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National Drug Intelligence Center |
The diversion and abuse of controlled14 prescription drugs are a significant concern for law enforcement officials and treatment providers nationwide. Traditional diversion methods (primarily doctor-shopping, theft, forged prescriptions, and unscrupulous physicians and pharmacists working alone or in association) remain the most common means by which individuals illegally acquire Schedule II prescription drugs, despite an increase in the number of states with active prescription drug monitoring programs (PDMPs) designed to reduce traditional prescription drug diversion methods. (See text box.) Controlled prescription drugs, primarily Schedule III and IV, are also diverted through Internet sales by rogue Internet pharmacies.15 However, the number of sites offering such drugs has decreased, most likely because of increased law enforcement pressure through improved cooperation among federal and state law enforcement agencies, Internet service providers (ISPs), package delivery services, and financial services companies typically used by rogue Internet pharmacy operators. Nationally, law enforcement reporting indicates the increased involvement by street gangs and outlaw motorcycle gangs (OMGs) in the retail-level distribution of diverted controlled prescription drugs.
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Prescription Drug Monitoring Programs Prescription Drug Monitoring Programs (PDMPs) are systems in which controlled prescription drug data are collected in a database, centralized by each state, and administered by an authorized state agency to facilitate the early detection of trends in diversion and abuse. As of October 2008, 38 states had enacted legislation permitting PDMPs or had operational PDMPs. Each state controls the language of its PDMP with regard to how the prescription information gathered as part of the program will be shared not only in the state but also with other states. For instance, one PDMP may share information among law enforcement, treatment providers, physicians, and pharmacists within the state but not with any agency in other states. Another state may opt to share its prescription data only with physicians and pharmacists nationwide, while a third state may choose to share all of its data with all other state agencies. |
Distributors and abusers of Schedule II controlled prescription drugs usually acquire the drugs through traditional diversion methods such as prescription fraud and doctor-shopping. Prescription drug distributors and abusers typically acquire Schedule II prescription drugs16 through the sharing of drugs among family and friends; doctor-shopping; theft from pharmacies, health care facilities, strangers, family, and friends; prescription fraud by theft of prescription pads or by computer-created prescription pads; and overprescribing by unscrupulous physicians. For example, NSDUH data for 2007 show that among individuals aged 12 or older who used pain relievers (typically Schedule II drugs) nonmedically in the past year, 56.5 percent reported that they obtained the pain relievers from a friend or relative for free. NSDUH data also show that 8.9 percent of individuals in the same cohort bought the drugs from a friend or family member, and 5.2 percent stole them from a friend or family member. Only 0.5 percent reported that they used the Internet to purchase prescription pain relievers for nonmedical use. Individuals who illegally acquire prescription drugs by traditional diversion methods usually acquire relatively small quantities17 of drugs per diversion incident.
Schedules III and IV controlled prescription drugs are principally acquired in large quantities through the Internet. Schedule III18 and Schedule IV19 prescription drugs are more likely than Schedule II drugs to be acquired from rogue Internet pharmacies. According to DEA, rogue pharmacy operators often recruit doctors who are willing to prescribe Schedules III and IV controlled prescription drugs because the doctors believe that these drugs are less harmful than Schedule II drugs. These physicians may also be less willing to prescribe Schedule II drugs because of the heavier criminal penalties associated with Schedule II drug violations. Law enforcement reporting indicates that individuals who illegally acquire prescription drugs through the Internet often acquire large quantities with each diversion incident.
The number of Internet sites offering sales of controlled prescription drugs decreased in 2008; however, the Internet is still the principal method used to acquire Schedules III and IV controlled prescription drugs. Federal law enforcement reporting indicates that the number of Internet sites offering controlled prescription drug purchases from rogue Internet pharmacies is decreasing. Cooperation between federal and state law enforcement agencies and ISPs as well as the package delivery services and financial services companies typically used by rogue Internet pharmacy operators has reduced the number of rogue pharmacies that operate on the Internet. Studies in 2007 and 200820 conducted by the National Center on Addiction and Substance Abuse (CASA) at Columbia University support the law enforcement reporting. According to CASA, the number of identified rogue Internet pharmacies advertising selected Schedules II, III, or IV controlled prescription drugs (portal sites) or offering to sell these drugs (anchor sites) decreased 37 percent, from 581 in 2007 to 365 in 2008 (see Figure 22). Similarly, the number of Internet sites offering selected drugs 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. 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 selected controlled substances did not require a physician's prescription, a percentage statistically unchanged from the 2007 study (84%). (See Figure 23) Of those sites that did require a prescription (24 sites), 50 percent accepted a faxed prescription, a 7 percent decrease from 2007. Faxed prescriptions significantly increase the opportunity for the multiple use of one prescription or the use of fraudulent prescriptions.
Figure 22. Rogue Pharmacies Operating on the Internet, 2004-2008
Source: National Center on Addiction and Substance Abuse at Columbia University.
Figure 23. Prescription Requirements of Internet Pharmacy Anchor Sites, 2004-2008
Source: National Center on Addiction and Substance Abuse at Columbia University.
