DOJ Seal COPS logo www.PopCenter.org Center for Problem-Oriented Policing Got a Problem? We’ve got answers! Log onto the Center for Problem-Oriented Policing website at www.popcenter.org for a wealth of information to help you deal more effectively with crime and disorder in your community, including: • Web-enhanced versions of all currently available Guides • Interactive training exercises • Online access to research and police practices • Online problem analysis module. Designed for police and those who work with them to address community problems, www.popcenter.org is a great resource in problem-oriented policing. Supported by the Office of Community Oriented Policing Services, U.S. Department of Justice. Problem-Oriented Guides for Police Problem-Specific Guides Series Guide No. 24 Prescription Fraud Julie Wartell Nancy G. La Vigne This project was supported by cooperative agreement #2002CKWX0003 by the Office of Community Oriented Policing Services, U.S. Department of Justice. The opinions contained herein are those of the author(s) and do not necessarily represent the official position of the U.S. Department of Justice. www.cops.usdoj.gov ISBN: 1-932582-33-9 May 2004 About the Problem-Specific Guides Series The Response Guides are one of three series of the Problem- Oriented Guides for Police. The other two are the Problem- Specific Guides and Problem-Solving Tools. The Problem-Oriented Guides for Police summarize knowledge about how police can reduce the harm caused by specific crime and disorder problems. They are guides to preventing problems and improving overall incident response, not to investigating offenses or handling specific incidents. Neither do they cover all of the technical details about how to implement specific responses. The guides are written for police—of whatever rank or assignment—who must address the specific problems the guides cover. The guides will be most useful to officers who: • understand basic problem-oriented policing principles and methods • can look at problems in depth • are willing to consider new ways of doing police business • understand the value and the limits of research knowledge • are willing to work with other community agencies to find effective solutions to problems. The Response Guides summarize knowledge about whether police should use certain responses to address various crime and disorder problems, and about what effects they might expect. Each guide: • describes the response • discusses the various ways police might apply the response • explains how the response is designed to reduce crime and disorder • examines the research knowledge about the response • addresses potential criticisms and negative consequences that might flow from use of the response • describes how police have applied the response to specific crime and disorder problems, and with what effect. The Response Guides are intended to be used differently from the Problem-Specific Guides. Ideally, police should begin all strategic decision-making by first analyzing the specific crime and disorder problems they are confronting, and then using the analysis results to devise particular responses. But certain responses are so commonly considered and have such potential to help address a range of specific crime and disorder problems that it makes sense for police to learn more about what results they might expect from them. Readers are cautioned that the Response Guides are designed to supplement problem analysis, not to replace it. Police should analyze all crime and disorder problems in their local context before implementing responses. Even if research knowledge suggests that a particular response has proved effective elsewhere, that does not mean the response will be effective everywhere. Local factors matter a lot in choosing which responses to use. Research and practice have further demonstrated that, in most cases, the most effective overall approach to a problem is one that incorporates several different responses. So a single response guide is unlikely to provide you with sufficient information on which to base a coherent plan for addressing crime and disorder problems. Some combinations of responses work better than others. Thus, how effective a particular response is depends partly on what other responses police use to address the problem. These guides emphasize effectiveness and fairness as the main considerations police should take into account in choosing responses, but recognize that they are not the only considerations. Police use particular responses for reasons other than, or in addition to, whether or not they will work, and whether or not they are deemed fair. Community attitudes and values, and the personalities of key decision-makers, sometimes mandate different approaches to addressing crime and disorder problems. Some communities and individuals prefer enforcement- oriented responses, whereas others prefer