1. 2012 Nevada Drug Summit
Tactical Diversion Investigations
and
The Connection to Heroin
Jeff Kallal
SupervisorySupervisor
Drug Enforcement Administration
Las Vegas, Nevada
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

2. DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

3. DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

4. Objectives
To understand how doctors and pharmacists
contribute to the amount of prescription pills
available in the illegal market
To recognize that opioid use can lead to
heroin addiction
To recognize the red flags involved in this
activity
To understand why it’s important to stem the
tide of illegal prescription pill distribution
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

5. Prescription Drug Abuse: A National
Crisis
6.1 million Americans 12 or older were
current users of prescription-type
psychotherapeutic drugs without medical
necessity
Prescription painkillers kill more people than
cocaine, heroin, and methamphetamine
combined
Seven of the top 10 drugs abused by high
school seniors are sold in pharmacies
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

6. Prescription Drug Abuse: A National
Crisis
Estimated cost of CPD diversion and abuse to
public and private medical insurers is $72.5
billion a year
33 percent of all US traffic fatalities involve
drug users
18 percent of motor vehicle driver deaths
involve drugs
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

7. Trends from
Across the
Nation
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

8. Ohio’s Drug Epidemic
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

9. South Florida’s Blight
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

10. Georgia on the Mind of Drug Dealers
“A worrisome new kind of drug dealer is gaining
a toehold in Georgia after fleeing crackdowns
in surrounding states, setting up in bedroom
communities northwest of Atlanta along I-75
to serve customers near and far”
Atlanta Journal-Constitution
July 9, 2011
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

11. Crisis on Long Island
16 Pharmacy robberies on Long Island from
October 2008 to July 2011
Armed robberies of pharmacies in NY state
increased 1400% in four years
Oxycodone prescriptions filled in Nassau and
Suffolk counties increased 46% from 2008 to
2010
Admissions to LI certified treatment programs
are up 26% in one year
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

12. Opioid Deaths: “The Real Orange
County”
80 accidental opioid-related deaths for South
[Orange] County and beach cities from 2007-2010
for people 24 and younger
“In a part of the world know for fun in the sun – and
money – teens and young adults are getting
wrecked on opioid-class prescriptions, and
especially heroin, like never before”
David Whiting, Columnist
The Orange County Register
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

13. Prescription Drug Threat in Nevada
CPD abuse contributed to more drug-related
deaths in Clark County than any other abused
substance
The most widely available and commonly
abused CPDs are opioids and depressants
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

14. Prescription Drug Threat in Nevada
The increasing distribution and abuse of CPD
pose a significant threat to Nevada
Nevadans consume about twice the national
average per capita of prescription narcotics
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

15. Prescription Drug Threat in Nevada
Las Vegas is a popular source destination for
CPDs
– Widely considered most prolific source destination in
Western region
California, Arizona, Utah, Colorado, Oregon, and
Washington
– Case intelligence also shows individuals travelling
from all over the United States
Alaska, Connecticut, Kentucky, Louisiana,
Massachusetts, Ohio, Tennessee, and Texas
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

16. Drug-Related Deaths Clark County
2006 v. 2011
Drug 2006 2007 2008 2009 2010 2011
% Change
CPDs 165 336 338 262 290 364 120%
Cocaine 115 58 39 44 29 68 -40%
Methamphetamine 80 56 34 55 56 107 33%
Heroin 35 45 17 8 5 33 -5%
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

17. Commonly Abused Opioids
Oxycodone (Schedule II)
– OxyContin is a brand name of a time
release version of oxycodone
– Users are susceptible to dependence
and tolerance within one to two weeks
Methadone (Schedule II)
 Morphine (Schedule II)
 Hydrocodone (Schedule III)
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

18. DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

19. Oxycodone
Many ways to abuse Oxycodone tablets:
- Orally
- Snorted
- Injected
- Smoked
Many users go through a transition:
- Other “pills” (Hydrocodone, Alprazolam, etc. are often mixed with
Oxycodone to make different “pharmaceutical cocktails” based
upon the abusers addiction.
- Heroin (Prescription drug abusers transition to heroin because it is
a cheaper and stronger ”high”)
- Transition occurs because 1 oxycodone tablet costs $25 to $40 vs.
1 gram Heroin $40
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

