How Are Prescription Drugs Obtained?

How are prescription drugs obtained? Most pharmaceuticals abused in the United States are obtained by doctor shopping, forged prescriptions, theft and, increasingly, via the Internet. To reduce the occurrence of pharmaceutical diversion by doctor shopping and prescription fraud, 21 states have established prescription monitoring programs (PMPs) that facilitate the collection, analysis, and reporting of information regarding pharmaceutical drug prescriptions. State-level PMPs have been effective in reducing the average time required to conduct pharmaceutical diversion investigations as well as reducing the estimated number of dosage units dispensed by pharmacies and physicians to suspected abusers. For example, the Kentucky Cabinet for Health Service reports that the Kentucky All Schedule Prescription Electronic Reporting (KASPER) system has reduced the average time to complete pharmaceutical drug investigations from 156 to 16 days. Moreover, according to the Office of National Drug Control Policy (ONDCP), establishment of the Nevada PMP has resulted in a 46 percent reduction in the estimated number of pharmaceutical dosage units distributed to suspected abusers.

National Electronic Prescription Monitoring Program

On October 5, 2004, the House of Representatives' Energy and Commerce Committee approved the amended version of the National All Schedules Reporting Act of 2003 (NASPER). The original Act was first proposed to Congress on September 30, 2002, by the American Society of Interventional Pain Physicians (ASIPP). If enacted in its proposed form, NASPER would result in the implementation of a national electronic prescription monitoring system to track Schedule II, III, and IV drug prescriptions. The proposed NASPER system is designed to reduce the abuse and diversion of prescription drugs by assisting physicians in monitoring patient drug use and by aiding law enforcement personnel in investigating pharmaceutical diversion. Under the proposed NASPER system, pharmacists would report to a central administrator the patient's identification number; the drug, date, and quantity dispensed; the prescribing physician; and the dispensing pharmacy. Data entered into the NASPER system could be used to track patient drug use, prescribing patterns of medical practitioners, prescription rates and patterns for specific drugs, prescription patterns in specific geographic locations, and prescription patterns for longtime users.

Source: U.S. Senate, S. 3033; Pain Physician.

How are prescription drugs obtained? Doctor Shopping
A common method of obtaining pharmaceuticals is doctor shopping. Individuals who divert and acquire pharmaceuticals through doctor shopping do so by visiting numerous doctors in an attempt to obtain multiple prescriptions for the drugs, particularly prescription narcotics such as OxyContin, Percocet, and Percodan. Doctor shoppers often falsify or exaggerate symptoms in order to obtain prescriptions for pharmaceuticals and often visit doctors they believe to be more likely to write prescriptions for such drugs. The individuals typically have their prescriptions filled at multiple pharmacies in order to avoid detection.

Florida Man Arrested for Doctor Shopping

On April 14, 2004, the Florida Department of Law Enforcement (FDLE) announced the arrest of a Florida man on charges related to doctor shopping. At the request of the Tampa Police Department, and based on information received from them, FDLE began a preliminary inquiry into allegations that the man was having numerous prescriptions for opiate-based painkillers filled at various pharmacies throughout the Tampa area within 30-day intervals. Various Tampa area doctors, without knowledge of the other prescriptions, allegedly issued the prescriptions that he supplied to multiple pharmacies. The FDLE investigation conducted into the allegations against the man revealed that he had made at least 34 visits to 14 different doctors between November 2002 and November 2003. During these visits, he obtained prescriptions for painkillers such as hydrocodone and oxycodone. He is charged with eight counts of doctor shopping. Each count is a third degree felony punishable by up to 5 years in state prison.

Source: Florida Department of Law Enforcement.

How are prescription drugs obtained? Prescription Fraud
Prescription fraud includes a variety of schemes commonly used to divert pharmaceuticals such as forging or altering prescriptions, producing counterfeit prescriptions, and calling in fictitious prescriptions to pharmacies by impersonating a physician. Pharmacists often recognize prescription fraud, particularly forged, altered, or counterfeit prescriptions, because the prescriptions are written in unfamiliar handwriting (often without abbreviations) or the prescription quantities, directions, or dosages differ from normal usage. Pharmacists also identify fraud when prescriptions resemble textbook examples or appear to be photocopied.

