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
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
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 email@example.com, via
the Web site www.rxdiversion.com, or by phone at