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Over the past several years, pharmaceutical abusers typically acquired the drugs through doctor-shopping, forged prescriptions, or unscrupulous physicians and pharmacists working alone or in association; however, many of these individuals have been dissuaded from using these methods because of prescription monitoring programs (PMPs)19 and increased law enforcement scrutiny. As a result, more abusers have shifted to other means of obtaining pharmaceuticals such as theft, purchases from Internet pharmacies, or acquisitions from retail distributors.
Pharmaceutical drug abusers in a growing number of states are having greater difficulty in acquiring drugs through prescription forgery, doctor-shopping, or indiscriminate prescribing. The number of states that have implemented PMPs to track prescriptions through traditional pharmacies has increased sharply, making the illegal acquisition of controlled pharmaceuticals much more difficult. Although several states have maintained some form of prescription monitoring for many decades, more effective electronic statewide programs began to be implemented in 2000. Since that time several states have implemented statewide PMPs to reduce prescription forgery, doctor-shopping, and indiscriminate prescribing by physicians. Sixteen states had implemented such programs by 2002, and by 2007, 24 states had implemented some form of a statewide PMP.
Criminal groups and abusers occasionally steal pharmaceutical drugs from delivery trucks that transport the drugs from manufacturers to wholesale or retail distributors. According to DEA, organized criminal groups occasionally target tractor-trailers transporting large shipments of controlled and noncontrolled pharmaceuticals from manufacturers to wholesale distributors and, more commonly, local courier trucks transporting the drugs to retail distributors such as pharmacies. DEA reporting suggests that thefts from tractor-trailers may be decreasing as thefts from smaller courier trucks increase. Although these thefts are infrequent and not currently considered a great threat, increased targeting of courier trucks is a concern. Investigators believe that tractor-trailer thefts have decreased in favor of courier truck thefts because small criminal groups are better able to target smaller trucks.
The number of Internet pharmacies selling controlled and noncontrolled pharmaceutical drugs has increased. The number of Internet pharmacies established since 2002 and particularly since 2005 has increased sharply. According to a study by the National Center on Addiction and Substance Abuse (CASA) at Columbia University, the number of Internet sites (pharmacies) offering Schedules II through V controlled prescription drugs increased 70 percent from 342 in 2006 to 581 in 2007. The study determined that 32 percent (187 of 581) of the sites were "anchor sites" (sites at which the customer could place an order and pay for the drugs), and the remaining 394 were simply portal sites that directed customers to the anchor sites. Of the anchor sites, 84 percent (157 of 187) did not require a prescription to purchase the drugs. Of the 30 sites that required a prescription, 57 percent (17 of 30) accepted a faxed prescription, increasing the risk of multiple use of one prescription or use of fraudulent prescriptions.
Methadone-related deaths and overdoses have increased sharply since the 1990s. According to the National Center for Health Statistics (NCHS), fatal overdoses involving methadone increased 390 percent from 1999 (786) to 2004 (3,849), the most recent national-level data available (see Table 12). Although national-level data are available only through 2004, analyses of state-level data in states with traditionally high rates of methadone-related deaths suggest that this trend has continued. For example, methadone-related deaths increased in 2005 and 2006 in Florida, Kentucky, Maryland, New Mexico, and North Carolina (see Table 13)--states in which methadone-related deaths have been relatively high for several years. Legitimate distribution of methadone also increased during this period, and the increase in methadone-related deaths appears to correspond closely with the increase in legitimate disbursements. Legitimate disbursement of methadone to pharmacies, hospitals, teaching institutions, and practitioners increased approximately 487 percent from 1999 (approximately 965,000 grams) through 2004 (over 4.7 million grams), and methadone-related deaths increased 390 percent. The cause of the increased number of methadone-related overdose deaths is multifaceted. These data indicate that in addition to methadone being used as treatment for heroin or other opiate addiction and for pain maintenance, some individuals may be seeking out the drug for abuse as it becomes more widely available. In addition, a new form of methadone (a 40-milligram diskette) intended for treatment of heroin and opiate addiction is sometimes inappropriately prescribed for pain maintenance, which may be contributing to some methadone overdoses.
Table 12. Number of National Methadone-Related Deaths, 1999-2004
Source: National Center for Health Statistics.
