Law Enforcement Track, National Rx Drug Abuse Summit, April 2-4, 2013. Health Care Investigations presentation by Karen Matthew and Agent Bruce DiVincenzo.

1. Health
Care
Inves.ga.ons
Karen
Ma3hew
Director
of
Inves.ga.ons
and
Inspec.ons,
North
Carolina
Department
of
Pharmacy
Agent
Bruce
DiVincenzo
Delaware
State
Police
Drug
Diversion
Unit

2. LEARNING
OBJECTIVES
–
1. List
signs
of
diversion
in
a
health
care
facility.
2. Outline
how
to
collaborate
with
clinicians
to
prevent
diversion.
3. Demonstrate
effec.ve
use
of
PDMP
by
law
enforcement
within
a
pharmacy.

3. Disclosure
Statement
• Karen
MaRhew
has
no
financial
rela.onships
with
proprietary
en..es
that
produce
health
care
goods
and
services.
• Bruce
DiVincenzo
has
no
financial
rela.onships
with
proprietary
en..es
that
produce
health
care
goods
and
services.

4. Health
Care
Facility
Diversion
Karen
MaRhew
April
2,
2013

5. WHAT
IS
DRUG
DIVERSION?
The
channeling
of
controlled
substances,
which
are
legally
manufactured
&
intended
to
be
used
legi.mately
for
medical
&
therapeu.c
needs
by
a
license
prac..oner,
pharmacist,
hospital,
nursing
home
or
medical
research
center,
to
an
illegal
use,
whether
it
be
for
personal
use
or
for
illegal
distribu.on
to
another
person.

6. IN
OTHER
WORDS……
Diver.ng
legi.mate
Drugs
for
illicit
or
illegal
purposes.

7. WHAT
DOES
HEALTH
CARE
FACILITY
MEAN?
• Hospitals
• Nursing
Homes
• Assisted
Living
Facili.es
• Group
Homes
• Clinics
• Physicians’
offices,
other
facili.es.

8. WHO
COMMITS
DIVERSION?
ANYONE!!

9. MORE
SPECIFICALLY:
• PRESCRIBERS
–
MD,
DO,
DDS,
DMD,
Vet,
DPM,
NP,
RN
PA,
CPP
• DISPENSERS
–
RPh.,
Tech,
Clerk,
Other
employees
• ADMINISTRATORS
–
RN,
LPN,
NA,
CMA,
CNA,
Med
techs
• OTHERS
–
who
have
access
through
employment
or
obtain
access

10. WHAT
IS
DIVERTED?
• High
Priced
Medica.ons
such
as
Erec.le
Dysfunc.on
Drugs,
Chemotherapy
,
etc.
• Drugs
Easily
Abused
–
Oxycodone,
Hydrocodone,
Morphine,
Fentanyl,
Dextroamphetamines,
Benzodiazepines
• Any
Type
of
Medica.on

11. THE
“WHYS”
OF
DIVERSION
• Addic.on
• Facilitate
the
addic.on
of
others
• Pseudoaddic.on
• To
sell
for
money
• To
provide
to
others,
par.es,
etc.
• Cost
of
prescrip.on
drugs
• To
facilitate
sexual
acts,
assaults,
etc.
• Every
reason
one
can
think
of

12. DRUG
FLOW
INTO
HEALTH
CARE
FACILITIES
CRADLE
TO
GRAVE
APPROACH

13. DRUG
FLOW
• Manufacturer
–
Wholesaler
(Pharmaceu.cal
Company)
Broker
Distributor
• Courier
Service
–
Delivery
to
the
Health
Care
Facility

14. DRUG
FLOW
• Health
Care
Facility
–
Pharmacy
Materials
Management
• Closed
Door
Pharmacy
–
Directly
into
ins.tu.on

15. DRUG
FLOW
Once
in
a
Hospital
:
-­‐
Inventoried
&
Stocked
in
Pharmacy
-­‐
Placed
onto
shelves/cabinets,
etc.
-­‐
Automated
Dispensing
Units/robots
-­‐
Vaults

16. DRUG
FLOW
Drugs
are
sent
out
of
the
pharmacy
-­‐
Based
on
Dr.
Order
-­‐
to
Basic
stock
-­‐
Nursing
Units
-­‐
Pa.ent
Areas
-­‐Specialty
Areas
(surgery,
CT
labs,
ED)
-­‐Outpa.ent
-­‐off-­‐site
areas

