Technologies	  in	  Preven/ng	  	          Diversion	            April	  2	  –	  4,	  2013	          Omni	  Orlando	  Reso...
Technologies	  in	  Preven@ng	  Diversion	  Moderator:	  Dr.	  Sarah	  Melton,	  Associate	  Professor	  of	  Pharmacy	  	...
Learning	  Objec@ves	  1.  Evaluate	  the	  impact	  of	  controlled	  substance	  diversion	  in	  the	  	  	  	  	  	  	...
Disclosure	  Statement	  •  Dr.	  ONeil	  is	  a	  consultant	  for	  the	  DEA,	  WV-­‐bureau	  of	  criminal	  Inves@ga@...
Overview	  •  Ini@al	  overview	  of	  employee	  behaviors	  and	     tac@cs	  in	  community	  and	  hospital	  sites	  ...
Impact	  of	  Drug	  Diversion	  in	  Hospital	         Pharmacies	  and	  Nursing	  Units	  •  Absolute	  inventory	  $	 ...
Counterfeit	  Drugs	  •  Actual	  TRUE	  incidence	  and	  cost	  is	  unknown	  •  Can	  be	  a	  major	  contributor	  i...
Counterfeit	  Drugs	  •  Accounts	  for	  about	  1%	  of	  total	  market	  sales	  of	     medica@ons	  •  One	  of	  th...
“Grazing”	  
Grazing	  “Behaviors”	  •  Overt	  self-­‐medica@ng	  •  Staff	  diagnosing	  /	  “encouraging”	  each	  other	     “Knowle...
Medica@on	  Sources	  •    BoHles	  in	  the	  pharmacy	  •    Pa@ent	  boHles	  •    Pa@ent	  carts	  •    Medica@on	  dr...
Grazing	  •    sexual	  enhancers	  •    an@depressants	  •    an@psycho@cs	  •    butalbital	  	  •    an@eme@cs	  (prome...
Pharmacy	  Community	  •  Trash	  •  Inventory	  altera@ons	  •  Overt	  Theh	  	  	  	  	  	  	  	  	  1.	  individual	  ...
Hospital	  Pharmacy	  •    Grazing	  •    Overfill	  •    Waste	  •    returns	  
Nursing	  •      Pa@ent	  complains	  of	  lack	  of	  pain	  relief	  •  	  Highly	  suspicious	  behavior	  by	  the	  s...
Nursing	  Techniques	  /	  Solu@ons	  Stealing	  pa@ent	  dose	  •  Order	  is	  for	  hydrocodone/APAP	  1-­‐2	  tablets	...
Other	  Sites	  within	  the	  Ins@tu@on	  •  OR	  /	  OR	  satellites	  anesthesiologist,	     anesthe@sts	  •  ERs	  
The	  Technology	  -­‐	  Basics	  •  Do	  official	  background	  checks	  regardless	  if	  you	  know	  the	  candidate	  ...
The	  Technology	  •  Hospital	  Pharmacy	  	  	  	  -­‐	  Point	  of	  entry	  to	  controlled	  substances	  	  	  	  -­...
Refractometer	  •  Very	  accurate	  tes@ng	  •  Provides	  a	  sense	  of	  “surveillance”	  as	  a	     deterrent	  	  •...
Tracking	  doses,	  nurses,	  tendencies	             Automated	  dispensing	  machines	  •  drug,	  unit,	  formula@on,	 ...
Tracking	  doses,	  nurses,	  tendencies	  •  PaHerns	  	  	  	  	  	  -­‐on	  floor	  sta@s@cal	  comparisons,	  signs	  o...
Counterfeit	  –	  Shipment	  Tracking	  •  RFID	  /	  GPS	  tracking	  of	  full	  shipments	  •  RFID	  /GPS	  tracking	 ...
Employee	  Diversion(retail)	  •  Hydrocodone	  is	  the	  number	  1	  prescribed	  item	     in	  the	  US	  •  Also	  a...
Automated	  Dispensing	  Cabinets	  • Strict	  control	  to	    inventory	  access	  • Records	  individual	    operator’s...
