Opiate overprescribing raises alarms about criminal activity

The nature of crime in Washington County is changing, and this has the county's sheriff, Donnie Smith, alarmed. "We've had four home invasions since December. That's new and it's troubling." He notes that this change is something being seen across the state, not just Washington County. "We've always been dealing with burglary -- people stealing to supply their [drug] habits." He says, "I have people coming to me now asking what they have to do to get a concealed weapon -- they're afraid."
Right now at least, the sheriff says, the general public is not at high risk. Substance abuse may be a factor in the recent rash of home invasions and subsequent arrests. But how the county's rising rate of substance abuse will play into crime levels in the future is a concern the sheriff shares with other law enforcement divisions.
According to the Maine Department of Health and Human Services' Office of Substance Abuse, 544,641 different Maine individuals filled at least one prescription for a Schedule II, III or IV drug in 2008. One year later Washington County was noted by the Maine Center for Disease Control as having the highest rate of a prescribed controlled substance use in the state, at a rate of 2.15 prescriptions per person versus the state average of 1.88 per person.
The whole state has seen an increase from 2005 through 2009, but the increase from Washington County's 2005 number of 1.54 controlled substance prescriptions per resident to its 2009 number "is troubling," says the sheriff. "Most of what we're dealing with is overprescribing." Smith explains that the combination of overprescribing and high unemployment creates an "income potential." It is a situation that creates "dealerBuser stuff -- selling their own prescriptions." And that, he notes, "is a very dangerous situation" that can lead to home invasions by users who are well aware of the drugs and cash present in the home of a patient with a legal prescription who both uses and sells the drugs.
The sheriff describes a number of challenges to alleviating the substance abuse problem. Funding cuts to mental health programs have caused his jail population to increase. "I've got a jail that's always full, and the majority are there because of substance abuse and mental illness. If we could solve those problems the jail would clear out by two‑thirds." Smith explains that those people suffering from mental health issues who are not receiving proper care will often resort to self‑medicating, which leads to additional problems.
Lack of education about abuse of substances, including alcohol and marijuana, is another area of concern. He'd like to see a Kindergarten through college health curriculum that brings in public safety and drug enforcement officials as just one aspect of an approach to substance abuse education that would be ongoing and age‑appropriate. "If someone tells you something in the fifth grade it lasts for about 15 minutes."

Prescriptions worth $24,000 a month in street value
Overprescribing is the top challenge, not just of law enforcement in the county but around the state. According to the sheriff, there are no laws against being under the influence of prescription drugs, unlike alcohol, even if a person has no prescription for the drug ingested. There are only laws that control possession. The sheriff illustrates how difficult this makes drug enforcement. If someone purchases a pill from someone who has a legal prescription and ingests it right after having bought it, the transaction is almost impossible to intercept by law enforcement officers.
As an example of overprescribing, the sheriff told of one individual who was receiving legally prescribed drugs for cancer care that had a street value of $24,000 a month. The individual was selling some of the drugs to earn a tidy income. The sheriff explained that another individual in the medical profession saw the amount of drugs being prescribed and described it as a quantity that should only be administered when someone is in the hospital. The matter is still under investigation.
Maine Drug Enforcement Agency Supervisory Special Agent Corey Bagley says that for his agents, "One of the biggest things is getting people to talk to us, giving us information. Our job depends on people helping us." The MDEA had two agents working in the county during 2010, each for between nine and 10 months. During that time they arrested 36 people on drug‑related crimes. Of those 90% were felony cases, of which 70% were prescription drug cases. Overdoses are "only reported to us when a death occurs" because of federal rules that govern patient confidentiality. "Prescriptions are a hard thing to get your hand around C people are allowed to have them. The only way to catch them is if they are caught selling."

Prescription monitoring program underutilized
The state has implemented two programs to restrict illegal distribution and access to prescription drugs: the drug take‑back program and the prescription monitoring program (PMP). The drug take‑back allows anyone with prescription drugs to safely turn over unfinished prescriptions for disposal, thus ensuring that unused prescriptions do not fall into the wrong hands.
The PMP is a registry of all prescriptions dispensed by commercial pharmacies, legal Internet and mail order sources for Schedule II through IV drugs. The state's prescribers may register to use the site to check to see if a patient is being overprescribed and is possibly "doctor shopping and pharmacy hopping," techniques described by both the sheriff and Bagley as something that substance abusers will do throughout the state until they get the drugs they want.
According to figures provided by the Office of Substance Abuse (OSA), which maintains the PMP, as of 2009 31% or 1,375 out of 4,400 Maine prescribers were using the registry. A breakdown of Washington County prescribers is given in a report issued by the Muskie School of Public Service in 2007. Only 19 of the county's prescribers had signed up to use the registry. According to statistics gathered by the OSA from Washington County: One Community and St. Croix Valley Healthy Communities, by the end of 2009 the 2007 number of prescribers using the PMP had tripled to 63 registered requesters, 28 of those being active requesters and with a total of 792 reports requested.
The PMP report statistics show how extensive the doctor and pharmacy shopping can be for someone intent upon abusing the system and thus how important the registry can be to catching abuses. In 2008 five individuals each used more than 19 prescribers and five each used 10 pharmacies.
"There are good doctors who are trying to help with this by using the PMP," says Smith. He adds, "Doctors should be using the PMP to follow up on a patient." Smith is sympathetic to those suffering from pain, having had two back surgeries himself. But he remembers that his prescriptions were for less than a week each and that was the end of it.
"Law enforcement will never be the whole picture. We need complete cooperation from society," says Smith. This cooperation includes youth and parent education, pain management training for healthcare providers, prescriber awareness and resource sharing and cooperation between law enforcement. The sheriff notes that some facilities are now conducting pill counts to make sure that drug counts match the patient's prescription use requirement.
It's not that most people are abusing the system or set out intending to do so. But doctors who overprescribe are a problem, Smith says, in particular with pain management. A complaint can be registered against a doctor for overprescribing with the MDEA for referral to the Attorney General's Office. According to Bagley, the attorney general then will refer the complaint to the Maine Board of Licensure in Medicine. "You rarely see licenses taken away," says Smith. In 2010 the Maine Board of Licensure took adverse licensing actions against 20 physicians and the Maine Board of Osteopathic Licensure did the same to seven doctors.
Additional tips provided by the sheriff for those with prescriptions include: store prescription bottles out of sight -- placing pill bottles on the kitchen counter, while a handy reminder, means that anyone can see them; savvy substance abusers read the obituaries to find people who have died of cancer -- this means that prescriptions are usually still in the home and can be stolen while the family is at the funeral. Using the take‑back program is a good way to immediately remove the prescriptions, and thus temptation, from the house.
"Prescription drugs are a major concern and issue especially in Washington County," says Bagley. He adds that people who have substance abuse problems "will do whatever they can to find" the pills that they want.