17. DRUG
FLOW
Once
a
drug
is
sent
out
of
the
pharmacy,
It
is
administered
according
to
the
Policy/procedure
of
the
ins.tu.on.
Example
–
Automated
Dispensing
Machines
Medica.on
Administra.on
Record
(MAR)

18. DRUG
FLOW
• Waste
–
pa.ent
refusal,
leh
over,
expired,
contaminated.
• Legally,
if
a
drug
is
signed
out,
it
must
be
administered
or
wasted.
May
be
returned
to
stock
under
ins.tu.onal
Policy,
state
law,
etc.

19. DRUG
FLOW
INTO
OTHER
FACILITIES
Nursing
Home
flow
is
similar
to
hospitals
except
they
Contract
with
LTC
pharmacies
or
retail
pharmacies
to
Provide
drugs
–
normally
pa.ent
specific

20. DRUG
FLOW
• Some
nursing
homes
&
other
facili.es
now
u.lize
automated
dispensing
machines.
(If
controlled
substances
are
administered,
need
DEA
registra.on
&
Board
permit).
• Other
nursing
homes
u.lize
medica.on
carts
• Some
use
unit
dose
carts,
pa.ent
specific
• Medica.ons
administered
to
pa.ents
by
RNS,
LPNS,
med
techs,
CNAs,
etc.

21. WHERE
DOES
DIVERSION
TAKE
PLACE?
ANYWHERE
WHERE
DRUGS
ARE
STORED

22. START
AT
THE
BEGINNING
Courier
Service:
Package
Disappears
Packages
are
not
sealed
completely
(altered)
Packing
is
different
than
past
deliveries
Change
in
delivery
schedules
Personnel
ac.ng
differently

23. NOW
WHAT?
Couriers
are
aware
they
are
delivering
drugs.
Ensure
there
are
good
tracking
systems
from
wholesaler
to
facility.
Once
package
is
delivered,
contents
need
to
be
inventoried
immediately
against
invoice/manifest.

24. DRUGS
ARRIVE
IN
THE
FACILITY
• Drugs
should
be
inventoried
&
stocked
as
soon
as
soon
as
possible.
• Whether
placed
in
an
automated
dispensing
machine,
medica.on
cart
or
vault,
they
should
be
stocked
immediately
to
help
cut
down
on
diversion.

25. TYPES
OF
DIVERSION
Diversion
in
a
pharmacy
of
a
health
care
facility
is
normally
commiRed
by
pharmacists
&
technicians.
Pharmacists
will
divert
from
automated
dispensing
machine,
vault,
when
preparing
or
mixing
medica.ons.
Technicians
ohen
divert
when
checking
in
deliveries,
stocking
the
pharmacy,
coun.ng
out
meds,
stocking
floor
units,
taking
return
meds
in
the
pharmacy.

26. WHO
DIVERTS
DRUGS
ON
FACILITY
UNITS?
• Nurses
–
RN,
LPN
• CNA,
CMA
• Physicians,
although
they
do
not
have
as
much
access
as
other
staff
• Anesthesiologists,
CRNAs
• Therapists,
surgery
techs,
others

27. NURSES
Addicted
Nurses
are
one
of
the
Most
widely
diverters
of
medica7ons
In
health
care
facili7es.
Few
facili7es
are
exempt
from
this
Problem.
More
cases
since
#
of
nurses
are
More
than
Rphs
or
techs.

28. DIVERSION
BY
NURSES
• Frequent
sign
outs
• Frequent
was.ng
• Subs.tu.on
• Dilu.on
• PCA
–
PT
Controlled
Administra.on
• IV
Drips
• Fentanyl
patches

29. DIVERSION
BY
NURSES
• Trash
• Sharps
Containers
• Destruc.on
• Restocks
• Signouts
for
Discharged
Pa.ents
• Documenta.on
Issues
• Stealing
from
Automated
Dispensing
machines
• Pa.ent
complaints
–
no
relief
for
pain,
etc.

