The Problem of Prescription Fraud
his guide describes the problem of prescription fraud, and reviews the factors that increase the risks of it. It then identifies a series of questions to help you analyze your local problem. Finally, it reviews responses to the problem, and what is known about them from evaluative research and police practice.
For the purposes of this guide, prescription fraud, which falls under the broader heading of “pharmaceutical diversion,” is defined as the illegal acquisition of prescription drugs for personal use or profit. This definition excludes theft, burglary, backdoor pharmacies,† and illegal importation or distribution of prescription drugs.
† “Backdoor pharmacies” are businesses not licensed/authorized to distribute pharmaceutical drugs.
Prescription fraud is a significant and growing problem. Almost half the law enforcement agencies responding to a 2000 National Drug Threat Survey listed pharmaceutical abuse as a problem in their jurisdiction, and a similar share reported observing dramatic increases in prescription fraud and pharmaceutical drug abuse.1
While prescription fraud is common throughout the country, its intensity varies from place to place. This is often due to trends in specific types of drugs popular in different regions. It is a serious form of illegal drug activity, rivaling that involving more traditional street drugs, such as heroin and cocaine. Nationwide in 1993, people spent an estimated $25 billion on prescription drugs in the illegal market, compared with $31 billion on cocaine, including crack.2 Put another way, a recent study concluded that the number of people who abuse prescription drugs each year roughly equals the number who abuse cocaine—about 2 to 4 percent of the population.3 The local scope of the problem is similar. For example, the state of Kentucky estimates that over half the drug cases investigated through a federal law enforcement initiative involved prescription drugs.4 And the Cincinnati Police Department’s Pharmaceutical Diversion Squad reported that, in nine years, over 2 million doses of prescription drugs had been diverted illegally in the city.5
People commit prescription fraud in numerous ways, including forging prescriptions, going to several doctors to get multiple prescriptions (termed “doctor shopping”), and altering prescriptions to increase the quantity. However, the true scope of prescription fraud is largely unknown, due to a number of factors. Successful offenders get caught less often, and police never detect most of their offenses—as with any crime. Unlike other crimes, however, much prescription fraud goes undetected because it is not a high police priority; very few local agencies systematically track it. Limited awareness and lack of oversight among doctors and pharmacists may also contribute to the problem. In addition, because those who commit prescription fraud usually pay for the prescriptions (either personally or through insurance), pharmacies are less likely to perceive themselves as victims, to view prescription fraud as a crime, and to report fraud. Despite these difficulties in determining the scope of the problem, it stands to reason that, as the legitimate prescription drug market increases,† prescription fraud will, as well.
† The National Association of Chain Drug Stores projected that, in 2002, the industry would yield $188.5 billion in sales: 40 percent from traditional chain drug stores, 20 percent from independent stores, 17.9 percent from mail orders, 12.5 percent from grocery store pharmacies, and 9.7 percent from mass merchants (National Association of Chain Drug Stores 2002).[
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Related Problems
Offenders obtain prescription drugs in various ways, often to make a profit. Related problems that require their own analyses and responses include the following:
- Medicaid fraud.Pharmacy workers sometimes commit Medicaid fraud, usually by substituting generic drugs for name brands, short counting pills, and filling prescriptions without a refill, then over-billing Medicaid. They may also bill Medicaid for drugs they never dispensed.6
- Online ordering.Many people try to obtain prescription drugs illegally through the Internet. While most websites require proof of prescriptions, people can easily fabricate them, and vendors do not routinely verify them.
- Theft.Pharmacy workers and healthcare providers, both of whom have easy access to prescription drugs, sometimes steal them.
- Burglary† and robbery. Offenders obtain prescription drugs by either burglarizing or robbing pharmacies.
† See the POP Guide on Burglary of Retail Establishments.
Factors Contributing to Prescription Fraud
Understanding the factors that contribute to prescription fraud will help you frame your own local analysis questions, determine good effectiveness measures, recognize key intervention points, and select appropriate responses.