The percentage of law enforcement agencies nationwide reporting street gang or OMG involvement in the distribution of diverted pharmaceuticals21 increased overall from 2004 through 2008. The percentage of state and local law enforcement agencies nationwide reporting street gang involvement in the distribution of diverted pharmaceuticals increased from 32.5 percent in 2004 to 44.2 percent in 2008, according to the NDTS 2008. The percentage of state and local law enforcement agencies nationwide that reported OMG involvement in the distribution of diverted pharmaceuticals also increased slightly, from 22.2 percent in 2004 to 25.9 percent in 2008. Reporting from law enforcement and treatment providers indicates that street dealers are rarely the primary source of supply for controlled prescription drug abusers of any age. However, abusers could increasingly seek these drugs from street gangs and OMGs as PDMPs and law enforcement initiatives make traditional diversion methods and Internet drug purchases more difficult.
Many abusers of controlled prescription drugs commit insurance fraud to finance the purchase of these drugs, and such activity has an enormous financial impact on society. According to law enforcement reporting, insurance fraud by individuals who acquire controlled prescription drugs through traditional diversion methods is widespread. Controlled prescription drug abusers often submit insurance claims for reimbursement or payment for the purchase of drugs diverted primarily through doctor-shopping. In fact, according to the Coalition Against Insurance Fraud (CAIF), Aetna Inc. reports that nearly half of its 1,065 member fraud cases in 2006 involved prescription benefits, and most were related to doctor-shopping. CAIF also reports that a typical doctor-shopper can cost insurers between $10,000 and $15,000 per year, and in their attempt to obtain controlled prescription drugs, abusers also commit insurance fraud by faking illnesses that require expensive medical tests. CAIF further reports that diversion of controlled prescription drugs 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, and much of that cost is passed on to consumers through higher annual premiums. Those costs include related emergency room treatment, hospital stays, physician's office visits, tests, and rehabilitation for the addicted doctor-shopper.
Overdose deaths related to opioid pain relievers have been increasing recently. The number of deaths involving controlled prescription drugs, particularly opioid pain relievers (such as oxycodone, hydrocodone, methadone, morphine, and fentanyl), increased from 2001 through 2005 and outpaced deaths involving illicit drugs in 2005 (the latest year for which data are available). The number of deaths involving prescription opioids increased 66 percent from approximately 3,484 in 2001 to 5,789 in 2005, according to the Centers for Disease Control and Prevention (CDC). Moreover, the number of methadone-related deaths increased 206 percent (1,456 to 4,462) and the number of deaths involving other synthetic narcotics increased 81 percent (962 to 1,744) during that time. For deaths in which multiple controlled prescription drugs were found, opioid pain relievers were the most commonly mentioned and accounted for approximately 38 percent of first-listed drugs on death certificates in 2005; nearly half of those deaths involved methadone.
Information regarding the number of rogue Internet pharmacies that sell controlled prescription drugs without a prescription, particularly Schedule II drugs, is limited. Individuals who conduct Internet pharmacy research do not actually purchase controlled prescription drugs as part of the study. For this reason it is difficult to determine which web sites sell controlled prescription drugs and which financial institutions will accept payment for the illicit purchase of such drugs. The U.S. Government Accountability Office (GAO) did purchase controlled prescription drugs as part of a 2004 study requested by a U.S. Senate subcommittee. During the study, GAO was able to purchase several Schedule II and III controlled substances without a prescription; however, no similar study has been conducted since that time.
The enactment of federal legislation will most likely reduce the number of rogue Internet pharmacies selling controlled prescription drugs. The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 was enacted in October 2008. The federal law amends the Controlled Substances Act and prohibits the delivery, distribution, and dispensing of controlled prescription drugs over the Internet without a prescription written by a doctor who has conducted at least one in-person examination of the patient. Provisions of the law increase the criminal penalties for illegal Internet prescribing of Schedules III, IV, and V controlled substances. The law will most likely deter some Internet pharmacy operators from engaging in "script mill" practices, which provide alleged medical consultations (for a fee) and prescriptions that are sent to local pharmacies or directly to customers, who can take them to a pharmacy to be filled.
14.
Not all prescription drugs are listed as controlled
prescription drugs in the Controlled Substances Act. However, many prescription
drugs are listed in Schedules I through V of the Controlled Substances Act because
of their high potential for abuse or addiction. Schedule I through V prescription
drugs primarily are narcotic pain relievers and central nervous system depressants
and stimulants. A complete list of controlled prescription drugs, by schedule, is
available on the DEA Office of Diversion Control Internet site (http://www.deadiversion.usdoj.gov/schedules/schedules.htm).
15.
Rogue Internet pharmacies are unlicensed, fraudulent,
and disreputable businesses that sell prescription drugs illegally.
16.
Schedule II drugs include several prescription
drugs, such as OxyContin (oxycodone), Percocet (oxycodone in combination with acetaminophen),
and Duragesic (fentanyl).
17.
Small quantities are typically therapeutic, personal
use amounts that would not attract the suspicion of physicians, pharmacists, insurers,
or other health care professionals.
18.
Schedule III drugs include several prescription
drugs such as Vicodin (hydrocodone in combination with acetaminophen).
19.
Schedule IV drugs include several prescription
drugs such as Xanax (alprazolam), Valium (diazepam), Ativan (lorazepam), and Ambien
(zolpidem).
20.
The National Center on Addiction and Substance
Abuse (CASA) has tracked the online availability of controlled substances since
2004; CASA conducts its research in the first quarter of each year.
21.
The term "diverted pharmaceuticals" as used in
the National Drug Threat Survey (NDTS) refers only to distribution of scheduled
prescription drugs prosecutable under the Federal Controlled Substances Act.
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