The instances and temptations of drug diversion occurring at the patient's home have always been a concern of law enforcement and health professionals. The most problematic situation is that of a chronic or terminal pain patient who is being prescribed large amounts of prescription opiates over a long period of time. Such patients may only visit their physician every 2 or 3 months, depending on their situation, but they obviously still need considerable pain relief on a daily basis. The most effective drugs in this type of pain relief, such as oxycodone, hydromorphone, fentanyl, and morphine, are also the most sought-after prescription drugs of abuse with the highest street values.
On some occasions, the patient has decided to sell part of his or her medication for huge profits and obviously did not need all of the drugs prescribed. One cancer patient made thousands of dollars a week from selling his 4-mg Dilaudid tablets to addicts on the street. He had been given a variety of other short-acting pain medication that was satisfying his needs at the time, but he insisted on receiving brand name Dilaudid when he filled his prescription, even though it was considerably more expensive. Prescription drug sellers would usually like the brand name drug as opposed to the generic since customers more readily recognize these drugs and sales are easier and more lucrative.
The caregiver, friend, or relative may also be the other culprit dipping into the large supplies of prescription drugs prescribed for the homebound patient. This may or may not happen with the knowledge of the patient. Patients understandably see caregivers and visiting relatives as their lifeline, and, even though they know or suspect pill thievery, they may very well not tell anyone.
The best answer to situations like these has been to try to limit the amount of controlled substances in the residence. A Drug Enforcement Agency (DEA)-approved method that I have educated physicians on for the past 2 years helped to curb this problem. Practitioners were allowed to write multiple prescriptions for these types of patients they only saw a few times a year. Each needed to be dated on the date written, but all but the first month of medication would say "do not fill until?."This method allowed the practitioner to effectively give the patient several months of prescription opiates, but only a month's supply would be present in the home at any one time.
On November 16, 2004, the DEA reversed that decision, indicating that it was the same as refilling a CII prescription. In fact, it also indicated in its decision that "writing multiple prescriptions on the same day with instructions to fill on different dates is a recurring tactic among physicians who seek to avoid detection when dispensing controlled substances for unlawful (nonmedical) purposes." This statement defies all logic, and could be nothing further from the truth.
This horrible decision has caused a wave of protest from health professionals, regulatory officials, pain patient advocates, and my association, the National Association of Drug Diversion Investigators, with almost half of its membership being law enforcement personnel. In addition to potentially causing inconvenience and pain for patients, the DEA has driven a wedge that will further separate local and state enforcement and regulatory agencies from legitimate practitioners.
As I write this, increased support has been generated to pressure the DEA to abandon this decision, including a well-written letter of protest from the Ohio Board of Pharmacy. In the meantime, the practice of well-intentioned practitioners trying to limit controlled substances in homes is suspended. These prescriptions should not be filled at pharmacies as CII prescriptions.
John Burke, director of the Warren County, Ohio, drug task force and retired commander of the Cincinnati Police Pharmaceutical Diversion Squad, is a 32- year veteran of law enforcement. For information, he can be reached by e-mail at firstname.lastname@example.org, via the Web site www.rxdiversion.com, or by phone at 513-336-0070.
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