20. OxyContin ® v. Heroin
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

21. DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

22. Cheaper heroin gives rise to new set of users
Atlanta Journal-Constitution
Heroin is mounting a comeback, appealing to a younger, more diverse
audience than ever before, experts say…
They’re driven by cost, he said. Heroin is much cheaper than, say, an
OxyContin tablet, which typically sells for $30.
“A lot of young kids start on grandma’s Percocets and they get hooked.”
said Lee, adding that prescription painkillers often serve as a gateway to
heroin use.
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

23. DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

24. Delco task force tackles heroin plague
September 09, 2012 By Mari A. Schaefer, Inquirer Staff Writer
Alarmed by a surge in heroin deaths, Delaware County officials
joined together for the first time Friday to attack a problem they see
devastating families and communities. There were 33 heroin-
related deaths in the county in the first six months of the year.
In 2011, there were 62 deaths, and in 2010 there were 50, said
Frederic Hellman, the county's medical examiner and a member of a
task force newly appointed to address the issue.
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

25. Southern California OxyContin Abusers
Switching to Heroin
By StopOxy
Monday,February 27th, 2012
Drug treatment officials in San Diego County recently reported that
the use of heroin by young adults has more than tripled since 2006.
According to Susan Bower, director of San Diego County Alcohol and
Drug Services, the increase in heroin use is “scary.” Admissions for
heroin addiction now account for nearly one in five of all treatment
admissions at facilities operated by the county.
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

26. Commonly Abused Depressants
Carisoprodol = Soma
(Schedule IV)
Clonazpam = Klonopin
(Schedule IV)
 Diazepam = Valium
(Schedule IV)
Alprazolam = Xanax
(Schedule IV)
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

27. Commonly Diverted Pills
Oxycodone Xanax (alprazolam) Lortab (hydrocodone)
Methadone Valium (Diazepam)
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

28. Pharmaceutical Cocktails
“Vegas” Cocktail Holy Trinity
- Hydrocodone - Oxycodone
- Alprazolam - Alprazolam
- Carisoprodol - Carisoprodol
These dangerous combinations are highly sought
after by Rx abusers and those in the night club
scene. The abusers ingest the pills simultaneously,
commonly with alcohol to increase the pills effects.
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

29. Methods of Diversion
Practitioners / Pharmacists
- Illegal distribution
- Self abuse
- Trading drugs for sex
Employee pilferage
- Hospitals
- Practitioners’ offices
- Nursing homes
- Retail pharmacies
- Manufacturing / distribution facilities
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

30. Methods of Diversion
Pharmacy / Other Theft
- Armed robbery
- Burglary (Night Break-ins)
- In Transit Loss (Hijacking)
- Smurfing
Patients / Drug Seekers
- Drug rings
- Doctor-shopping
- Forged / fraudulent / altered
prescriptions
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

31. Methods of Diversion
The Medicine cabinet / Obituaries
The Internet
Rogue Pain Clinics
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

32. The Practice of Good Medicine
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

33. The Practice of Bad Medicine
No exam or brief exam where doctor may not
even touch the patient
No equipment in the office
The doctor may be the only medical staff;
other workers may be clerical staff only
Doctors see excessive numbers of patients in a
work day
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

34. Results of Bad Medicine
Increased pills on the streets
More addicts in the community
Increased crimes
Overdoses and deaths
Increased cost of legitimate medical care
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

35. Drug Dealers?
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

36. Who
we
are!
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

37. Tactical Diversion Mission
The Tactical Diversion Squad (TDS) program
combines the resources of DEA with State and
local law enforcement agencies in an
innovative effort directed at doctor shoppers,
prescription forgers, and prevalent retail-level
violators. Physicians and pharmacies involved
in retail diversion schemes are also targeted
based on information developed by the TDS.
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

38. Las Vegas Tactical Diversion Squad
Participants
• Drug Enforcement Administration
• Las Vegas Metropolitan Police
Department
• Nevada Highway Patrol
• North Las Vegas Police Department
• Henderson Police Department
• Federal Bureau of Investigation
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

