Drug Diversion and Pain Management: Finding a Balance

As a police officer for 43 years and the commander of the Warren County, Ohio drug task force and a retired commander of the Cincinnati Police Department Pharmaceutical Diversion squad, Commander John J. Burke has seen or heard just about every variation of drug diversion you can think of. Attendees at Thursday’s packed-house session, “Drug Diversion and Pain Management: Finding a Balance,” were treated to more than a few of Burke’s better anecdotes. Although the subject of drug diversion is obviously a very serious one, Burke’s easy way with a story had the attendees in stitches, but also on the edge of their seats.

Though Burke has been a lifelong member of law enforcement, he did not hesitate to point out the fraternity’s struggles with drug diversion. Burke stunned attendees when he said that U.S. Customs has more than 1,200 drug dogs, but not a single dog at the border to sniff pharmaceuticals. He acknowledged that many PAINWeek attendees have probably experienced some frustration with law enforcement: “They don’t know much about [drug diversion], so they tend to shy away from it. You’re trying to report it, and they’re not assisting.”

Burke admitted that “law enforcement has been very slow to get on board. I laugh when I hear a colleague call and ask, ‘Hey, what do you think of this new problem?’ Well, it’s gotten a lot worse over the years, but it’s far from new.”

Burke’s simple definition of drug diversion is “any criminal act involving a prescription drug.” There are many forms of diversion besides doctor-shopping, he said, and most of them dwarf the problems that pain management professionals deal with regularly, in terms of their impact on the pharmaceutical drug marketplace. Burke reminded the audience, though, that it’s easy to get tunnel vision and think that every patient is trying some funny business, when the truth is that the vast majority of patients are legitimate. “Any time someone scams you, it can potentially harm a person seeking legitimate treatment. You’re a human being. If you get scammed, the next patient is more likely to get two aspirin. That’s just human nature. ” Burke thinks of the work of the National Association of Drug Diversion Investigators as advocating for those who are seeking proper medication to treat their pain.

Far and away the top controlled substance for abuse is hydrocodone, for which many generics are available and which is a schedule III drug. “It’s an effective drug, and it’s prescribed a lot, so it’s going to be diverted,” Burke said. “Drug diversion units spend half their time on hydrocodone alone.” He talked a bit about Purdue’s reformulation of Oxycontin to make it harder to dissolve, and expressed hope that it will be effective in reducing diversion of the popular drug. “By the end of this year, we’ll see whether or not it’s been effective.”

Burke also briefly covered the other substances most likely to be diverted, including enzodiazepenes (Xanax), carisoprodol, stimulants (Adderral and Ritalin), nasal spray, tramadol, methodone, and fentanyl. Regaring fentanyl, Burke told of two unusual cases he was familiar with; one woman was putting 7 fentanyl in a huge bottle of vodka, which she would finish. Another man was presenting to his physician with severe burns on his abdomen. After heavy pressing from the physician, the man admitted that he was running a hot iron over the fentanyl patch to increase the speed of the drug’s delivery.

Other anecdotes were a little more light-hearted. Two involved scammers using their pets to divert from veterinarians. One had actually trained his dog to cough in an effort to get a prescription for hydrocodone syrup. One man had a little lapdog named Dolly, Burke recounted. He told the vet that Dolly had a little anxiety, and he wanted some valium for her. “Don’t all lapdogs have a little anxiety?” Burke joked. “I asked if we could seize the dog as an asset forfeiture!”

Burke then talked about the various ways diversion occurs, including forged or altered scripts, doctor shoppers, pharmacy robberies and burglaries, and illegitimate internet vendors. He drew a clear distinction between robberies—which are almost exclusively carried out by addicts—and burglaries, which are almost exclusively carried out by those who want to sell pharmaceuticals. “You probably already know this, but I can’t say it enough: If an addict sticks a gun in your face, you give him whatever they want and get them out of your pharmacy.”

The problem of itinerant vendors is also immense. In 2006, Burke said, there were 34 rogue pharmacies identified, and they had sold over 98 million dosages of hydrocodone in a year. It would take 1,118 legitimate pharmacies (on average) to dispense that amount of hydrocodone in a year. Burke then told another funny anecdote about a friend who had been getting Viagra for $4 a tablet. “I didn’t have any idea how much Viagra normally costs, but I have a daughter-in-law who is a pharmacist.” The attendees, sensing were this was going, started laughing before Burke hit the punchline: “Before even thinking, I called my daughter-in-law and said, ‘I have a friend who needs to know how much Viagra costs.’”

Turning more serious, Burke talked about the possibility that someday soon pills will have individual serial numbers. “We’ll be able to track who prescribed that pill, who dispensed it, and who is supposed to be taking it. Can you imagine the power of having that information, from a law enforcement perspective? It won’t happen in my career, but for those of you who are younger, it may.”

Though Burke applauded the pharmaceutical companies for their efforts to reformulate abused drugs and to fund task forces like NADDI, he expressed surprise that health insurers hadn’t gotten more involved in trying to solve diversion issues. He pointed to a statistic that opioid abusers cost health insures almost $16,000 a year on average, versus a cost of about $1,830 for non-abusers. “You’d think the insurance companies would be more interested in the problem,” he said.

As for pain management professionals, Burke talked about how they can help limit smaller scale diversion through patient education and awareness. Although it wouldn’t be possible for every pain management physician to tell a patient every detail, Burke suggested a video that patients could watch that would inform them about the dangers of diversion. “Patient education needs to be better. Patients need not just instructions on how to take the drug, but about all the risks associated with handling a controlled substance. They need to know that their alcoholic cousin may be interested in their pain drugs. The typical drug seeker is every bit as addicted as a heroin or cocaine addict. These drugs can kill someone if they get in the wrong hands.”

One portion of the session that had attendees nodding their heads in acknowledgment was Burke’s run-down of a typical drug-seeker’s visit: “You now become the finest physician in the world. You sit somewhere around the right hand of God. Then, the patient will mispronounce the drug slightly enough to be understood, saying “I once had something that worked well for me, percocine…or something, and if you’ll just give me 1,000 of those, I’ll be on my way.” The patient will become agitated when cut off from his or her drug of choice. Pain management professionals may be threatened with a lawsuit. And the patient will leave abruptly when the scam doesn’t work. “What’s important is that you’ve sent a clear message: your scam won’t work here.”

In the context of discussing why patients abuse prescription drugs, Burke returned to the lack of law enforcement focus on diversion. “Did you know that the NYPD has no one who works on prescription drug abuse full time?” he asked. “We fight all the time about law enforcement’s ignorance. This is a huge issue. It doesn’t involve drive-by shootings, but people are still dead, aren’t they?”