30. ISSUES
SPECIFIC
TO
NURSING
HOMES
• Storing
of
Delivered
Medica.ons
• Medica.on
Counts
at
Change
of
Shih
• Punch
outs
on
Unit
Dose
cards
• MAR
changes
• Expired
medica.ons,
leh-­‐over
pa.ent
medica.ons
• Falsifying
orders
• Subs.tu.on
of
medica.ons
• Pa.ent
complaints

32. CHARACTERISTICS
Job
Performance
Employment
History
Changes
in
Behavior/Moods
Appearance
Quality
of
Employees
Documenta.on
Issues
Working
Over.me
or
Offers
to
Do
So
Taking
over
others’
pa.ents
Showing
up
when
not
on
duty
Check
&
Balance
on
medica.ons
Policies/procedures

33. WHAT
CAN
BE
DONE?
• Collabora.on
between
health
care
professionals
and
law
enforcement
• Training
for
all
staff
in
health
care
facili.es
on
diversion
&
what
to
look
for
• Good
policies
&
procedures
in
place
• Zero
tolerance
for
diversion
in
health
care
facility
–
Pa.ent
Safety
is
Utmost!
• Referral
of
employee
to
employee
assistance
program

34. WHAT
CAN
BE
DONE?
• Background
Checks
including
criminal
history
• Verifying
License
Informa.on
with
Regulatory
Boards
• Checks
&
Balances
of
En.re
Medica.on
Flow
• Inventorying
of
Drugs
at
all
Levels
• Use
of
Biometric
measures
on
automated
devices
• Random
Drug
Tes.ng
• Random
Review
of
Drug
flow
to
determine
weak
points
• Check
of
expired
drugs,
return
to
stock

35. WHAT
CAN
BE
DONE?
• Rigorous
Security
Measures
• Think
of
Drugs
as
Money!
• Close
Observa.on/Supervision
of
Employees
Handling
Medica.ons
• Training
for
all
employees
• Preven.on
is
best
measure
• Always
look
for
new
systems
such
as
bar
coding,
etc.

36. USE
OF
PDMP
• NC
has
had
PMP
(CSRS)
for
almost
4
years
• Only
@
28%
of
all
prescribers
signed
up
• Less
than
26%
of
Rphs
signed
up
• Useful
tool
to
check
for
doctor
shoppers,
forgers,
etc.
• Some
pharmacies
do
not
have
internet
access
• Cannot
provide
to
law
enforcement
in
NC
• Board
has
limited
access

37. Limita.ons
of
PMP
• Only
as
good
as
data
sent
in
from
pharmacies
• In
one
review
of
pa.ent
informa.on
on
prescrip.ons,
20%
informa.on
was
incorrect
prescriber,
drug,
etc.
• In
NC,
limita.ons
on
info
on
prescribers
who
are
“over-­‐prescribing”
• No
access
by
local
law
enforcement
• Changes
being
reviewed
now
• No
mandatory
use
by
prescribers

38. Contact
Informa.on
Karen
MaRhew
Director
of
Inves.ga.ons
&
Inspec.ons
NC
Board
of
Pharmacy
919-­‐246-­‐1050
kmaRhew@ncbop.org

39. QUESTIONS?

40. Collabora.on
with
Pharmacists
to
Prevent
Diversion
Through
Use
of
the
PDMP
April
2
–
4,
2013
Omni
Orlando
Resort
at
ChampionsGate

41. Learning
Objec.ves
• What
law
enforcement
can
do
to
encourage
collabora.on
with
pharmacists
to
reduce
diversion
at
the
pharmacy
counter.
• Learn
from
several
examples
how
the
PDMP
when
used
by
pharmacists,
can
aid
law
enforcement
in
improving
inves.ga.ve
outcomes.

42. Disclosure
Statement
Agent
Bruce
DiVincenzo
has
no
disclosed
no
relevant,
real
or
apparent
personal
or
professional
financial
rela.onships.

43. • Review
nine
(9)
minute
video
concerning
crimes
occurring
at
the
pharmacy
counter
and
how
the
ac.ons
taken
by
pharmacy
staff
can
aid
law
enforcement
in
the
reduc.on
of
diversion.
• Diversion
which
occurs
at
the
pharmacy
counter
is
vastly
underreported.
Law
enforcement
can
aid
in
improving
this
outcome.
My
PERSONAL
belief
is
that
the
problem
is
HUGE.
Unless
an
agency
becomes
involved
on
a
regular
basis
in
the
inves.ga.on
and
prosecu.on
of
these
crimes,
the
amount
of
drug
diversion
occurring
at
the
pharmacy
counter
will
remain
a
significant
source
of
diverted
controlled
drugs
which
con.nue
to
devastate
our
communi.es.
You
just
don’t
know
un.l
you
look!!