Abuse of and Addiction to Prescription Drugs
The biggest factor driving prescription fraud is the increasing abuse of and addiction to prescription drugs. Prescription drug abuse is significant and rising rapidly. In 2000, an estimated 2 million Americans over the age of 12 used prescription pain relievers for the first time, up from 400,000 in the mid-1980s.7 In 2001, an estimated 11.1 million people used prescription drugs non-medically, and more than 6 million abused pain relievers. 8
This increase is reflected in overdose cases. Visits to emergency rooms increased significantly from 1994 to 2001 for overdoses on narcotic prescription pain relievers.9 “Other substances of abuse,” which are usually those marketed legally as prescription or over-the-counter drugs, represented 43 percent of emergency room drug mentions in 2001.10 Law enforcement officials have witnessed similar trends, estimating that, of the 20 most commonly abused drugs, over half are obtainable by prescription.11
Types of Prescription Drugs Abused
The prescription drugs that law enforcement agencies most frequently listed as commonly abused include Valium (diazepam) and Vicodin (hydrocodone), as well as Xanax (alprazolam), OxyContin (oxycodone), Lorcet, Dilaudid, Percocet, Soma, Darvocet, and morphine.12 Many of these top the lists of prescription drugs used nonmedically by youths and young adults, who tend to favor pain relievers such as codeine, methadone, Demerol (meperidine), Percocet, Vicodin, and OxyContin.13
Many experts attribute the growth in prescription drug abuse in part to the recent availability of OxyContin, an oral, controlled-release form of oxycodone that acts for 12 hours.14 As prescribed by a doctor, OxyContin is a very effective pain reliever. However, when crushed and snorted or mixed with water and injected, the drug delivers all of its power in one punch, producing a high similar to that experienced with heroin.15 Thus, heroin addicts favor OxyContin, but it has also taken hold among the general population.
Illegal use of OxyContin has spread throughout many regions of the United States, and has significantly impacted the volume of prescription fraud and related problems nationwide. For example, nearly 85 percent of 1999 arrests for writing false prescriptions in Maryland involved oxycodone products, including OxyContin.16 In Florida, lab submissions indicated that police are increasingly seizing oxycodone: between 1995 and 2000, oxycodone lab submissions increased by 161 percent. OxyContin has taken hold both because it can be addictive and because it commands high dollars on the black market, with a street value of as much as $80 per 80-milligram dose.17
Hydrocodone, the third most prescribed drug in 2000, is among the most abused of prescription drugs, according to the National Clearinghouse for Alcohol and Drug Information.18 It is similar to oxycodone but is less potent, with less potential for abuse.19 In certain regions, Vicodin, a form of hydrocodone, is becoming a popular target for prescription fraud, usually among women who become addicted after originally being prescribed the drug for pain relief.20
Types of Offenders
Unlike perpetrators of other drug-related crimes, prescription fraud offenders span a wide range of ethnic, social, educational, and economic backgrounds. Often, they become addicted to drugs legally prescribed to them, then try to get additional drugs illegally. Other offenders, already addicted to street drugs, discover how to convert prescription drugs into more potent substances. Among youth, abuse of prescription drugs is often a gateway to use and abuse of illegal drugs, such as marijuana. The elderly and healthcare workers are also susceptible to prescription drug addiction and fraud.
