12/14/2011

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Paul SchmidtPaul SchmidtPaul SchmidtPaul Schmidt32 years in Law Enforcement32 years in Law Enforcement32 years in Law Enforcement32 years in Law Enforcement

Drug Enforcement Administration (Retired)Drug Enforcement Administration (Retired)Drug Enforcement Administration (Retired)Drug Enforcement Administration (Retired)Regulatory and ComplianceRegulatory and ComplianceRegulatory and ComplianceRegulatory and Compliance

Prescription drug abuse is the

fastest growing addiction problem in the United States

Outreach by Community Resources

and Law Enforcement Through

Education

Enforcement

Treatment

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1.) Pharmaceutical prescription abuse is the fastest growing addiction problem in the United States of America.

A. True

B. False

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2.) What are common beliefs held by young adults concerning the use of pharmaceutical medications?

a.) All my friends get high on pharmaceuticals and they have no issues using them.

b.) Young adults do not want the perception of hanging out with drug dealers.

c.) Getting high using pharmaceuticals feels good and is safe.

d.) All the above.

3.) The term “Doctor Shopping” refers to an individual or group of individuals that target specific practices or clinics in an attempt to obtain pharmaceutical prescriptions by false and unlawful means.

A. True

B. False

4.) Following established “best” practice procedures which include an audit function at your office will help identify possible cases of fraud, strengthen your prevention techniques and give you the ability to remedy fraud once it is discovered.

A. True

B. False

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� For the first time, high school students were

asked questions about prescription drugs.

� Overall, 1 in 5 students admitted taking

prescription drugs that were not prescribed

to them.

These drugs included:Adderall OxyContin® Percocet

Ritalin Vicodin® Xanax®

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� Over the past year, people aged 12 and older, who used

pain relievers for “non medical” applicationsindicated they received their drugs from:

→ 55.3% friend or relative for free,prescriptions obtained from a single doctor

→ 17.6% obtained from doctor

→ 4.8% drug dealer or unknown individual

→ >1% bought from the Internet

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� A dramatic softening in young adult attitudes

and beliefs over the past two years

“friends usually get high at parties”

increased from 69% to 75%

“don’t want to hang around drug users”

“Young Adults believe that pharmaceuticals are safe”

11% increase in use of alcohol

67% increase in use of Ecstasy

19% increase in use of marijuana

51% belief that “being high feels good”

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Fentanyl (Schedule II)

Methadone (Schedule II)

OxyContin (Schedule II)

Hydrocodone (Schedule III)

Cough Syrup (Schedule V)

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� Various reports of overdose deaths from mixing Fentanylwith heroin or cocaine, or ingesting the “patch”

� Fentanyl is diverted from designed products; however,it is becoming more common to find illicit manufacturedFentanyl available on the streets

� Manufacture of Fentanyl required an expert chemist;however, today synthetic formulas are available on theInternet with “Do It Yourself” guides

� Inexpensive to manufacture resulting in a highprofit margin

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“Growing drug problem” (according to toxicology experts)“Growing drug problem” (according to toxicology experts)“Growing drug problem” (according to toxicology experts)“Growing drug problem” (according to toxicology experts)

Abuse linked to:Abuse linked to:Abuse linked to:Abuse linked to:

◦ Increased prescribing by doctors to treat pain

◦ High level of diversion to illicit market

Inexpensive:Inexpensive:Inexpensive:Inexpensive:

◦ Insurance companies prefer Methadone because of price

Increasing chances of an Increasing chances of an Increasing chances of an Increasing chances of an overdose:overdose:overdose:overdose:

◦ Remains in the body much longer than other similar substances –effects can last up to 24 hours

◦ Although chemically unlike morphine or heroin, produces many of the same effects

◦ Overdose and deaths have tripled since 1999

Street PricesStreet PricesStreet PricesStreet Prices: $2 to $10 mg tablet

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Customers/ Drug Abuse

Doctor-shopping

Forged / fraudulent /alteredprescriptions

The medicine cabinet

Employee pilferage

Hospitals

Practitioners’ offices

Nursing homes

Pain Clinics

The Internet

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Practitioners/Pharmacists

Illegal distribution

Self abuse

Trading drugs for sex

Retail pharmacies

Manufacturing / distribution facilities

Pharmacy/Other Theft

Armed robbery

Burglary (Night Break-ins)

In Transit Loss (Hijacking)

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Individual Patients Individual Patients Individual Patients Individual Patients Target Target Target Target PhysiciansPhysiciansPhysiciansPhysicians� Obtain prescriptions from multiple physicians

� Physicians willing to prescribe controlled substances over an extended period of time with little or no oversight

