Pharmaceuticals

Introduction

The diversion and abuse of pharmaceutical narcotics, depressants, and stimulants are a significant threat to the United States. A review of the most recent national-level drug prevalence studies indicates that rates of abuse for prescription drugs have increased sharply since the early to mid-1990s but appear to be stabilizing at high levels. The consequences of prescription drug abuse also have increased since the early to mid-1990s and have continued to increase during the past 2 reporting years.

The availability of prescription drugs has increased since the late 1990s. Legitimate commercial production and disbursals of pharmaceutical drugs, particularly prescription narcotics, have increased sharply since the late 1990s, making more of the drugs available for diversion. Most pharmaceutical controlled substances that are abused in the United States are diverted by forged prescriptions, doctor shopping, and theft; however, law enforcement agencies report that diversion of prescription drugs via the Internet, often through Internet-based pharmacies, has increased sharply since the mid- to late 1990s.

Although most law enforcement agencies are concerned about diversion and abuse of prescription drugs, national-level drug survey data show that only a small percentage of state and local law enforcement agencies report that pharmaceuticals are the greatest drug threat to their areas. However, that percentage may be increasing. NDTS 2004 data indicate that 3.1 percent of state and local law enforcement agencies nationwide identify pharmaceuticals as their greatest drug threat, up from 2.4 percent in 2003. Regionally, more state and local law enforcement agencies in the Northeast (4.9%), Southeast (4.0%), and Midwest (3.2%) identify pharmaceuticals as their greatest drug threat than agencies in the Southwest (0.3%), Pacific (0.2%), and West (0.0%).

Despite a demonstrable rise in pharmaceutical drug abuse since the mid-1990s, NDTS data indicate that there remains less violence or property crime associated with pharmaceuticals than with most other drugs of abuse. NDTS 2004 data indicate only 2.2 percent of state and local law enforcement agencies nationwide reported that pharmaceuticals were the drugs that most contributed to violent crime in their areas--higher than MDMA (0.2%) but much lower than crack (40.7%), methamphetamine (34.2%), powder cocaine (7.7%), heroin (5.8%), and marijuana (4.6%). Regionally, a higher percentage of agencies in the Northeast Region (4.0%) reported that pharmaceuticals were the drugs that most contributed to violent crime in their areas than did agencies in the Midwest (2.6%), Southeast (2.0%), Southwest (0.3%), Pacific (0.2%), or West (0.0%). Similarly, only 2.5 percent of state and local law enforcement agencies nationwide reported that pharmaceuticals were the drugs that most contributed to property crime in their areas--higher than MDMA (0.1%) but much lower than crack (35.6%), methamphetamine (32.7%), heroin (12.3%), marijuana (9.5%), and powder cocaine (5.2%). Regionally, a higher percentage of agencies in the Northeast Region (4.4%) reported that pharmaceuticals were the drugs that most contributed to property crime in their areas than did agencies in the Southeast (3.0%), Midwest (2.2%), Pacific (0.7%), Southwest (0.3%), or West (0.2%).

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Demand

The rate of abuse for prescription drugs is relatively high compared with rates of abuse for other drug types. NSDUH data indicate that 6.3 percent of persons aged 12 or older reported nonmedical use of a prescription-type pain reliever, tranquilizer, stimulant (including both illicit and prescription methamphetamine), or sedative (not including over-the-counter drugs) in 2003, second only to marijuana (10.6%) and much higher than cocaine (2.5%) and heroin (0.1%).

Trends in Abuse

MTF data indicate that rates of abuse for prescription narcotics ("Other Narcotics") such as hydrocodone (Vicodin), oxycodone (OxyContin), hydromorphone (Dilaudid), and codeine have increased sharply over the past decade.¹⁸ According to MTF, the rate of past year abuse for prescription narcotics increased among twelfth graders from 1992 (3.3%), to 1997 (6.2%), and 2002 (9.4%) but remained relatively stable at 9.5 percent in 2004. Among young adults (aged 19 to 28), the rate of past year abuse for prescription narcotics increased steadily each year from 1992 (2.5%) to 2001 (5.0%) but increased significantly from 2002 (5.1%) to 2003 (8.5%). NSDUH data show that past year nonmedical use of pain relievers was relatively stable from 2002 to 2003 for those aged 12 to 17 (7.6% and 7.7%, respectively), 18 to 25 (11.4% and 12.0%), and 26 or older (3.1% and 3.3%).