collaborative, community-oriented, or harm-reduction approaches. These guides will not necessarily alter those preferences, but are intended to better inform them. The COPS Office defines community policing as “a policing philosophy that promotes and supports organizational strategies to address the causes and reduce the fear of crime and social disorder through problem- solving tactics and police-community partnerships.” These guides emphasize problem-solving and police-community partnerships in the context of addressing specific public safety problems. For the most part, the organizational strategies that can facilitate problem-solving and police- community partnerships vary considerably and discussion of them is beyond the scope of these guides. These guides have drawn on research findings and police practices in the United States, the United Kingdom, Canada, Australia, New Zealand, the Netherlands, and Scandinavia. Even though laws, customs and police practices vary from country to country, it is apparent that the police everywhere experience common problems. In a world that is becoming increasingly interconnected, it is important that police be aware of research and successful practices beyond the borders of their own countries. Each guide is informed by a thorough review of the research literature and reported police practice and is anonymously peer-reviewed by line police officers, police executives and researchers prior to publication. The COPS Office and the authors encourage you to provide feedback on this guide and to report on your own agency’s experiences dealing with a similar problem. Your agency may have effectively addressed a problem using responses not considered in these guides and your experiences and knowledge could benefit others. This information will be used to update the guides. If you wish to provide feedback and share your experiences it should be sent via e-mail to cops_pubs@usdoj.gov For more information about problem-oriented policing, visit the Center for Problem-Oriented Policing online at www.popcenter.org. This website offers free online access to: • the Problem-Specific Guides series • the companion Response Guides and Problem-Solving Tools series • instructional information about problem-oriented policing and related topics • an interactive problem-oriented policing training exercise • an interactive Problem Analysis Module • a manual for crime analysts • online access to important police research and practices • information about problem-oriented policing conferences and award programs. Acknowledgments The Problem-Oriented Guides for Police are produced by the Center for Problem-Oriented Policing, whose officers are Michael S. Scott (Director), Ronald V. Clarke (Associate Director) and Graeme R. Newman (Associate Director). While each guide has a primary author, other project team members, COPS Office staff and anonymous peer reviewers contributed to each guide by proposing text, recommending research and offering suggestions on matters of format and style. The project team that developed the guide series comprised Herman Goldstein (University of Wisconsin Law School), Ronald V. Clarke (Rutgers University), John E. Eck (University of Cincinnati), Michael S. Scott (University of Wisconsin Law School), Rana Sampson (Police Consultant), and Deborah Lamm Weisel (North Carolina State University.) Members of the San Diego; National City, California; and Savannah, Georgia police departments provided feedback on the guides’ format and style in the early stages of the project. Cynthia E. Pappas oversaw the project for the COPS Office. Research for the guide was conducted at the Criminal Justice Library at Rutgers University under the direction of Phyllis Schultze. Suzanne Fregly edited this guide. Contents About the Problem-Specific Guides Series ................i Acknowledgments ....................v The Problem of Prescription Fraud ............1 Related Problems .............3 Factors Contributing to Prescription Fraud .............3 Abuse of and Addiction to Prescription Drugs ...........4 Types of Prescription Drugs Abused .............4 Types of Offenders ...................6 Types of Fraud ...........8 Understanding Your Local Problem ............13 Asking the Right Questions ...............13 Victims ................13 Offenders .......................13 Locations/Times ..................14 Capturing and Analyzing Data ..........15 Measuring Your Effectiveness ...............15 Responses to the Problem of Prescription Fraud ..............17 General Requirements for an Effective Strategy .............18 Specific Responses to Prescription Fraud ..............21 Increasing the Risk of Detection ........21 Increasing the Effort Required to Commit Prescription Fraud ..... 