Target Target Target Target PharmaciesPharmaciesPharmaciesPharmacies

� Utilize multiple pharmacies to fill the orders to avoid suspicion

� Pharmacies known to dispense controlled substances without asking questions

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Trafficking Trafficking Trafficking Trafficking Organizations:Organizations:Organizations:Organizations:Recruit individuals to obtain narcoticsRecruit individuals to obtain narcoticsRecruit individuals to obtain narcoticsRecruit individuals to obtain narcotics� Patients often have legitimate medical conditions (favorite targets: seniors, nursing homes, homeless shelters)

� With cooperating physician or staff, patients never see physician

→ False identification, obtained from consenting individuals, used

to “create” medical records and obtain scripts (Medicaid fraud)

� Pay patients for their narcotics and services

Target physiciansTarget physiciansTarget physiciansTarget physicians� Those known to prescribe with little or no follow-up

� Sympathetic to patients’ medical situation

� Commonly long distance from patients’ residence

Utilize Medicaid (or state public health)Utilize Medicaid (or state public health)Utilize Medicaid (or state public health)Utilize Medicaid (or state public health)� Reduces cost of office visits and controlled substances at pharmacy

� Increases profit margin

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Trafficking Organizations Trafficking Organizations Trafficking Organizations Trafficking Organizations (continued)� Often provide transportation of patients to/from physicians and pharmacies, or delivery of medication (maintains legitimate cover)

� Often provide funding to cover expenses, such as office visit and prescription

� Maintain distribution outlets (sells both prescriptions and controlled substances)

Supported by “PillSupported by “PillSupported by “PillSupported by “Pill----Mill” physicians and pharmaciesMill” physicians and pharmaciesMill” physicians and pharmaciesMill” physicians and pharmacies

� Physicians and pharmacies that “sell” scripts and narcotics to large volume of drug seekers

� Characteristics of pill-mill physicians

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Fake prescriptions:Fake prescriptions:Fake prescriptions:Fake prescriptions:

Use real physician name and DEA Registrant Number • Contact Information false or “fake office” • Organizations set-up actual offices with contactinformation and staff (change locations often to avoiddetection)

Prescription printing services utilized • Not required to ask questions or verify informationprinted

• Use of out of state internet based printing services• Licensing of printing services in some states to reducefraud

Stolen prescriptions---- Forged, “Smurfed” to large number of differentpharmacies

Common “behind the counter” Common “behind the counter” Common “behind the counter” Common “behind the counter” thefttheftthefttheft→ Inadequate background checks of pharmacy staff

→ Systematic � Use computer ordering system

� Take possession at time of delivery (prior to inventory)

Target Schedule Target Schedule Target Schedule Target Schedule (III (III (III (III thru thru thru thru V)V)V)V)→ Inventory requirements vary by State

→ Schedule II security more stringent

Pharmacy and delivery vehicles Pharmacy and delivery vehicles Pharmacy and delivery vehicles Pharmacy and delivery vehicles → Burglary/robbery

→ Known distribution organizations

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� Common patterns Common patterns Common patterns Common patterns of of of of abuse by abuse by abuse by abuse by

prescribing physicians prescribing physicians prescribing physicians prescribing physicians and and and and usersusersusersusers

Preferred Prescriptions Preferred Prescriptions Preferred Prescriptions Preferred Prescriptions ““““Holy TrinityHoly TrinityHoly TrinityHoly Trinity””””Schedule II and III narcotics (Oxycontin®, Vicodin®)

Schedule IV Benzodiazapines (Xanax®, Valium®)

Non-Controlled Muscle Relaxants/Sedative (Soma®)

Non-Controlled Opioid Analgesic-Tramadol (Ultram®) substituted for schedule II/III narcotic

� PrePrePrePre----written written written written prescriptions prescriptions prescriptions prescriptions andandandand

medical records medical records medical records medical records Sponsored by “Pill-Mill” physicians

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� Florida Florida Florida Florida Pain ClinicsPain ClinicsPain ClinicsPain Clinics→ Heavy concentrations in Miami-Dade, Broward and West PalmBeach counties (small geographical area)

→ Physician and pharmacy are co-located

→ Primarily Cash; $200 for initial office visit, $150 forfollow-up visit if required

→ $825 to $950 for cocktail (Oxycodone, Xanax®, & Soma®)

→ 100% mark-up from non-affiliated Pharmacy

→ Average 180 to 210 pills per prescription(120 Oxy; 60 Xanax® & 30 Soma®)

→ Out-of-State patients:� Distribution to identified states of Maryland, Virginia, Kentucky, Tennessee, Ohio for $30 to $40 per pill*

� DTOs transport patients to clinics every two weeks to meet with as many doctors as possible during a 2-3 day timeframe

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Rank State Total Rank State Total Rank State Total Rank State Total Rank State Total

