Responses to the Problem of Prescription Fraud

Your analysis of your local prescription fraud problem should give you a better understanding of the factors contributing to it. Once you have analyzed your local problem and established a baseline for measuring effectiveness, you should consider possible responses to address the problem.

The following response strategies provide a foundation of ideas for addressing your particular prescription fraud problem. These strategies are drawn from a variety of research studies and police reports. Several of these strategies may apply to your community’s problem. It is critical that you tailor responses to local circumstances, and that you can justify each response based on reliable analysis. In most cases, an effective strategy will involve implementing several different responses. Law enforcement responses alone are seldom effective in reducing or solving the problem. Do not limit yourself to considering what police can do: give careful consideration to who else in your community shares responsibility for the problem and can help police better respond to it.

Unfortunately, information regarding the strategies’ effectiveness is severely limited, because few of the strategies have been evaluated. The government has provided limited funding to police to reduce prescription fraud, and virtually no funding to evaluate task force and state and local police efforts around the country. There has been some government funding for state prescription monitoring programs and general awareness campaigns, but these efforts also have been minimally evaluated.

General Requirements for an Effective Strategy

Because the prescription fraud problem crosses several disciplines, addressing it must be a coordinated effort at all stages. The following stakeholders are among the most critical in controlling prescription fraud.†

† Stakeholders should be aware of the Health Insurance Portability and Accountability Act (HIPAA) regarding privacy and data-sharing.

• Law enforcement. The Drug Enforcement Administration (DEA) has created the Office of Diversion Control as a “central source for national policy guidance, support, and intelligence information collection and sharing” regarding pharmaceutical diversion issues. Many states and local jurisdictions have specialized personnel, units, or task forces to implement prescription fraud prevention strategies. There is a need for specialized training on controlled and non-controlled substances and the drug scheduling system pharmacists use; state criminal laws and pharmacy regulations; types of forged and altered prescriptions; typical scams; and prescription fraud prevention techniques. Police should also educate prescribers about the various prescription fraud tactics and extent of the local problem.

• Healthcare providers. In general, healthcare providers should prescribe medication only when necessary, identify abuse and addiction, and provide resources to help patients handle addiction problems. They also should report all thefts of prescription pads to police and local pharmacies. The DEA (1999) [Full text] has created an information brochure for healthcare practitioners that gives specific guidance and outlines their responsibilities regarding prescription drug abuse and diversion.

• Pharmacists. In an information brochure for pharmacists, the DEA (2000b) [Full Text] recommends using common sense, sound professional practice, and proper dispensing procedures and controls (see sidebar). Pharmacists should provide clear information to users about how to take the drug, be able to recognize fraudulent prescriptions, inform police about problem people and prescriptions, and follow through with investigations and court proceedings. Others have also created guidelines to help pharmacists recognize abuse and fraud.39

In addition to the above, other key stakeholders are pharmaceutical companies and a variety of state and federal government agencies, such as health and medical boards and the Food and Drug Administration (FDA), which controls drug scheduling. A few of the larger pharmaceutical companies have recently worked with police to curtail prescription fraud, but most importantly, they need to continue to educate people about taking drugs safely under a doctor’s care.†

† For example, Purdue (the maker of OxyContin) has sponsored meetings with DEA and FDA officials, hired police officers to educate company personnel and serve as liaisons, and analyzed demographic data about geographic areas of abuse to help predict where the next problem will be and focus their efforts accordingly. Through informational forums, Abbott Laboratories (the maker of Vicodin) instructs prescribers and pharmacists about the potential for Vicodin abuse.

States are responsible for creating laws that govern the prescribing and dispensing of prescription drugs, licensing drug prescribers, and investigating complaints and imposing sanctions for violations of state medical practice laws. States also regulate pharmacy practice and license pharmacists and pharmacies, ensure compliance with state and federal laws, and require the maintenance of prescription records.

In 1991, the National Institutes of Health’s National Institute on Drug Abuse (NIDA) sponsored a technical review and meetings on the impact of prescription drug diversion- control systems on medical practice and patient care. In 2001, a public information campaign was conducted regarding prescription drug misuse and abuse, and federal funding was made available for research.†

† Neither the 1991 evaluation nor the 2001 funding was directly related to the responses discussed in this guide.

Effective prescription fraud responses must be well coordinated among the various stakeholders, and based on a thorough understanding of your local problem. Police cannot change the fact that people will abuse and become addicted to prescription drugs, but they can use various strategies, in concert with other stakeholders, to reduce and prevent prescription fraud in their jurisdiction.