24 Reducing Rewards to Offenders .......30 Removing Excuses .................30 Responses With Limited Effectiveness ............31 Appendix:Summaryof Responses to Prescription Fraud ...33 Endnotes ......................37 References ....................39 About the Authors.............45 RecommendedReadings ..............47 Other Problem-Oriented Guides for Police .........51 The Problem of Prescription Fraud This 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 The Cincinnati Police Department's Pharmaceutical Diversion Squad reported that, in 9 years, more than 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). 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. 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. § See the POP Guide on Burglary of Retail Establishments. 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 Image of altered prescription Prescription altered to change the type of drug from Tylenol II to Tylenol IV Image of altered prescription Prescription altered to change the number of refills from one to four Image of altered prescription Prescription altered to change the quantity from 12 to 120 Image of altered prescription 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 • 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). • 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) 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) recommends using common sense, sound professional practice, and proper dispensing procedures and controls (see box below). 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 Fraudulent Prescription Prevention Techniques 1. Know the prescriber and his or her signature. 2. Know the prescriber's DEA number. 3. Know the patient (or get a profile if you do not). 4. Check the date on the prescription. Has it been presented within a reasonable time? 5. Telephone the prescriber for verification or clarification if you have any questions. The patient should give a plausible reason for any discrepancy before you dispense the drug. 6. If you are in doubt, request proper identification. Doing so increases offenders' risk of getting caught. 7. If you believe a prescription is forged or altered, do not dispense it–call the local police. 8. If you believe that you have discovered a pattern of prescription abuses, contact the state pharmacy board or the DEA. Source: U.S. Drug Enforcement Administration (2000b). 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 1. 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 (New Mexico), 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 (Kansas) use a PharmAlert hotline for notification, while Abington (Pennsylvania) 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. 2. 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 web site at www.rxdiversion.com.] 3. 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. Purdue Pharma's 10-Point Plan to Reduce Prescription Drug Abuse and Diversion 1. Educate healthcare professionals about the problem. 2. Create tamper-resistant prescription pads. 3. Implement programs such as Painfully Obvious,™ a prescription drug abuse awareness and education initiative for middle and high school students (for information, see www.painfullyobvious.com). 4. Provide opioid therapy documentation kits/medical guidelines (information about proper prescribing of opioid analgesics) to healthcare professionals. 5. Distribute educational brochures about the problem. 6. Implement prescription monitoring programs. 7. Establish educational programs with the law enforcement community. 8. Conduct research on abuse, diversion, and addiction. 9. Curtail cross-border smuggling. 10. Develop abuse-resistant medicines. Increasing the Effort Required to Commit Prescription Fraud 4. 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. 5. Employing security measures. Health profession stakeholders can use several strategies to control facilitators and harden targets. 5a. 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 5b. 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). 5c. 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 (Virginia), 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. 5d. 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. 6. 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. 7. 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. 8. 