Drug Diversion Awareness PRESENTED BY JACKSONVILLE SHERIFFS OFFICE

Drug Diversion Awareness PRESENTED BY: JACKSONVILLE SHERIFF’S OFFICE: DETECTIVE WAYNE HESTER DETECTIVE DONNIE SLAYTON

DISCLAIMER The views and opinions expressed by any individuals during this presentation are that of the speaker’s and do not necessarily represent the views, opinions, or positions of the Jacksonville Sheriff’s Office, North Florida HIDTA, or any of its subsidiary programs or divisions, nor of the Annual Primary & Cardiovascular Symposium, it’s board or it’s coordinators. All materials contained herein or otherwise affiliated were produced in good faith for educational purposes for medical personnel. All reasonable efforts have been made to ensure the information contained in these lectures was current and accurate at the time of publication.

Objectives 1) Participant will recount the scope of Rx Opioid drug abuse problem nationally and locally. 2) Participants will list strategies to prevent drug seekers from manipulating participants into helping feed the seeker’s addiction. 3) Participant will list strategies to mitigate diversion opportunities in daily practice.

What is the North Florida HIDTA PDDDS A Federal drug initiative focusing on 13 counties Effectively a task force made up of a variety of agencies PDDDS-One initiative within NFHIDTA directed to address the effects of crimes associated to prescription narcotics FOCUS � Traditional Prescription Drug Investigations v v v Doctor Shopping Obtaining Rx Drugs by Fraud Diversion by Healthcare Professionals � Non-Traditional Prescription Drug Investigations v v Designer Drugs Investigate, monitor and track: q q q Synthetic Drug and Heroin Trends Tracking of New Drug Trends Safety Concerns for First Responders

Differing Agencies and Roles They Play as they relate to healthcare and controlled substances • Local agencies (Sheriff’s Office and local police) -Function is to enforce state laws, protect citizens. Not typically involved in regulatory enforcement • Department of Health – Enforces regulations and rules related to State Issued Healthcare Licensures • FDLE – Florida’s State Criminal Investigative Agency-enforce State Laws • Federal Law Enforcement Agencies (FBI, DEA, FDA) While these agencies may work with local agencies, they primarily enforce Federal laws. • DEA Diversion – Enforce the Controlled Substances Act (CSA) and the Chemical Diversion and Trafficking Act (CDTA) regarding the manufacture, distribution and dispensing of legally produced controlled substances and listed chemicals… See DEA website for more detail

Is Prescription Drug Abuse a Concern? • Approximately 80% of the worlds pain pills are consumed in the U. S. • One person dies in the United States every 19 minutes from a prescription drug overdose • Drug overdose deaths have surpassed vehicle accident related deaths to become the leading cause of accidental deaths in the United States Source – 2011 Congressional Testimony from American Society of Internal Pain Physicians

CDC Data �Each day, more than 1, 000 people are treated in emergency departments for not using prescription opioids as directed. �The most common drugs involved in prescription opioid overdose deaths include: • Methadone • Oxycodone • Hydrocodone https: //www. cdc. gov/drugoverdose/data/overdose. html

CDC Data �The U. S. opioid epidemic is continuing, and drug overdose deaths nearly tripled during 1999– 2014. Among 47, 055 drug overdose deaths that occurred in 2014 in the United States, 28, 647 (60. 9%) involved an opioid. https: //www. cdc. gov/mmwr/volumes/65/wr/mm 655051 e 1. htm

Transfer • • • Heroin abuse is 19 times higher among previous Controlled Pain Drug (CPD) abusers Recent studies show that four out of five Heroin initiates (new users) had previously abused prescription pain pills – not necessarily prescribed While only 3. 6% of CPD abusers switch to Heroin – 79. 5% of Heroin initiates are former CPD abusers DEA website statistics

Heroin Trends in U. S. The number of heroin-related deaths jumped from 5, 925 in 2012 to 8, 257 in 2013 — a 39 percent increase — according to CDC data released in January 2015. The number of persons with heroin dependence or abuse doubled in a decade, increasing from 214, 000 in 2002 to 467, 000 in 2012 National Survey on Drug Use and Health.

