentists, and even veterinarians. During the past 14 years one lady stands out when it comes to our investigations of drug diversion. She was visiting 69 doctors at one time, and having the prescriptions filled at over 21 different pharmacies in a three state area. She generated over $80,000 in health care fraud since the majority of the crimes were committed by using a large private health care insurer. However, the majority of doctor shoppers are visiting between 5-10 practitioners, with health care fraud numbers reaching $10-$15,000 for each diverter per year. This represents an enormous source of illegally gained prescription drugs in the United States each year. There is no accurate account of how many billions of dollars are lost as the result of prescription drug scams and the use of private and public health care insurers. It is important to note that the formation and maintenance of a law enforcement accessible prescription monitoring program in individual states will provide information to greatly assist in the detection and prosecution of doctor shoppers. CRIMINAL PRACTITIONERS We must always remember that the vast majority of practitioners are honest members of their profession and seek to provide healing and comfort to the rest of us. In fact, the Federation of State Medical Boards indicates that less than 1% of physicians in this country are ever sanctioned for anything, not just improper prescribing. However, the small percentage that engages in true criminal behavior can be responsible for causing and/or maintaining hundreds or thousands of addicts in your jurisdiction. They are nothing less than drug dealers, regardless of the license or shingle they hang at their office. These offenses typically involve an exchange of prescriptions for sex, street drugs, and ultimately, money. These operations exist across the country in the crudest form which may involve little or no office staff, no appointments, and long lines outside the doctor’s door waiting for their turn to receive prescriptions. They exist in the largest urban areas to some of the smallest rural parts of our nation. With some law enforcement and regulatory attention, these types of operations can usually be dismantled within a few months. The more sophisticated criminal practitioner is a much bigger challenge for authorities. This individual will appear on the surface to be much more legitimate than the first example mentioned. He/she will require specific complaints during a cursory examination that can warrant a certain popular prescription drug of abuse being prescribed. In addition, this practitioner is likely heavily involved in health care fraud of all types. The investigation and ultimate prosecution of these more sophisticated offenders may very well require one to two years to complete. It will also require that law enforcement cooperate with several other agencies such as regulatory, health care fraud, Internal Revenue Service, and private industry. HEALTH FACILITY DIVERSION One area of prescription drug abuse that is often overlooked, but perhaps the most important, is the diversion of prescription drugs from health facilities such as hospitals and nursing homes. The reason that this form of diversion is important is that oftentimes innocent patients are the ultimate victims of this type of drug diversion. Nursing personnel constitute the bulk of this type of pharmaceutical diversion. In the late 1990’s, our Cincinnati unit was arresting a nurse about once a week for diverting drugs from health facilities. There are many methods used by the diverting nurse, methods that are often not discovered until the abuser has reached incredible doses of controlled substances. One form of drug diversion is what is commonly referred to as “substitution”. Those involved in this practice may remove a potent pain relieving narcotic from a syringe and replace it with water. An unsuspecting nurse then later injects a pain patient with what is now water, obviously providing no pain relief. This, in my opinion, is the most sinister form of pharmaceutical diversion, and worthy of penitentiary time for these offenders. RX PATROL Rx PATROL (Pattern Analysis Tracking Robberies & Other Losses) is a project developed by the pharmaceutical company Purdue Pharma. It is designed to assist law enforcement in solving pharmacy robberies, burglaries, and other major crimes committed in these establishments. The company funds a national computer database that is overseen by Capt. Richard Conklin of the Stamford, Connecticut Police Department. Law enforcement agencies and pharmacies provide information concerning pharmacy felonies to Capt. Conklin, who has them entered into the database. When an offense is entered, it also searches the database for potential matches. When a match is possible, the two agencies are contacted to share this possible crime solving information. The program is only as good as the amount of participation we in law enforcement provide. I would urge you to become involved in this valuable program by providing your pharmacy crime information to the database. You can learn more about RxPATROL by going to the program’s website at www.rxpatrol.org NADDI The National Association of Drug Diversion Investigators (NADDI) is a non-profit organization devoted to providing prescription drug abuse education to its members. Membership includes law enforcement, regulatory agents, health care fraud investigators, the pharmaceutical industry, and health professionals. NADDI has 14 state chapters with over 2,500 members, and conducts regional training across the country during the year. This year’s national conference is November 15-18, 2005, in Myrtle Beach, NC. A variety of prescription drug abuse educational opportunities are included in NADDI membership, including a brand new Internet course that will be available very soon on the website at www.naddi.org CONCLUSION Although prescription drug abuse is not commonly associated with street violence, the deaths and destruction that surround pharmaceutical diversion often exceeds that of illicit substances. The abuse and diversion of prescription drugs unfortunately remains a very healthy criminal enterprise. In order to reduce this criminal behavior and the loss of life, it is essential that law enforcement agencies become more aggressive in pursuing these offenses. |
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