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. Table 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 Hawaii/1992/Electronic/II, III, IV/Public Safety Idaho/1967/Uncopyable paper/II, III, IV/Pharmacy Board Idaho/1997/Electronic/II, III, IV/Pharmacy Board Idaho/1961/Electronic/II/Human Services Illinois/1987/Single-copy & electronic/II, III, IV, V/Public Safety Indiana/1987/Single-copy & electronic/II, III, IV, V/Public Safety Indiana/1998/Electronic/II, III, IV, V/Public Health Kentucky/1992/Electronic/II/Public Health Massachusetts/1988/Electronic/II, III, IV, V/Consumer and Industry Services Massachusetts/1995/Electronic/II, III, IV/Pharmacy Board Michigan/1988/Electronic/II, III, IV, V/Consumer and Industry Services Michigan/1995/Electronic/II, III, IV/Pharmacy Board Nevada/1994/Electronic/II/Pharmacy Board New Mexico/1972/Single-copy,serialized,electronic/II,benzodiazepine/Public Health New York/1972/Single-copy,serialized,electronic/II,benzodiazepine/Public Health New York Oklahoma/1990/Electronic/II/Narcotics and Dangerous Drugs Control Oklahoma/1978/Electronic/II, III/Pharmacy Board Rhode Island/1981/Single-copy,serialized,electronic/II/Public Safety Texas/1981/Single-copy,serialized,electronic/II/Public Safety Utah/1995/Electronic/II, III, IV, V/Professional Licensure Utah/1984/Triplicate/II, III, IV, V/Pharmacy Board Washington/1995/Electronic/II/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), 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. gov and 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 legitimate patients' 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 obtained from the RxNET mission statement, a state grant application and discussions with task force members. Reducing Rewards to Offenders 9. 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 10. 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 11. 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.) 12. 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. Appendix Appendix: Summary of Responses to Prescription Fraud 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. Response No. Page No. Response How It Works Works Best If… Considerations Increasing the Risk of Detection 1. 21 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. 22 Improving pharmacists' screening ofprescriptions 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 Response No. Page No. Response How It Works Works Best If… Considerations 3. 22 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 4. 24 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. 24 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 Direct …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 Response No. Page No. Response How It Works Works Best If… Considerations 6. 25 Prescribing drugs electronically transmission of prescriptions (via computer) from prescribers to pharmacists eliminates the problems offalse 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. 26 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. 26 Maintaining a Prescription Monitoring Program Tracking and monitoring prescription drugs aids in identifying patterns ofproblem 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 ofadministering the program Reducing Rewards to Offenders 9. 30 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 Response No. Page No. Response How It Works Works Best If… Considerations Removing Excuses 10. 30 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 Responses With Limited Effectiveness 11. 31 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. 32 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 AppendixEndnotes 37 Endnotes 1 National Drug Intelligence Center (2000). 2 National Drug Strategy Network (1996). 3 Zickler (2001). 4 Mitka (2000). 5 Mitka (2000). 6 Payne and Dabney (1997). 7 Substance Abuse and Mental Health Services Administration (2002b). 8 Substance Abuse and Mental Health Services Administration (2003). 9 Substance Abuse and Mental Health Services Administration (2003). 10 Substance Abuse and Mental Health Services Administration (2002a). 11 Palm Beach County Sheriff's Department (2003). 12 National Drug Intelligence Center (2000). 13 Substance Abuse and Mental Health Services Administration (2003). 14 Substance Abuse and Mental Health Services Administration (2003). 15 Ramer (2001). 16 National Drug Intelligence Center (2001b). 17 Kalb (2001). 18 Schober (2001). 19 Ramer (2001). 20 Mitka (2000). 21 National Institute on Drug Abuse (2002). 22 Substance Abuse and Mental Health Services Administration (2003). 23 Ramer (2001). 24 National Drug Intelligence Center (2000). 25 National Institute on Drug Abuse (2002). 26 National Institute on Drug Abuse (2002). 27 National Institute on Drug Abuse (2002). 28 Mitka (2000). 29 National Institute on Drug Abuse (2002). 30 National Drug Intelligence Center (2000). 31 Ramer (2001). 32 Aiken (2001). 33 U.S. Drug Enforcement Administration (2000b). 34 Wilford (1990). 35 Fountain et al. (1997). 36 Fountain et al. (1997). 37 National Drug Intelligence Center (2001a). 38 U.S. Drug Enforcement Administration (2000b). 39 Wick (1995). 40 Clarke (1997). 41 National Association of State Controlled Substances Authorities and Alliance of States With Prescription Monitoring Programs (2002) . 42 UK Department of Health (1998). 43 Middleton (2000). 44 Joranson et al. (2002); U.S. Drug Enforcement Administration (2000a); U.S. General Accounting Office (1992, 2002). 45 Cooper et al. (1993). 46 Cooper et al. (1993). 47 Forgione, Neuenschwander, and Vermeer (2001). 48 Florida Department of Law Enforcement (2001). 