Specific Responses to Prescription Fraud

Some responses to prescription fraud fall under the category of “situational crime prevention.” Such prevention (1) is directed at highly specific forms of crime; (2) involves managing, designing, or manipulating the immediate environment in as systematic and long-term a way as possible; and (3) makes crime more difficult and risky, or less rewarding and excusable, as judged by a wide range of offenders.40

Increasing the Risk of Detection

1. Informing doctors and pharmacists of fraudulent activity. One strategy that many police agencies, task forces, and pharmacy associations deem effective is to share information on prescription fraud scams and offenders through bulletins and mass communication. If prospective scam targets (e.g., the emergency room doctor who is about to be the third person in one day to see John Doe about his bad back, or the pharmacist who does not know about the stolen prescription pad) are informed, the offender’s risk of being detected greatly increases.  Jurisdictions such as Albuquerque, N.M., San Diego, and Tarrant County, Texas, use FaxAlert to notify doctors, pharmacies, and medical clinics of drug diversion-related activity. Each month, the Tarrant County Medical Society also distributes a health-scam report. The state of Colorado and Johnson County, Kan., use a PharmAlert hotline for notification, while Abington, Pa., police hand out fliers describing the scam and containing a photo of the suspect or fraudulent prescription. After implementing this strategy in 1991, Abington saw arrests increase from one per year to one to two per month. In addition to notifying practitioners and pharmacists about specific prescription scams, police should also inform and update them on the methods and profiles of offenders in their jurisdiction. 
2. Improving pharmacists’ screening of prescriptions and patients. Pharmacists are the “gatekeepers” or last lines of defense against prescription fraud. They should regularly check patients’ identification, verify doctors’ information, and use their experience and knowledge to judge when a patient’s behavior is suspicious or a prescription is fraudulent. [Pharmaceutical Diversion Education offers fraud-detection training for pharmacists (and police). For information, visit their website, at www.rxdiversion.com ]
3. Educating the public about prescription abuse and fraud. Several large-scale efforts have been made to educate the public about prescription abuse and fraud. Although these have not been police efforts, making the public aware that abuse and addiction are the underlying cause of much prescription fraud† makes these initiatives valuable.

   † Although most offenders commit prescription fraud to get drugs for personal use (due to addiction), and most crime prevention efforts have targeted this underlying cause, this does not lessen the importance of dealing with offenders who commit fraud strictly for financial gain.

   In 2000, the Community Antidrug Coalitions of America convened 15 coalition leaders to discuss prescription drug abuse in their communities and identify messages, materials, and methods to better educate the public, education departments, healthcare providers, and community-based organizations. In 2001, NIDA partnered with several national organizations† and distributed 400,000 postcards in several major cities with messages about the dangers of prescription drugs.

   † Organizations included the American Pharmaceutical Association, Pharmaceutical Research and Manufacturers of America, American Academy of Family Physicians, AARP, National Council on Patient Information and Education, National Community Pharmacists Association, and National Chain Drug Store Association.

   Campaigns such as these let offenders know that police and the health field are paying attention (and that they risk being detected). In addition, such campaigns can help enlist offenders’ friends and relatives to provide informal guardianship by better detecting suspicious activity, and providing help before the problem escalates.

Increasing the Effort Required to Commit Prescription Fraud

4. Verifying prescriptions. Pharmacists should try to verify every prescription. This includes making callbacks on all phoned-in prescriptions and checking doctors’ names, phone numbers, and DEA numbers. They should also keep a file of doctors in their jurisdiction, with contact information and signatures. Finally, if they cannot immediately verify a prescription, they should dispense only 24 hours’ worth of medication, until they can do so.
5. Employing security measures. Health profession stakeholders can use several strategies to control facilitators and harden targets.
   1. Using tamper-resistant prescription pads. Such pads should include some or all of the following features: serial numbers, prescriber information, watermarks, intricate lines, and/or heat- or light-sensitive messages. Each feature increases the effort needed to copy or alter a prescription. Several states have found serialized forms to be an effective deterrent to prescription forgery and counterfeiting.41
   2. Increasing the precautions the practitioner’s receptionist and answering service take. One practice is to use a security code to prevent people from impersonating the practitioner and telling the receptionist or answering service to hold calls or retrieve messages. Another is to not give out the practitioner’s DEA number to someone not known (e.g., someone claiming to be calling from an insurance company).
   3. Checking photo identification. Pharmacists should ask for photo identification to verify that people are who they say they are and that names match those on prescriptions.† Oftentimes, offenders use an alias or have someone claiming to be a friend or relative pick up prescriptions.

      † A similar—but as yet unimplemented—strategy is to take a fingerprint for identification purposes. In Pulaski, Va., large-pharmacy owners successfully fought a proposed requirement to do so, and in Arizona, proposed legislation to take a fingerprint for Medicaid purposes did not pass.

   4. Keeping prescription pads in a secure place. Easy access to prescription pads is a readily controllable risk factor for theft. The UK Department of Health issued a circular that outlines measures to take to secure prescription forms.42 The measures include keeping a record of forms received, keeping the supply to a minimum, securely storing forms, keeping access to a minimum, and reporting losses immediately.