Dangerous Heroin Trends • “Hollywood Heroin” – Heroin cut with Fentanyl • Xylazine-Heavy animal sedative being used as a cutting agent for heroin Both are also used independently as a stand alone drug of abuse •

New Problem CDC https: //www. cdc. gov/drugoverdose/data/fentanyl-le-reports. html

Local Statistics Florida Medical Examiner Data � In 2015, Florida Heroin Deaths escalated to 779, a 74% increase from 2014; and a 2, 400% increase from 2010. In addition, Fentanyl deaths increased from 538 to 911 from 2014 -2015…over 69%. � In 2015, North Florida Heroin Deaths rose to 45, a 181% increase from 2014; and a 10, 000% increase from 2010. In addition, Fentanyl deaths increased from 33 to 56 from 2014 -2015…nearly 70%. Year Rx Opioid Deaths Heroin Deaths Fentanyl Deaths FL/North FL 2010 3248/350 48/1 NR 2011 3125/344 57/3 NR 2012 No Data 2013 2361/351 193/14 NR 2014 2514/306 408/16 538/33 2015 3163/355 779/45 911/56 *NR= Not Recorded Source: Florida Department of Law Enforcement (Medical Examiner) - Drugs identified in Deceased Persons Data compiled by Drug Free Duval

Substance Abuse Treatment admissions from July 2015 -June 2016 Source: Florida Department of Children and Families

Jacksonville Fire Rescue Department (JFRD) Reports Jacksonville Fire and Rescue Data o In the past two years, the number of 9 -1 -1 calls for suspected overdose have tripled. o The administration of naloxone (opioid reversal drug) by Paramedics has increased fivefold (399%). o Nearly one-tenth of JFRD’s entire medical supply budget will be spent on naloxone. o In 2015, JFRD transported 1, 903 patients suspected as overdose at a cost of $1, 895, 388. 00. o In 2016, JFRD transported 3, 156 patients suspected as overdose at a cost of $3, 143, 376. 00. JFRD Data supplied courtesy of Drug Free Duval

Trends of “Pill Seekers” �Doctor Shopping �Manipulation of both physicians when referred to pain management �Patient Reports meds stolen to police �Refuse alternate methods of treatment �Maintaining one physician in FL and a second in GA �“ER” Shoppers

“Doctor Shoppers” �F. S. S. 893. 13(7)a(8) Withhold information from a practitioner from whom the person seeks to obtain a controlled substance or a prescription for a controlled substance that the person making the request has received a controlled substance or a prescription for a controlled substance of like therapeutic use from another practitioner within the previous 30 days.

Recommended Language “Pain Management Agreement”

Ways to Discourage Drug Seekers �Don’t allow patient to tell you what medications they need. �If working in ER don’t be an easy target. �Keep close communication (particularly related to controlled medications) with other physicians treating your patient whether you made the referral or the patient was referred to you. �Use PDMP! �Implement a “pain management agreement” into your practice.

What is Drug Diversion occurs when an individual, in a position of trust, who is allowed legal access to controlled substances for the purpose of dispensing for approved medical purposes to patients redirects any controlled substance from the course of its’ legally intended purpose to an illegal purpose to include: Use by the individual person diverting the substance � Use by an unauthorized 3 rd party � For illegal sale/profit/trade � other �

Duty to Report Drug Diversion Under Florida State Statutes 893. 07 (5 b) “in the event of the discovery of theft or significant loss of controlled substances, report such theft or significant loss to the sheriff of that county within 24 hours after discovery. A person who fails to report a theft or significant loss of a controlled substance commits a misdemeanor”.