49 Wesson and Smith (1990). 50 Wesson and Smith (1990). 51 Goetz (2001). References Aiken, J. (2001). "City Targets Illegal Prescription Drug Trade." www.cnn.com/2001/HEALTH/04/10/drug. diversion. Alliance of States With Prescription Monitoring Programs (1999). The Goals of Prescription Monitoring. Waltham (Massachusetts): Alliance of States With Prescription Monitoring Programs. Clarke, R. (ed.) (1997). Situational Crime Prevention: Successful Case Studies (2nd ed.). Albany (New York): Harrow and Heston. Community Antidrug Coalitions of America (2001). Prescription Drug Abuse Prevention – Where Do We Go From Here? Alexandria (Virginia): Community Antidrug Coalitions of America. Cooper, J., D. Czechowicz, S. Molinari, and R. Petersen (eds.) (1993). Impact of Prescription Drug Control Systems on Medical Practice and Patient Care, NIDA Research Monograph 131. Rockville (Maryland): National Institute on Drug Abuse. Florida Department of Law Enforcement, Office of Statewide Intelligence (2001). Overview of Prescription Drug Abuse and the Oxycodone Problem in Florida. Tallahassee (Florida): Florida Department of Law Enforcement. Forgione, D., P. Neuenschwander, and T. Vermeer (2001). "Diversion of Prescription Drugs to the Black Market: What the States Are Doing to Curb the Tide." Journal of Health Care Finance 27(4):65–78. Fountain, J., P. Griffiths, M. Farrell, M. Gossop, and J. Strang (1997). "Diversion Tactics: How a Sample of Drug Misusers in Treatment Obtained Surplus Drugs to Sell on the Illicit Market." International Journal of Drug Policy 9:159–167. Goetz, K. (2001). "The OxyContin Pipeline: Multistate Network Keeps Appalachia Hooked, Cincinnati Part of 'Near-Epidemic.'" Cincinnati Enquirer, February 25. Joranson, D., G. Carrow, K. Ryan, L. Schaefer, A. Gilson, P. Good, J. Eadie, S. Peine, and J. Dahl (2002). "Pain Management and Prescription Monitoring." Journal of Pain and Symptom Management 23(3):231–238. Kalb, C. (2001). "Playing With Pain Killers" Newsweek, April 9. Middleton, H. (2000). "Electronically Transmitted Prescriptions -A Good Idea?" The Pharmaceutical Journal 265(7107): 172–176. Mitka, M. (2000). "Abuse of Prescription Drugs: Is a Patient Ailing or Addicted?" JAMA: Journal of the American Medical Association 283(9):1126–1130. National Association of Chain Drug Stores (2002). Community Pharmacy Projections. www.nacds.org/userassets/PDF_files/ 2002_projections.pdf. National Association of State Controlled Substances Authorities and Alliance of States With Prescription Monitoring Programs (2002). Prescription Monitoring Program Model Act. www.nascsa.org/resolutions/ res0201.pdf. AppendiRefer ces 41 National Drug Intelligence Center (2001a). National Drug Threat Assessment 2002. www.usdoj.gov/ndic/pubs07/716/716p.pdf. (2001b). "OxyContin Diversion and Abuse." Information Bulletin (January):1–6. www.usdoj.gov/ ndic/pubs/651/651p.pdf. (2000). National Drug Threat Assessment 2001: The Domestic Perspective. Johnstown (Pennsylvania): U.S. Department of Justice, National Drug Intelligence Center. Also available at www.usdoj.gov/ndic/pubs/647/index.htm. National Drug Strategy Network (1996). "Prescription Drug Abuse Rivals Illicit Drug Abuse, Some See Double Standard in Law Enforcement." New Briefs – Drug Use Trends. www.ndsn.org/oct96/prescrip.html. National Institute on Drug Abuse (2002). Prescription Drugs: Abuse and Addiction. Research Report Series. www.nida.nih.gov/ResearchReports/Prescription/ prescription6.html. Palm Beach County Sheriff's Department (2003). www. pbso.org/units/drugdiversion. Payne, B., and D. Dabney (1997). "Prescription Fraud: Characteristics, Consequences, and Influences." Journal of Drug Issues 27(4):807–820. Purdue Pharma L.P. (2002). Purdue's Antidiversion Efforts: Purdue Pharma's 10-Point Plan to Reduce Prescription Drug Abuse and Diversion Without Compromising Patient Access to Proper Pain Control. Stamford (Connecticut): Purdue Pharma L.P. Ramer, P. (2001). Overview of Prescription Drug Abuse and the Oxycodone Problem in Florida. Tallahassee, Fla.: Florida Department of Law Enforcement, Office of Statewide Intelligence. Schober, B. (2001). "Prescription Drug Fraud Steadily Rising." www.naddi.org/news/drugfraudrising.asp. Substance Abuse and Mental Health Services Administration (2003). "Nonmedical Use of Prescription-Type Drugs Among Youths and Young Adults." The NHSDA Report. Research Triangle Park (North Carolina): Research Triangle Institute. (2002a). Emergency Department Trends From the Drug Abuse Warning Network, Final Estimates, 1994–2001. Rockville (Maryland): Department of Health and Human Services, Office of Applied Studies. (2002b). Results From the 2001 National Household Survey on Drug Abuse: Volume I. Summary of National Findings. Rockville (Maryland): U.S. Department of Health and Human Services, Office of Applied Studies. Texas Department of Public Safety (2000). Texas Prescription Program. Austin: