Building Cases Across State Lines

April 10-12, 2012 Walt Disney World Swan Resort

Learning Objectives: 1. Evaluate the roles of practitioners, regulatory authorities, state and federal investigators and prosecutors in pharmaceutical drug crime cases, with an emphasis on how individuals and agencies can collaborate to achieve common goals. 2. Describe the evolution of the prescription pill epidemic and outline the uses and limitations of prescription drug monitoring programs to aid in multi-state investigations. 3. Identify problem areas and common roadblocks to effective multi-state investigations from a prosecutor’s perspective, with a discussion of the prosecutor’s role in working with the investigator in early case development.

Disclosure Statement

•  All presenters for this session, Agent Bruce DiVincenzo and Hon. Vernon Stejskal, have disclosed no relevant, real or apparent personal or professional financial relationships.

Pharmacists

  In the majority of diversion cases, the pharmacist is a key witness and a great source of information.

  For both intrastate and interstate cases, the information stored in the databases of the various chain pharmacies on filled prescriptions, provides valuable evidence in criminal matters related to diversion investigations.

Pharmacists - continued

•  In some cases, the pharmacist can determine if the target of the investigation has filled scripts at other chain stores in other states as well as in your jurisdiction.

•  Be aware of the pharmacy’s corporate or legal office contact person for searches of of pharmacy records in ALL stores in the chain. Take the time to establish contact and fax numbers and e-mail addresses for the appropriate person in the corporation.

Pharmacies Within Your Jurisdiction

•  A helpful tool to have for each investigator is a complete listing of every pharmacy within your jurisdiction. List name, address, phone and fax number and consider a broadcast fax capability to notify all stores at once when an investigation requires doing so.

•  Another tool that can be used is the e-mail address of the district offices of the chain stores and any individually owned pharmacies. This is also an efficient method for getting the necessary information to the pharmacists and also for obtaining information needed in your investigation

Alerts

•  Provide examples to the session of some of the various formats used.

•  Important points on any alert. Fairness to the patient if activity being investigated is not yet determined to be criminal. The police department does not want to interfere with lawful prescribing.

•  Alerts can improve interaction with your pharmacies and increase the information that is provided to the investigator.

Regulatory Authorities

•  Cooperation is essential with regulators. In some cases, by sharing the law enforcement perspective on critical issues, you may be able to accomplish goals in conjunction with the regulators that will allow for more effective enforcement in drug diversion investigations.

•  Review Secure Script Legislation and how the cooperation worked to make the legislation a reality.

Out of State Partners •  If you find that you are affected by individuals from other

jurisdictions committing diversion crimes in your area, begin to develop a plan and various points of contact in other jurisdictions for collaboration and assistance.

•  Know which agency or persons in neighboring states or counties or cities is responsible for drug diversion cases. Is there a designated agency that you can share &/or obtain information with about your case? A listing of the various agency e-mail addresses, phone numbers and contact person is important.

•  Establish contact and let agencies know that your are investigating these crimes in your area.

DEA

•  The DEA is an invaluable partner in diversion investigation and has tremendous resources and experience at it’s disposal. Prepare for those cases involving interstate crimes by being familiar with the diversion investigators from the DEA who work in your jurisdiction.

•  As an agent with federal authority, , the diversion investigator is familiar with the manner in which cases are presented at a federal level and is knowledgeable regarding the Code of Federal Regulations and how it may apply to your investigation.

Evolution of the Controlled Substance Abuse

Epidemic •  From the law enforcement perspective, the increase in abuse

of controlled substances is related to some degree on how profitable it is to sell these drugs to other abusers. Viewed by some as “safer” than illegal drugs, the misuse by many allowed people inclined to such behavior as drug sellers to make “easy” money.

•  The difficulty in obtaining these drugs is relatively easy when compared to the risks involved with “street” drug purchases. With pills you “deal” with a doctor and / or pharmacist and the risk is low for arrest.

•  In many cases, the pills are provided to friends or family.

Interstate Forged Script Cases

•  Once you have established the identity of the suspect in your case, use this identification to review out of state criminal arrest history, especially recent arrest records for similar crimes perhaps involving a similar forged prescription and / or vehicles involved. Review Baltimore based practitioner case and related evidence.

•  Check with chain pharmacies to review prescriptions by doctor / practice name.

Prescription Data Monitoring Programs – Ideal Standards

•  Many states have operational programs in place and several other states are moving forward to operational status.

•  Access between states by diversion investigators should not be prohibited or made difficult. VA experience.

