1. Drug Diversion Awareness
Presented by:
Jacksonville Sheriff’s Office:
Detective Wayne Hester
Detective Donnie Slayton

2. 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.

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

4. 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
Doctor Shopping
Obtaining Rx Drugs by Fraud
Diversion by Healthcare Professionals
Non-Traditional Prescription Drug Investigations
Designer Drugs
Investigate, monitor and track:
Synthetic Drug and Heroin Trends
Tracking of New Drug Trends
Safety Concerns for First Responders

5. 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

6. 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

8. 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

9. 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.

10. DEA website statistics
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

11. 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.
2012 National Survey on Drug Use and Health.

12. 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

13. New Problem
CDC

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

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

16. Jacksonville Fire Rescue Department (JFRD) Reports
Jacksonville Fire and Rescue Data
o In the past two years, the number of 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,
o In 2016, JFRD transported 3,156 patients suspected as overdose at a cost of $3,143,
JFRD Data supplied courtesy of Drug Free Duval

17. 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

18. “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.

19. Recommended Language “Pain Management Agreement”

20. 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.

21. What is Drug Diversion
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 3rd party
For illegal sale/profit/trade
other

22. Duty to Report Drug Diversion
Under Florida State Statutes (5b) “in the event of the discovery of the 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”.

23. Pitfalls to Avoid When Working in Hospital
Nurses who are diverting will gravitate to MDs who grant more liberal use of pain meds and other therapies 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

24. 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.”
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.”
Mary Ann B. Copp, April 1, 2009

25. IPN Intervention Project for Nurses
IPN P.O. Box Jacksonville Beach, FL phone: • fax: questions/comments:
To make a referral and/or confidential consultation --- Call
PRN
Professionals Resource Network PO Box Fernandina Beach, FL 32035
Fax:

26. 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

27. 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.

28. How hard is it to find your NPI#?
Internet search for “physician NPI numbers then pick one….
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: | TTY”

29. Disposal in Household Trash Rx Drop Boxes
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.
Rx Drop Boxes
DUVAL COUNTY LOCATIONS
JSO Police Memorial Building
501 Bay Street East
Jacksonville, FL 32202
Neptune Beach Police Department
200 Lemon Street
Neptune Beach, FL 32266
Walgreens Company
6006 Beach Blvd
Jacksonville, FL 32216
1801 North Davis Street
Jacksonville, FL 32209
Smart Pharmacy, Inc.
14003 Beach Blvd, Suite
Jacksonville, FL 32250
Benzer FL6, LLC
6132 Merrill Road, Suite 12
Jacksonville, FL 32277
USN – Naval Hospital
2080 Child Street, Building 950
Jacksonville, FL 32214
AIDS Healthcare Foundation
2 Shircliff Way, Suite 900
Jacksonville, FL 32204
CLAY COUNTY LOCATIONS
Rural Health Care, Inc.
1305 North Orange Avenue, Suites
Green Cove Springs, FL 32043
100 Commercial Drive
Keystone Heights, FL 32656
ST JOHN’S COUNTY LOCATIONS
860 North A1A
Ponte Vedra, FL 32082
105 Whitehall Drive, Suites
St. Augustine, FL 32086
FLAGLER COUNTY LOCATIONS
1109 Southwest Palm Coast Parkway
Palm Coast, FL 32137
460 Southwest Palm Coast Parkway, Suite 5
PUTNAM COUNTY LOCATIONS
Walgreens Pharmacy
719 Highway 19 South
Palatka, FL 32177
1302 River Street, P.O. Drawer 817
1213 State Road 20, P.O. Box 190
Interlachen, FL 32148
306 Union Avenue
Crescent City, FL 32112

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

32. A Substance-Abuse Prevention Community Coalition
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

33. 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,

34. Sources https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm
Mary Ann B. Copp, April 1, 2009
January 30, 2015
Drug Fee Duval
Florida Department of Law Enforcement (Medical Examiner)
Florida Department of Children and Families

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