National Drug Intelligence Center   National Prescription Drug Threat Assessment 2009   April 2009   UNCLASSIFIED

Diversion of CPDs

CPDs are diverted for nonmedical use. Law enforcement reporting and statistical data indicate that CPD diversion nationwide increased overall from 2004 through 2007. According to the National Forensic Laboratory Information System (NFLIS),16 the estimated number of diverted CPDs analyzed by state and local laboratories nationwide increased for most of the commonly diverted and abused prescription opioid pain relievers and benzodiazepines from 2003 through 2007, the latest year for which such data are available. (See Figure 4.) The highest percentage increases for the 5-year period were for the prescription opioid pain relievers hydrocodone (118%), morphine (111%), and methadone (109%). Dosage unit CPD17 seizures reported to the NSS fluctuated from 2003 through 2008; the highest number of dosage units was seized in 2003. The number of pills seized fluctuated as well, peaking in 2006. The number of milliliters of CPDs seized annually increased significantly, while the number of kilograms fluctuated over the 6-year period. (See Table 2.)

Figure 4. Estimated Number of Total Analyzed Controlled Prescription Drug Items, 2003-2007

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Source: National Forensic Laboratory Information System.
Note: Since 2001, NFLIS has produced estimates for the number of drug items and drug cases analyzed by state and local laboratories from a nationally representative sample of laboratories.

Table 2. Controlled Prescription Drug Seizures Reported to the National Seizure System, by Measurement Provided, 2003-2008

Source: National Seizure System.
Note: Data are presented in the format reported with regard to unit of measure.
Schedule II through IV CPDs reported to NSS during this period include barbiturates, clonazepam, codeine, Darvocet®, Darvon®, depressants, Dilaudid® (hydromorphone), hydrocodone (Vicodin®), lorazepam (Ativan®), meperidine (Demerol®), methadone, morphine, oxycodone, Ritalin® (methylphenidate), stimulants, Tylenol III®, Valium® (diazepam), Xanax® (alprazolam), and Percocet®. The category “Other Prescription Drugs” was also reported; however, that category has been omitted from this table because it probably included noncontrolled prescription drugs.

Abusers of opioid pain relievers divert the drugs through various methods, including prescription fraud, theft, and exploitation of the Internet; however, most diversion occurs when individuals with a prescription pass their drugs to family and friends. NSDUH data show that among individuals aged 12 or older who used prescription opioid pain relievers nonmedically in the past year, 56.5 percent reported that they acquired these drugs from a friend or relative for free. Additionally, 81 percent of those who acquired the pain relievers from a friend or relative indicated that the drugs originally were acquired from one doctor. NSDUH data also show that 18.1 percent acquired the drugs directly from one doctor, 8.9 percent bought the drugs from a friend or family member, and 5.2 percent stole them from a friend or family member. Moreover, 4.1 percent purchased the opioid pain relievers from a dealer or stranger, and only 0.5 percent reported that they purchased prescription opioid pain relievers on the Internet.

Rogue Internet pharmacies18 are a significant source for diverted CPDs, particularly Schedule III and Schedule IV drugs. Unscrupulous physicians and pharmacists working through rogue Internet pharmacies engage in "script mill" practices whereby patients obtain CPDs without a face-to-face medical evaluation. Rogue pharmacy operators often recruit doctors who believe that Schedule III and IV prescription drugs are less scrutinized than Schedule II prescription drugs and, therefore, are more willing to prescribe them to a patient. Some physicians who prescribe Schedule III and IV prescription drugs without meeting with a patient may be less willing to do so with Schedule II prescription drugs because the criminal penalties for violations involving Schedule II drugs can be four times higher than those involving Schedule III and IV drugs.19 Additionally, the requirement for a hard copy of a Schedule II prescription makes Internet diversion more difficult to accomplish. Distributors and abusers typically acquire larger quantities of Schedule III and IV prescription drugs per diversion incident than Schedule II prescription drugs. Further, legitimate patients purchasing Schedule III and IV CPDs on the Internet typically obtain larger quantities of the drugs per order, according to DEA.