39. Pills are sold on the streets or used by the
addicts = Diversion
(Criminal act of illegal distribution)
21 USC 841 (a)(1)
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

40. Federal Criminal Charges
Related To Prescription Drugs
Federal Criminal Code and Rules
Controlled Substances Act (CSA)
Title 21 – Food and Drugs Chapter 13 – Drug Abuse
Prevention and Control
Part D – Offenses and Penalties § 841 through § 865
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

41. State Criminal Charges
Related to Prescription Drugs
Nevada Revised Statutes:
NRS 453.321: Sales of Controlled Substances
NRS 453.339-5: Trafficking in Controlled Substances – Schedule II
NRS 453.331: Unlawful Acts relating to Distribution of Controlled Substances
by Registrants i.e. signing blank Rx pads in advance.
NRS 453.381: Limitations on prescribing, possessing, administering,
transporting, and dispensing controlled substances ** only prescribe or
administer Controlled substances for legitimate medical purposes and in the
usual course of professional practice.
NRS 453.333: Penalties for making available controlled substances that cause
death. Imprisonment/ Fines/ Forfeitures.
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

42. Rules and Regulations
Governing Registrants
Code of Federal Regulations (CFR)
Title 21 - Food and Drugs, parts 1300 – End
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

43. What
we
look
for!
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

44. Commonly
Abused
Prescription
Drugs
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

45. Oxycodone
Powerful synthetic opiate legally used in long
term pain treatment
Many forms of Oxycodone: from 5mg to 80mg
tablets, including immediate release to controlled
release properties. Now comes in a liquid form as
well
Roxies, Percocet, Big Boys, Oxies, Oxy 80s, “O”
Rings
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

46. Oxycodone
Schedule II drug – high abuse potential and high
physical dependence
Schedule II substances carry the highest penalty
in sentencing guidelines
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

47. Street Prices
 $2- $4 – Diazepam (Valium) 5mg
 $2- $4 – Alprozolam (Xanax) 2mg
 $3- $5 – Hydrocodone (Vicodin) 10mg
 $25 - $40 – Oxycodone (Oxycontin) 30mg
 $25 – Morphine Sulfate (MS Contin) 60mg
 $ 5 – Methadone 10mg
Ex. 100 OxyContin 30mg weighs approx. 28 grams
and has the street value=$2,500 to $4,000
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

48. Types of Violators
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

49. Tactical Diversion Targets
Not all targets are DEA Registrants
Doctors : medical and osteopathic
Nurse practitioners
Physician Assistants
Medical Assistants
Dentists
Pharmacies
Pharmacists
Pharmacy Technicians
Patients
Drug distributors
Doctor shoppers
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

50. Cases Against Dirty Doctors and
Pharmacists
 Our investigations begin with information
on the doctor’s and pharmacy’s practices
 Intelligence from various sources
Information from database checks
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

51. Our Sources of Information
Complaints
Citizens
Coroner/Medical Examiner’s Office
Licensing boards
Documents/Databases
Prescription reports
Other information
Ordering habits
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

52. Additional Sources of Info
Former/current patients and customers
Former/current employees
Anonymous tips
Family members of patients who have died
Other law enforcement agencies
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

53. Red Flags
Pill transactions taken place in pharmacy
parking lot
Long lines at the office and the pharmacy
Groups traveling together to appointments
and pharmacy
Vehicles ‘camping out’ in parking lot
Office open for “unusual” number of hours --
either really short hours or into the night
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

54. Red Flags
Carloads of people drive across multiple states to
get pills / out of state tags in lot
Doctor offers to write prescriptions in pharmacy
parking lot; pharmacist is asked to fill them
without asking questions
Doctor and a pharmacist-in-charge agree to refer
“patients” back-and-forth; patients sign
agreement in doctor’s office to go to specific
pharmacy (kickbacks paid to doctor)
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

55. Red Flags
Patients report that doctor has them fill the
prescription and bring some of the pills back to
him
Doctor writes prescriptions in exchange for work
or other favors
Patients bring family and friends to doctor-they
all get the same prescriptions
Fee for visit ($100-$400) cash is paid directly to
doctor when prescription is written
Sliding Pay Scales
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