6. Prescribing drugs electronically. The prescriber electronically transmits prescriptions directly to the pharmacist. This eliminates the problems of false phoned-in prescriptions, forged and altered prescriptions, and stolen prescription pads. It also eliminates pharmacist errors due to illegible prescriptions. In addition, the process itself is more accurate, cost-effective, and time-efficient. A project in Denmark showed savings, for the pharmacist and patient, in time that would otherwise be spent on the telephone and waiting for callbacks.43

   Electronic prescribing is at different stages of exploration and implementation in the United States and abroad. The UK National Health Service was exploring the idea in 2000. In the States, the National Association of Chain Drug Stores and the National Community Pharmacists Association ( www.ncpanet.org) agreed to collaborate on a system in February 2003. A few smaller jurisdictions in the have also created pilot projects. The DEA is considering moving in this direction as part of its larger e-commerce initiative.

7. Creating or changing laws regarding prescription fraud. Many states have implemented or changed laws to more effectively deal with prescription fraud. These new laws increase the penalty or punishment for prescription fraud, and/or specifically address individual aspects of it. For instance, the state of Florida created 893.13(7a9) specifically to target doctor shopping. California’s Health and Safety Code 11173 includes the phrase “attempt to obtain,” which allows police to charge someone even if he or she does not complete the fraud.Such well-defined laws make it easier to prosecute and convict offenders.
8. Maintaining a Prescription Monitoring Program. Prescription Monitoring Programs (PMPs), also called Multiple-Copy Prescription Programs, entail varying methods of tracking and monitoring certain prescription drugs. The general goals of the programs are to educate and inform prescribers, pharmacists, and the public regarding specific prescription drugs; use information for public health initiatives and for early intervention and prevention; and assist in investigations and enforcement. Underlying this is the need to protect patient confidentiality.

   As noted in the following table, state programs vary widely regarding the type of monitoring used (e.g., triplicate or electronic), the schedule of drugs covered, and the type of agency administering them.

   Prescription Monitoring Programs, by State†
   State	Program Enactment Year	Program Type	Schedule of Drugs Covered	Administrative Agency
   California	1939	Triplicate/electronic	II	Justice
   Hawaii	1943	Duplicate	II	Public Safety
   	1992	Electronic	II, III, IV
   Idaho	1967	Uncopyable paper	II, III, IV	Pharmacy Board
   	1997	Electronic	II, III, IV
   Illinois	1961	Electronic	II	Human Services
   Indiana	1987	Single-copy/electronic	II, III, IV, V	Public Safety
   Kentucky	1998	Electronic	II, III, IV, V	Public Health
   Massachusetts	1992	Electronic	II	Public Health
   Michigan	1988	Electronic	II, III, IV, V	Consumer and Industry Services
   Nevada	1995	Electronic	II, III, IV	Pharmacy Board
   New Mexico	1994	Electronic	II	Pharmacy Board
   New York	1972	Single-copy, serialized/electronic	II, benzodiazepine	Public Health
   Oklahoma	1990	Electronic	II	Narcotics and Dangerous Drugs Control
   Rhode Island	1978	Electronic	II, III	Pharmacy Board
   Texas	1981	Single-copy, serialized/electronic	II	Public Safety
   Utah	1995	Electronic	II, III, IV, V	Professional Licensure
   Washington	1984	Triplicate	II, III, IV, V	Pharmacy Board
   West Virginia	1995	Electronic	II	Pharmacy Board

   † This table was current as of March 2001 (National Association of State Controlled Substances Authorities and Alliance of States With Prescription Monitoring Programs [Full text]), and includes only those states that have (or have had) some form of PMP. The program enactment year is that of the original program, and does not reflect any subsequent changes to it. The Michigan and Idaho information was updated from www.michigan.govand www.accessidaho.org, respectively, on March 2, 2003. According to a General Accounting Office report in May 2002, New Mexico ended its program in 2000, and West Virginia ended its program in 1998, but enacted legislation to create a new one in 2002.

   Several studies and publications have addressed how PMPs affect diversion and medical practice, and most have reported positive results.44 PMPs are successful in identifying and preventing drug diversion, and have had minimal, or no, negative impact on medical practice. Individual states have also assessed their programs.

