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Health	  Care	  Inves.ga.ons	              Karen	  Ma3hew	       Director	  of	  Inves.ga.ons	  and	        Inspec.ons,	  ...
LEARNING	  OBJECTIVES	  –	  1.  List	  signs	  of	  diversion	  in	  a	  health	  care	  facility.	  2.  Outline	  how	  t...
Disclosure	  Statement	  •  Karen	  MaRhew	  has	  no	  financial	  rela.onships	     with	  proprietary	  en..es	  that	  ...
Health	  Care	  Facility	  Diversion	  	  Karen	  MaRhew	  April	  2,	  2013	  
WHAT	  IS	  DRUG	  DIVERSION?	  The	  channeling	  of	  controlled	  substances,	  which	  are	  legally	  manufactured	  ...
IN	  OTHER	  WORDS……	     Diver.ng	  legi.mate	  Drugs	  for	  illicit	  or	  illegal	  purposes.	  
WHAT	  DOES	  HEALTH	  CARE	  FACILITY	  MEAN?	  •    Hospitals	  •    Nursing	  Homes	  •    Assisted	  Living	  Facili.e...
WHO	  COMMITS	  DIVERSION?	         ANYONE!!	  
MORE	  SPECIFICALLY:	  •  PRESCRIBERS	  –	  MD,	  DO,	  DDS,	  DMD,	  Vet,	  DPM,	  NP,	  RN	     PA,	  CPP	  •  DISPENSER...
WHAT	  IS	  DIVERTED?	  •  High	  Priced	  Medica.ons	  such	  as	  Erec.le	     Dysfunc.on	  Drugs,	  Chemotherapy	  ,	  ...
THE	  “WHYS”	  OF	  DIVERSION	  •    Addic.on	  •    Facilitate	  the	  addic.on	  of	  others	  •    Pseudoaddic.on	  •  ...
DRUG	  FLOW	  INTO	  HEALTH	  CARE	             FACILITIES	        CRADLE	  TO	  GRAVE	  APPROACH	  
DRUG	  FLOW	  •  Manufacturer	  –	  	        	  Wholesaler	  (Pharmaceu.cal	  Company)	        	  Broker	        	  Distri...
DRUG	  FLOW	  •  Health	  Care	  Facility	  –	         	  Pharmacy	         	  Materials	  Management	  •  Closed	  Door	 ...
DRUG	  FLOW	  Once	  in	  a	  Hospital	  :	           	  -­‐	  Inventoried	  &	  Stocked	  in	  Pharmacy	           	  -­‐...
DRUG	  FLOW	  Drugs	  are	  sent	  out	  of	  the	  pharmacy	           	  -­‐	  Based	  on	  Dr.	  Order	           	  -­...
DRUG	  FLOW	  Once	  a	  drug	  is	  sent	  out	  of	  the	  pharmacy,	  It	  is	  administered	  according	  to	  the	  P...
DRUG	  FLOW	  •  Waste	  –	  pa.ent	  refusal,	  leh	  over,	  expired,	         	  contaminated.	  •  Legally,	  if	  a	 ...
DRUG	  FLOW	  INTO	  OTHER	  FACILITIES	  Nursing	  Home	  flow	  is	  similar	  to	  hospitals	  except	  they	  Contract	...
DRUG	  FLOW	  •  Some	  nursing	  homes	  &	  other	  facili.es	  now	  u.lize	  	        	  automated	  dispensing	  mach...
WHERE	  DOES	  DIVERSION	  TAKE	  PLACE?	               ANYWHERE	                WHERE	  DRUGS	  ARE	  STORED	  
START	  AT	  THE	  BEGINNING	  Courier	  Service:	        	  Package	  Disappears	        	  Packages	  are	  not	  sealed...
NOW	  WHAT?	  Couriers	  are	  aware	  they	  are	  delivering	           	  drugs.	  Ensure	  there	  are	  good	  tracki...
DRUGS	  ARRIVE	  IN	  THE	  FACILITY	  •  Drugs	  should	  be	  inventoried	  &	  stocked	  as	  soon	        	  as	  soon...
TYPES	  OF	  DIVERSION	  Diversion	  in	  a	  pharmacy	  of	  a	  health	  care	  facility	         	  is	  normally	  com...
WHO	  DIVERTS	  DRUGS	  ON	  FACILITY	                    UNITS?	  •  Nurses	  –	  RN,	  LPN	  •  CNA,	  CMA	  •  Physicia...