Texas Department of Public Safety. UK Department of Health (1998). "Security of Prescription Forms." National Health Service Circular 1998/062. (1997). "Alan Milburn Takes Direct Action Against #100M Prescription Fraud." Press release, June 19. AppendiRefer ces 43 U.S. Drug Enforcement Administration, Diversion Control Program (2000a). A Closer Look at State Prescription Monitoring Programs. Washington, D.C.: U.S. Drug Enforcement Administration. www.deadiversion.usdoj. gov/pubs/rx_monitor/index.html. (2000b). "A Pharmacist's Guide to Prescription Fraud." Informational Brochures 1(1). (1999). "Don't Be Scammed by a Drug Abuser." Informational Brochures 1(1). (1998). Prescription Accountability Resource Guide. Washington D.C.: U.S. Drug Enforcement Administration. U.S. General Accounting Office (2002). Prescription Drugs: State Monitoring Programs Provide Useful Tool to Reduce Diversion. Washington, D.C.: U.S. General Accounting Office. (1992). Prescription Drug Monitoring: States Can Readily Identify Illegal Sales and Use of Controlled Substances. Washington, D.C.: U.S. General Accounting Office. Wesson, D. and D. Smith (1990). "Prescription Drug Abuse." Western Journal of Medicine 152(5):613–616. Wick, J. (1995). "Outsmarting Prescription Fraud." Pharmacy Times 61 (April):33, 35–36. Wilford, B. (1990). "Abuse of Prescription Drugs." Addiction Medicine 152 (May):609–612. Zickler, P. (2001). "NIDA Scientific Panel Reports on Prescription Drug Misuse and Abuse." Research News, NIDA Notes 16(3) (August). About the Authors Nancy G. La Vigne Nancy G. La Vigne is a senior research associate at the Urban Institute in Washington, D.C. She directs several projects related to prisoner reentry, including a multi-state, longitudinal study of the reentry experience. Dr. La Vigne has extensive experience in criminal justice research, crime policy, and the legislative process and has published research in the areas of situational crime prevention, community policing, and geographic analysis of crime. She was the founding director of the National Institute of Justice's Crime Mapping Research Center; research director for the Texas Punishment Standards Commission; and a consultant to the Police Executive Research Forum, the National Council on Crime and Delinquency, and the National Development and Research Institute. Dr. La Vigne holds a doctorate from Rutgers University and a master's degree in public affairs from the University of Texas at Austin. Julie Wartell Julie Wartell is the crime analyst coordinator for the San Diego District Attorney's Office. She was previously the project director of the East Valley COMPASS (Community Mapping, Planning, and Analysis for Safety Strategies) initiative, a crime analyst for the San Diego Police Department, senior research and technology associate at the Institute for Law & Justice, a research associate at the Police Executive Research Forum, and a fellow at the National Institute of Justice Crime Mapping Research Center. Ms. Wartell has conducted a wide range of research on various crime problems and police issues, worked on the San Diego Police Department's strategic plan, coordinated the development of a series of crime mapping training modules, and conducted extensive training of police officers and crime analysts in crime analysis and problem-oriented policing. She has edited or authored numerous publications, including Crime Mapping Case Studies: Successes in the Field. Ms. Wartell holds a master's degree in public administration from San Diego State University and a bachelor's degree from the University of California at San Diego. Recommended Readings • A Police Guide to Surveying Citizens and Their Environments, Bureau of Justice Assistance, 1993. This guide offers a practical introduction for police practitioners to two types of surveys that police find useful: surveying public opinion and surveying the physical environment. It provides guidance on whether and how to conduct cost- effective surveys. • Assessing Responses to Problems: An Introductory Guide for Police Problem-Solvers, by John E. Eck (U.S. Department of Justice, Office of Community Oriented Policing Services, 2001). This guide is a companion to the Problem-Oriented Guides for Police series. It provides basic guidance to measuring and assessing problem-oriented policing efforts. • Conducting Community Surveys, by Deborah Weisel (Bureau of Justice Statistics and Office of Community Oriented Policing Services, 1999). This guide, along with accompanying computer software, provides practical, basic pointers for police in conducting community surveys. The document is also available at www.ojp.usdoj.gov/bjs. • Crime Prevention Studies, edited by Ronald V. Clarke (Criminal Justice Press, 1993, et seq.). This is a series of volumes of applied and theoretical research on reducing opportunities for crime. Many chapters are evaluations of initiatives to reduce specific