Table 13. Number of Methadone-Related Deaths in Select States, 2005-2006
Source: Florida Department of Law Enforcement Medical Examiner's Commission; Kentucky Office of State Medical Examiner; Maryland Office of State Medical Examiner; New Mexico Department of Health; North Carolina Office of the Chief Medical Examiner.
Parents are less likely to talk to their children about the dangers of prescription drug abuse than they are about heroin, cocaine, crack, MDMA, marijuana, or alcohol abuse. Although the dangers of prescription drug abuse are generally understood by parents, and rates of use for prescription drugs are higher than those for most other major drugs of abuse, relatively few parents discuss prescription drug abuse with their teenage children. According to Partnership Attitude Tracking Study (PATS) data for 2006, 81.5 percent of parents perceive abuse of prescription drugs to be a growing problem among teenagers, yet only 36.2 percent of parents discuss with their children the dangers of using prescription drugs to get high--a lower percentage than for other major drugs of abuse or alcohol (see Table 14). PATS 2005 teen data (the latest data available) also show that 44 percent of adolescents in grades 7 through 12 did not perceive a great risk in trying pain relievers such as Vicodin (hydrocodone) or OxyContin (oxycodone) that a doctor did not prescribe for them. When the teens who reported using nonprescribed pain relievers were asked their reasons for using the drugs, 62 percent said that the drugs were easy to get from their parents' medicine cabinets, 51 percent said that the drugs were not "illegal" drugs, and 49 percent said that they could claim they had a prescription if caught with the drugs, according to PATS.
Table 14. Percentages of Parents Who Discuss the Dangers of Drug Abuse "a lot" With Their Children, 2006
The percentage of parents discussing the dangers of prescription drug abuse is lower than the percentage discussing any other surveyed drug, except for MDMA.
Source: Partnership Attitude Tracking Study.
The extent to which high rates of both legitimate use and abuse of prescription drugs affects rates of use for illegal drugs such as heroin, cocaine, and methamphetamine is unclear. Law enforcement reporting indicates that some prescription narcotics abusers switch to heroin when prescription narcotics are unavailable. Moreover, according to an Ohio Substance Abuse Monitoring (OSAM) study of heroin abusers between the ages of 18 and 30 in Ohio, 65 percent of the participants report having been addicted to prescription opioids before abusing heroin. Although some studies (such as the OSAM study) suggest that the use of prescription drugs may predispose an individual to illegal drug use, other studies are inconclusive, and some suggest that prescription drug use may actually reduce occurrences of "self-medicating" with illegal drugs. Notwithstanding several seemingly conflicting studies, national-level demand studies seem to show little direct correlation. For example, Monitoring the Future (MTF) data show that from 2000 through 2006, rates of past year abuse for prescription narcotics, sedatives, and tranquilizers among twelfth graders were relatively stable overall. However, during that same period past year rates of use for cocaine, crack, heroin, marijuana, methamphetamine, and MDMA decreased overall among twelfth graders. Similarly, NSDUH data show that from 2002 through 2006, rates of past year prescription narcotics abuse among individuals 12 and older increased, while rates of abuse for cocaine, crack, heroin, marijuana, methamphetamine, and MDMA either remained stable or declined.
Law enforcement will most likely be challenged to monitor a growing number of foreign-based Internet pharmacies as Americans become more accustomed to acquiring their drugs from such sources. According to a Pharmaceutical Research and Manufacturers of America (PhRMA) survey released in June 2007, approximately 5.4 million adults in the United States (2.5% of the population) have purchased prescription drugs from a foreign country such as Canada or Mexico in their lifetime. Moreover, approximately 50 percent of the survey respondents report that the reason they purchased drugs from another country was that they did not have a prescription for the drug(s) that they wanted. The survey further showed that 31 percent of the pharmaceutical purchases were conducted through Internet pharmacies. Furthermore, according to a 2007 CASA study, 48 percent (91 of 187) of Internet sites offering direct sales of pharmaceutical drugs to individuals indicated that the drugs would be shipped from a foreign country, while 26 percent (48 of 187) indicated that the drugs would be shipped from an U.S. pharmacy, and 26 percent (48 of 187) gave no indication of the source of the drug.
19. Prescription monitoring programs (PMPs) are systems in which controlled substance prescription data are collected in a centralized database and administered by an authorized state agency to facilitate the early detection of trends in diversion and abuse.
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