NURSES	  Addicted	  Nurses	  are	  one	  of	  the	  Most	  widely	  diverters	  of	  medica7ons	  In	  health	  care	  fac...
DIVERSION	  BY	  NURSES	  •    Frequent	  sign	  outs 	          	  	  •    Frequent	  was.ng	  •    Subs.tu.on	  •    Dil...
DIVERSION	  BY	  NURSES	  •    Trash	  •    Sharps	  Containers	  •    Destruc.on	  •    Restocks	  •    Signouts	  for	  ...
ISSUES	  SPECIFIC	  TO	  NURSING	  HOMES	  •    Storing	  of	  Delivered	  Medica.ons	  •    Medica.on	  Counts	  at	  Cha...
CHARACTERISTICS	  Job	  Performance	  Employment	  History	  Changes	  in	  Behavior/Moods	  Appearance	  Quality	  of	  E...
WHAT	  CAN	  BE	  DONE?	  •  Collabora.on	  between	  health	  care	  professionals	  	  	         	  and	  law	  enforcem...
WHAT	  CAN	  BE	  DONE?	  •  Background	  Checks	  including	  criminal	  history	  •  Verifying	  License	  Informa.on	  ...
WHAT	  CAN	  BE	  DONE?	  •  Rigorous	  Security	  Measures	  •  Think	  of	  Drugs	  as	  Money!	  •  Close	  Observa.on/...
USE	  OF	  PDMP	  •  NC	  has	  had	  PMP	  (CSRS)	  for	  almost	  4	  years	  •  Only	  @	  28%	  of	  all	  prescribers...
Limita.ons	  of	  PMP	  •  Only	  as	  good	  as	  data	  sent	  in	  from	  pharmacies	  •  In	  one	  review	  of	  pa.e...
Contact	  Informa.on	  Karen	  MaRhew	  Director	  of	  Inves.ga.ons	  &	  Inspec.ons	  NC	  Board	  of	  Pharmacy	  919-­...
QUESTIONS?	  
Collabora.on	  with	  Pharmacists	  to	  Prevent	  Diversion	  Through	  Use	  of	                the	  PDMP	             ...
Learning	  Objec.ves	  •  What	  law	  enforcement	  can	  do	  to	  encourage	     collabora.on	  with	  pharmacists	  to...
Disclosure	  Statement	  	  	  	  	  Agent	  Bruce	  DiVincenzo	  	  has	  no	  disclosed	  no	                 relevant,	...
•  Review	  nine	  (9)	  minute	  video	  concerning	  crimes	  occurring	     at	  the	  pharmacy	  counter	  and	  how	 ...
•  Pharmacy	  crimes	  –	  Forgery,	  Doctor	  and	  Pharmacy	     shopping.	  	  These	  crimes	  are	  underreported,	  ...
•  The	  video	  is	  our	  effort	  in	  DE	  to	  let	  the	  clinician	  know	     what	  evidence	  is	  used	  by	  pr...
•  The	  amount	  of	  drugs	  diverted	  	  by	  a	  single	     defendant	  –	  Delaware	  County	  PA	  and	  New	     ...
•  Use	  of	  PDMP	  -­‐	  	  Examples	  of	  actual	  cases	  where	     the	  PDMP	  is	  effec.ve	  in	  providing	  lea...
•  3.	  	  Counterfeit	  scripts	  -­‐	  	  Phila	  Hospital	  -­‐	  	  PDMP	     Administrator	  checked	  further	  aher...
•  The	  PDMP	  is	  a	  valuable	  aid	  in	  the	  prosecu.on	  of	  criminals	  involved	     in	  the	  diversion	  of...
•  Thank	  you	  for	  your	  aRen.on.	  	  I	  do	  hope	  that	  I	     provided	  informa.on	  you	  find	  helpful	  in...
Health care investigations_final
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Health care investigations_final

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Law Enforcement Track, National Rx Drug Abuse Summit, April 2-4, 2013. Health Care Investigations presentation by Karen Matthew and Agent Bruce DiVincenzo.