crime and disorder problems. • Excellence in Problem-Oriented Policing:The 1999 Herman Goldstein Award Winners. This document produced by the National Institute of Justice in collaboration with the Office of Community Oriented Policing Services and the Police Executive Research Forum provides detailed reports of the best submissions to the annual award program that recognizes exemplary problem- oriented responses to various community problems. A similar publication is available for the award winners from subsequent years. The documents are also available at www.ojp.usdoj.gov/nij. • Not Rocket Science? Problem-Solving and Crime Reduction, by Tim Read and Nick Tilley (Home Office Crime Reduction Research Series, 2000). Identifies and describes the factors that make problem-solving effective or ineffective as it is being practiced in police forces in England and Wales. • Opportunity Makes the Thief: Practical Theory for Crime Prevention, by Marcus Felson and Ronald V. Clarke (Home Office Police Research Series, Paper No. 98, 1998). Explains how crime theories such as routine activity theory, rational choice theory and crime pattern theory have practical implications for the police in their efforts to prevent crime. • Problem Analysis in Policing, by Rachel Boba (Police Foundation, 2003). Introduces and defines problem analysis and provides guidance on how problem analysis can be integrated and institutionalized into modern policing practices. • Problem-Oriented Policing, by Herman Goldstein (McGraw-Hill, 1990, and Temple University Press, 1990). Explains the principles and methods of problem-oriented policing, provides examples of it in practice, and discusses how a police agency can implement the concept. • Problem-Oriented Policing and Crime Prevention, by Anthony A. Braga (Criminal Justice Press, 2003). Provides a thorough review of significant policing research about problem places, high-activity offenders, and repeat victims, with a focus on the applicability of those findings to problem-oriented policing. Explains how police departments can facilitate problem-oriented policing by improving crime analysis, measuring performance, and securing productive partnerships. • Problem-Oriented Policing: Reflections on the First 20 Years, by Michael S. Scott (U.S. Department of Justice, Office of Community Oriented Policing Services, 2000). Describes how the most critical elements of Herman Goldstein's problem-oriented policing model have developed in practice over its 20-year history, and proposes future directions for problem-oriented policing. The report is also available at www.cops.usdoj.gov. • Problem-Solving: Problem-Oriented Policing in Newport News, by John E. Eck and William Spelman (Police Executive Research Forum, 1987). Explains the rationale behind problem-oriented policing and the problem-solving process, and provides examples of effective problem-solving in one agency. • Problem-Solving Tips: A Guide to Reducing Crime and Disorder Through Problem-Solving Partnerships by Karin Schmerler, Matt Perkins, Scott Phillips, Tammy Rinehart and Meg Townsend. (U.S. Department of Justice, Office of Community Oriented Policing Services, 1998) (also available at www.cops.usdoj. gov). Provides a brief introduction to problem-solving, basic information on the SARA model and detailed suggestions about the problem-solving process. • Situational Crime Prevention: Successful Case Studies, Second Edition, edited by Ronald V. Clarke (Harrow and Heston, 1997). Explains the principles and methods of situational crime prevention, and presents over 20 case studies of effective crime prevention initiatives. • Tackling Crime and Other Public-Safety Problems: Case Studies in Problem-Solving, by Rana Sampson and Michael S. Scott (U.S. Department of Justice, Office of Community Oriented Policing Services, 2000) (also available at www.cops.usdoj.gov). Presents case studies of effective police problem-solving on 18 types of crime and disorder problems. • Using Analysis for Problem-Solving: A Guidebook for Law Enforcement, by Timothy S. Bynum (U.S. Department of Justice, Office of Community Oriented Policing Services, 2001). Provides an introduction for police to analyzing problems within the context of problem-oriented policing. • Using Research: A Primer for Law Enforcement Managers, Second Edition, by John E. Eck and Nancy G. LaVigne (Police Executive Research Forum, 1994). Explains many of the basics of research as it applies to police management and problem-solving. Other Problem-Oriented Guides for Police Problem-Specific Guides series: 1. Assaults in and Around Bars. Michael S. Scott. 2001. ISBN: 1-932582-00-2 2. Street Prostitution. Michael S. Scott. 2001. ISBN: 1-932582-01-0 3. Speeding in Residential Areas. Michael S. Scott. 2001. ISBN: 1-932582-02-9 4. Drug Dealing in Privately Owned Apartment Complexes. Rana Sampson. 2001. ISBN: 1-932582-03-7 5. False Burglar Alarms. Rana Sampson. 