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June 1991
PHARMACEUTICAL DIVERSION AND ABUSE:
OUR NATION'S OTHER DRUG PROBLEM
By
Thomas C. Babicke
Diversion Investigator and Instructor
Drug Enforcement Administration
Quantico, Virginia
The news today seems to be the BIG C--cocaine, crack,
cartel, and Colombia. Record drug seizures are being made
across the globe. Illicit drugs and drug-related crimes persist
everywhere. There is not a State, city, school, or even a
family in America that has not heard about or seen the damaging
effects of drugs. Yet, a startling fact remains. Even if the
flood of illicit drugs into the United States could be
eradicated, and every marijuana or coca field destroyed before
it was cultivated, the United States would still have a ready
supply of drugs. The misuse and abuse of pharmaceutical
prescription drugs would still be a law enforcement problem.
This article examines the historical development of various
pharmaceutical substances and discusses tactics that may lessen
the abuse of such substances.
HISTORY OF CONTROLLED SUBSTANCES
Narcotics
Throughout history, pharmaceutical companies and
individuals have searched for new and more effective drugs to
cope with problems such as pain, depression, anxiety, insomnia,
and obesity. One of the first to do so in modern history was a
German scientist, Frederick Serturner, who extracted morphine
from opium in 1805. Morphine, a narcotic, is very effective in
relieving pain; however, it is also 10 times more potent than
opium and 10 times more addictive. In 1832, codeine, another
narcotic, was isolated, and by 1853, Alexander Wood had invented
the hypodermic syringe.
The American Civil War (1861-1865), the Prussian-Austrian
War (1866), and the Franco-Prussian War (1870) broadened the use
of such narcotics as morphine and codeine in treating wounded
soldiers. As a result, morphine addiction became known as the
"soldiers disease." Then, in 1898, Bayer Laboratories marketed
heroin, which is three times more potent and addictive than
morphine.
Barbiturates
The development of barbiturates followed the same course as
narcotics. From 1903, when the first barbiturate was created,
through the 1970s, the American public had access to an
increasing number of this class of drugs. (1) In fact, the
benzodiaze-pines as a combined class of drugs easily are the
most prescribed drugs in the country.
Stimulants
This class of drugs followed its own course of development.
In the 1930s, amphetamines were first used to counteract
narcolepsy and later as an appetite suppressant. But, by the
end of the decade, the Third Reich had found an alternate use
for them--to increase the efficiency of the German army. In
1944, American soldiers were also advised to use amphetamines.
And, in 1969, astronaut Gordon Cooper was ordered to take an
amphetamine to increase his alertness prior to a manual re-entry
of the space module.
Even the general populace is well aware of amphetamines
effects. And, although amphetamines and some other stimulants
have been placed in Schedule II, and their use in long-term
obesity treatment restricted, other similar drugs, such as
phentermine, phendimetrazine, and diethylpropion, are still
readily prescribed.
SPECIAL PROBLEMS FOR LAW ENFORCEMENT
Pharmaceutically controlled substances provide law
enforcement with various unique problems, basically because they
can be both legal in one case and illegal in another. For
example, a heroin junkie has a prescription for hydromorphone
(Dilaudid), a powerful narcotic. Does the addict have a legal
prescription? Was the doctor aware of his addiction to heroin?
Such questions must be answered because hydromorphone can easily
be used to replace heroin.
Law enforcement officers may be confronted with another
example of legal or illegal prescription drug use. For
instance, in this fictitious account, Mrs. Johnson receives a
prescription for Xanax, a benzodiazepine, after an appointment
with Dr. Smith on Monday. On Tuesday, she sees Dr. Jones and
receives a prescription for Valium, another benzodiazepine. On
Wednesday, a visit to Dr. Taylor provides a prescription for
Tranxene, also a benzodiazepine. Basically, Mrs. Johnson
acquires different drugs from different doctors, an action that
quite possibly is illegal.
Prescription fraud is another problem for law enforcement.
This occurs when offenders either steal prescription pads or
alter or photocopy prescriptions. Some ingenious individuals
have even had their own prescription pads printed along with a
telephone number answered by a fictitious nurse.
Then, there are the occasional problems with some doctors,
dentists, pharmacists, and others in the medical profession.
These few unscrupulous individuals contribute to the misuse or
abuse of controlled drugs by prescribing drugs illegally and for
illegitimate purposes. In some cases, they may even deal drugs
or prescriptions or may be abusing prescription drugs
themselves.
LAW ENFORCEMENT DIRECTIONS
There are several ways to attack prescription drug abuse
and the diversion of these drugs into illicit traffic. First,
communication between law enforcement departments is essential.
Doctor shoppers and prescription forgers do not usually stay in
one location; therefore, in order to build a case against such
criminals, it is often necessary to contact neighboring police
departments for additional information.
Law enforcement personnel must also be properly trained to
recognize a script forger or doctor shopper, to read
prescriptions, and to know which pharmacies will fill
questionable prescriptions. Officers should also be thoroughly
familiar with how to confiscate a prescription as evidence with
minimum difficulty.
In addition, officers or investigators must be familiar
with the effects and legitimate uses of controlled substances.
For example, if several drugs are prescribed simultaneously, do
any have similar central nervous system effects? Law
enforcement personnel must also understand, for example, that a
specialist, such as an oncologist, may legitimately prescribe a
strong narcotic for a terminally ill patient. At the same time,
they must also know that it would be highly unusual, and most
likely illegal, for a dentist to prescribe amphetamines.