Youth. The most dramatic increases in illegal prescription drug use in recent years have been among youth. Of the estimated 11.1 million people using prescription drugs non-medically in 1999, nearly half (5.4 million) were aged 12 to 25.21 Non-medical prescription drug use is often accompanied by other illicit drug use: one study found that 63 percent of 12- to 25-year-olds who had used prescription drugs non-medically in the past year had also used marijuana in the past year.22 Non-medical use of a prescription drug found in the home can quickly lead to burglary, theft, and drug sales. For example, in 2001, a 14-year-old Florida boy died of an OxyContin overdose the day after he and a friend stole about 50 pills during a residential burglary.23 Likewise, a number of police agencies have reported incidents of schoolchildren’s selling prescription drugs, particularly Ritalin, to classmates.24 Research shows that non-medical use of prescription drugs (mostly pain relievers such as Percodan and Vicodin) among youth is rising.25
Women. Women may be more likely than men to commit prescription fraud, as they are 48 percent more likely to be prescribed an abusable (i.e., narcotic or antianxiety) drug.26 While overall, men and women have roughly similar rates of non-medical prescription drug use, research has shown that among women and men who use a sedative, antianxiety drug, or hypnotic, women are almost twice as likely to become addicted.27 In San Diego, the typical prescription fraud offender is a middle-class woman, who often becomes addicted after being prescribed a pain reliever for a legitimate health problem.28
Older adults. Older adults are more susceptible to prescription drug abuse because they use such drugs at a rate three times that of the general population, and also often have trouble following their doctor’s dosage instructions.29 Given the high rate of prescription drug misuse among the elderly, it is possible that addiction is common as well, which could ultimately lead to prescription fraud.
Existing addicts. Several police agencies have observed increases in prescription drug abuse among heroin addicts and users of other illegal drugs. Users often take prescription drugs to ease the effects of those other drugs.30 Conversely, some experts have observed that those who become addicted to OxyContin and lose their health insurance often turn to heroin for a similar, and cheaper, high.31
Healthcare workers. Healthcare workers are in a unique position to acquire and abuse prescription drugs. While many offenders steal drugs while working, others steal prescription pads or write illegal prescriptions for friends. Of the 250 felony arrests made by the Cincinnati Police Department’s Drug Diversion Unit in 1999, almost a third involved healthcare workers, including doctors, nurses, and hospital workers.32
Types of Fraud
Prescription fraud can take many forms. The most common tactics are to forge or alter a prescription, to “doctor shop,” and to phone in fraudulent prescriptions posing as an employee of a doctor’s office. Theft of prescription pads is also common.
Forging prescriptions. Forging prescription slips has become easier as the cost of high-quality copying equipment has dropped. Some offenders even go so far as to paint glue on the top edge of the slip to give the appearance that it was ripped from a pad.
Altering prescriptions. The first resort of many users of legally prescribed drugs who become addicted is to alter a legitimate prescription to change the type of drug, increase the number of refills, increase the quantity, or add drugs (see examples below). Another tactic is to copy legitimate prescriptions for multiple uses.33
Prescription altered to change the type of drug from Tylenol II to Tylenol IV
Prescription altered to change the number of refills from one to four
Prescription altered to change the quantity from 12 to 120
Prescription altered to add a drug (Alprazolam)
Doctor shopping. Those who doctor shop often go to multiple doctors, emergency rooms, and pharmacies and feign symptoms or gain sympathy to obtain prescriptions. Common feigned ailments include migraine headaches, toothaches, cancer, psychiatric disorders, and attention deficit disorder.34 In addition, offenders may deliberately injure themselves to get a prescription from an emergency room. Another approach is to claim to be from out of town and to have forgotten to pack prescription drugs,35 or to claim to have lost the drugs from a legitimate prescription.36 Given recent statistics on the number of prescriptions doctors write, doctor shopping may be the prescription fraud tactic with the highest success rate: the Centers for Disease Control and Prevention reports that the number of written prescriptions per office visit increased by 34 percent between 1985 and 2000.37
Calling in prescriptions. Prescription fraud in the form of impersonating medical staff and calling in false prescriptions poses the greatest challenge with regard to identifying suspects. Typically, offenders call in a prescription when the doctor’s office is closed, in case the pharmacist calls the office to confirm that the prescription is legitimate; some offenders leave their own phone numbers for verification. Offenders are often patients or employees of the doctor they are impersonating, and tend to act overly friendly on the phone to give the impression that they regularly call in prescriptions.
Stealing blank prescription forms. Some offenders steal prescription pads from doctor’s† offices and write prescriptions for either themselves or fictitious patients. They may change the phone number so that they or an accomplice can answer verification calls.38
† Doctor’s offices include physician’s, veterinarian’s, and dentist’s offices.