•  Doctors should be encouraged to review patient’s records when prescribing controlled substances.

•  It is recommended as well that medical practices obtain from each new patient a government issued photo ID to be kept as part of the patient file. Suggestion made to Medical Society in DE. Many are doing this.

•  Pharmacists – Essential to have access- as they play a primary role in patient safety and can observe the patient history as well. Partnerships with the pharmacists in your jurisdiction will yield dividends. Medical practitioners and pharmacists are the main “gatekeepers” on which law enforcement depends. Example: training that may will be offered by agency.

Prescription Data Monitoring Programs – Ideal Standards - Continued

•  Data captured - an ESSENTIAL item of data that needs to be collected in each transaction is the identification number from the government issued photo ID which is used by the person receiving the drugs. In so many cases, the name of the patient is fictitious or used without that person’s knowledge. Prescribing records will not be as accurate without documenting the ID of the receiver of the controlled substance. An ID requirement is an essential part of enforcing violations of the controlled substance laws and should be part of the recorded data by the pharmacy for the PDMP.

Prescription Data Monitoring Programs – Ideal Standards - Continued

•  Recently North Carolina enacted a law requiring that ID be obtained in all Schedule II transactions and certain Schedule III transactions and recorded by the pharmacy -$10.00 check example at bank. By having this requirement (either law or regulation) in your state, the chances for a successful investigation are greatly increased.

•  Investigative agencies need to be part of the discussion when it comes to requirements and laws pertaining to controlled substances.

•  The example shown by UTAH shows how access should properly take place for diversion investigators. Very similar to a check via NCIC for criminal history currently available to law enforcement. This should be the minimum standard for

access!

Training for Practitioners and Pharmacists

•  Investigative agencies should offer training where possible to inform practitioners and pharmacists about how best to work with law enforcement and what can be expected as a result of that cooperation.

•  Encourage reporting of felony crimes by pharmacists to law enforcement. Clearly it is better to have designated individuals or units of investigators that a pharmacist can readily contact when a felony has occurred. Establish networks in your jurisdiction. Important – If practitioners and pharmacists do not report the crimes, you will not be as effective in your investigations.

Training for Practitioners and Pharmacists - continued

•  Court – who will be needed, what records are important to the case.

•  With proper coordination between the “gatekeepers” and law enforcement, in most cases, court appearances can be minimized. Prosecutors work with medical professionals to minimize the time away from the practice. Build on this.

Control the Playing Cards •  A secure script program is an essential tool for reducing

prescription forgery. Many forms are available via the internet and those involved in the crime of prescription forgery for profit are familiar with such suppliers of “tamper resistant” prescription paper.

•  The state has an interest in reducing these opportunities for forgery. Newspaper article – support from local media

•  Discuss the plan used in some jurisdictions. •  Remember - blank scripts are a form of drug diversion

currency. •  This tool reduces diversion at the access point. PDMP’s are an

after the fact tool.

Prosecutors

•  Know what information and evidence is required by your prosecutor for presentation before a criminal court. Their experience can guide you as you conduct your investigations.

•  Civil prosecutors - Very knowledgeable regarding regulations pertaining to medical practitioners. Discuss questionable situations with them. Attend hearings to learn about the boards that conduct hearings.

Medical Examiner

•  Review the findings of the ME to determine what C/S are being reported as causes of death. In many cases the cause of death is a combination of more than one drug. Be aware of any dominant trend. Knowing what substances are causing the unintended drug poisonings in your jurisdiction is vital and will direct your efforts and inform other stakeholders so as to encourage their participation.

Public Health Statisticians ; ARCOS

•  Another helpful source for determing what is causing unintentional deaths in your jurisdiction is the Department of Public Health Statistical Record.

•  Deaths and causes of death are tracked. Trends can be observed.

•  Familiarize your agency with the ARCOs statistics maintained by the DEA on drug sales to pharmacies and practitioners within your jurisdiction. Per capita sales records are also available and can offer information helpful to your investigations.

Valid Concerns •  Please be aware that there exists concern by some groups in

the community that law enforcement may have a chilling affect on patient’s right to prescription pain medication. Work to allay that concern.

•  Law enforcement is well aware of the valid needs of patients and avoids entanglement with such patients.

•  Stress that we deal with violations of the controlled substance laws and other criminal acts involving diverted drugs. Law enforcement does not want to be improperly perceived as interfering with effective pain management.

•  Point out to leaders of the various advocacy groups in your area what your investigations entail and that you are aware that some individuals do receive a high amount of narcotics as part of a validly prescribed treatment.