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Transcript of "Health care investigations_final"

  1. 1. Health  Care  Inves.ga.ons   Karen  Ma3hew   Director  of  Inves.ga.ons  and   Inspec.ons,  North  Carolina     Department  of  Pharmacy     Agent  Bruce  DiVincenzo  Delaware  State  Police  Drug  Diversion   Unit  
  2. 2. LEARNING  OBJECTIVES  –  1.  List  signs  of  diversion  in  a  health  care  facility.  2.  Outline  how  to  collaborate  with  clinicians  to   prevent  diversion.  3.  Demonstrate  effec.ve  use  of  PDMP  by  law   enforcement  within  a  pharmacy.  
  3. 3. Disclosure  Statement  •  Karen  MaRhew  has  no  financial  rela.onships   with  proprietary  en..es  that  produce  health   care  goods  and  services.    •  Bruce  DiVincenzo  has  no  financial   rela.onships  with  proprietary  en..es  that   produce  health  care  goods  and  services.    
  4. 4. Health  Care  Facility  Diversion    Karen  MaRhew  April  2,  2013  
  5. 5. WHAT  IS  DRUG  DIVERSION?  The  channeling  of  controlled  substances,  which  are  legally  manufactured  &  intended  to  be  used  legi.mately  for  medical  &  therapeu.c  needs  by  a  license  prac..oner,  pharmacist,  hospital,  nursing  home  or  medical  research  center,  to  an  illegal  use,  whether  it  be  for  personal  use  or  for  illegal  distribu.on  to  another  person.  
  6. 6. IN  OTHER  WORDS……   Diver.ng  legi.mate  Drugs  for  illicit  or  illegal  purposes.  
  7. 7. WHAT  DOES  HEALTH  CARE  FACILITY  MEAN?  •  Hospitals  •  Nursing  Homes  •  Assisted  Living  Facili.es  •  Group  Homes  •  Clinics  •  Physicians’  offices,  other  facili.es.  
  8. 8. WHO  COMMITS  DIVERSION?   ANYONE!!  
  9. 9. MORE  SPECIFICALLY:  •  PRESCRIBERS  –  MD,  DO,  DDS,  DMD,  Vet,  DPM,  NP,  RN   PA,  CPP  •  DISPENSERS  –  RPh.,  Tech,  Clerk,  Other  employees  •  ADMINISTRATORS  –  RN,  LPN,  NA,  CMA,  CNA,  Med   techs  •  OTHERS  –  who  have  access  through  employment  or   obtain  access  
  10. 10. WHAT  IS  DIVERTED?  •  High  Priced  Medica.ons  such  as  Erec.le   Dysfunc.on  Drugs,  Chemotherapy  ,  etc.  •  Drugs  Easily  Abused  –  Oxycodone,  Hydrocodone,   Morphine,  Fentanyl,  Dextroamphetamines,   Benzodiazepines  •  Any  Type  of  Medica.on  
  11. 11. THE  “WHYS”  OF  DIVERSION  •  Addic.on  •  Facilitate  the  addic.on  of  others  •  Pseudoaddic.on  •  To  sell  for  money  •  To  provide  to  others,  par.es,  etc.  •  Cost  of  prescrip.on  drugs  •  To  facilitate  sexual  acts,  assaults,  etc.  •  Every  reason  one  can  think  of  
  12. 12. DRUG  FLOW  INTO  HEALTH  CARE   FACILITIES   CRADLE  TO  GRAVE  APPROACH  
  13. 13. DRUG  FLOW  •  Manufacturer  –      Wholesaler  (Pharmaceu.cal  Company)    Broker    Distributor  •  Courier  Service  –    Delivery  to  the  Health  Care  Facility  
  14. 14. DRUG  FLOW  •  Health  Care  Facility  –    Pharmacy    Materials  Management  •  Closed  Door  Pharmacy  –    Directly  into  ins.tu.on  
  15. 15. DRUG  FLOW  Once  in  a  Hospital  :    -­‐  Inventoried  &  Stocked  in  Pharmacy    -­‐  Placed  onto  shelves/cabinets,  etc.    -­‐  Automated  Dispensing  Units/robots    -­‐  Vaults  
  16. 16. DRUG  FLOW  Drugs  are  sent  out  of  the  pharmacy    -­‐  Based  on  Dr.  Order    -­‐  to  Basic  stock    -­‐  Nursing  Units    -­‐  Pa.ent  Areas    -­‐Specialty  Areas  (surgery,  CT      labs,  ED)    -­‐Outpa.ent    -­‐off-­‐site  areas  
  17. 17. DRUG  FLOW  Once  a  drug  is  sent  out  of  the  pharmacy,  It  is  administered  according  to  the  Policy/procedure  of  the  ins.tu.on.  Example  –  Automated  Dispensing        Machines            Medica.on  Administra.on      Record      (MAR)  
  18. 18. DRUG  FLOW  •  Waste  –  pa.ent  refusal,  leh  over,  expired,    contaminated.  •  Legally,  if  a  drug  is  signed  out,  it  must  be      administered  or  wasted.   May  be  returned  to  stock  under  ins.tu.onal   Policy,  state  law,  etc.  