Biometric	  Safe	  •  Bolted	  to	  the	  floor	  •  Controlled	  access	  with	  biometric	  scan	  
Analy@cs	  Predic/ve	  indicators	  •  Cycle	  count	     adjustments	  •  Overriding	     replenishment	  	     orders	  ...
Point	  of	  Sale	  with	  Remote	  Monitoring	  •  Remote	  video	  monitoring	  •  Point	  of	  sale	  data	  is	  avail...
Remote	  Monitoring	    Incident	  Report	  
Policies	  and	  Procedures	  Zero	  tolerance	  on	  employee	    pilferage	  for	  controlled	              substances	  
Prescrip@on	  Drug	  Abuse	  Epidemic	                 25	                                                                ...
Drug	  Fact	  Over	  100	  People	  die	  from	  drug	  overdoses	  every	                   day	  in	  the	  United	  Sta...
Drug	  Fact	  •  For	  every	  death	  there	  are:	     – 10	  treatment	  admissions	  for	  abuse	     – 32	  emergency...
Drug	  Fact	  •  Most	  prescrip@on	  pain	  killers	  are	     prescribed	  by	  primary	  care	  and	     internal	  med...
Drug	  Fact	  •  Enough	  prescrip@on	  pain	  killers	  were	     prescribed	  in	  2011	  to	  medicate	  every	     Ame...
Analy@cs	  Suspicious	  Ac@vity	  Prac@ce	  of	  pharmacy	  is	  changing	  and	  pharmacists	  must	  be	  more	  aware	 ...
Pharmacist’s	  Corresponding	                Responsibili@es	  (CSA)	  •  Must	  consider	  the	     geographical	  distan...
Pill	  Mill	  Clinics	  •  Escalated	  from	  Florida	  •  LiHle	  state	  regulatory	  oversight	     – Doctor	  dispensi...
Ten	  Arrested	  In	  Strike	  Against	  Florida	  “Pill	  Mill”	  
The	  Migra@on	  
Suspicious	  Ac/vity	  •  Pharmacists	  play	  an	  important	  role	  in	  the	     diversion	  of	  controlled	  substan...
Report	  Suspicious	  Ac@vity	  •  Pharmacist	  should	     – Gather	  informa@on	        •  Prescriber	  name	           ...
Pharmacy	  Systemic	  Approach	  Chain	  data	  Top	  Oxycodone	                           Pharmacy	  generated	  data	  S...
Analysis	  (Corporate)	  •  Top	  oxycodone	  and	  hydrocodone	  dispensing	     pharmacies	  •  Top	  oxycodone	  and	  ...
Analy@cs	  •  Na@onal	  Controlled	  Substance	  Ra@ng	     Solu@on*	  	      – Na@onal	  database	  	            •  Purch...
Na@onal	  Dashboard	  •  The	  Na@onal	  Dashboard	  will	  be	  color-­‐coded	     based	  on	  the	  metric	  selected	 ...
Na@onal	  Dashboard	  
Pharmacy	  Clinic	  Protocol 	  	  •  Checklist	  to	  review	  a	  prescriber’s	  office	     –  Onsite	  visit	  (pictures...
Clinic	  Protocol	  •  The	  protocol	  is	  not	  only	  used	  for	     prescribers	  of	  opioids	  such	  as	     oxyc...
Poten@al	  Ac@on	  Edit	  in	  Computer	  •  LeHer	  sent	  to	  the	  prescriber	  sta@ng	  this	     pharmacy	  will	  n...
Suspicious	  Prescriber	  •  Prescriber	     –  Prescribed	  695,811	  total	  dosage	  units	  of	  oxycodone	        con...
Systemic	  Approach	  Store	  generated	  data	  Distribu@on	   •  Pharmacy	  Manager	  requests	  a	  threshold	        t...
Systemic	  Approach	  Prescriber	  Data	  Trends	                        •  Top	  6	  prescribers	  were	  prac@cing	  in	...
Systemic	  Approach	  Store/Site	  Visit	  Clinic	  Protocol	     •  Based	  on	  the	  informa@on	  from	  completed	  by...
Systemic	  Approach	  Edits	  LeHer	  to	  Prescriber.	                                 •  Based	  on	  prescriber	  analy...