   In New York, implementing the triplicate program greatly lowered the number of schedule II prescription forgeries. After adding benzodiazepine, there was a large decrease in the number of prescriptions filled, an increase in its street price, and a significant decline in the number of emergency department mentions of it, compared with an increase in the rest of the country. In addition, no evidence was found that this program adversely affected medical practice or interfered with legitimate drug use.45

   The state of Rhode Island surveyed practitioners and reported positive results in terms of reducing abuse and forgeries, and most respondents believed there was no problem with legitimatepatients’ getting their prescriptions filled.46 Indiana reported a sharp increase in the street price of Dilaudid after implementing its program, and Michigan found that its electronic system reduced handling time and did not increase cost.47

   Addressing Prescription Fraud in San Diego† The California Department of Justice, Bureau of Narcotics Enforcement, established RxNET in 2002. This multifaceted team includes state agents, local law enforcement investigators, military police, the DEA, and a representative from the state’s Department of Insurance. The overall goal of the task force is to reduce drug diversion through the enforcement of drug laws and investigation of prescription fraud offenders. Such offenders include doctors and pharmacists who illegally prescribe, dispense, and/or administer drugs; people who steal prescription forms, forge/alter prescriptions, and/or pass fraudulent prescriptions; and patients who use multiple doctors to get drugs. Task force personnel train medical professionals to identify methods used to illegally obtain drugs. Through the task force, there has been an increased exchange of information on drug diversion cases among law enforcement, the Medical Board of California, the Department of Consumer Affairs, and the Board of Pharmacy. The task force has also established a relationship with the district attorney’s office, which has created a special position to handle prescription fraud cases and is working with RxNET to establish a streamlined Drug Court process. An extensive database was created to capture, track, and analyze information on prescription fraud cases and offenders. The task force also uses the state monitoring program data internally, and they hope to enhance the program by disseminating appropriate information to the various stakeholders. Currently, a fax-alert system is used to notify pharmacies and doctors throughout the county about offenders and scams, but there are plans to create a secure, free-access Internet site for clients to check information online.

   † This information was obtain ed from the RxNET mission statement, a state grant application and discussions with task force members.

Reducing Rewards to Offenders

9. Curbing distribution. Specific efforts have been made to limit the dosage or distribution of a particular drug for a target population or region. For instance, Florida and four other states limit OxyContin prescriptions to 120 pills per month per patient.48 Besides dosage, the number of refills could be limited. When prescribers do not specify a refill number, patients can illegally add one.

Removing Excuses

10. Facilitating compliance with the law. There are currently three avenues to help facilitate drug offenders’ compliance with the law: drug treatment/rehabilitation, Narcotics Anonymous, and Drug Court.† While all have been evaluated extensively, none has been evaluated specifically for pharmaceutical abusers/prescription fraud offenders. Yet anecdotal evidence reveals that Drug Court (in conjunction with Narcotics Anonymous, attendance of which is a requirement) is the most promising because there are ramifications if the offender does not fulfill the commitments. One distinct advantage of Drug Court (over jail) is that upon successful completion, the charges are expunged from the offender’s record. This is especially important to professionals who do not want a black mark on their records. Because of the high number of prescription fraud offenders who are professionals (many in the healthcare field), police investigators believe this is potentially a very effective response.

    † You can get more information about Drug Court through your local jurisdiction or from the national website, at www.nadcp.org.

Responses With Limited Effectiveness

Because most of the responses discussed here have not been evaluated, it is difficult to determine which ones have limited effectiveness. Some feel that the existing state monitoring systems, while effective, would be even more so if all states had such programs, and program databases were nationally linked.49 One article noted, “Despite triplicate prescriptions, new laws, and an increasing web of regulations designed to control prescription medications, the abuse of prescription drugs has continued.”50 Another stated, “Increased police investigations and the threat of federal prison have not slowed the OxyContin pipeline to Kentucky.”51

11. Using crackdowns. Crackdowns usually yield an immediate but limited impact, and often do not produce long-term results. A police or medical board crackdown on a specific doctor or pharmacy prone to prescription fraud may put that doctor or pharmacy out of commission, but prescription drug abusers will simply move on to the next doctor or pharmacy that does not have sufficient prevention measures in place. Given the inadequate amount of resources devoted to crackdowns on prescription fraud, the practice cannot be sustained as a means to prevent or reduce the problem. (For a discussion of law enforcement efforts in particular, see The Benefits and Consequences of Police Crackdowns, Response Guide No. 1 in this series.)
12. Creating a prescription database. Many pharmacies maintain a database of their customers. These “patient profiles” track previous prescriptions filled and provide information that aids in filling current ones. Although a pharmacist may note repeat prescriptions at his or her pharmacy, a customer’s attempts to get prescriptions filled at other pharmacies go undetected. Only a limited number of chain pharmacies share a common database, and we are not aware of any database shared among all pharmacies in a jurisdiction.† A customer’s getting a high number of prescriptions filled at multiple pharmacies in one city is much more efficiently detected through a jurisdiction-wide prescription database. The Internet would be an easy means to share such information.

    † In 1999, the Pharmacy Guild of Australia established a patient database that links 66 of its 5,000 member pharmacies with each other, as well as with the Health Insurance Commission. No evaluations have been done on the effectiveness of this initiative.