Baltimore Woman Indicted for Passing Counterfeit Prescriptions

On March 3, 2004, the Attorney General for the State of Maryland announced that a Baltimore woman was indicted on February 26, 2004, in the Baltimore City Circuit Court with possessing a controlled dangerous substance by counterfeit prescription, counterfeiting prescriptions, passing counterfeit prescriptions, and conspiracy to commit these crimes. The indictment alleges that she produced and passed counterfeit prescriptions for Percocet on six occasions starting on April 29, 2003, and ending on June 6, 2003.

Source: Office of the Maryland Attorney General.

How are prescription drugs obtained? Unscrupulous Physicians
Illegal prescribing by unscrupulous physicians is a significant source of diverted pharmaceuticals. Corrupt physicians create fraudulent prescriptions to obtain drugs for personal use, and they also write prescriptions for individuals without a legitimate need for the drug for a fee. Unscrupulous physicians sometimes collaborate with unscrupulous pharmacists who dispense the drugs for an additional fee.

Maryland Dentist Pled Guilty to Unlawfully Prescribing Percocet

On January 15, 2004, the DEA Washington Field Division announced that a Hyattsville, Maryland, dentist pled guilty to two indictments in which he was charged with the unlawful distribution of oxycodone. The Hyattsville dentist acknowledged that beginning in September 2001 and continuing until his arrest in May 2003, he wrote prescriptions for female patients for several controlled substances including Percocet, OxyContin, Vicodin, other hydrocodones, and alprazolam without a legitimate medical purpose. He further admitted that he conducted no physical examination or dental treatment, maintained no patient file or record, and solicited sexual favors in return for the unlawful prescriptions. He was arrested in May 2003 after an undercover Maryland State police officer, posing as a Percocet addict, received prescriptions for Percocet on two occasions.

Source: Drug Enforcement Administration.

How are prescription drugs obtained? Theft
Millions of pharmaceutical drug dosage units are diverted each year through theft from pharmacies, manufacturers, distributors, importers/exporters, and from individuals with legitimate prescriptions. The amount of pharmaceutical dosage units diverted annually from 2000 to 2003 through theft fluctuates but has increased overall for most drugs, particularly for prescription narcotics like OxyContin. According to DEA, the number of pharmaceutical dosage units diverted through theft from pharmacies, manufacturers, distributors, and importers/exporters has increased from 2,379,389 in 2000 to 2,753,928 in 2003.

Table 1. Theft of Pharmaceuticals From Pharmacies, Manufacturers, Distributors, and Importers/Exporters, in Dosage Units, 2000-2003
Drug 2000 2001 2002 2003
Codeine 569,425 1,223,205 596,972 622,132
Dilaudid 37,531 22,647 23,072 41,668
Lorcet 100,548 540,997 126,451 360,115
Lortab 686,197 451,091 340,325 738,584
OxyContin 260,688 519,597 587,168 464,312
Percocet 421,063 127,525 193,085 278,581
Percodan 14,646 12,704 9,151 34,102
Ritalin 117,408 123,720 74,541 67,751
Valium 171,883 176,280 145,070 146,683
Total 2,379,389 3,197,766 2,095,835 2,753,928

Source: Drug Enforcement Administration.

Employees of pharmaceutical drug manufacturers and commercial distributors account for much of the pharmaceuticals diverted through theft; however, others steal pharmaceuticals as well. According to the 2002 National Retail Security Survey Final Report published by the University of Florida, retailers attribute 48 percent of pharmaceutical inventory loss to employee theft. Individuals also break into pharmacies or clinics to steal pharmaceuticals or commit armed robberies to acquire the drugs. Individuals also steal pharmaceuticals from friends or relatives who possess legitimate prescriptions.

Pharmacy managers and law enforcement agencies in areas that have experienced a high number of pharmacy break-ins and armed robberies have taken specific steps to reduce pharmaceutical theft. For example, many pharmacies have stopped distributing specific pharmaceuticals that thieves most often target, such as OxyContin. Law enforcement in some communities, such as Boston (MA) and Pikeville (KY), have increased patrols in and around pharmacies to deter or detect break-ins and robberies.