Pitfalls to Avoid When Working in Hospital � Nurses who are diverting will gravitate to MDs who grant more liberal use of pain meds and otherapies as "standing orders", often with excuse “as courtesy to not disturb MD”. � Comprehensive electronic order sets to cover multiple "as needed" conditions such especially pain, nausea, anxiety, and insomnia need to be closely scrutinized. Check with facility pharmacy managers who are best at eliminating ambiguity. � Avoid wide pain score ranges or dose ranges, the more specific the instructions, less opportunity for diversion or medication misadventure

When Addiction Hits Home �“Doctors and other health care workers are addicted to drugs in the same proportion as the general population, around 10 to 14 percent. ” http: //www. physicianhealthprogram. com/addiction-news/drug-addicted-doctors-health-care-professionals/ January 30, 2015 “REPORTING AN IMPAIRED COLLEAGUE Substance abuse usually is noted first by fellow staff members. Some nurses may be reluctant to report a colleague. However, those who remain quiet about a colleague's drug abuse risk patient care and safety, the facility's reputation, and even their colleague's life. ” http: //www. modernmedicine. com/modern-medicine/news/modernmedicine/modern-medicine-feature-articles/drug-addictionamong-nurses-con? page=full, Mary Ann B. Copp, April 1, 2009

IPN Intervention Project for Nurses � IPN P. O. Box 49130 Jacksonville Beach, FL 32240 phone: 904 -270 -1620 • fax: 904 -270 -1633 questions/comments: apark@ipnfl. org � To make a referral and/or confidential consultation --- Call IPN @ 1 -800840 -2720 � PRN � Professionals Resource Network PO Box 16510 Fernandina Beach, FL 32035 � 904 -277 -8004 800 -888 -8776 � http: //www. flprn. org/contact � admin@flprn. org � Fax: 904 -261 -3996

Stimulants �Amphetamine and dextroamphetamine /methylphenidate �Rise in our cases involving these meds �Commonly abused at street level and among healthcare professionals �Common sources: Patients prescribed meds but not using full Rx Doctor shoppers Diversion

Just when you thought it was safe Protect you DEA# and NPI# �Recent Trend: Bad guys take a physicians name, DEA# and NPI#, then combine that with an operating practice not related to the physician. The combination is used on either counterfeit prescriptions or that information is used to make a fraudulent call-in for controlled medications. Most commonly Promethazine/Phenergan with codeine and Benzodiazepines.

How hard is it to find your NPI#? � Internet search for “physician NPI numbers then pick one…. � https: //npiregistry. cms. hhs. gov/ According to this site: “The NPI Registry Public Search is a free directory of all active National Provider Identifier (NPI) records. Healthcare providers acquire their unique 10 -digit NPIs to identify themselves in a standard way throughout their industry. Individuals or organizations apply for NPIs through the CMS National Plan and Provider Enumeration System (NPPES). After we supply an NPI, we publish the parts of the NPI record that have public relevance, including the provider's name, specialty (taxonomy) and practice address. CMS provides this service based on federal law (45 CFR Part 162). We also supply this directory in a full download file, or through an Application Programming Interface (API). If you are a provider with questions about your record, our Enumerator can assist you: 800. 465. 3203 | 800. 692. 2326 TTY”