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The number of Internet sites offering to sell CPDs appears to have decreased in 2008; however, the Internet may remain a significant source of supply for Schedule III and IV drugs. Federal law enforcement reporting indicates that the number of Internet sites offering to sell CPDs decreased in 2008. Federal officials cite cooperation between federal and state law enforcement agencies, Internet service providers (ISPs), package delivery services, and financial services companies typically used by rogue Internet pharmacy operators as a primary reason for the reduction in rogue pharmacies that operate on the Internet. Studies conducted by CASA confirm the law enforcement reporting. According to CASA, the number of identified rogue Internet pharmacies that advertised (portal sites) or offered to sell (anchor sites) selected Schedule II, III, or IV prescription drugs decreased 37 percent, from 581 in 2007 to 365 in 2008. (See Figure 5.) The number of Internet sites that offered CPDs20 for sale decreased from 187 in 2007 to 159 in 2008. Most of the Internet pharmacies identified in the CASA study appeared to be rogue Internet pharmacies.21 In fact, only two of the 159 anchor sites identified in 2008 were certified by the National Association of Boards of Pharmacy (NABP) as legitimate pharmacy sites. Approximately 85 percent of the sites that offered to sell CPDs did not require a physician's prescription, a percentage statistically unchanged from the 2007 study (84 percent).

Figure 5. Internet Sites Advertising or Offering to Sell Controlled Prescription Drugs, 2004-2008

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Source: National Center on Addiction and Substance Abuse at Columbia University.

A relatively small number of unscrupulous physicians lose their DEA registrations for improper prescribing practices. DEA estimates that in any given year, fewer than 1 in 10,000 physicians (0.01%)22 lose their DEA registration based on a DEA investigation for improper prescribing. Unscrupulous physicians who do prescribe CPDs outside the course of professional practice, however, can divert a large quantity of drugs. Typically, CPD abusers are aware of the physicians in their areas who are willing to supply unlawful services for a cash fee. When doctors are arrested, lose their registrations, or lose their licenses, the resulting decrease in availability of CPDs on the street usually leads to increases in treatment admissions and/or the street prices of diverted CPDs, according to DEA reporting.

Millions of dosage units of CPDs were stolen or lost in transit from 2003 through 2007. Significant quantities of CPDs were diverted from legitimate commerce through armed robberies, customer theft, employee pilferage, transit losses, and night break-ins at pharmacies between 2003 and 2007, according to the latest data available from DEA (see Table 3). The amount of CPDs stolen or lost in transit seemingly increased from approximately 19.4 million milliliters/quantities in 2003 to nearly 28.3 million milliliters/quantities in 2007; however, of the 28.3 million milliliters/quantities reported stolen in 2007, 16 million were quickly recovered by law enforcement officials. (See text box.)

Table 3. Schedule II-V Controlled Prescription Drugs Reported Stolen or Lost in Transit Nationwide in Milliliters* and Quantities,** 2003-2007

Source: Drug Enforcement Administration.
* Milliliters include ampules, syringes, injectibles, bottles, vials, lotions/ointments, liquids, and nasal spray.
** Quantities include tablets, capsules, patches, lollipops, powders, diskettes, and suppositories.
Note: Over 16 million of the 18 million dosage units lost in transit in one incident in 2007 were recovered.

The amount of CPDs stolen in armed robberies doubled from over 0.5 million milliliters/quantities in 2003 to nearly 1.1 million in 2007; the amount stolen by customers during that time decreased from nearly 79,000 to slightly more than 66,000 milliliters/quantities. The amount of CPDs stolen by employees of healthcare facilities and pharmacies decreased from 8.9 million milliliters/quantities in 2003 to 4.5 million in 2007. The amount lost in transit increased from more than 1.4 million milliliters/quantities in 2003 to more than 18.5 million in 2007; however, when the 16 million recovered units are subtracted from the total, the amount lost in transit is slightly more than 2.5 million (still an increase). The amount of CPDs stolen in night break-ins of pharmacies decreased substantially, from more than 8.5 million milliliters/quantities in 2003 to more than 4 million milliliters/quantities in 2007; however, the quantity of CPDs stolen in such break-ins peaked substantially in 2005 at 15.7 million milliliters/quantities. While these data indicate that significant quantities of scheduled drugs are lost or stolen annually, DEA reports that the amount of such drugs actually distributed on the illicit market is unknown because a portion of the lost and stolen drugs are quite likely recovered but not reported to DEA.