Understanding Your Local Problem
The information provided above is only a generalized description of prescription fraud. You must combine the basic facts with a more specific understanding of your local problem. Analyzing the local problem carefully will help you design a more effective response strategy.
Asking the Right Questions
The following are some critical questions you should ask in analyzing your particular problem of prescription fraud, even if the answers are not always readily available. Your answers to these and other questions will help you choose the most appropriate set of responses later on.
Victims
- Whom does prescription fraud directly victimize? Pharmacists (who are duped into dispensing drugs not legitimately prescribed)? Doctors (who unknowingly prescribe to doctor shoppers, whose prescription pads are stolen, or whose names are used for prescription call-ins or forgeries)? Insurance companies and Medicaid (who sometimes pay for fraudulent prescriptions)?
- Whom does prescription fraud indirectly affect (those who commit the fraud and are addicted, and/or their loved ones)?
Offenders
- What are the offenders’ characteristics (e.g., age, gender, profession)?
- Where do they live, go to school, or work? How do those locations correspond to fraud locations (e.g., are some pharmacies or doctor’s offices more likely targets than others)?
- What is the pattern of offending? Is the fraud intermittent or regular? Is there a regular time span between fraudulent acts (e.g., based on how long it takes to exhaust a supply of drugs)?
- What are the offenders’ motives? Are they addicted to prescription drugs? Selling the drugs on the black market? Both? (You can interview offenders to collect this information. Undercover investigations, buys, and surveillance can reveal more about their practices).
- Do offenders act alone or as part of a group?
- What are their preferred tactics?
Locations/Times
- Where does prescription fraud occur? To detect patterns, you should conduct location analyses based on the tactic used (e.g., doctor shopping patterns will spatially differ from prescription call-in patterns ). Location analyses can also help you determine which targets are most vulnerable. For example, fraud in specific areas may indicate where offenders live or work.
- At what specific locations is fraud most common? Are certain doctors or pharmacies less likely to detect and report fraud? Are certain types of pharmacies (e.g., “mom and pop” stores, versus chain stores) more susceptible to fraud?
- What specific types of prescription drugs are diverted in your community or region? It is important to note that the prescription fraud problem and types of drugs diverted can vary greatly from region to region.
- When does prescription fraud occur (i.e., when do offenders try to have prescriptions filled)? Time of day? Day of week? As with location analyses, temporal analyses should be tactic-specific. Those who phone in prescriptions, for example, are more likely to do so during doctors’ off hours, when pharmacies cannot verify the prescriptions.
Capturing and Analyzing Data
Prescription fraud poses a unique challenge to local police because it is not typically captured in computer-aided dispatch or records management systems. Departments that have succeeded in measuring and analyzing prescription fraud in their jurisdictions have done so by creating a separate database for prescription fraud and other pharmaceutical diversion incidents. When considering creating a database, your agency should examine the questions above, and decide how to track each incident to best answer the most possible questions.
Measuring Your Effectiveness
Measurement allows you to determine to what degree your efforts have succeeded, and suggests how you might modify your responses if they are not producing the intended results. You should take measures of your problem before you implement responses, to determine how serious the problem is, and after you implement them, to determine whether they have been effective. All measures should be taken in both the target area and the surrounding area. (For more detailed guidance on measuring effectiveness, see the companion guide to this series, Assessing Responses to Problems: An Introductory Guide for Police Problem-Solvers.)
The following are potentially useful measures of the effectiveness of responses to prescription fraud:
- reduced number of reported prescription fraud cases;
- changes in arrest patterns for drug possession and sales in your and neighboring jurisdictions;
- changes in types of prescription fraud (e.g., if you curtail phone-ins, offenders might change tactics);
- changes in locations of prescription fraud;
- changes in types of drugs obtained through prescription fraud; and
- reduced number of prescriptions filled for certain target drugs, such as OxyContin.
It is important to remember that some of these measures may be misleading, depending on the types of responses your department applies to the problem. For example, if you launch a public education campaign for pharmacists and doctors, you may find that the amount of prescription fraud—as measured by crimes reported to the police—increases.
