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National Drug Intelligence Center Pharmaceuticals Drug Threat Assessment November 2004 DiversionMost pharmaceuticals abused in the United States are diverted by doctor shopping, forged prescriptions, theft and, increasingly, via the Internet. To reduce the occurrence of pharmaceutical diversion by doctor shopping and prescription fraud, 21 states have established prescription monitoring programs (PMPs) that facilitate the collection, analysis, and reporting of information regarding pharmaceutical drug prescriptions. State-level PMPs have been effective in reducing the average time required to conduct pharmaceutical diversion investigations as well as reducing the estimated number of dosage units dispensed by pharmacies and physicians to suspected abusers. For example, the Kentucky Cabinet for Health Service reports that the Kentucky All Schedule Prescription Electronic Reporting (KASPER) system has reduced the average time to complete pharmaceutical drug investigations from 156 to 16 days. Moreover, according to the Office of National Drug Control Policy (ONDCP), establishment of the Nevada PMP has resulted in a 46 percent reduction in the estimated number of pharmaceutical dosage units distributed to suspected abusers.
Doctor ShoppingA common method of diverting pharmaceuticals is doctor shopping. Individuals who divert and acquire pharmaceuticals through doctor shopping do so by visiting numerous doctors in an attempt to obtain multiple prescriptions for the drugs, particularly prescription narcotics such as OxyContin, Percocet, and Percodan. Doctor shoppers often falsify or exaggerate symptoms in order to obtain prescriptions for pharmaceuticals and often visit doctors they believe to be more likely to write prescriptions for such drugs. The individuals typically have their prescriptions filled at multiple pharmacies in order to avoid detection.
Prescription FraudPrescription fraud includes a variety of schemes commonly used to divert pharmaceuticals such as forging or altering prescriptions, producing counterfeit prescriptions, and calling in fictitious prescriptions to pharmacies by impersonating a physician. Pharmacists often recognize prescription fraud, particularly forged, altered, or counterfeit prescriptions, because the prescriptions are written in unfamiliar handwriting (often without abbreviations) or the prescription quantities, directions, or dosages differ from normal usage. Pharmacists also identify fraud when prescriptions resemble textbook examples or appear to be photocopied.
Unscrupulous PhysiciansIllegal prescribing by unscrupulous physicians is a significant source of diverted pharmaceuticals. Corrupt physicians create fraudulent prescriptions to obtain drugs for personal use, and they also write prescriptions for individuals without a legitimate need for the drug for a fee. Unscrupulous physicians sometimes collaborate with unscrupulous pharmacists who dispense the drugs for an additional fee.
TheftMillions of pharmaceutical drug dosage units are diverted each year through theft from pharmacies, manufacturers, distributors, importers/exporters, and from individuals with legitimate prescriptions. The amount of pharmaceutical dosage units diverted annually from 2000 to 2003 through theft fluctuates but has increased overall for most drugs, particularly for prescription narcotics like OxyContin. According to DEA, the number of pharmaceutical dosage units diverted through theft from pharmacies, manufacturers, distributors, and importers/exporters has increased from 2,379,389 in 2000 to 2,753,928 in 2003.
Employees of pharmaceutical drug manufacturers and commercial distributors account for much of the pharmaceuticals diverted through theft; however, others steal pharmaceuticals as well. According to the 2002 National Retail Security Survey Final Report published by the University of Florida, retailers attribute 48 percent of pharmaceutical inventory loss to employee theft. Individuals also break into pharmacies or clinics to steal pharmaceuticals or commit armed robberies to acquire the drugs. Individuals also steal pharmaceuticals from friends or relatives who possess legitimate prescriptions. Pharmacy managers and law enforcement agencies in areas that have experienced a high number of pharmacy break-ins and armed robberies have taken specific steps to reduce pharmaceutical theft. For example, many pharmacies have stopped distributing specific pharmaceuticals that thieves most often target, such as OxyContin. Law enforcement in some communities, such as Boston (MA) and Pikeville (KY), have increased patrols in and around pharmacies to deter or detect break-ins and robberies.
Internet PharmaciesPharmaceuticals increasingly are diverted via the Internet because many Internet pharmaceutical distributors--often referred to as Internet pharmacies--offer prescription drugs to customers without requiring a prescription, physician consultation, or verification. Estimates as to the number of Internet pharmacies vary widely. For example, the National Board of Pharmacy estimates that the number of Internet pharmacies has increased from none in the mid- to late 1990s to between 400 and 1,000 in 2003. However, in January 2004 the National Center on Addiction and Substance Abuse (CASA) identified only 157 Internet sites distributing controlled pharmaceuticals to individual users, although an additional 338 Internet sites provided links to one or several of the 157 pharmaceutical distribution sites. Nevertheless, of the 157 Internet sites identified by CASA, 64 (40.7%) did not require any prescription or physician consultation to purchase prescription drugs. Moreover, 77 (49.0%) of the Internet sites only required customers to report their symptoms in an online questionnaire prior to receiving the prescription drug--there was no requirement for personal physician verification of the symptoms. Faxed prescriptions were required by 7 (4.4%) and mailed prescriptions were required by 3 (1.9%) of the sites. The remaining 6 (3.8%) sites made no reference to any prescription requirement. CASA further reports that the Internet pharmacy sites most often offered benzodiazepines such as Xanax and Valium, followed by narcotic analgesics such as fentanyl, hydrocodone, and oxycodone, and stimulants such as Ritalin and Adderall. Moreover, none of the 157 Internet sites included security procedures preventing children from purchasing prescription drugs.
FBI reporting indicates that many unscrupulous Internet pharmacy operators recruit corrupt physicians to write fraudulent prescriptions for their customers. FBI further reports that unscrupulous physicians are paid as much as $1,500 per day for writing fraudulent prescriptions for Internet pharmacy patients. Some Internet pharmacies, including some based in Mexico and Canada, distribute counterfeits of popular brand name pharmaceuticals that often contain inactive ingredients, incorrect ingredients, or improper dosages. According to FBI, most counterfeit pharmaceuticals are produced in India and China, and in some countries counterfeit pharmaceuticals are quite prevalent. In fact, FBI reporting indicates that as much as 60 percent of the pharmaceuticals sold in China, Nigeria, Thailand, Cambodia, and Indonesia are counterfeit. The Food and Drug Administration (FDA) reports that the level of counterfeit drug distribution within the United States is very low compared with other countries; however, occurrences of distribution of counterfeit pharmaceuticals in the United States are increasing. As a result, FDA counterfeit drug investigations have increased from 6 in 1997 to 22 in 2003.
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