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National Drug Intelligence Center |
Insurance fraud is used to finance the purchase of CPDs. According to law enforcement reporting, some individuals and criminal groups divert CPDs through doctor-shopping and use insurance fraud to fund their schemes. In fact, Aetna, Inc. reports that nearly half of its 1,065 member fraud cases in 2006 (the latest year for which data are available) involved prescription benefits, and most were related to doctor-shopping, according to the Coalition Against Insurance Fraud (CAIF). CAIF further reports that diversion of CPDs collectively costs insurance companies up to $72.5 billion annually, nearly two-thirds of which is paid by public insurers. Individual insurance plans lose an estimated $9 million to $850 million annually, depending on each plan's size; much of that cost is passed on to consumers through higher annual premiums. CAIF also reports that a typical doctor-shopper can cost insurers between $10,000 and $15,000 per year in total costs related to diversion as well as emergency room treatment, hospital stays, physician's office visits, tests, and rehabilitation. To illustrate the magnitude of this problem, from 2004 through July 2008, NDIC Document and Media Exploitation (DOMEX)37 teams supported 101 federal diversion cases; approximately 20 percent involved public or private insurance fraud. Individuals and criminal groups that commit insurance fraud multiple times are at risk of being identified by insurance companies; thus, they eventually turn to cash payment for the prescription drugs to avoid scrutiny.
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Government Employees Arrested in Health Insurance/OxyContin® Scam On August 6, 2008, the Miami-Dade (Florida) Police Department and the Miami-Dade County State Attorney's Office announced arrest warrants for 62 individuals, 52 of whom were public employees, charging them with crimes related to alleged health insurance fraud to obtain large quantities of OxyContin®. According to the Florida State Attorney's Office, beginning in January 2003, six recruiters enlisted local government employees and others to participate in an illegal operation in which those recruited would provide their health insurance identification information to a recruiter. The government employees and others who were recruited allegedly obtained prescriptions for OxyContin® (for which they had no medical need) from a complicit physician. They then presented the fraudulent prescriptions at local pharmacies in Miami-Dade County to obtain the OxyContin® tablets and sold the pills for cash to another individual involved in the scam. The government employees and others recruited also submitted insurance claims to their employer-issued health insurance company, fraudulently claiming reimbursement for the cost of the prescriptions. Officials estimate that approximately 130 medically unnecessary prescriptions for OxyContin® were presented to the pharmacies, accounting for more than 12,000 tablets with an estimated street value of almost $400,000. Source: Florida State Attorney's Office. |
Proceeds derived from the sale of diverted CPDs are laundered by distributors using methods similar to those employed by traditional drug traffickers. Rogue Internet pharmacy operators and unscrupulous physicians and pharmacists who divert and distribute CPDs primarily launder the illicit proceeds they derive through traditional depository institutions--banks, savings associations, and credit unions--typically through structured transactions, particularly deposits, according to law enforcement reporting. They also use other techniques that involve money orders and casinos. Law enforcement reporting reveals that unscrupulous physicians and pharmacists also launder illicit proceeds by investing in real estate, luxury vehicles, and high-tech electronic equipment; such purchasing activities generally do not raise suspicion, because individuals in these professions commonly purchase high-value items. Additionally, some physicians funnel large amounts of illicit proceeds through their own medical practices or other legitimate businesses, while some pharmacists use illicit proceeds to expand their pharmacy holdings.
CPD abuse is most prevalent among young adults. Past month nonmedical use of CPDs is evident among individuals from teens to the elderly but is most prevalent among 18 to 25 year olds, according to NSDUH. (See Figure 12.) NSDUH data indicate that abuse rates among young adults were relatively stable from 2003 through 2007; however, law enforcement and treatment providers reported in July 2008 that some college age individuals were increasingly abusing stimulants (amphetamines and methylphenidate). They reportedly use the drugs to help them remain awake to study for extended periods. Moreover, some medical and law students as well as young professionals reportedly use stimulants nonmedically as performance enhancers to enable them to study longer or work for longer periods, which they believe gives them an edge over their peers. Some treatment providers report that students are initially attracted to stimulants because of their ability to enhance performance or to moderate the effects of other drugs used to enhance performance; however, many abusers become dependent on the drugs and require treatment.
Figure 12. Percentage of Past Month Nonmedical Use of Psychotherapeutics,* by Age, 2003-2007
Source: National Survey on Drug Use and Health.
*
NSDUH collectively categorizes pain relievers,
stimulants, tranquilizers, and sedatives as "psychotherapeutics."