Pharmacy Intern Sentenced to Jail for Pharmacy Drug Theft

On April 24, 2002, the Office of the Massachusetts Attorney General announced that a former Somerville, Massachusetts, pharmacy intern pled guilty to 17 counts of uttering false prescriptions, one count of stealing controlled substances from a pharmacy, two counts of filing false Medicaid claims, nine counts of filing false care claims, three counts of larceny, and one count of making false entries in corporate books. The intern admitted to stealing many liters of narcotic fluids and more than 40,000 pills, including 16,000 tablets of Vicodin and 5,770 tablets of Xanax. A Middlesex County Superior Court judge sentenced the intern to 2? years in the Middlesex County House of Correction, suspended, with 18 months to serve. The judge ordered the intern to pay restitution of $35,000 to defrauded insurers.

Source: Office of the Massachusetts Attorney General.

How are prescription drugs obtained? Internet Pharmacies
Pharmaceuticals increasingly are diverted via the Internet because many Internet pharmaceutical distributors--often referred to as Internet pharmacies--offer prescription drugs to customers without requiring a prescription, physician consultation, or verification. Estimates as to the number of Internet pharmacies vary widely. For example, the National Board of Pharmacy estimates that the number of Internet pharmacies has increased from none in the mid- to late 1990s to between 400 and 1,000 in 2003. However, in January 2004 the National Center on Addiction and Substance Abuse (CASA) identified only 157 Internet sites distributing controlled pharmaceuticals to individual users, although an additional 338 Internet sites provided links to one or several of the 157 pharmaceutical distribution sites. Nevertheless, of the 157 Internet sites identified by CASA, 64 (40.7%) did not require any prescription or physician consultation to purchase prescription drugs. Moreover, 77 (49.0%) of the Internet sites only required customers to report their symptoms in an online questionnaire prior to receiving the prescription drug--there was no requirement for personal physician verification of the symptoms. Faxed prescriptions were required by 7 (4.4%) and mailed prescriptions were required by 3 (1.9%) of the sites. The remaining 6 (3.8%) sites made no reference to any prescription requirement. CASA further reports that the Internet pharmacy sites most often offered benzodiazepines such as Xanax and Valium, followed by narcotic analgesics such as fentanyl, hydrocodone, and oxycodone, and stimulants such as Ritalin and Adderall. Moreover, none of the 157 Internet sites included security procedures preventing children from purchasing prescription drugs.

Internet Pharmacy Ring Indicted

On December 29, 2003, the Federal Bureau of Investigation (FBI) announced that a 108-count indictment was unsealed against 3 companies and 10 individuals across the country. Together, they allegedly set up a massive Internet pharmacy ring that used dozens of web sites like to hawk dangerous and addictive drugs without the medical supervision required by law. In the process, they dispensed millions of dosage units of drugs and made more than $150 million. A doctor, who ultimately pled guilty in the case, authorized more than 22,000 prescriptions yet never met with a single patient, performed an exam, took a patient history, or verified medical information provided. A pharmacist, who also pled guilty, ran a pharmacy in Virginia and dispensed more than 2.5 million pills yet knew that the customers' identities had not been verified and that some customers were buying massive amounts of drugs. Because so many prescriptions were filled, the pharmacist often did not even have time to prepare and review them all.

Source: Federal Bureau of Investigation.

FBI reporting indicates that many unscrupulous Internet pharmacy operators recruit corrupt physicians to write fraudulent prescriptions for their customers. FBI further reports that unscrupulous physicians are paid as much as $1,500 per day for writing fraudulent prescriptions for Internet pharmacy patients.

Some Internet pharmacies, including some based in Mexico and Canada, distribute counterfeits of popular brand name pharmaceuticals that often contain inactive ingredients, incorrect ingredients, or improper dosages. According to FBI, most counterfeit pharmaceuticals are produced in India and China, and in some countries counterfeit pharmaceuticals are quite prevalent. In fact, FBI reporting indicates that as much as 60 percent of the pharmaceuticals sold in China, Nigeria, Thailand, Cambodia, and Indonesia are counterfeit. The Food and Drug Administration (FDA) reports that the level of counterfeit drug distribution within the United States is very low compared with other countries; however, occurrences of distribution of counterfeit pharmaceuticals in the United States are increasing. As a result, FDA counterfeit drug investigations have increased from 6 in 1997 to 22 in 2003.