Rx Abuse-Scope of the Problem

Rx Abuse- Scope of the Problem Charles F. Cichon

Disclosure Information  Consultant/Independent Contractor: – Endo Pharmaceuticals, Inc.

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Learning Objectives  Review the Centers for Disease Control (CDC) weigh in on the prescription drug abuse problem as it relates to law enforcement  List the various issues facing law enforcement and state regulators regarding the abuse, misuse and diversion of prescription medicines

CDC Weighs in on Rx Drug Abuse  “Prescription drug abuse is the fastest growing drug problem in the United States”  The increase has been “driven by increased use of a class of prescription drugs called opioid analgesics.”

CDC – The Problem  Approximately one death every 19 minutes due to unintentional drug overdose occurred in the U.S. in 2007.  For every death related to an opioid analgesic, nine persons are admitted for substance abuse treatment, 35 visit emergency departments, 161 report drug abuse or dependence, and 461 report nonmedical use of opioid analgesics.  Rates of misuse and overdose death are highest among men, persons aged 20-64 years, non-Hispanic whites, and poor and rural populations.

CDC – The Problem  The two main populations at risk for prescription drug overdose are the approximately 9 million persons who report long-term medical use of opioids and the roughly 5 million persons who report nonmedical use -- use without a prescription or medical need.  Drug distribution of opioid prescribing through the pharmaceutical supply chain was the equivalent of 96 mg of morphine per person in 1997 and approximately 700 mg per person in 2007, an increase of more than 600 percent. "That 700 mg of morphine per person is enough for everyone in the United States to take a typical 5 mg dose of Vicodin every 4 hours for 3 weeks."

PHARMACEUTICAL DIVERSION  Best drugs for pain are the best drugs to obtain a “high”  Successful pain drugs= increased prescribing=more drugs available=more abuse  Increases demand and street values  Extended Release (ER) products contain concentrated amounts of medication  Successful compromise of ER Rx=euphoria!

SOURCE OF DIVERTED DRUGS  Forged and Altered Prescriptions  “Doctor Shoppers”  Prescribers/Dispensers of Rx Drugs  Drugged Driving  Pill Mills  Internet  Pharmacy Robbery & Burglary  International Smuggling

INTERNATIONAL SMUGGLING  Alprazolam with roots in Mexico  Not dispensed in the United States  Delivered to Southwest Ohio 200,000 dosage units a month for 3.5 years  100% profit made on each load  Arrests made and over 100,000 dosage units confiscated  Miami nightclub scene  Activity continues

PHARMACY ROBBERIES  Usually addicted individual involved  CII’s often the target  Weapon or threat of weapon involved  Potentially very dangerous situation  Cooperate with the offender  Remind police to check ER runs

PHARMACY BURGLARIES  Involve the after-hours entry of a pharmacy  Smash and grab likely addicted perpetrator  Usually planned criminal enterprises  Entry through the roof-adjoining business  Alarm disabled  Possible entry into safe  Hundreds of thousands of dollars street value Rx drugs often removed

Rx Patrol  Funded by Purdue Pharma  Reports of pharmacy robbery  Reports of pharmacy burglary  Reports of major pharmacy crime  Database for law enforcement  Only as good as the information provided by LE and pharmacy personnel  Reporting can be done online www.rxpatrol.org

INTERNET DIVERSION  According to ONDCP- Identified 34 rogue Internet pharmacies in 2006  Dispensed over 98 million dosages of hydrocodone  Would take 1,118 average pharmacies to equal amount dispensed by the 34 illegal Internet apothecaries

INTERNET PHARMACIES  National Association of Boards of Pharmacy (2011)  NABP lists 7,234 Internet Drug Websites as NOT Recommended  6,018 (83%) do not require valid Rx, consultation with an RPh or take insurance  Only 3.4% of those reviewed appeared to be “potentially legitimate”

TOP Rx DRUGS OF ABUSE  HYDROCODONE (Vicodin, Lortab, Lorcet) $6- $8  OXYCODONE (Percocet, Percodan, Tylox) $6 - $8 OxyContin-?) (Oxycodone IR- $1 mg.)  ALPRAZOLAM (Xanax) $3  METHADONE ($10-$40 per dose)  OXYMORPHONE (Opana/Opana ER) $40+  METHYLPHENIDATE (Ritalin) $10 - $12

OTHER SIGNIFICANT PROBLEMS  Buprenorphine (Subutex) $1 mg.  Tramadol (Ultram) $1-$2  Diazepam (Valium) $1-$2  Fentanyl (Duragesic/Actiq) $8-$40