Specific legal expertise and training is often necessary to
investigate pharmaceutical diversion cases. For example, an
investigation may involve fourth and fifth amendment rights and
how they apply to practitioners or to a patient's right to
privacy. In addition, the agencies that investigate these
crimes differ from jurisdiction to jurisdiction. Therefore, to
build a successful case, officers and investigators must be
familiar with various applicable laws.
MULTIPLE COPY PRESCRIPTION PROGRAMS
Prescription Program Legislation
Gathering information about doctor shoppers, script
forgers, or physicians selling prescriptions and investigating
the resulting cases can often be difficult, tedious, and time
consuming. However, several States have found a partial answer
to this problem in the form of a Multiple Copy Prescription
Program (MCPP). Currently, nine States, including California,
Hawaii, Idaho, Illinois, Indiana, Michigan, New York, Rhode
Island, and Texas, have passed multiple copy prescription
legislation, in most cases for Schedule II drugs only.
The prescription forms are provided to physicians at a
nominal cost and are usually in three parts; however, Rhode
Island and Hawaii use two-part forms. In most States the
pharmacy that fills the prescription maintains the original
form, the prescribing physician keeps a copy, and the third copy
is sent to the designated State agency for statistical purposes.
These multiple copy prescription laws have had some
dramatic effects. The State of Illinois, Department of
Alcoholism and Substance Abuse, published an analysis of their
triplicate prescription form program for 1985 through 1988. (2)
According to this enlightening report, prescriptions stolen by
street users were used primarily to acquire two sought-after
prescription drugs, namely hydromorphone (Dilaudid) and
phenmetrazine (Preludin). According to the report, "Totals for
Fiscal Year 1988 show a drastic reduction in the number of
diverted dosage units reported in Fiscal Year 1985. Diverted
hydromorphone dosage units dropped from 29,314 in FY 1985 to
1600 in FY 1988...Phenmetrazine dosage units which totalled
6,090 in FY 1985 have dropped to 0 in FY 1988. (3)"
In addition, the State of New York, in a bold move,
extended their triplicate prescription law to include
benzodiazepines. These drugs, which include drugs such as
Valium and Xanax, are the most prescribed pharmaceuticals in the
United States. The results were substantial. In a letter dated
June 6, 1989, to the DEA Administrator, the Secretary to New
York's Governor reported that "during a week in December 1988
and a week in January 1989...benzodiazepine prescriptions filled
by 21 pill mill pharmacies in New York City had fallen by 79
percent...." (4)
Obstacles to MCPPs
Obviously, MCPPs can be very effective in stopping
pharmaceutical drug diversion. But a program such as this is
not without controversy. Large pharmaceutical companies have
continually lobbied against these prescription programs. In
addition, the American Medical Association (AMA) does not
support the concept of MCPPs and has proposed its own
alternative in the form of prescription forms labeled PADS
(Prescription Analysis and Data Synthesis) and PADS II.
However, the dramatic effect of MCPPs cannot be disputed.
MCPPs help to:
* Acquire controlledsubstance prescription information at
the patient level (Federal information systems do not
monitor controlled substances at this level);
* Reduce the abuse and isuse of Schedule II and
othercovered controlled substances without adversely
affecting the supply of these drugs for legitimate
medical needs;
* Discourage the indiscriminate prescribing and dispensing
of affected controlled substances by monitoring the
prescribing physicians;
* "...collect information for law enforcement and
regulatory purposes which identified potential
controlled substance diversion by prescribing and
dispensing practitioners, doctor shoppers and other drug
abusers, and prescription forgers"; (5)
* Reduce prescription forgery by limiting the availability
of prescription blanks, which could be stolen or
acquired by potential prescription forgers.
For the most part, States that have enacted multiple copy
prescription programs have experienced many or all of these
benefits. As a result, States using MCPPs have also been able
to squelch the critics complaints quite effectively by citing
the programs accomplishments.
CONCLUSION
The diversion, misuse, and abuse of pharmaceutically
controlled substances has long been a law enforcement problem.
Continued cooperation and the sharing of information among the
various law enforcement agencies are essential to develop the
expertise to investigate these crimes. However, tools such as
Multiple Copy Prescription Programs have helped to deal with
this problem effectively and need to be promoted. In fact, a
report of the White House Conference for a Drug Free America
recommends that "all states should adopt legislation
establishing multiple-copy prescription programs." (6)
But, none of these efforts can be truly effective without a
concerted effort to educate the public about the dangers of
prescription medication abuse. Only then can the United States
deal with its other drug problem.
FOOTNOTES
(1) In 1903, Barbitol was synthesized and first used.
Barbitol was followed by phenobarbitol (Luminal) in 1912,
amobarbitol (Amytal) in 1923, pentobarbital (Nembutal) along
with secobarbital (1930). Then, in 1946, meprobamate (Miltown)
was patented, followed by the first benzodiazepine
clordiazepoxide (Librium) in 1947. Diazepam (Valium), a smaller
dosage but more potent benzodiazepine, supplanted Librium in the
early 1970s. Valium was the leading seller among all
prescriptions from 1972 to 1978.
(2) Triplicate Prescription Control Section, "1988
Operation Report With a Four Year Analysis," State of Illinois,
Department of Alcoholism and Substance Abuse, 1988.
(3) Ibid.
(4) Letter to DEA Administrator John Lawn from Gerald C.
Crotty, Secretary to Governor Mario Cuomo of New York, dated
June 6, 1989.
(5) U.S. Department of Justice, Drug Enforcement
Administration, "Multiple Copy Prescription Programs Resource
Guide," July 1987, pp. 4-5.
(6) Final Report, The White House Conference for a Drug
Free America, Washington, D.C., 1988, p. 66.