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 (see www.hhs.gov/ocr/privacysummary.pdf)[PDF].
- 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
- 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.
- 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 ]
- 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
- 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.
- Employing security measures. Health profession stakeholders can use several strategies to control facilitators and harden targets.
- 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
- 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).
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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.
- 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.
- 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.
- 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.
- 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
- 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
- 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
- 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.)
- 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.
Summary of Responses
The table below summarizes the responses to prescription fraud, the mechanism by which they are intended to work, the conditions under which they ought to work best, and some factors you should consider before implementing a particular response. 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.
| Increasing the Risk of Detection | ||||
| ## | Response | How It Works | Works Best If... | Considerations |
| 1 | Informing doctors and pharmacists of fraudulent activity | Sharing information on offenders and scams through bulletins and mass communication increases the risk of apprehension, thereby deterring potential offenders | …the information is shared throughout the jurisdiction, and quickly | A means of networking/communication that reaches the most people possible (e.g., faxes or the Internet) should be used |
| 2 | Improving pharmacists’ screening of prescriptions and patients | Pharmacists act as “gatekeepers” by checking ID, verifying doctor information, and detecting suspicious behavior | …pharmacists are consistent in screening and report fraudulent activity to police | Takes time, effort, and experience, both for pharmacists and police |
| 3 | Educating the public about prescription abuse and fraud | Increasing the awareness of prescription abuse and fraud through local and national efforts allows more people to identify friends and family members engaged in fraudulent activity | …informational campaigns are multidisciplinary and target specific populations | Initiatives should provide statistics and other specific information (e.g., if the target group is youth, use youth-related data); can be resource-intensive |
| Increasing the Effort Required to Commit Prescription Fraud | ||||
| ## | Response | How It Works | Works Best If... | Considerations |
| 4 | Verifying prescriptions | Pharmacists do callbacks on phoned-in prescriptions and check doctors’ information, maintain a file of doctors, and dispense only a limited dosage until they can verify prescriptions | …pharmacists are consistent in the verification process, refuse to fill unverifiable prescriptions, and report suspicious activity to police | Takes time, effort, and resources |
| 5 | Employing security measures | Strategies include using tamper-resistant prescription pads, increasing the precautions the practitioner’s receptionist and answering service take, checking photo ID, and keeping prescription pads in a secure place, all increasing the difficulty for would-be offenders | …all security measures are consistently used, and fraud is not being committed internally (by employees of the doctor’s office) | Tamper-resistant pads can be costly; checking ID can be time-consuming; measures are ineffective against internal fraud |
| 6 | Prescribing drugs electronically | Direct transmission of prescriptions (via computer) from prescribers to pharmacists eliminates the problems of false phoned-in prescriptions, forged and altered prescriptions, and stolen prescription pads | …all pharmacists and prescribers in the jurisdiction are doing so | Cost of setting up systems and maintaining system security; getting buy-in from doctors and pharmacists; once implemented, very cost-effective and time-efficient |
| 7 | Creating or changing laws regarding prescription fraud | Specific, targeted laws make it easier to prosecute and convict offenders | …used in conjunction with other prevention and education efforts | Can be time- and resource-intensive; does not address the underlying problem |
| 8 | Maintaining a Prescription Monitoring Program | Tracking and monitoring prescription drugs aids in identifying patterns of problem behavior | …the program covers the drugs most often abused, and data are used proactively | Patient confidentiality; limited to only the drugs covered (which varies by state); cost of administering the program |
| Reducing Rewards to Offenders | ||||
| ## | Response | How It Works | Works Best If... | Considerations |
| 9 | Curbing distribution | Limiting the dosage or distribution of a drug reduces the opportunity for offenders to easily obtain large quantities of it | …focused on a particular problem drug or target group/region | There will always be exceptions: patients who need higher dosages or more frequent refills. |
| Removing Excuses | ||||
| ## | Response | How It Works | Works Best If... | Considerations |
| 10 | Facilitating compliance with the law | Programs such as drug treatment/ rehabilitation, Narcotics Anonymous, and Drug Court help to prevent repeat offenses | …used in conjunction with one another, there are consequences for nonparticipation, and offenders want to change | Resources are needed to ensure attendance and compliance with program rules |
| Removing Excuses | ||||
| ## | Response | How It Works | Works Best If... | Considerations |
| 11 | Using crackdowns | Police and/or medical boards target specific doctors or pharmacies to identify and curtail illegal activity | …the effort can be sustained for multiple people or pharmacies over an extended period | Extensive resources are required (and not generally available); without prevention measures in place, illegal activity will resume in the long term |
| 12 | Creating a prescription database | Pharmacies are able to verify patient information and monitor the number of prescriptions previously issued | …multiple—or all—pharmacies in the jurisdiction share the database | Cost of, and cooperation required for, implementing a networked system; patient confidentiality |
Endnotes
[1] National Drug Intelligence Center (2000).[Full Text ]
[2] National Drug Strategy Network (1996). [Full Text ]
[3] Zickler (2001). [Full Text ]
[4] Mitka (2000).