Disposal in Household Trash Rx Drop Boxes DUVAL COUNTY LOCATIONS � If no medicine take-back programs or DEA- authorized collectors are available in your area, you can also follow these simple steps to dispose of most medicines in the household trash: � Mix medicines (do not crush tablets or capsules) with an unpalatable substance such as dirt, kitty litter, or used coffee grounds � Place the mixture in a container such as a sealed plastic bag � Throw the container in your household trash � Scratch out all personal information on the prescription label of your empty pill bottle or empty medicine packaging to make it unreadable, then dispose of the container. 501 Bay Street East Jacksonville, FL 32202 200 Lemon Street Neptune Beach Police Department Neptune Beach, FL 32266 6006 Beach Blvd Walgreens Company Jacksonville, FL 32216 1801 North Davis Street Walgreens Company Jacksonville, FL 32209 14003 Beach Blvd, Suite Smart Pharmacy, Inc. Jacksonville, FL 32250 6132 Merrill Road, Suite 12 Benzer FL 6, LLC Jacksonville, FL 32277 2080 Child Street, Building 950 USN – Naval Hospital Jacksonville, FL 32214 2 Shircliff Way, Suite 900 AIDS Healthcare Foundation Jacksonville, FL 32204 CLAY COUNTY LOCATIONS 1305 North Orange Avenue, Suites 120 -123 Rural Health Care, Inc. Green Cove Springs, FL 32043 100 Commercial Drive Rural Health Care, Inc. Keystone Heights, FL 32656 ST JOHN’S COUNTY LOCATIONS 860 North A 1 A Walgreens Company Ponte Vedra, FL 32082 105 Whitehall Drive, Suites 109 -114 Rural Health Care, Inc. St. Augustine, FL 32086 FLAGLER COUNTY LOCATIONS 1109 Southwest Palm Coast Parkway Walgreens Company Palm Coast, FL 32137 460 Southwest Palm Coast Parkway, Suite 5 Rural Health Care, Inc. Palm Coast, FL 32137 PUTNAM COUNTY LOCATIONS 719 Highway 19 South Walgreens Pharmacy Palatka, FL 32177 1302 River Street, P. O. Drawer 817 Rural Health Care, Inc. Palatka, FL 32177 1213 State Road 20, P. O. Box 190 Rural Health Care, Inc. Interlachen, FL 32148 306 Union Avenue Rural Health Care, Inc. Crescent City, FL 32112 JSO Police Memorial Building

Efforts to be discreet Our goal is to partner with the healthcare community.

Drug Free Duval: A Substance-Abuse Prevention Community Coalition • • • Dedicated to freedom from substance abuse for all Work with all sectors to create and sustain an environment and culture that supports healthy opportunity and wellness Example of current work on Opioids/Heroin: • Development of a 100+ member North Florida Opioid Heroin Task Force • Using data, created a logic model identifying risk behaviors, root causes, gaps in resources, a plan to solve the issues and specific strategies to deploy • Identified specific goals – reduce EMS calls & Narcan administrations of opioids and ED admissions and deaths by Heroin/Fentanyl

Drug Free Duval: North Florida Opioid Heroin Task Force • Created a strategic plan to be implemented through three committees: • Healthcare Education and Training: Conceive, design or select curriculum, and train the medical community related to opioid indications, use, misuse, protocols, monitoring and responses to overdose and addiction • Community Education and Training: Conceive, design or select curriculum, and train the community on pain, opioid indications, use, misuse, patient options, intervention/treatment/recovery support, safe storage & disposal and responses to overdose • Policies and Practices: determine best policies and practices related to evaluating and treating pain, and the role/use of opioids; educating decision-makers to address gaps and change policies to support health and wellness For information, email: sally@dfdjax. org

Sources � � � https: //www. cdc. gov/mmwr/volumes/65/wr/mm 655051 e 1. htm https: //www. cdc. gov/drugoverdose/data/overdose. html http: //www. ipnfl. org/ipnfaq. html http: //www. flprn. org http: //www. physicianhealthprogram. com/addiction-news/drug-addicted-doctors-health-care-professionals/ http: //www. modernmedicine. com/modern-medicine/news/modernmedicine/modern-medicine-feature-articles/drug-addiction-amongnurses-con? page=full, Mary Ann B. Copp, April 1, 2009 http: //www. physicianhealthprogram. com/addiction-news/drug-addicted-doctors-health-care-professionals/ January 30, 2015 Drug Fee Duval www. drugfreeduval. org http: //www. DEA. gov Florida Department of Law Enforcement (Medical Examiner) Florida Department of Children and Families

Questions Detective Wayne Hester Office (904)256 -5994 Cell (904)545 -8544