Nearly one third of past year substance abuse initiates reported that their first drug was a psychotherapeutic. In 2007 an estimated 2.7 million individuals aged 12 or older reported having used an illicit drug for the first time within the past 12 months, according to NSDUH. Nearly one-third initiated with psychotherapeutics (30.6 percent--including 19 percent with pain relievers, 6.5 percent with tranquilizers, 4.1 percent with stimulants, and 1.1 percent with sedatives; see Figure 13), while a majority reported that their first drug was marijuana (56.2%). Many of these substance abuse initiates used more than one substance; first-time use of marijuana and first-time nonmedical use of psychotherapeutics are often co-occurring phenomena. The specific drug categories with the largest number of recent initiates among persons aged 12 or older were pain relievers (2,147,000) and marijuana or hashish (2,090,000), according to NSDUH. (See Figure 14.) Additionally, more initiates (1,232,000) tried prescription tranquilizers nonmedically for the first time in 2007 than tried any illicit drug other than marijuana or hashish (2,090,000).
Figure 13. Specific Drug Used When Initiating Illicit Drug Use Among Past Year Initiates of Illicit Drugs, Aged 12 or Older, 2007
Source: National Survey on Drug Use and Health.
Figure 14. Past Year Initiates for Specific Illicit Drugs Among Persons Aged 12 or Older, in Thousands, 2007
Source: National Survey on Drug Use and Health.
Past month abuse rates for prescription pain relievers, tranquilizers, and sedatives among individuals 12 and older were stable overall from 2003 through 2007. According to NSDUH data, pain relievers were the psychotherapeutic drug used most frequently for nonmedical purposes in 2007--an estimated 5.2 million individuals aged 12 or older, or 2.1 percent of the population, reported past month nonmedical use of prescription pain relievers in 2007--the same percentage that reported nonmedical use in 2006, according to NSDUH. (See Figure 15.) Moreover, the rate of past month nonmedical use of pain relievers, tranquilizers, and sedatives among individuals 12 or older in 2007 did not differ significantly from the 2003 rate.
Figure 15. Past Month Nonmedical Use of Psychotherapeutics by Individuals 12 and Older, in Percentages, 2003-2007
Source: National Survey on Drug Use and Health.
* Differences between the 2003 and 2004 sedative estimates and the 2007 sedative
estimates are statistically significant at the 0.01 level.
Most national-level prevalence data indicate that CPD abuse rates among teenagers have remained stable, while NSDUH data indicate a significant decrease in pain reliever and stimulant abuse rates. Monitoring the Future (MTF), Partnership Attitude Tracking Study (PATS), and CASA data indicate that abuse rates among teenagers for most CPDs remained stable from 2003 through 2008. Additionally, the percentage of eighth and twelfth graders reporting nonmedical use of the opioid pain reliever Vicodin®38 (hydrocodone) was stable, and changes in the rates of nonmedical use of OxyContin®39 (oxycodone) were not statistically significant among teenagers, according to MTF. (See Table 5.) Moreover, in the 2008, 2007 and 2005 PATS surveys, 19 percent of teenagers reported using a prescription drug40 not prescribed for them, slightly lower than the 21 percent who reported using such drugs in 2004. (See Figure 16.) The percentage of teenagers reporting that they knew friends or classmates who abused prescription drugs remained relatively stable overall from 2004 through 2008 (see Figure 17), according to CASA. NSDUH data indicate that pain reliever and stimulant abuse rates among persons aged 12 to 17 decreased significantly overall from 2003 through 2007. (See Figure 18.)