44. • Pharmacy
crimes
–
Forgery,
Doctor
and
Pharmacy
shopping.
These
crimes
are
underreported,
and
in
many
metropolitan
areas
not
inves.gated
at
all.
Significant
amounts
of
diverted
drugs
are
the
result.
• Educate
the
clinicians
about
the
law
(code
and
statute
)
that
governs
your
jurisdic.on.
Assist
them
and
work
together
for
the
reduc.on
of
diverted
drugs
in
your
community.
Work
to
increase
repor.ng!
Examples
from
experience
–
3
Friday
nights
in
a
row!

45. • The
video
is
our
effort
in
DE
to
let
the
clinician
know
what
evidence
is
used
by
prosecutors.
Discuss
trial
probability
-­‐
minimal.
Pharmacists
provide
many,
if
not
most
of
the
leads
provided
to
law
enforcement
in
DE.
Pharmacists
working
together
with
law
enforcement
can
make
a
difference.
Example
–
we
don’t
have
that.
• Climate
Change
–
What
I
have
learned
from
pharmacists
about
the
change
resul.ng
from
the
increase
in
drug
seeking
crimes
and
the
effect
this
has
on
medical
prac..oners.
Never
experienced
such
behavior
by
alleged
pa.ents.

46. • The
amount
of
drugs
diverted
by
a
single
defendant
–
Delaware
County
PA
and
New
Castle
County
DE
2010
to
2012
-­‐
25,000
dosage
units
Percocet
10/325.
• A
pre-­‐PDMP
inves.ga.on.
Discuss
M/O.
Ini.ally
report
to
us
by
a
dedicated
pharmacist

47. • Use
of
PDMP
-­‐
Examples
of
actual
cases
where
the
PDMP
is
effec.ve
in
providing
leads
to
law
enforcement:
• 1.
Aids
in
determining
the
extent
of
the
forgeries
occurring.
Recent
–
Dr
S…..
• 2.
Iden.fy
the
ac.vity
of
a
doctor
shopper.
Reported
by
another
dedicated
pharmacist.
Involved
doctors
in
two
states.
Ongoing
case….

48. • 3.
Counterfeit
scripts
-­‐
Phila
Hospital
-­‐
PDMP
Administrator
checked
further
aher
viewing
writer’s
alert
and
provided
other
leads
based
on
address
of
hospital.
Ongoing
case……
4. Extent
of
damage
-­‐
NY
script
case.
Crime
occurs
in
DE,
scripts
filled
also
in
NJ
and
PA
and
North
Carolina.
PDMP
aided
in
determining
where
the
suspects
had
been.
Also
Brooklyn
suspects
in
DE
and
Pocono
area
of
PA.
Ongoing
case…..

49. • The
PDMP
is
a
valuable
aid
in
the
prosecu.on
of
criminals
involved
in
the
diversion
of
controlled
substances.
• It
is
the
presenter’s
hope
that
government
issued
photo
ID
will
be
a
required
part
of
the
data
captured
in
every
transac.on
involving
the
dispensing
of
a
controlled
substance.
Prosecu.ons
are
made
possible
and
some.mes
enhanced
by
the
inclusion
of
this
ID
informa.on
as
part
of
the
PDMP
data
and
most
difficult
to
begin
without
this
ID
informa.on.
• The
PDMP
remains
a
work
in
progress.
For
addi.onal
reading
on
where
this
process
is
heading,
please
review
the
wri.ngs
from
Brandeis
University
on
this
topic.
Excellent
source.

50. • Thank
you
for
your
aRen.on.
I
do
hope
that
I
provided
informa.on
you
find
helpful
in
your
work
in
your
jurisdic.on.
• If
there
are
any
ques.ons
here
or
even
later,
I
am
always
glad
to
discuss
any
ques.ons
you
may
have.
• Thank
you
to
Opera.on
Unite
for
invi.ng
me
to
speak.
I
am
thankful
for
your
good
work
and
learn
a
great
deal
from
my
.me
here.