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The percentage of state and local law enforcement agencies reporting high levels of prescription depressant and narcotic diversion/illicit use increased overall in the United States from 200623 through 2008, while the percentage of agencies reporting high levels of prescription stimulant diversion/illicit use decreased or was stable in most regions. The most significant increases in the percentages of law enforcement agencies reporting high levels of diversion/illicit use of pharmaceuticals were for depressants, according to the NDTS. (See Table 4.) The greatest increases occurred in the Pacific (167%), New York/New Jersey (89%), and Mid-Atlantic (83%) OCDETF Regions.24 Moreover, in 2008 more than one-half of law enforcement agencies in seven of nine OCDETF Regions reported high levels of diversion/illicit use of narcotics. The greatest increases over the 3-year period occurred in the Pacific (107%), Florida/Caribbean (72%), and West Central Regions (72%). The percentage of law enforcement agencies reporting high levels of diversion/illicit use of stimulants trended upward in only four of the nine regions and downward in three regions; in two regions there were no changes overall.

Table 4. Percentage of Law Enforcement Agencies Reporting High Levels of Diversion/Illicit Use of Pharmaceuticals, 2006*-2008

Source: National Drug Threat Surveys.
* NDTS survey question was changed beginning in 2006; previous data are not comparable.

CPD diversion is prevalent throughout the United States; however, CPD diversion is highest in eastern states. Law enforcement officials in the eastern portion of the United States report the highest levels of diverted CPD availability, according to NDTS data. (See Figure 6.) The largest percentage--61 percent--of law enforcement agencies reporting high availability of pharmaceuticals in 2008 was in the Southeast OCDETF Region. Law enforcement agencies also reported high availability in the Mid-Atlantic, New England, Florida/Caribbean, and Great Lakes Regions. The percentage of law enforcement agencies in the United States reporting high availability of pharmaceuticals has trended upward in most OCDETF Regions over the past 5 years, with the exception of the Florida/Caribbean Region,25 where 5 percent fewer agencies reported high availability over that period, and in the New England Region, where availability remained relatively stable.

Figure 6. Percentage of Law Enforcement Agencies Reporting High Availability of Pharmaceuticals, by OCDETF Region, 2004-2008

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Source: National Drug Threat Surveys.

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CPD diversion is associated with increases in crime. Law enforcement agencies are increasingly associating CPD diversion and abuse with violent and property crimes nationwide, particularly in regions where CPD availability is high. The percentage of law enforcement agencies reporting an association between the diversion and abuse of CPDs and property or violent crime trended upward from 2004 through 2008, according to the NDTS. (See Figure 7.) The highest percentages of law enforcement agencies reporting an association between property crime and CPD diversion and abuse were in the New England, Great Lakes, and Mid-Atlantic OCDETF Regions (15.1%, 10.0%, and 8.8%, respectively). The highest percentages of law enforcement agencies reporting an association between violent crime and CPD diversion and abuse were in the New England, Great Lakes, and Florida/Caribbean Regions (9.8%, 6.2%, and 5.5%, respectively). (Law enforcement agencies in these regions also reported high availability of diverted pharmaceuticals;26 see Figure 6.) The percentage of overall change annually was slight; however, over the 5-year period, the trend upward was 3.5 percent for property crime and 1.3 percent for violent crime.27 State and local law enforcement agencies in several areas of the United States report that some murders, retail thefts, daytime break-ins, thefts at seasonal camps, car break-ins, pharmacy burglaries, and mail and identity theft that have occurred in their jurisdictions have been linked to diversion and abuse of CPDs. Moreover, some treatment providers anecdotally report that prescription opioid abusers engage in criminal activity to obtain money when they can no longer afford to purchase the quantity of drugs that they require to achieve their intended euphoria or to prevent opioid withdrawal symptoms.