Addi@onal	  Technology	  Tools	                (under	  development)	  •  Poten@al	  edit	  through	  “third	  party	     ...
Summary	  •  Pharmacies	  should	  consider	  developing	  a	     comprehensive	  analy@cal	  approach	  to	  iden@fy	    ...
Pa@ent	  Diversion	  Behavior	  •  Armed	  Robberies	  rose	  81%	  from	  2006	  to	     2010	  •  The	  number	  of	  do...
Reason	  Pharmacies	  are	  Targeted	  •  Easy	  to	  find	  and	  easy	  access	  •  Open	  extended	  hours	  •  Typicall...
Preven@on	  Tips	  -­‐	  Training	  •  Understand	  and	  observe	  behaviors	  of	  poten@al	  robber	      1.  Purposely...
Preven@on	  Tips	  -­‐	  Training	  •  Wipe	  counters	  and	  front	  doors	     – Finger	  prints	  •  Stage	  par@ally	...
During	  an	  Event	  •    Primary	  concern	  –	  Safety	  of	  coworkers	  and	  customers	  •    Do	  not	  resist	  • ...
For@fica@on	  Sugges@ons	  Based	  on	  	                 Risk	  Level	  •  Height	  Strip	  Cameras	   •  Public	  view	  ...
Exterior	  Ligh@ng	  and	  Cameras	  •  Increasing	  the	  foot	  candles	  of	  exterior	  ligh@ng	  •  Exterior	  camera...
Robbery	  Poster	  •  Overt	  warning	  to	     the	  suspect	  and	     customers	  for	     awareness	  •  Trained	  ass...
Reward	  Offers	               Asking	  concerned	               ci@zens	  for	  their	               help	  to	  resolve	 ...
“Bait	  BoHles”	  
Tracking	  Devices	  •  GPS	  tracking	  system	  •  Law	  Enforcement	  Tool	  •  Immediate	  no@fica@on	  of	  robbery	  ...
Tracking	  Devices	  •    Hidden	  within	  the	  inventory	  •    Fully	  automa@c	  •    Updates	  GPS	  loca@on	  every...
Tracking	  Points	  •  9:27	  PM	  –	  Device	  ac@ve	  on	  Server	  •  9:29	  PM	  –	  Unit	  gains	  GPS	  and	  is	  S...
Outcome	  •  Police	  arrested	  2	  subjects	  at	  the	  scene	  •  Recovered	  weapons	  and	  evidence	  of	  the	  ev...
QUESTIONS	  •  Thank	  you	  •  Dr.	  Michael	  O’Neil	  •  Janet	  Hart	  R.Ph.	  
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Pharmacy Track, National Rx Drug Abuse Summit, April 2-4, 2013, Technologies in Preventing Diversion presentation by Janet Hart and Dr. Michael O'Neil

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Technologies in preventing_diversion-ne_wweb

  1. 1. Technologies  in  Preven/ng     Diversion   April  2  –  4,  2013   Omni  Orlando  Resort     at  ChampionsGate  
  2. 2. Technologies  in  Preven@ng  Diversion  Moderator:  Dr.  Sarah  Melton,  Associate  Professor  of  Pharmacy                                                Prac@ce,  GaHon  College  of  Pharmacy  Prac@ce  Presenters:    Janet  Hart,  Director,  Government  Affairs,  Rite  Aid                                              Dr.  Michael  O’Neil,  Drug  Diversion  Consultant  DEA  /BCI                                                Professor,  Dept.  of  Pharmacy  Prac@ce,  South  College                                                  School  of  Pharmacy  
  3. 3. Learning  Objec@ves  1.  Evaluate  the  impact  of  controlled  substance  diversion  in  the                hospital  seVng.  2.  Iden@fy  primary  methods  of  diversion  in  the  pharmacy  and                  on  nursing  units.  3.  Iden@fy  processes  to  maximize  the  use  of  technology  in                diversion  preven@on,  detec@on,  and  management.  