Table 5. Trends in Annual Prevalence of Nonmedical Use of Prescription Drugs in Grades 8, 10, and 12, by Percentage, 2004-2008
| 2004 | 2005 | 2006 | 2007 | 2008 | |
|---|---|---|---|---|---|
| Amphetamines | |||||
| 8th Grade | 4.9 | 4.9 | 4.7 | 4.2 | 4.5 |
| 10th Grade | 8.5 | 7.8 | 7.9 | 8.0 | 6.4 |
| 12th Grade | 10.0 | 8.6 | 8.1 | 7.5 | 6.8 |
| OxyContin® | |||||
| 8th Grade | 1.7 | 1.8 | 2.6 | 1.8 | 2.1 |
| 10th Grade | 3.5 | 3.2 | 3.8 | 3.9 | 3.6 |
| 12th Grade | 5.0 | 5.5 | 4.3 | 5.2 | 4.7 |
| Ritalin® | |||||
| 8th Grade | 2.5 | 2.4 | 2.6 | 2.1 | 1.6 |
| 10th Grade | 3.4 | 3.4 | 3.6 | 2.8 | 2.9 |
| 12th Grade | 5.1 | 4.4 | 4.4 | 3.8 | 3.4 |
| Sedatives | |||||
| 8th Grade | NA | NA | NA | NA | NA |
| 10th Grade | NA | NA | NA | NA | NA |
| 12th Grade | 6.5 | 7.2 | 6.6 | 6.2 | 5.8 |
| Tranquilizers | |||||
| 8th Grade | 2.5 | 2.8 | 2.6 | 2.4 | 2.4 |
| 10th Grade | 5.1 | 4.8 | 5.2 | 5.3 | 4.6 |
| 12th Grade | 7.3 | 6.8 | 6.6 | 6.2 | 6.2 |
| Vicodin® | |||||
| 8th Grade | 2.5 | 2.6 | 3.0 | 2.7 | 2.9 |
| 10th Grade | 6.2 | 5.9 | 7.0 | 7.2 | 6.7 |
| 12th Grade | 9.3 | 9.5 | 9.7 | 9.6 | 9.7 |
| Other narcotics | |||||
| 8th Grade | NA | NA | NA | NA | NA |
| 10th Grade | NA | NA | NA | NA | NA |
| 12th Grade | 9.5 | 9.0 | 9.0 | 9.2 | 9.1 |
Source: Monitoring the Future.
NA-Not
available.
Figure 16. Percentage of Teenagers Who Used a Prescription Pain Reliever or Stimulant Not Prescribed for Them, 2004-2008*
Source: Partnership Attitude Tracking Study.
*
The Partnership Attitude Tracking Study teen
report for 2006 was held for review and comparison with the 2007 data and as of
March 4, 2009, had not been released. These are the most recent comparable data.
Figure 17. Percentage of Teenagers With Friends or Classmates Who Abuse Prescription Drugs, 2004-2008
Source: National Center on Addiction and Substance Abuse at Columbia University.
Figure 18. Past Month Use of Psychotherapeutics Among 12- to 17-Year-Olds, in Percentages, 2003-2007
Source: National Survey on Drug Use and Health.
* The difference between the 2003 and 2007
estimates for pain relievers is statistically significant at the 0.01 level.
** The difference between the 2006 and 2007
estimates for tranquilizers is statistically significant at the 0.05 level.
CPD-related deaths involving opioid pain relievers increased from 2001 through 2005. The number of unintentional deaths nationwide involving prescription opioid analgesics increased 114 percent, from approximately 3,994 in 2001 to 8,541 in 2005, according to the CDC. (See Figure 19.) Unintentional poisoning deaths in which methadone was mentioned increased 220 percent, from 1,158 in 2001 to 3,701 in 2005. Moreover, the number of unintentional prescription opioid analgesic deaths surpassed the number of cocaine and heroin deaths throughout the period. State medical examiner studies indicate that a high percentage of individuals who die from prescription drug overdoses have a history of substance abuse, many have no prescriptions for their drugs and misuse them in combination with illicit drugs, and some alter them by crushing and snorting them or dissolving and injecting them.
Figure 19. Unintentional Prescription Opioid Analgesic, Cocaine, and Heroin Deaths Nationwide, 2001-2005
Source: Centers for Disease Control and Prevention.
The number of treatment admissions and ED visits involving nonmedical use of CPDs varied depending on the drug type. The number of treatment admissions with prescription opioids (other opiates41) as the primary reported drug of abuse increased 71 percent from 52,840 in 2003 to 90,516 in 2007 (the most recent year for which such data are available), according to TEDS. At the same time, heroin treatment admissions steadily decreased from 273,996 to 246,871. Additionally, the number of treatment admissions for tranquilizers increased slightly during that time, from 8,164 in 2003 to 9,949 in 2007. Conversely, the number of treatment admissions for prescription barbiturates as the primary drug of abuse has been declining, and admissions are not frequently reported.
ED visits for nonmedical use of narcotic analgesics and benzodiazepines increased from 2004 through 2006 (the most recent year for which comparable data are available; see Table 6). The number of ED visits for nonmedical use of narcotic analgesics42 increased 39 percent, from 144,644 in 2004 to 201,280 in 2006, according to the Drug Abuse Warning Network (DAWN) and 20 percent from 2005 through 2006. Specifically, ED visits involving hydrocodone/combinations, morphine/combinations, and oxycodone/combinations43 increased 44, 46, and 56 percent, respectively. ED mentions involving nonmedical use of benzodiazepines increased 36 percent (143,546 to 195,625) from 2004 through 2006.