According to MTF, the rates of past year abuse of prescription depressants have increased overall since 1992. MTF data for 2003 show that rates of past year abuse for prescription tranquilizers such as alprazolam (Xanax) and diazepam (Valium) increased among twelfth graders from 2.8 percent in 1992, to 5.5 percent in 1998, to 7.7 percent in 2002, but then decreased somewhat to 7.3 percent in 2004. Among young adults (aged 19 to 28), the rate of past year abuse for prescription tranquilizers has increased from 1992 (3.4%), to 1998 (3.8%), to 2002 (7.0%) and remained relatively stable at 6.8 percent in 2003. MTF data also indicate an overall increase in the rate of past year abuse for prescription sedatives (barbiturates) among twelfth graders from 1992 (2.8%), to 1998 (5.5%), to 2002 (6.7%) but then decreased somewhat to 6.5 percent in 2004. The rate of past year abuse of prescription sedatives also increased among young adults from 1.6 percent in 1992, to 2.5 percent in 1998, to 3.9 percent in both 2002 and 2003. NSDUH data show that past year nonmedical use of tranquilizers was unchanged from 2002 to 2003 for those aged 12 to 17 (2.3% in both years) and 26 or older (1.5% in both years); the change in rates for those aged 18 to 25 (4.9% to 5.3%) was not significant. NSDUH data further show that past year nonmedical use of sedatives was quite stable from 2002 to 2003 for those aged 12 to 17 (0.6% and 0.5%, respectively), 18 to 25 (0.5% in both years), and 26 or older (0.4% and 0.3%).

Very limited national-level data regarding abuse of prescription stimulants, particularly methylphenidate (Ritalin), indicate that rates of abuse are declining. Past year rates of abuse for methylphenidate have been tracked only since 2001; however, the data indicate an overall decrease from 2001 to 2004 among eighth (2.9% to 2.5%) and tenth (4.8% to 3.4%) graders. Among twelfth (5.1% to 4.0%) graders past year rates of use have fluctuated from 2001 (5.1%), to 2002 (4.0%), to 2003 (4.0%), to 2004 (5.1%). MTF data show that the rate of past year abuse of methylphenidate among young adults was 2.9 percent in both 2002 and 2003. NSDUH data show that past year nonmedical use of stimulants (including methamphetamine) declined from 2002 to 2003 for those aged 12 to 17 (2.6% and 2.3%, respectively), 18 to 25 (3.7% and 3.5%), and 26 or older (0.8% and 0.6%).

Consequences of Abuse

Data regarding ED mentions and treatment admissions indicate that the consequences of prescription drug abuse have increased overall since the early to mid-1990s, with the exception of methylphenidate. DAWN data reveal that the number of ED mentions for "Narcotic Analgesics" increased steadily from 1995 (20,910), to 1998 (32,573), and 2001 (64,786), then increased an additional 25 percent from 2001 to 2002 (64,786 to 81,002). (See Figure 51.) Similarly, DAWN data show steady increases in the number of ED mentions for benzodiazepines from 1995 (76,548) to 1998 (88,808) and 2001 (103,972). (See Figure 52.) The number of ED mentions for this drug category increased by 2 percent (103,972 to 105,752) from 2001 to 2002--the smallest year-to-year increase since the 1998-1999 period (88,808 to 90,539, respectively). The estimated number of ED mentions for methylphenidate has decreased steadily from 1995 (1,860) to 1998 (1,728) and 2001 (1,279), declining again, albeit only slightly, to 1,245 in 2002.

Figure 51. Emergency department mentions for narcotic analgesics, 1995-2002.

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Source: Drug Abuse Warning Network.

Figure 52. Emergency department mentions for benzodiazepines, 1995-2002.

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Source: Drug Abuse Warning Network.

The most recently available data from TEDS indicate that the number of admissions to publicly funded drug treatment facilities for prescription drug abuse has increased steadily since 1992. For example, the number of admissions for "Other Opiates" (prescription narcotics and opium) increased from 13,671 in 1992, to 16,121 in 1995, to 19,941 in 1998, to 29,054 in 2000, to 45,605 in 2002, the most recent year for which such data are available (see Figure 53). The number of admissions for benzodiazepines also has increased steadily from 1992 (2,882), to 1995 (3,222), to 1998 (4,524), to 2002 (7,226).

Figure 53. Treatment admissions for opiates other than heroin, 1992-2002.

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Source: Treatment Episode Data Set.