1 FL 40,821,651 12 CO 120,235 22 WA 27,152 32 LA 7,651 42 RI 900

2 OH 834,233 13 WI 114,180 23 IL 26,830 33 NE 7,196 43 ND 800

3 GA 675,964 14 MI 83,323 24 VA 24,712 34 MA 7,020 44 VT 800

4 MD 423,742 15 AL 65,102 25 AZ 24,391 35 CT 6,836 45 KS 410

5 CA 275,213 16 MO 64,439 26 AK 22,170 36 ID 5,826 46 WV 400

6 TN 228,022 17 NH 41,400 27 MS 20,682 37 MN 4,540 47 DC 400

7 PA 222,987 18 NY 31,814 28 OR 17,600 38 IA 4,500 48 HI 300

8 NC 160,208 19 IN 28,817 29 TX 12,786 39 AR 2,770 49 DE 200

9 KY 159,068 20 NJ 28,563 30 SD 8,972 40 MT 1,960 50 WY 100

10 NV 122,702 21 OK 28,292 31 ME 8,500 41 UT 1,517 51 NM 100

11 SC 122,366

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� Abuse of Abuse of Abuse of Abuse of AdderallAdderallAdderallAdderallSchedule II Amphetamine

Used to treat ADHD, effective in weight loss

Abuse prevalent among college students

Used to enhance/lengthen academic performance

Replace coffee and “Red Bull” type stimulants

$5.00 to $10.00 per pill on illicit market

Tablet can be snorted, injected or smoked

Adderall abusers; are five times more likely to also Adderall abusers; are five times more likely to also Adderall abusers; are five times more likely to also Adderall abusers; are five times more likely to also abuse prescription pain relievers, eight times more abuse prescription pain relievers, eight times more abuse prescription pain relievers, eight times more abuse prescription pain relievers, eight times more likely to abuse Benzodiazepineslikely to abuse Benzodiazepineslikely to abuse Benzodiazepineslikely to abuse Benzodiazepines

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� Counterfeit Pharmaceuticals:Counterfeit Pharmaceuticals:Counterfeit Pharmaceuticals:Counterfeit Pharmaceuticals:Often obtained through internet sources, both domestic and foreign

Internet sources advertise on Business-to-Business (B2B) sites, such a Alibaba.com, Tradeboss.com, etc.

Substances usually obtained through foreign wholesalers

Substances contain wide variety of ingredients, some can be toxic, or active ingredients are in insufficient levels to be effective

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DextromethorphanDextromethorphanDextromethorphanDextromethorphan (DXM)(DXM)(DXM)(DXM)Over-the-counter (OTC) cough suppressant found in more than 120 cold medications, either alone or in some sort of combination.

Street Names: Street Names: Street Names: Street Names: Triple C, Skittling, Robo-trippingEffects: Effects: Effects: Effects: Euphoria; Auditory hallucinations similar to PCP or Ketamine

Abuse : Abuse : Abuse : Abuse : Orally

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Plateau Dose (mg) Behavioral Effects

1st 100-200 Mild stimulation

2nd 200-400 Euphoria and hallucinations

3rd 300-600Distorted visual perceptions

Loss of motor coordination

4th 500-1500 Dissociative sedation

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� Electronic Prescription system for schedule IInarcotics

� Doctor’s need-to-know their patients andestablish a bona fide physician-patient relationship recognizing signs of abuse and/or misuse of prescribed medications

� Patients know the system and can manipulateit exposing the work within it (example)

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Good business practices in place

PREVENTIONPREVENTIONPREVENTIONPREVENTION

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Good audit procedures in place

DETECTIONDETECTIONDETECTIONDETECTION

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GOOD REMEDY TO GOOD REMEDY TO GOOD REMEDY TO GOOD REMEDY TO

FRAUDFRAUDFRAUDFRAUD

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http://www.justice.gov/dea/

http://www.deadiversion.usdoj.gov/

#202-307-1000

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1.) Pharmaceutical prescription abuse is the fastest growing addiction problem in the United States of America.

A. True

B. False

12/14/2011

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2.) What are common beliefs held by young adults concerning the use of pharmaceutical medications?

a.) All my friends get high on pharmaceuticals and they have no issues using them.

b.) Young adults do not want the perception of hanging out with drug dealers.

c.) Getting high using pharmaceuticals feels good and is safe.

d.) All the above.

3.) The term “Doctor Shopping” refers to an individual or group of individuals that target specific practices or clinics in an attempt to obtain pharmaceutical prescriptions by false and unlawful means.

A. True

B. False

4.) Following established “best” practice procedures which include an audit function at your office will help identify possible cases of fraud, strengthen your prevention techniques and give you the ability to remedy fraud once it is discovered.

A. True

B. False

12/14/2011

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Thank You for sharing your

time and knowledge today

QUESTIONS?

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