Figure 7. Percentage of Law Enforcement Agencies Reporting an Association Between Diverted Pharmaceuticals and Crime, 2004-2008

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Source: National Drug Threat Surveys.
Note: Such trends are not reflected in DEA investigative and intelligence systems.

DTO involvement in CPD diversion and distribution is minimal; however, street gangs are increasingly distributing the drugs. The diversion and distribution of CPDs by DTOs and criminal groups have not been reported to any meaningful extent by law enforcement officials throughout the nation. Some law enforcement agencies and treatment providers as well as federal and private surveillance surveys have reported, however, that some CPD abusers purchase drugs from strangers and "dealers." Additionally, periodic law enforcement reporting indicates that some street dealers who sell marijuana, heroin, and cocaine have started to sell CPDs. While DTOs and criminal groups do not appear to be heavily involved in CPD distribution, law enforcement reporting does indicate that street gang and OMG involvement in CPD distribution has increased in many areas of the country. The percentage of law enforcement agencies nationwide reporting street gang involvement in illicit pharmaceutical distribution trended upward from approximately 32 percent in 2004 to 44 percent in 2008, according to the NDTS. Regionally, the percentage of law enforcement agencies reporting street gang involvement in CPD distribution during those years ranged from an average of 30 percent in the Mid-Atlantic and New England Regions to an average of 49 percent in the Southwest Region. (See Figure 8.) A few law enforcement agencies in California reported in 2008 that African American street gangs had become involved in OxyContin® distribution and that Caucasian young adults were purchasing OxyContin® from these street gang members. Moreover, one law enforcement agency in New Hampshire reported in 2008 that Bloods gang members routinely obtain OxyContin® in Massachusetts and distribute the drug in its jurisdiction, while another law enforcement agency in Texas reported in 2008 that female associates of street gangs and OMGs earn income primarily by selling diverted CPDs that they obtain through prescription fraud. Finally, a law enforcement agency in Washington State reported in 2008 that some African American street gang members were involved in the distribution of CPDs.

Figure 8. Percentage of Law Enforcement Agencies Reporting Street Gang Involvement in Pharmaceutical Distribution, by OCDETF Region, 2004-2008

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Source: National Drug Threat Surveys.

According to NDTS estimates, the percentage of law enforcement agencies nationwide reporting OMG involvement in illicit pharmaceutical distribution trended upward from approximately 22 percent in 2004 to 26 percent in 2008; however, regionally, that percentage fluctuated. (See Figure 9.) The percentage of law enforcement agencies reporting OMG involvement in CPD distribution between 2004 and 2008 ranged from an average of 20 percent in the Southeast Region to an average of 32 percent in the Pacific Region. A law enforcement agency in Virginia reported in 2008 that the War Lords Motorcycle Gang had established a local chapter, and its members reportedly were involved in trafficking Schedule II and III prescription drugs.

Figure 9. Percentage of Law Enforcement Agencies Reporting OMG Involvement in Pharmaceutical Distribution, by OCDETF Region, 2004-2008

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Source: National Drug Threat Surveys.

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Teenagers find diverted CPDs readily available; they can often obtain them at no cost. According to CASA's 2008 National Survey of American Attitudes on Substance Abuse XIII, for the first time in the survey's history, more teenagers reported that prescription drugs28 were easy to purchase without a prescription (19%) than reported that beer was easy to purchase (15%). Teenagers also reported that they could easily obtain CPDs from family and friends. Of the 1,002 teens participating in the 2008 CASA survey who knew a prescription drug abuser, one-third reported that the abusers could get prescription drugs from home, the medicine cabinet, or parents, while another one-third reported that abusers could acquire prescription drugs from friends or classmates.

Friends or relatives are the primary sources for CPDs among most abusers. More than half of the nonmedical users of prescription-type opioid pain relievers, tranquilizers, stimulants, and sedatives obtained the drugs they used most recently "from a friend or relative for free," according to 2006 and 2007 NSDUH data. NSDUH data further reveal that among individuals aged 12 or older who used opioid pain relievers nonmedically in the past 12 months, 55.7 percent reported in 2006 that they had obtained the opioid pain relievers from a friend or relative for free, and 56.5 percent reported the same in 2007. Another 9.3 and 8.9 percent bought the drugs from a friend or family member in 2006 and 2007, respectively. Moreover, data from a 2006 study released in the June 2008 edition of the American Journal of Public Health indicated that 22.9 percent of 700 participants in the study "loaned" their medications29 to someone else, and 26.9 percent "borrowed" someone else's prescription medication. Nearly 22 percent of study participants reported sharing prescription pain medications.