Rx Drugged Driving  Little known about the overall prevalence  DUI offenders tested for alcohol on street or lab  Once legal limit is surpassed- testing stops  Unknown if Rx drugs also present  Combination of Rx drugs, marijuana, and/or alcohol can produce increased impairment

Rx Counterfeiting  Huge problem in the United States  Non Controlled Medicines high $$ targeted  Appearance of pills and packaging almost identical  Requires testing from the manufacturer  Can be integrated into the retail drug supply  Terrorism (Financing and Creating)  RFID &/or Serialized pills possible solution

Counterfeiter’s Manufacturing Facilities

How does it get in?

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Prescription Reformulations  OxyContin® - Purdue Pharma  In retail market August 2010  “OC” indicia replaced by “OP”  80mg. Tablets slightly larger  Street preliminary indications- OxyContin much less desirableheroin use exploding  Oxycodone IR has become new Rx abused

® OxyContin Abuse

 All indications are that the reformulation of OxyContin® is working  Lowering of street price  Lowering of street demand  Continued surge of oxycodone IR (30mg.) AKA: “Perc 30’s)  Surge in abuse of heroin  Signs of oxymorphone (Opana) abuse

WHY Rx DRUGS ?  Less risk of overdose  Easier to obtain through “legal” script  Cheaper than cocaine and heroin  Less risk of detection - lack of enforcement

TYPICAL Rx DRUG SEEKER  Every bit as addicted as the heroin and cocaine addict  Spends most of their waking hours planning on how to get their drugs  Consumes much of their time deciding how to scam the prescriber!

TYPICAL Rx DRUG SEEKER  Compliments physician  Deliberately mispronounces drug name  Agitated when cut off drugs of choice  Threatens lawsuit  Leaves abruptly when scam does not work

DOCTOR SHOPPERS Keith S. • • • • •

28 years old Blanchard, Oklahoma 2007 – 2009 obtained 4,533 dosages of pain Rx 195 different OK health care professionals 105 separate OK pharmacies

ULTIMATE DOCTOR SHOPPER Stephen M. Y. • • • • • •

32 years old Anchorage, Alaska (2005-2009) Husband of Federal Postal employee 313 different physicians/dentists/nurse practitioners 62 different pharmacies Medical claims over $600,000

HEALTH CARE FRAUD According to “Prescription for Peril” (Mahon)  Opioid abusers cost health insurers $15,884 per year per patient (2005)  Non-abusers cost insurers $1,830 per year  Over 8x higher  $72.5 billion in fraud in the abuse of opioids  Enormous cost for everyone

Government Accountability Office (GAO) Report  2006 – 2007 – CA, IL, NY, NC, TX

 65,000 Beneficiaries illegally acquired CDS through multiple physicians “doctor shopping”  $63 million Fraudulent Medicaid payments  $2.3 million physicians barred Medicaid

The Wall Street Journal on Wednesday revealed new details of a federal prescription drug sting that ultimately

ILLEGAL PRESCRIBERS AND “PILL MILLS”

Oxycodone Express  “Pain Management” clinics in Florida  Some decrease seen- attempted startups in Georgia and other states  Long lines obtaining oxycodone IR at clinics  Van loads of folks from Midwest going to these clinics  Filling Rx’s in Florida or other states

A Look Inside a Florida Pill Mill  Orlando – in a 3 month period, 1 physician prescribed more oxycodone than all doctors in California  Clinic managers crushed and snorted pain meds in the office  3,200 oxycodone pills disappeared 1 day  Security guard fired for reporting a drug deal on the parking lot

Florida Pill Mill Investigation  75 patients had 64 criminal records – 42 arrested for drugrelated crimes  Cash]- insurance not accepted  $160 - $300 per visit  Signs = patients needed to bring empty pill bottles – price list for available pills

Pill Mill “Red Flags”  Physician has minimal to no training in pain management  Patient volume (daily 100+)  Patients from other states (carpool)  Clinic run on cash only basis  Similar prescription “cocktail” for each patient  Drugs dispensed onsite

PRESCRIPTION MONITORING PROGRAMS (PMP’S)  Enacted by individual states to track the prescribing/dispensing of Rx drugs  Most involve only controlled substances  All involve access to health professionals  Varied availability for law enforcement  Valuable tool for investigators especially if easily accessible  Electronic databases  Can identify diversion and reduce health care fraud

Thank You! QUESTIONS?