  19. 19. DRUG  FLOW  INTO  OTHER  FACILITIES  Nursing  Home  flow  is  similar  to  hospitals  except  they  Contract  with  LTC  pharmacies  or  retail  pharmacies  to  Provide  drugs  –  normally  pa.ent  specific  
  20. 20. DRUG  FLOW  •  Some  nursing  homes  &  other  facili.es  now  u.lize      automated  dispensing  machines.    (If  controlled    substances  are  administered,  need  DEA    registra.on  &  Board  permit).  •  Other  nursing  homes  u.lize  medica.on  carts  •  Some  use  unit  dose  carts,  pa.ent  specific  •  Medica.ons  administered  to  pa.ents  by  RNS,  LPNS,    med  techs,  CNAs,  etc.  
  21. 21. WHERE  DOES  DIVERSION  TAKE  PLACE?   ANYWHERE   WHERE  DRUGS  ARE  STORED  
  22. 22. START  AT  THE  BEGINNING  Courier  Service:    Package  Disappears    Packages  are  not  sealed  completely      (altered)    Packing  is  different  than  past  deliveries    Change  in  delivery  schedules    Personnel  ac.ng  differently  
  23. 23. NOW  WHAT?  Couriers  are  aware  they  are  delivering    drugs.  Ensure  there  are  good  tracking  systems    from  wholesaler  to  facility.  Once  package  is  delivered,  contents  need    to  be  inventoried  immediately    against  invoice/manifest.  
  24. 24. DRUGS  ARRIVE  IN  THE  FACILITY  •  Drugs  should  be  inventoried  &  stocked  as  soon    as  soon  as  possible.  •  Whether  placed  in  an  automated  dispensing    machine,  medica.on  cart  or  vault,  they    should  be  stocked  immediately  to  help  cut  down    on  diversion.  
  25. 25. TYPES  OF  DIVERSION  Diversion  in  a  pharmacy  of  a  health  care  facility    is  normally  commiRed  by    pharmacists  &  technicians.  Pharmacists  will  divert  from  automated    dispensing  machine,  vault,  when    preparing  or  mixing  medica.ons.  Technicians  ohen  divert  when  checking  in    deliveries,  stocking  the  pharmacy,    coun.ng  out  meds,  stocking  floor  units,    taking  return  meds  in  the  pharmacy.  
  26. 26. WHO  DIVERTS  DRUGS  ON  FACILITY   UNITS?  •  Nurses  –  RN,  LPN  •  CNA,  CMA  •  Physicians,  although  they  do  not  have  as  much   access  as  other  staff  •  Anesthesiologists,  CRNAs  •  Therapists,  surgery  techs,  others  
  27. 27. NURSES  Addicted  Nurses  are  one  of  the  Most  widely  diverters  of  medica7ons  In  health  care  facili7es.  Few  facili7es  are  exempt  from  this  Problem.  More  cases  since  #  of  nurses  are    More  than  Rphs  or  techs.  
  28. 28. DIVERSION  BY  NURSES  •  Frequent  sign  outs      •  Frequent  was.ng  •  Subs.tu.on  •  Dilu.on  •  PCA  –  PT  Controlled  Administra.on  •  IV  Drips  •  Fentanyl  patches  
  29. 29. DIVERSION  BY  NURSES  •  Trash  •  Sharps  Containers  •  Destruc.on  •  Restocks  •  Signouts  for  Discharged  Pa.ents  •  Documenta.on  Issues  •  Stealing  from  Automated  Dispensing  machines  •  Pa.ent  complaints  –  no  relief  for  pain,  etc.  