Footnotes

16. The National Forensic Laboratory Information System (NFLIS) is a program sponsored by DEA, Office of Diversion Control. NFLIS systematically collects results from drug analyses conducted by state and local forensic laboratories. Because of changes in reporting, NFLIS data should not be used for trending analysis.
17. Includes seizures of CPDs from air cargo, air passengers, buses, express mail/parcel, mail, maritime cargo, individuals on foot, trains, and all vehicles including tractor-trailers and cargo vehicles.
18. The Ryan Haight Online Pharmacy Consumer Protection Act of 2008, enacted in October 2008, legally established the definition of "online pharmacy." The Act prohibits the delivery, distribution, or dispensing of CPDs over the Internet without a prescription written by a doctor who has conducted at least one in-person examination of the patient. This Act is expected to have a significant impact on CPD diversion and abuse by decreasing the number of rogue Internet pharmacies operating on the Internet.
19. Federal trafficking penalties for illegal Internet distribution of Schedule II drugs are not more than 20 years imprisonment for the first offense and a fine of $1 million for an individual and $5 million for other than an individual. Federal trafficking penalties effective as of October 2008 for Schedule III drugs are not more than 10 years imprisonment (up from 5 years) and fines of not more than $500,000 (up from $250,000) for an individual and $2.5 million (up from $1 million) for other than an individual. Penalties effective as of October 2008 for Schedule IV drugs are not more than 5 years imprisonment (up from 3 years) and fines of not more than $250,000 for an individual and $1 million for other than an individual.
20. The National Center on Addiction and Substance Abuse (CASA) at Columbia University used a list of drugs that included controlled prescription drugs as defined by DEA in Schedules II through V but concentrated on prescription drugs in Schedules II and III.
21. The goal of the CASA study was to uncover as many web sites as possible that were involved in the sale of CPDs by using Internet searches and e-mail advertisements. CASA researchers did not complete any transactions by purchasing the drugs because doing so would have been illegal. The methodology used in this study can be found at http://www.casacolumbia.org/articlefiles/531-2008%20You've%20Got%20Drugs%20V.pdf
22. Approximately 750,000 medical doctors and doctors of osteopathic medicine were registered with DEA in 2006.
23. Survey data prior to 2006 are not comparable because of changes in the format of the question.
24. For the purposes of this report, regional discussions will be delineated along boundaries established under the Organized Crime Drug Enforcement Task Force (OCDETF) program. The OCDETF program was established in 1982 to mount a comprehensive attack against organized drug traffickers. The OCDETF program is the centerpiece of the United States Attorney General's drug strategy to reduce the availability of drugs by disrupting and dismantling major DTOs and money laundering organizations and related criminal enterprises. The program operates nationwide and combines the resources and unique expertise of numerous federal agencies in a coordinated attack against major drug trafficking and money laundering organizations. See Figure 6 for regional demarcations.
25. Federal law enforcement reporting indicates that numerous investigations from 2006 through 2008 targeting diversion using the Internet have significantly decreased the number of rogue Internet pharmacies operating in Florida. The success of these initiatives is believed to have had a considerable impact on the availability of CPDs in the state.
26. The NDTS uses the term "diverted pharmaceuticals" with the understanding that law enforcement agencies responding to the survey would report diverted pharmaceutical activity related only to distribution of scheduled prescription drugs prosecutable under the Federal Controlled Substances Act.
27. NDTS data regarding the association between violent and property crime and illicit drugs are shown in Figures 23 and 24 in Appendix A, respectively.
28. The specific drugs mentioned in the survey question were OxyContin®, Percocet®, Vicodin®, and Ritalin®.
29. Specific medication categories listed in the survey were allergy, pain, mood, antibiotic, acne, birth control, and "other."

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