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. 