The instances and temptations of drug diversionoccurring at the patient's home have always been aconcern of law enforcement and health professionals.The most problematic situation is that of a chronic or terminalpain patient who is being prescribed large amounts of prescriptionopiates over a long period of time. Such patientsmay only visit their physician every 2 or 3 months, dependingon their situation, but theyobviously still need considerablepain relief on a daily basis. Themost effective drugs in this type ofpain relief, such as oxycodone,hydromorphone, fentanyl, andmorphine, are also the mostsought-after prescription drugs ofabuse with the highest street values.
On some occasions, the patienthas decided to sell part of his orher medication for huge profitsand obviously did not need all ofthe drugs prescribed. One cancerpatient made thousands of dollarsa week from selling his 4-mg Dilaudidtablets to addicts on the street.He had been given a variety ofother short-acting pain medication that was satisfying hisneeds at the time, but he insisted on receiving brand nameDilaudid when he filled his prescription, even though it wasconsiderably more expensive. Prescription drug sellerswould usually like the brand name drug as opposed to thegeneric since customers more readily recognize these drugsand sales are easier and more lucrative.
The caregiver, friend, or relative may also be the other culpritdipping into the large supplies of prescription drugs prescribedfor the homebound patient. This may or may nothappen with the knowledge of the patient. Patients understandablysee 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 tolimit the amount of controlled substances in the residence.A Drug Enforcement Agency (DEA)-approved method that Ihave educated physicians on for the past 2 years helped tocurb this problem. Practitioners were allowed to write multipleprescriptions for these types of patients they only sawa few times a year. Each needed to be dated on the date written,but all but the first month of medication would say "donot fill until?."This method allowed the practitioner toeffectively give the patient several months of prescriptionopiates, but only a month's supply would be present in thehome at any one time.
On November 16, 2004, the DEA reversed that decision,indicating that it was the same asrefilling a CII prescription. In fact,it also indicated in its decision that"writing multiple prescriptions onthe same day with instructions tofill on different dates is a recurringtactic among physicians who seekto avoid detection when dispensingcontrolled substances forunlawful (nonmedical) purposes."This statement defies all logic, andcould be nothing further from thetruth.
This horrible decision has causeda wave of protest from health professionals,regulatory officials, painpatient advocates, and my association,the National Association ofDrug Diversion Investigators, with almost half of its membershipbeing law enforcement personnel. In addition topotentially causing inconvenience and pain for patients, theDEA has driven a wedge that will further separate local andstate enforcement and regulatory agencies from legitimatepractitioners.
As I write this, increased support has been generated topressure the DEA to abandon this decision, including a well-writtenletter of protest from the Ohio Board of Pharmacy.In the meantime, the practice of well-intentioned practitionerstrying to limit controlled substances in homes is suspended.These prescriptions should not be filled at pharmaciesas CII prescriptions.
John Burke, director of the Warren County, Ohio,drug task force and retired commander of the CincinnatiPolice Pharmaceutical Diversion Squad, is a 32-year veteran of law enforcement. For information, hecan be reached by e-mail at firstname.lastname@example.org, viathe Web site www.rxdiversion.com, or by phone at513-336-0070.