V. Overview of Supply Reduction
A significant challenge in developing a strategy to reduce the non-medical use of controlled substance prescription drugs involves understanding how the prescription drugs are diverted for illicit use, and which of those methods are most commonly used. Unlike drugs such as heroin or marijuana which are presumptively illegal and often obtained through clandestine, secretive transactions, controlled substance prescription drugs are available for legitimate purposes through one’s physician and pharmacy. For this reason, mechanisms that are otherwise legal are often manipulated to acquire controlled substance prescription drugs for illegal purposes.
The Administration’s strategy to reduce opportunities for the diversion of controlled substance prescription drugs seeks to address each method of diversion. Because reliable data ranking each of these methods of diversion by prevalence does not exist, for the first time in 2005, the NSDUH incorporated questions into the Survey to identify sources of diverted prescription drugs. These data are expected to be released in September 2006. The 2006 Survey will seek even more detailed data from respondents as to methods of diversion.
Although there are no firm data that rank methods of acquisition of prescription drugs for non-medical purposes by frequency, specific methods of diversion have been identified. The
Administration’s Synthetics Strategy seeks to address each specific method: doctor shopping or other prescription fraud, shipping illegal prescriptions from online pharmacies, over-prescribing, theft and burglary (from residences, pharmacies, etc.), selling pills to others, receiving at little or no cost, from friends or family.
Strategy to Reduce Doctor Shopping or Other Prescription Fraud: Prescription Drug Monitoring Programs. The 2004, 2005, and 2006 National Strategies recognized the problem of prescription drug diversion via “doctor shopping.” Generally, this term refers to the visit by an individual—who may or may not have legitimate medical needs—to several doctors, each of whom writes a prescription for a controlled substance. The abuser or addict will visit several pharmacies, receiving more of the drug than intended by any single physician, typically for the purpose of using the drug for psychoactive effects. Associated illegal activities may include the forgery of prescriptions, further multiplying the extent of diversion, or the sale or transfer of the drug to others. In many states, physicians and pharmacists have not been able to automatically cross-check other prescriptions given to the same patient.
In 2004, the Administration announced its intent to respond to this problem by supporting Prescription Drug Monitoring Programs (PDMPs). These programs are designed to reduce prescription fraud and doctor shopping by giving physicians and pharmacists more complete information about a patient’s controlled substance prescriptions. These programs vary by State, but generally share the characteristic of allowing prescribers (e.g., a physician) and dispensers (e.g., a pharmacist) to input and receive accurate and timely controlled substance prescription history information, while ensuring patient access to needed treatment. Most States also have some mechanism for law enforcement to receive this information in cases where criminal activity is suspected. Health care providers can use this information as a tool for early identification of patients at risk for addiction and initiate appropriate medical interventions. The justice system can use this information to assist in the enforcement of laws controlling the sale and use of controlled substance prescription medication.
At the beginning of this Administration, approximately 15 PDMPs were in existence in the Nation. The program has expanded to 33 States with active or planned PDMPs—more than double the number in existence in 2001.
A critical avenue of Federal support for States is through the Harold Rogers Prescription Drug Monitoring Grants Program at the Department of Justice. These grants can be used to implement or enhance PDMPs at the State level. The 2007 Budget continues funding for the Rogers Program at the Justice Department, following the funding stream approved by the Congress since 2003. The President has requested that Congress provide $9.9 million for the program in fiscal year 2007 in order to expand the program to new States and enhance the program where it already exists. Officials at ONDCP, the Department of Health and Human Services, and the Department of Justice work with state policymakers to better understand best practices where the programs already exist.
Strategy to Reduce Illegal Access to Controlled Prescription Medications: Internet pharmacies. As the number of Americans with Internet access has increased, so too have opportunities for individuals to acquire controlled substance prescription drugs over the Internet.
The benefits of allowing individuals with a valid prescription to get their prescriptions over the Internet, from a legitimate pharmacy are acknowledged, particularly for people living in rural areas or individuals who are homebound due to illness, disability or other factors. There are legitimate pharmacies that provide services over the Internet and that operate well within the bounds of both the law and sound medical practice. The National Association of Boards of Pharmacy has established a registry of pharmacies that operate online and meet certain criteria, including compliance with licensing and inspection requirements of their State and each State to which they dispense pharmaceuticals.
However, the anonymity of the Internet has enabled proliferation of Web sites that facilitate illicit transactions for controlled substance prescription drugs. These rogue online pharmacy Web sites and links to those sites enable controlled substances to be ordered without a valid prescription. The sites have given drug abusers/ drug addicts and illegal providers a venue to circumvent the law and medically approved prescribing practices by physicians.
Also in existence are Web sites that advertise themselves as pharmacies, but do not operate in the same manner as legitimate pharmacies. Many of these Web sites advertise the sale of controlled substances without a prescription. Such online Web sites usually act as a facilitator, or link, between an individual seeking controlled substance prescription drugs and a doctor and a pharmacy willing to provide these drugs without determining whether the individual has a legitimate medical need. Of particular concern is the “pseudoexam”, a cursory, abbreviated medical interaction provided by the Internet site to facilitate a cursory consultation by a doctor via computer or telephone for customers. This consultation is unable to elicit meaningful health information, because the doctor writing the prescription does not see the patient to verify the information provided by the individual. For example, Web sites have no independent means to verify the age of the recipient, enabling a minor to log onto a Web site and claim an inaccurate age. Doctors, frequently paid by the number of prescriptions they sign in this system, have no incentive to spend time seeking additional patient information. Law enforcement has discovered Web site-affiliated doctors who sign hundreds or thousands of prescriptions a day. After receiving the prescription from the doctor, the facilitator will then submit the prescription to a cooperating pharmacy. Because there is no identifying information on the Web site, it is difficult for law enforcement to track the individuals supervising the Web site.
The Administration is using available tools to conduct investigations of rogue Internet-facilitator Web sites, with the purpose of intercepting controlled substance prescriptions illegally sent into the United States through the mail system. For example, the DEA’s Internet investigation unit at its Special Operations Division coordinates Internet cases. The DEA has issued immediate suspensions of numerous Internet pharmacies. DOJ has prosecuted doctors and pharmacies who illegally distribute via the Internet. States can also play a significant role in addressing the problem of online facilitators, particularly through PDMPs.
As part of the Administration’s work with States regarding PDMPs over the next three years, States will be encouraged to consider addressing, either by statute, regulation, or interstate agreement, situations in which:
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Pharmacies in the State dispense or deliver controlled substance prescription drugs to an address of a patient in another State;
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Pharmacies or other dispensers located in another State dispense or deliver controlled substance prescription drugs to an address of a patient in their own State; and
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Pharmacies or other dispensers in another State that dispense or deliver controlled substance prescription drugs to a patient with an official address in their own State.
The Administration will continue to use the tools at its disposal to target, investigate, prosecute, and dismantle illicit online pharmacies.
Strategy to Reduce Improper Prescribing. The overwhelming majority of prescriptions written in America are responsibly issued on the basis of legitimate medical reasons. A small number of physicians over-prescribe controlled substances, either carelessly, or deliberately. This source of prescriptions drugs facilitates drug addiction. The number of physicians responsible for this problem is a very small fraction of those licensed to dispense controlled substances in the United States. Law enforcement conducts investigations to establish whether the prescribing practice is consistent with sound medical judgment and prevailing medical standards. As part of the Administration's strategy to reduce opportunities to divert controlled substance prescriptions, law enforcement will continue to examine situations where prescriptions for controlled substances are unusually and obviously high, in the absence of legitimate circumstances.