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Availability

There are no conclusive estimates as to the total amount of diverted prescription narcotics, depressants, and stimulants available in domestic drug markets. However, data regarding legitimate commercial disbursal of prescription pharmaceuticals indicate that the amount of prescription drugs disbursed to pharmacies, hospitals, practitioners, and teaching institutions has increased sharply over the past 4 years, thereby rendering more of the drug available for diversion. According to DEA, pharmaceutical drug disbursals have increased overall since 2000, particularly for OxyContin. In fact, OxyContin disbursals have increased sharply since 2000 while disbursals of other prescription narcotics such as Percodan and Lortab have decreased. OxyContin disbursals (in grams) increased from 2000 (10,415,575), to 2001 (14,002,125), to 2002 (15,118,153), to 2003 (16,982,548)--a 63.0 percent increase from 2000 to 2003. During that same period Percodan and Lortab disbursals (in grams) decreased an overall 27.4 percent from 2000 (454,301), to 2001 (407,625), to 2002 (375,155), to 2003 (329,792). Similar data are not available for depressants or stimulants.

Wide-ranging law enforcement reporting indicates that the availability of diverted prescription drugs has increased over the past 3 years, an assertion seemingly supported by national-level drug survey data. NDTS 2004 data reveal that the percentage of state and local law enforcement agencies reporting high or moderate availability of pharmaceuticals increased from 70.0 percent in 2002, to 72.3 percent in 2003, and 75.6 percent in 2004. NDTS 2004 data further indicate that 17.8 percent of state and local law enforcement agencies described the availability of diverted prescription drugs as low and that only 3.6 percent reported that diverted pharmaceuticals were not available in their areas.

Pharmaceutical Diversion and Distribution

Most prescription drugs abused in the United States are diverted by "doctor shopping" (a practice whereby persons who may or may not have a legitimate ailment visit numerous physicians to obtain drugs in excess of what should be legitimately prescribed), forged prescriptions, theft, and increasingly via the Internet. To reduce the occurrence of pharmaceutical diversion by doctor shopping and prescription fraud, 21 states have established prescription monitoring programs that facilitate the collection, analysis, and reporting of information regarding pharmaceutical drug prescriptions. State-level prescription monitoring programs have been effective in reducing both the average time required to conduct pharmaceutical diversion investigations and the estimated number of dosage units dispensed by pharmacies and physicians to suspected abusers. For example, the Kentucky Cabinet for Health Service reports that the Kentucky All Schedule Prescription Electronic Reporting (KASPER) system has reduced the average time to complete pharmaceutical drug investigations from an average of 156 days to an average of 16 days. Moreover, according to ONDCP, establishment of the Nevada prescription monitoring program has resulted in a 46 percent reduction in the estimated number of pharmaceutical dosage units distributed to suspected abusers.

Doctor Shopping

A common method of diverting prescription drugs is doctor shopping. Individuals who divert and acquire pharmaceuticals through doctor shopping do so by visiting numerous doctors in an attempt to obtain multiple prescriptions for the drugs, particularly prescription narcotics such as OxyContin, Percocet, and Percodan. Doctor shoppers often falsify or exaggerate symptoms in order to obtain prescriptions for pharmaceuticals and often visit particular doctors who they believe are more likely to grant prescriptions. The individuals typically have their prescriptions filled at several different pharmacies to avoid detection.

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Prescription Fraud

Prescription fraud includes a variety of schemes commonly used to divert prescription drugs, such as forging or altering prescriptions, producing counterfeit prescriptions, and calling in fictitious prescriptions to pharmacies by impersonating a physician. Pharmacists often recognize prescription fraud, particularly forged, altered or counterfeit prescriptions, because the prescriptions are written in unfamiliar handwriting (often without abbreviations) or the prescription quantities, directions, or dosages differ from normal usage. Pharmacists also identify fraud when prescriptions resemble textbook examples or appear to be photocopied.

Unscrupulous Physicians

Illegal prescribing by unscrupulous physicians is a significant source of diverted pharmaceuticals. Corrupt physicians create fraudulent prescriptions to obtain drugs for personal use, and they also write prescriptions for individuals without a legitimate need for the drug for a fee. Unscrupulous physicians sometimes collaborate with unscrupulous pharmacists, who dispense the drugs for an additional fee.

Pharmaceutical Theft

Millions of pharmaceutical drug dosage units are diverted each year through theft from pharmacies, manufacturers, distributors, importers/exporters, and individuals with legitimate prescriptions. The amount of pharmaceutical drug dosage units diverted annually through theft fluctuates but increased overall from 2000 to 2003 for most drugs. According to DEA, the number of pharmaceutical dosage units diverted through theft from pharmacies, manufacturers, distributors, and importers/exporters increased from 2,379,389 in 2000 to 2,753,928 in 2003. (See Table 21)

Table 21. Theft of Pharmaceuticals From Pharmacies, Manufacturers, Distributors, and Importers/Exporters, in Dosage Units, 2000-2003

Source: Drug Enforcement Administration.