2001. ISBN: 1-932582-04-5 6. Disorderly Youth in Public Places. Michael S. Scott. 2001. ISBN: 1-932582-05-3 7. Loud Car Stereos. Michael S. Scott. 2001. ISBN: 1-932582-06-1 8. Robbery at Automated Teller Machines. Michael S. Scott. 2001. ISBN: 1-932582-07-X 9. Graffiti. Deborah Lamm Weisel. 2002. ISBN: 1-932582-08-8 10. Thefts of and From Cars in Parking Facilities. Ronald V. Clarke. 2002. ISBN: 1-932582-09-6 11. Shoplifting. Ronald V. Clarke. 2002. ISBN: 1-932582-10-X 12. Bullying in Schools. Rana Sampson. 2002. ISBN: 1-932582-11-8 13. Panhandling. Michael S. Scott. 2002. ISBN: 1-932582-12-6 14. Rave Parties. Michael S. Scott. 2002. ISBN: 1-932582-13-4 15. Burglary of Retail Establishments. Ronald V. Clarke. 2002. ISBN: 1-932582-14-2 16. Clandestine Drug Labs. Michael S. Scott. 2002. ISBN: 1-932582-15-0 17. Acquaintance Rape of College Students. Rana Sampson. 2002. ISBN: 1-932582-16-9 18. Burglary of Single-Family Houses. Deborah Lamm Weisel. 2002. ISBN: 1-932582-17-7 19. Misuse and Abuse of 911. Rana Sampson. 2002. ISBN: 1-932582-18-5 20. Financial Crimes Against the Elderly. Kelly Dedel Johnson. 2003. ISBN: 1-932582-22-3 21. Check and Card Fraud. Graeme R. Newman. 2003. ISBN: 1-932582-27-4 22. Stalking. The National Center for Victims of Crime. 2004. ISBN: 1-932582-30-4 23. Gun Violence Among Serious Young Offenders. Anthony A. Braga. 2004. ISBN: 1-932582-31-2 24. Prescription Fraud. Julie Wartell and Nancy G. La Vigne. 2004. ISBN: 1-932582-33-9 25. Identity Theft. Graeme R. Newman. 2004 ISBN: 1-932582-35-3 26. Crimes Against Tourists. Ronald W. Glesnor and Kenneth J. Peak. 2004 ISBN: 1-932582-36-3 27. Underage Drinking. Kelly Dedel Johnson. 2004 ISBN: 1-932582-39-8 28. Street Racing. Kenneth J. Peak and Ronald W. Glensor. 2004. ISBN: 1-932582-42-8 29. Cruising. Kenneth J. Peak and Ronald W. Glensor. 2004. ISBN: 1-932582-43-6 30. Disorder at Budget Motels. Karin Schmerler. 2005. ISBN: 1-932582-41-X 31. Drug Dealing in Open-Air Markets. Alex Harocopos and Mike Hough. 2005. ISBN: 1-932582-45-2 32. Bomb Threats in Schools. Graeme R. Newman. 2005. ISBN: 1-932582-46-0 33. Illicit Sexual Activity in Public Places. Kelly Dedel Johnson. 2005. ISBN: 1-932582-47-9 34. Robbery of Taxi Drivers. Martha J. Smith. 2005. ISBN: 1-932582-50-9 35. School Vandalism and Break-Ins. Kelly Dedel Johnson. 2005. ISBN: 1-9325802-51-7 36. Drunk Driving. Michael S. Scott, Nina J. Emerson, Louis B. Antonacci, and Joel B. Plant. 2005. ISBN: 1-932582-57-6 37. Juvenile Runaway. Kelly Dedel. 2006 ISBN: 1932582-39-8 38. The Exploitation of Trafficked Women. Graeme R. Newman. 2006. ISBN: 1-932582-59-2 39. Student Party Riots. Tamara D. Madensen and John E. Eck. 2006. ISBN: 1-932582-60-6 40. People with Mental Illness. Gary Cordner. 2006. ISBN: 1-932582-63-0 41. Child Pornography on the Internet. Richard Wortley and Stephen Smallbone. 2006. ISBN: 1-932582-65-7 42. Witness Intimidation. Kelly Dedel. 2006. ISBN: 1-932582-67-3 Response Guides series: • The Benefits and Consequences of Police Crackdowns. Michael S. Scott. 2003. ISBN: 1-932582-24-X • Closing Streets and Alleys to Reduce Crime: Should You Go Down This Road? Ronald V. Clarke. 2004. ISBN: 1-932582-41-X • Crime Prevention Publicity Campaign. Emmanuel Barthe. 2006 ISBN: 1-932582-66-5 • Shifting and Sharing Responsibility for Public Safety Problems. Michael S. Scott and Herman Goldstein. 2005. ISBN: 1-932582-55-X • Partnering with Businesses to Address Public Safety Problems. Sharon Chamard. 2006. ISBN: 1-932582-62-2 • Video Surveillance of Public Places. Jerry Ratcliffe. 2006. ISBN: 1-932582-58-4 Problem-Solving Tools series: • Assessing Responses to Problems: An Introductory Guide for Police Problem-Solvers. John E. Eck. 2002. ISBN: 1-932582-19-3 • Researching a Problem. Ronald V. Clarke and Phyllis A. Schultz. 2005. ISBN: 1-932582-48-7 • Using Offender Interviews to Inform Police Problem Solving. Scott H. Decker. 2005. ISBN: 1932582-49-5 • Analyzing Repeat Victimization. Deborah Lamm Weisel. 2005. ISBN: 1-932582-54-1 Upcoming Problem-Oriented Guides for Police Problem-Specific Guides Domestic Violence Bank Robbery Drive-by Shootings Disorder at Day Laborer Sites Crowd Control at Stadiums and Other Entertainment Venues Traffic Congestion Around Schools Problem-Solving Tools Risky Facilities Response Guides Crime Prevention Through Environmental Design For more information about the Problem-Oriented Guides for Police series and other COPS Office publications, please call the COPS Office Response Center at 800.421.6770 or visit COPS Online at www.cops.usdoj.gov. For More InForMatIon: U.S. Department of Justice Office of Community Oriented Policing Services 1100 Vermont Avenue, N.W. Washington, DC 20530 To obtain details on COPS programs, call the COPS Office Response Center at 800.421.6770 Visit COPS Online at the address listed below. e07063400 Updated Date: July 06, 2006 ISBN: 1-932582-33-9 www.cops.usdoj.gov