[5] Mitka (2000).
[6] Payne and Dabney (1997).
[7] Substance Abuse and Mental Health Services Administration (2002b). [Full Text ]
[8] Substance Abuse and Mental Health Services Administration (2003). [Full Text ]
[9] Substance Abuse and Mental Health Services Administration (2003). [Full Text ]
[10] Substance Abuse and Mental Health Services Administration (2002a). [Full Text ]
[11] Palm Beach County Sheriff’s Department (2003). [Full Text ]
[12] National Drug Intelligence Center (2000). [Full Text ]
[13] Substance Abuse and Mental Health Services Administration (2003). [Full Text ]
[14] Substance Abuse and Mental Health Services Administration (2003). [Full Text ]
[15] Ramer (2001). [Full Text ]
[16] National Drug Intelligence Center (2001b). [Full Text ]
[17] Kalb (2001).
[18] Schober (2001). [Full Text ]
[19] Ramer (2001). [Full Text ]
[20] Mitka (2000).
[21] National Institute on Drug Abuse (2002). [Full Text ]
[22] Substance Abuse and Mental Health Services Administration (2003). [Full Text ]
[23] Ramer (2001). [Full Text ]
[24] National Drug Intelligence Center (2000). [Full Text ]
[25] National Institute on Drug Abuse (2002). [Full Text ]
[26] National Institute on Drug Abuse (2002). [Full Text ]
[27] National Institute on Drug Abuse (2002). [Full Text ]
[28] Mitka (2000).
[29] National Institute on Drug Abuse (2002). [Full Text ]
[30] National Drug Intelligence Center (2000). [Full Text ]
[31] Ramer (2001). [Full Text ]
[32] Aiken (2001). [Full Text ]
[33] U.S. Drug Enforcement Administration (2000b).[Full Text ]
[34] Wilford (1990).
[35] Fountain et al. (1997).
[36] Fountain et al. (1997).
[37] National Drug Intelligence Center (2001a). [Full Text ]
[38] U.S. Drug Enforcement Administration (2000b). [Full Text ]
[39] Wick (1995).
[40] Clarke (1997).
[41] National Association of State Controlled Substances Authorities and Alliance of States With Prescription Monitoring Programs (2002). [Full Text ]
[42] UK Department of Health (1998). [Full Text ]
[43] Middleton (2000). [Full Text ]
[44] Joranson et al. (2002); U.S. Drug Enforcement Administration (2000a) [Full Text ]; U.S. General Accounting Office (1992[Full Text ], 2002[Full Text ]).
[45] Cooper et al. (1993). [Full Text ]
[46] Cooper et al. (1993). [Full Text ]
[47] Forgione, Neuenschwander, and Vermeer (2001).
[48] Florida Department of Law Enforcement (2001). [Full Text ]
[49] Wesson and Smith(1990). [Full Text ]
[50] Wessonand Smith(1990). [Full Text ]
[51] Goetz (2001). [Full Text ]
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