  30. 30. ISSUES  SPECIFIC  TO  NURSING  HOMES  •  Storing  of  Delivered  Medica.ons  •  Medica.on  Counts  at  Change  of  Shih  •  Punch  outs  on  Unit  Dose  cards  •  MAR  changes  •  Expired  medica.ons,  leh-­‐over  pa.ent  medica.ons  •  Falsifying  orders  •  Subs.tu.on  of  medica.ons  •  Pa.ent  complaints  
  31. 31. CHARACTERISTICS  Job  Performance  Employment  History  Changes  in  Behavior/Moods  Appearance  Quality  of  Employees  Documenta.on  Issues  Working  Over.me  or  Offers  to  Do  So  Taking  over  others’  pa.ents  Showing  up  when  not  on  duty  Check  &  Balance  on  medica.ons  Policies/procedures  
  32. 32. WHAT  CAN  BE  DONE?  •  Collabora.on  between  health  care  professionals        and  law  enforcement  •  Training  for  all  staff  in  health  care  facili.es  on    diversion  &  what  to  look  for  •  Good  policies  &  procedures  in  place    •  Zero  tolerance  for  diversion  in  health  care  facility  –      Pa.ent  Safety  is  Utmost!  •  Referral  of  employee  to  employee  assistance    program  
  33. 33. WHAT  CAN  BE  DONE?  •  Background  Checks  including  criminal  history  •  Verifying  License  Informa.on  with  Regulatory   Boards  •  Checks  &  Balances  of  En.re  Medica.on  Flow  •  Inventorying  of  Drugs  at  all  Levels  •  Use  of  Biometric  measures  on  automated  devices  •  Random  Drug  Tes.ng  •  Random  Review  of  Drug  flow  to  determine  weak   points  •  Check  of  expired  drugs,  return  to  stock  
  34. 34. WHAT  CAN  BE  DONE?  •  Rigorous  Security  Measures  •  Think  of  Drugs  as  Money!  •  Close  Observa.on/Supervision  of    Employees  Handling  Medica.ons  •  Training  for  all  employees  •  Preven.on  is  best  measure  •  Always  look  for  new  systems  such  as    bar  coding,  etc.  
  35. 35. USE  OF  PDMP  •  NC  has  had  PMP  (CSRS)  for  almost  4  years  •  Only  @  28%  of  all  prescribers  signed  up  •  Less  than  26%  of  Rphs  signed  up  •  Useful  tool  to  check  for  doctor  shoppers,   forgers,  etc.  •  Some  pharmacies  do  not  have  internet  access  •  Cannot  provide  to  law  enforcement  in  NC  •  Board  has  limited  access  
  36. 36. Limita.ons  of  PMP  •  Only  as  good  as  data  sent  in  from  pharmacies  •  In  one  review  of  pa.ent  informa.on  on    prescrip.ons,  20%  informa.on  was    incorrect  prescriber,  drug,  etc.  •  In  NC,  limita.ons  on  info  on  prescribers  who    are  “over-­‐prescribing”  •  No  access  by  local  law  enforcement  •  Changes  being  reviewed  now  •  No  mandatory  use  by  prescribers  
  37. 37. Contact  Informa.on  Karen  MaRhew  Director  of  Inves.ga.ons  &  Inspec.ons  NC  Board  of  Pharmacy  919-­‐246-­‐1050  kmaRhew@ncbop.org  
  38. 38. QUESTIONS?  
  39. 39. Collabora.on  with  Pharmacists  to  Prevent  Diversion  Through  Use  of   the  PDMP   April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  40. 40. Learning  Objec.ves  •  What  law  enforcement  can  do  to  encourage   collabora.on  with  pharmacists  to  reduce   diversion  at  the  pharmacy  counter.  •  Learn  from  several  examples  how  the  PDMP   when  used  by  pharmacists,  can  aid  law   enforcement  in  improving  inves.ga.ve   outcomes.    
  41. 41. Disclosure  Statement          Agent  Bruce  DiVincenzo    has  no  disclosed  no   relevant,  real  or  apparent  personal  or   professional  financial  rela.onships.  
  42. 42. •  Review  nine  (9)  minute  video  concerning  crimes  occurring   at  the  pharmacy  counter  and  how  the  ac.ons  taken  by   pharmacy  staff  can  aid  law  enforcement  in  the  reduc.on  of   diversion.  •  Diversion  which  occurs  at  the  pharmacy  counter  is  vastly   underreported.    Law  enforcement  can  aid  in  improving  this   outcome.    My  PERSONAL  belief  is  that  the  problem  is   HUGE.    Unless  an  agency  becomes  involved  on  a  regular   basis  in  the  inves.ga.on  and  prosecu.on  of  these  crimes,     the  amount  of  drug  diversion  occurring  at  the  pharmacy   counter  will  remain  a  significant  source  of  diverted   controlled  drugs  which  con.nue  to  devastate  our   communi.es.  You  just  don’t  know  un.l  you  look!!  