56. Successes
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

57. Las Vegas doctor charged with illegally
distributing prescription drugs:
Las Vegas doctor who advocates medical
marijuana therapy has been charged with
illegally distributing prescription drugs. Federal
agents arrested James Tinnell, 73, on Tuesday.
He appeared Wednesday before U.S. Magistrate
Judge Lawrence Leavitt and was released on his
own recognizance.
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

58. Las Vegas doctor among 3 indicted in
oxycodone ‘pill mill’ case:
Federal authorities have indicted a Las Vegas
doctor, his unlicensed medical assistant and an
alleged conspiring pharmacist in connection
with illegally distributing painkillers. Dr. Henri
Wetselaar, 87, David Litwin, 52, and Jason C.
Smith, 43, each have been charged with one
count of conspiracy to distribute oxycodone.
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

59. Another Las Vegas doctor arrested in
prescription drugs case:
Another Las Vegas physician has been arrested in a
federal crackdown on prescription drug abuse. A
federal indictment unsealed Wednesday charged
Sebastian M. Paulin Jr. with six counts of distribution of
controlled substances, four counts of money laundering
and one count of structuring transactions to evade
reporting requirements. The government also is
seeking forfeiture of $1.2 million. Paulin, 65, was taken
into custody on Wednesday and then released on his
own recognizance.
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

60. Vegas doctor arrested for illegally
dispensing drugs and burglary:
A Las Vegas doctor has been arrested on numerous
charges including burglary and illegally prescribing and
dispensing drugs. 51-year-old Dr. James Eells was
arrested last Thursday on dozens of counts for each
charge. It is alleged that Dr. Eells wrote at least 41
prescriptions for his brother-in-law, Todd Hallenbec,
from Jan. 2010 through June 2011. The prescriptions
were for oxycodone, methylin, methylphenidate,
carisoprodol, and alprazolam. Upon arrest, Eells told
police he does not have a license to dispense drugs and
the prescriptions were intended for the treatment of
indigent patients.
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

61. Las Vegas Doctor Accused of Selling
Drugs:
The I-Team has uncovered that a prominent
hospital doctor was arrested for illegally selling
thousands of powerful painkiller drugs. The
doctor, who at one time was the Chief of
Internal Medicine at Centennial Hills Hospital,
was snagged in an undercover drug sting.
Federal drug enforcement agents say Dr.
VinayBararia sold nearly $50,000 worth of
oxycodone painkillers.
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

62. What You Don’t See In The News Paper
• Civil penalties up to a million dollars
• Seizures of assets, to include real estate and
financial accounts in excess of four million
dollars
• Revocation of DEA Registration and
applicable State Licensing
• Legal Fees
• Embarrassment and distrust amongst your
associates
• Loss of livelihood
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

63. Challenges
Criminal cases against doctors
are complicated, time-consuming
and require much greater
resources than typical drug
investigations. Prescription drugs
are, after all, legal.
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

64. Challenges
“Halo Effect”
Political influence
Social standing
Highly regarded professions
Powerful professional organizations
Halo Effect” results in lenient
prosecution
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

65. Challenges
Manpower
-Budget restraints across Federal, State, &
Local Law Enforcement limit required
resources to address epidemic
Complex Investigation
-Learning curve for investigators
Expensive
-Medical expert fees $300 plus an hour
-Expense of multiple Undercover visits
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

66. Our Tools for Success!
Criminal Investigations
Civil Penalties
Administrative Sanctions
Education
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

67. We don’t want Nevada to be the next
South Florida!
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

68. Our Goal: Put the criminals away!
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

69. The Way Ahead
Foster collaborative investigative efforts
Dismantle the practices of dirty doctors,
pharmacists and their criminal networks in
Nevada
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V

70. WWW.DEADIVERSION.USDOJ.GOV
Jeff Kallal Jayne Tomko-Griffin
Supervisory Special Agent Diversion Group Supervisor
(702) 759-8068 (702) 759-8111
Jeffrey.G.Kallal@USDOJ.GOV Jayne.M.Tomko@USDOJ.GOV
Jennifer Zavestoski
Registration Program Specialist
(702) 759-8202
Jennifer.N.Zavestoski2@USDOJ.GOV
DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V