Employees of pharmaceutical drug manufacturers and commercial distributors account for most of the pharmaceuticals diverted through theft; however, others steal pharmaceuticals as well. According to the 2002 National Retail Security Survey report, retailers attribute 48 percent of pharmaceutical inventory loss to employee theft. Individuals also break into pharmacies or clinics to steal pharmaceuticals or commit armed robberies to acquire the drugs. Individuals also steal pharmaceuticals from friends or relatives who possess legitimate prescriptions.

Pharmacy managers and law enforcement agencies in areas that have experienced a high number of pharmacy break-ins or armed robberies have taken specific steps to reduce pharmaceutical theft. For example, many pharmacies have stopped distributing specific pharmaceuticals that thieves most often target, such as OxyContin. Some communities have increased law enforcement patrols around pharmacies to deter or detect break-ins and robberies.

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Internet

Prescription drugs are increasingly diverted via the Internet because many Internet pharmaceutical distributors--often referred to as Internet pharmacies--offer prescription drugs to customers without requiring prescriptions or physician consultation or verification. Estimates as to the number of Internet pharmacies vary widely. For example, the National Board of Pharmacy estimates that the number of Internet pharmacies has increased from none in the mid- to late 1990s to between 400 and 1,000 in 2003. However, in January 2004 the National Center on Addiction and Substance Abuse (CASA) identified only 157 Internet sites distributing controlled pharmaceuticals to individual users, although an additional 338 Internet sites provided links to one or several of the 157 pharmaceutical distribution sites. Nevertheless, of the 157 Internet sites identified by CASA, 64 (40.8%) did not require any prescription or physician consultation to purchase prescription drugs. Moreover, 77 (49.0%) of the Internet sites only required customers to report their symptoms in an online questionnaire before they could receive the prescription drug--there was no requirement for personal physician verification of the symptoms. Faxed prescriptions were required by seven (4.4%) and mailed prescriptions were required by three (1.9%) of the sites. The remaining six (3.8%) sites made no reference to any prescription requirement. CASA further reports that the Internet pharmacy sites most often offered benzodiazepines (alprazolam and diazepam), followed by narcotic analgesics (fentanyl, hydrocodone, and oxycodone), and stimulants (methylphenidate). None of the 157 Internet sites included security procedures restricting children from purchasing prescription drugs.

FBI reporting indicates that many unscrupulous Internet pharmacy operators recruit corrupt physicians to write fraudulent prescriptions for their customers. The FBI further reports that unscrupulous physicians are paid as much as $1,500 per day for writing fraudulent prescriptions for Internet pharmacy patients.

Some Internet pharmacies, including some based in Mexico and Canada, distribute counterfeits of popular brand-name pharmaceuticals that often contain inactive ingredients, incorrect ingredients, or improper dosages. According to FBI, most counterfeit pharmaceuticals are produced in India and China, and in some countries counterfeit pharmaceuticals are quite prevalent. In fact, FBI reporting indicates that as much as 60 percent of the pharmaceuticals sold in China, Nigeria, Thailand, Cambodia, and Indonesia are counterfeit. The Food and Drug Administration (FDA) reports that the level of counterfeit drug distribution within the United States is very low compared with other countries; however, occurrences of counterfeit pharmaceutical distribution in the United States are increasing. As a result, FDA counterfeit drug investigations have increased from 6 in 1997 to 22 in 2003 (see Figure 54).

Figure 54. Counterfeit drug cases, 1997-2003.

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Source: Food and Drug Administration.

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Outlook

The abuse of pharmaceutical drugs is likely to decline in the near term. MTF data indicate that rates of past year use for pharmaceutical narcotics, depressants, and stimulants have increased sharply from the early to mid-1990s to 2001-2002 but have since declined for nearly every surveyed age group. In fact, only rates of past year use for prescription narcotics among young adults (aged 19 to 28) have increased from 2001 (5.0%) to 2003 (8.5%). Rates of past year use for prescription stimulants and depressants have declined or remained stable for every surveyed age group from 2002 to 2003.

Despite a possible rise in the diversion of pharmaceutical drugs via the Internet, pharmaceutical drug diversion is likely to decrease overall in the near term. Sharp increases in law enforcement pressure on unscrupulous physicians as well as increasing use of statewide prescription monitoring programs could sharply reduce the diversion of prescription drugs through illegal prescribing, prescription fraud, and doctor shopping. Moreover, increasing protection of pharmaceutical drug inventories at individual pharmacies will likely further reduce the amount of pharmaceuticals diverted through theft.

End Note

18. This report cites trademarked names such as Vicodin and OxyContin in discussing the diversion and abuse of such substances. The use of any trademarked names in this assessment does not imply any criminal activity, criminal intent, or misdealing on the part of the companies that manufacture these drugs. All such citations are made for reference purposes only.

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