  4. 4. Disclosure  Statement  •  Dr.  ONeil  is  a  consultant  for  the  DEA,  WV-­‐bureau  of  criminal  Inves@ga@on,   The  US  AHorneys  Office,  Na@onal  Associa@on  of  Dental  Boards  and  has   provided  con@nuing  educa@on  for  in  chronic  pain  management  and   prescrip@on  drug  diversion  for  Endo  Pharmaceu@cals.  •  Janet  Hart  has  no  relevant  financial  rela@onships  with  commercial   interests  to  disclose  
  5. 5. Overview  •  Ini@al  overview  of  employee  behaviors  and   tac@cs  in  community  and  hospital  sites  •  Overview  of  technologies  used  to  combat   diversion  behaviors    •  Physician  Driven  Diversion  •  “Customer”  oriented  diversion:  focus  on   robberies  and  burglaries  
  6. 6. Impact  of  Drug  Diversion  in  Hospital   Pharmacies  and  Nursing  Units  •  Absolute  inventory  $  costs            -­‐controls  v.  non-­‐controls  •  Costs  of  impairment          -­‐pharmacist  /  techs            -­‐nurses            -­‐management  •  Cost  to  the  pa@ent          -­‐injury,  death  
  7. 7. Counterfeit  Drugs  •  Actual  TRUE  incidence  and  cost  is  unknown  •  Can  be  a  major  contributor  in  community  and   hospital  pharmacy  Bevacizumab  (for  cancer  treatment)  United  States  of  America,  2012  Affected  19  medical  prac@ces  in  the  USA.  The  drug  lacked  ac@ve  ingredient  1  Sildenasil  (for  erec/le  dysfunc/on)  United  Kingdom,  2012  Smuggled  into  the  UK.  Contained  undeclared  ac@ve  ingredients  with  possible  serious  health  risks  to  the  consumer    (Source  -­‐  WHO  Fact  Sheet)  
  8. 8. Counterfeit  Drugs  •  Accounts  for  about  1%  of  total  market  sales  of   medica@ons  •  One  of  the  primary  reasons  corporate   pharmacies  do  not  allow  ‘drug  take-­‐backs’  
  9. 9. “Grazing”  
  10. 10. Grazing  “Behaviors”  •  Overt  self-­‐medica@ng  •  Staff  diagnosing  /  “encouraging”  each  other   “Knowledge  does  not  grant  privilege!”  •  Blatant  theh  for  $,  sex  
  11. 11. Medica@on  Sources  •  BoHles  in  the  pharmacy  •  Pa@ent  boHles  •  Pa@ent  carts  •  Medica@on  drawers  •  Stock  •  Automated  dispensing  machines  •  Trash  (broken,  spilled  medica@ons)  
  12. 12. Grazing  •  sexual  enhancers  •  an@depressants  •  an@psycho@cs  •  butalbital    •  an@eme@cs  (promethazine))  •  tramadol  •  muscle  relaxants  •  aspirin,  ibuprofen    
  13. 13. Pharmacy  Community  •  Trash  •  Inventory  altera@ons  •  Overt  Theh                  1.  individual  pills  v.  boHles                2.  dilu@ons  •  Inten@onal  miscounts  •  Dropped  meds  /  broken  meds  •  Forged  prescrip@ons  •  Adding  “false”  refills  to  old  prescrip@ons  •  Sharing  /  Borrowing  passwords  
  14. 14. Hospital  Pharmacy  •  Grazing  •  Overfill  •  Waste  •  returns  
  15. 15. Nursing  •  Pa@ent  complains  of  lack  of  pain  relief  •   Highly  suspicious  behavior  by  the  staff  in  ques@on  sugges@ng  impairment.                        Increased  tardys,  change  in  appearance,  worsening  behavior,  increased  errors    •   The  nurse  in  ques@on  was  "too  busy  or  forgot"  to  secure  a  witness  for  a  waste  •   The  controlled  substance  count  is  incorrect  when  the  nurse  in  ques@on  works,                        ohen  repe@@vely  •   Suspected  forged  signatures  •   The  nurse  in  ques@on  states  "gave  access  code"  to  another  nurse  •  The  frequently  forgets  to  document  in  the  pa@ent’s  record  
  16. 16. Nursing  Techniques  /  Solu@ons  Stealing  pa@ent  dose  •  Order  is  for  hydrocodone/APAP  1-­‐2  tablets  Q4-­‐6Hr  Prn  Pain              Over  IM/IV  administra@on  •  Subs@tu@ng  a  dose              1.  oral  (capsule,  liquid)            2.  IV    •  Falsifying  waste  •  New  and  used  patches            1.  replace  new  with  old            2.  reuse  old  patches  •  WriHen  -­‐Verbal  /  telephone  orders  that  are  false  
  17. 17. Other  Sites  within  the  Ins@tu@on  •  OR  /  OR  satellites  anesthesiologist,   anesthe@sts  •  ERs  
  18. 18. The  Technology  -­‐  Basics  •  Do  official  background  checks  regardless  if  you  know  the  candidate  or   their  families  •  Call  at  least  2  previous  employers  •  Random  drug  tes@ng    (for  the  right  drugs)  •  Do  not  allow  people  to  be  alone  in  pharmacy  •  Double  sign  off  inventories  •  No  coats,  purses,  backpacks,  etc.  in  pharmacy  area  •  LIMIT  ACCESS!  
