Strong Management Pain Provider, Law Enforcement Partnerships Needed

LAS VEGAS — In the United States, approximately 1900 drug-related emergency department visits occur every day, accounting for an estimated $3.8 million in related healthcare costs1 — staggering numbers that still fall short of conveying the human toll of illicit drug use. 

Better partnerships between healthcare providers and law enforcement officers can help ensure that criminal activity related to prescription pain medications is more effectively communicated to better stop perpetrators in their tracks.

Marc Gonzales, PharmD, a training and education coordinator at the National Association of Drug Diversion Investigators (NADDI), explained the various manners in which prescription pain medications stray from the purview of patients who need them the most to the illicit drug market during his session, Scammers, Shammers, & Thieves. “You will be amazed at the lengths people have gone to in an effort to divert drugs,” he said.

From unethical providers to doctor-shopping patients and internet pharmacies, Dr. Gonzalez outlined the myriad ways determined individuals obtain controlled substances using fraud, deceit, and subterfuge.

There are several tell-tale signs of fraudulent practitioners: crowded waiting rooms that require code words for entry, multiple patients to an examining room, practices that do not accept new patients, and clinicians who write prescriptions in fewer than 4 minutes without even performing an examination. 

Other examples of “pill mills,” or clinics where physicians sell narcotics directly to people for cash, include clinics where patients ask for specific drugs and receive them, those that direct patients to particular pharmacies to have their prescriptions filled, those that bill patients by the prescription instead of by the office visit, and still others that charge patients additional “administrative fees” for writing prescriptions. 

The problem also persists in the absence of fraud on the part of healthcare providers. Clinicians whose practices are ethically sound still have reason to worry about patients who “doctor shop” and who are willing to travel far distances and across state lines to illegally obtain prescription pain medications. In some documented cases, individual patients have visited nearly 200 clinicians and slightly more than 100 pharmacies in a single year.

Citing an Associated Press article, Dr. Gonzalez detailed the actions of a 60-year-old Medicaid patient who was seeing multiple doctors to obtain prescriptions for narcotic OxyContin and then selling those pills to a dealer for as much as $1000. Medicaid is billed approximately $1000 for a 60- to 80-pill prescription and another $23 to $39 for the cost of each clinic visit.

Findings from a 2009 US Government Accountability Office report indicate that Medicaid pharmaceutical fraud in just 5 states—California, Illinois, New York, North Carolina, and Texas—cost taxpayers an estimated $63 million dollars.2

When these patients exhaust real-world options, yet another opportunity exists: online pharmacies. The lack of regulation in this marketplace poses a new threat to consumer safety in the form of counterfeit or mislabeled medications.

“The transnational sale of prescription drugs through online pharmacies mirrors traditional drug dealing, with the drugs delivered via mail rather than in person and transactions being executed using services such as PayPal, Green Dot, and Western Union,” Dr. Gonzales reported. 

The National Association of Boards of Pharmacy (NABP) reviewed 7541 internet pharmacies and deemed only 258 “potentially legitimate.” Only 1% of those reviewed were accredited as an NABP Verified Internet Pharmacy Practice Site.3 

How Can Clinicians Protect Themselves?

By taking a proactive role in liaising with local law enforcement officials to report prescription opioid abuse, diversion, and fraud when they see it, healthcare practitioners can better protect themselves against drug diversion investigations. 

In his community in California, Dr. Gonzales partnered with the Ventura County Interagency Pharmaceutical Crimes Unit to improve the way clinicians and members of law enforcement communicate. He and the narcotics agent who heads the unit met with every pharmacy and clinic in the county to disseminate brochures and information about antidiversion programs and to establish a tip hotline that clinicians could call to report suspicious behavior and activity. Area pharmacies that were part of the program displayed posters indicating their partnership with the crimes unit to deter potential perpetrators.

“Clinicians feel very comfortable now that they have this type of communication with law enforcement. When diversion happens, healthcare practitioners feel violated. Yes, we may get duped, but now we have a means to report these people,” said Dr. Gonzales.

The outreach program also extended beyond educational programs for clinicians and pharmacists to encompass local schools, parents, and teachers. “The unit in Ventura County is very progressive. They believe that if you need to report patients, then they have larger treatment issues and should be treated for addiction, not just incarcerated,” Dr. Gonzales said. 

In addition to interacting proactively with members of law enforcement and the community, he recommended healthcare practitioners adopt several other practice policies, including obtaining thorough drug histories for patients, establishing a policy that no patient receives a pain prescription on the first visit, and hiring an administrative assistant specifically to communicate with the pharmacy and regulatory agencies about any questions that may arise.

“Tell the pharmacy, ‘Here’s the phone number to call. I guarantee this information will get to me.’ This will keep regulatory out of your office,” said Dr. Gonzales. “When they try to contact a provider and there is no answer, they will call the medical board, which is mandated by the legislature to open an investigation.”

By following these steps, if a problem does arise, the clinician has already established him- or herself as someone who goes above and beyond the community standard for an ordinary reasonable practitioner. 

“Word gets out on the street. Those actively engaged in drug diversion know the easy marks, what they can get away with, who is on your staff, the layout of your office, and if you keep drugs there,” Dr. Gonzales warned. “You should make an effort to know a lot more about them.”

Opening up clear lines of communication with law enforcement agencies and establishing themselves as proactive members of a community that fights these types of illicit behavior will help healthcare practitioners ensure that the appropriate authorities are attuned, receptive, and ready to act when assistance is needed. 


  1. Xiang Y, Zhao W, Xiang H, Smith GA. ED visits for drug-related poisoning in the United States, 2007. Am J Emerg Med. 2011;30(2):293-301.
  2. US Government Accountability Office. Medicaid: Fraud and Abuse Related to Controlled Substances Identified in Selected States. GAO-09-957.  Available at: Accessed August 17, 2015.
  3. Levine G. Rx drug abuse in the United States: the contributing role of rogue internet drug outlets.  Available at: Accessed August 17, 2015.