Table 6. Emergency Department Visits for Nonmedical Use of Selected Controlled Prescription Drugs and Percent of Change, 2004-2006
| Percent of Change* | |||||
|---|---|---|---|---|---|
| 2004 | 2005 | 2006 | 2004, 2006 | 2005, 2006 | |
| Benzodiazepines | 143,546 | 189,704 | 195,625 | 36 | -- |
| alprazolam | 46,526 | 57,419 | 65,236 | 40 | -- |
| clonazepam | 28,178 | 30,648 | 33,557 | -- | -- |
| diazepam | 15,619 | 18,433 | 19,936 | -- | -- |
| lorazepam | 17,674 | 23,210 | 23,720 | -- | -- |
| Stimulants | 9,801 | 10,965 | 13,892 | 42 | -- |
| amphetamine-dextroamphetamine | 2,303 | 2,669 | 5,027 | 118 | -- |
| methylphenidate | 2,446 | 2,519 | 2,192 | -- | -- |
| Narcotic Analgesics | 144,644 | 168,376 | 201,280 | 39 | 20 |
| codeine/combinations | 7,171 | 6,180 | 6,928 | -- | -- |
| fentanyl/combinations | 9,823 | 11,211 | 16,012 | -- | -- |
| hydrocodone/combinations | 39,844 | 47,192 | 57,550 | 44 | -- |
| hydromorphone/combinations | 3,385 | 4,714 | 6,780 | -- | -- |
| meperidine/combinations | 782 | 383 | 1,440 | -- | -- |
| methadone | 36,806 | 42,684 | 45,130 | -- | -- |
| morphine/combinations | 13,966 | 15,762 | 20,416 | 46 | -- |
| oxycodone/combinations | 41,701 | 52,943 | 64,888 | 56 | -- |
| propoxyphene/combinations | 6,744 | 7,648 | 6,220 | -- | -- |
Source: Drug Abuse Warning Network 2006.
*
These columns denote statistically significant
(p<0.05, where "p" is an estimate of the probability that the result has occurred
by statistical accident) increases or decreases between estimates for the periods
shown. A dash (--) in a table cell indicates a change that was not statistically
significant.
Some prescription opioid abusers (particularly teens and young adults) switch to heroin. Treatment providers in some areas of the United States anecdotally reported in 2008 that a few prescription opioid abusers switch to heroin as they build tolerance to prescription opioids and seek a more euphoric high. Traditionally it was more common for some heroin abusers to switch to opioid CPDs in the absence of their drug of choice. Further anecdotal reporting by treatment providers indicates that some prescription opioid abusers are switching to heroin in a few areas where heroin is less costly or more available than prescription opioids. Diverted CPDs are often more readily available than heroin in all drug markets; however, prescription opioids are typically more expensive than heroin. For example, oxycodone abusers with a high tolerance may ingest 400 milligrams of the drug daily (five 80-milligram tablets), for an average cost of $400. These abusers could maintain their addictions with 2 grams of heroin daily, at a cost of one-third to one-half that of prescription opioids, depending on the area of the country and the purity of the heroin. Such reporting may be an indicator that an increasing number of prescription opioid abusers might switch to heroin and treatment providers could experience an increase in heroin admissions. DEA has not evidenced a trend in any investigative or intelligence systems showing the substitution of heroin for opioid CPDs.
37.
The NDIC Document and Media Exploitation (DOMEX)
Branch extracts vital information from document- or computer-related evidence seized
in connection with law enforcement and intelligence operations. The evidence is
used to further the investigation.
38.
Vicodin® is specifically mentioned in this survey.
39.
OxyContin® is specifically mentioned in this survey.
40.
Prescription pain reliever or stimulant.
41.
The category "other opiates" in SAMHSA data refers
to codeine, Dilaudid®, morphine, Demerol®, opium, oxycodone, and any other drug
with morphine-like effects. It does not include heroin or nonprescription methadone
(methadone obtained and used without a legal prescription).
42.
Narcotic analgesics include buprenorphine/combinations,
codeine/combinations, fentanyl/combinations, hydrocodone/combinations, hydromorphone/combinations,
meperidine/combinations, methadone, morphine/combinations, oxycodone/combinations,
and propoxyphene/combinations.
43.
Oxycodone/combination CPDs are manufactured with
either aspirin or acetaminophen.
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