  43. 43. •  Pharmacy  crimes  –  Forgery,  Doctor  and  Pharmacy   shopping.    These  crimes  are  underreported,  and  in   many  metropolitan  areas  not  inves.gated  at  all.     Significant  amounts  of  diverted  drugs  are  the  result.  •  Educate  the  clinicians  about  the  law  (code  and  statute  )   that  governs  your  jurisdic.on.    Assist  them  and  work   together  for  the  reduc.on  of  diverted  drugs  in  your   community.  Work  to  increase  repor.ng!    Examples   from  experience  –  3  Friday  nights  in  a  row!  
  44. 44. •  The  video  is  our  effort  in  DE  to  let  the  clinician  know   what  evidence  is  used  by  prosecutors.    Discuss  trial   probability  -­‐  minimal.    Pharmacists  provide  many,  if  not   most  of  the  leads  provided  to  law  enforcement  in  DE.     Pharmacists  working  together  with  law  enforcement   can  make  a  difference.  Example  –  we  don’t  have  that.    •  Climate  Change  –  What  I  have  learned  from   pharmacists  about  the  change  resul.ng  from  the   increase  in  drug  seeking  crimes  and  the  effect  this  has   on  medical  prac..oners.    Never  experienced  such   behavior  by  alleged  pa.ents.  
  45. 45. •  The  amount  of  drugs  diverted    by  a  single   defendant  –  Delaware  County  PA  and  New   Castle  County  DE  2010  to  2012    -­‐    25,000   dosage  units  Percocet  10/325.    •  A  pre-­‐PDMP  inves.ga.on.    Discuss  M/O.     Ini.ally  report  to  us  by  a  dedicated  pharmacist    
  46. 46. •  Use  of  PDMP  -­‐    Examples  of  actual  cases  where   the  PDMP  is  effec.ve  in  providing  leads  to  law   enforcement:  •  1.    Aids  in  determining    the  extent  of  the  forgeries   occurring.  Recent  –  Dr  S…..  •  2.  Iden.fy  the  ac.vity  of  a  doctor  shopper.     Reported  by  another  dedicated  pharmacist.       Involved  doctors  in  two  states.    Ongoing  case….  
  47. 47. •  3.    Counterfeit  scripts  -­‐    Phila  Hospital  -­‐    PDMP   Administrator  checked  further  aher  viewing   writer’s  alert  and  provided  other  leads  based  on   address  of  hospital.    Ongoing  case……  4.  Extent  of  damage  -­‐    NY  script  case.    Crime  occurs   in  DE,  scripts  filled  also  in  NJ  and  PA  and  North   Carolina.    PDMP  aided  in  determining  where  the   suspects  had  been.    Also  Brooklyn  suspects  in  DE   and  Pocono  area  of  PA.      Ongoing  case…..        
  48. 48. •  The  PDMP  is  a  valuable  aid  in  the  prosecu.on  of  criminals  involved   in  the  diversion  of  controlled  substances.      •  It  is  the  presenter’s  hope  that  government  issued  photo  ID  will  be  a   required  part  of  the  data  captured  in  every  transac.on  involving  the   dispensing  of  a  controlled  substance.    Prosecu.ons  are  made   possible  and  some.mes  enhanced  by  the  inclusion  of  this  ID   informa.on  as  part  of  the  PDMP  data  and  most  difficult  to  begin   without  this  ID  informa.on.    •  The  PDMP  remains  a  work  in  progress.    For  addi.onal  reading  on   where  this  process  is  heading,  please  review  the  wri.ngs  from   Brandeis  University  on  this  topic.    Excellent  source.  
  49. 49. •  Thank  you  for  your  aRen.on.    I  do  hope  that  I   provided  informa.on  you  find  helpful  in  your   work  in  your  jurisdic.on.  •  If  there  are  any  ques.ons  here  or  even  later,  I  am   always  glad  to  discuss  any  ques.ons  you  may   have.  •  Thank  you  to  Opera.on  Unite  for  invi.ng  me  to   speak.    I  am  thankful  for  your  good  work  and   learn  a  great  deal  from  my  .me  here.  
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