  19. 19. The  Technology  •  Hospital  Pharmacy        -­‐  Point  of  entry  to  controlled  substances        -­‐  ID  badge    swipes        -­‐  refractometer  drug  tes@ng        -­‐  IV  product  /  waste  tes@ng  and  QA  
  20. 20. Refractometer  •  Very  accurate  tes@ng  •  Provides  a  sense  of  “surveillance”  as  a   deterrent    •  IV  rooms,  nursing  units,  ORs,  satellite   pharmacies  
  21. 21. Tracking  doses,  nurses,  tendencies   Automated  dispensing  machines  •  drug,  unit,  formula@on,  person,  place,  @me  
  22. 22. Tracking  doses,  nurses,  tendencies  •  PaHerns            -­‐on  floor  sta@s@cal  comparisons,  signs  out  more  than  other                        nurses                -­‐excessive  documen@ng  waste                -­‐uses  larger  vials  for  smaller  doses                -­‐mul@ple  breaks  •  Medica@on  changes    •  Doses  given              -­‐range  doses                -­‐range  schedule  (Q4-­‐6)              -­‐PRNS  •  Shih  /  nurse  comparisons  •  Witness  end  of  shih  counts  
  23. 23. Counterfeit  –  Shipment  Tracking  •  RFID  /  GPS  tracking  of  full  shipments  •  RFID  /GPS  tracking  of  single  boHles  “NYPD  Will  Implant  GPS  Chips  Into  Pill  Bo>les  To   Combat  PrescripBon  Drug  Abuse”  
  24. 24. Employee  Diversion(retail)  •  Hydrocodone  is  the  number  1  prescribed  item   in  the  US  •  Also  a  highly  diverted  item  •  Abusers  typically  take  15  to  20  tablets  a  day    •  Reports  have  shown  abusers  taking  in  excess   of  100  tablets  a  day  for  personal  use  •  Most  employee  diversion  is  for  self  use  and   profit  
  25. 25. Automated  Dispensing  Cabinets  • Strict  control  to   inventory  access  • Records  individual   operator’s  access     to  system  • Daily  discrepancy   reports  generated  
  26. 26. Biometric  Safe  •  Bolted  to  the  floor  •  Controlled  access  with  biometric  scan  
  27. 27. Analy@cs  Predic/ve  indicators  •  Cycle  count   adjustments  •  Overriding   replenishment     orders  •  Ordering  from  the   outside  vendor  •  Purchases  do  not   balance  dispensing  
  28. 28. Point  of  Sale  with  Remote  Monitoring  •  Remote  video  monitoring  •  Point  of  sale  data  is  available  •  Transac@on  analysis  by  individual   user  •  Excep@on  based  reports     automa@cally  generated     with  video  back  up  
  29. 29. Remote  Monitoring   Incident  Report  
  30. 30. Policies  and  Procedures  Zero  tolerance  on  employee   pilferage  for  controlled   substances  
  31. 31. Prescrip@on  Drug  Abuse  Epidemic   25   22.5   20  Millions   15   10   5   0.6   1   1.4   0.3   0   Heroin   Inhalants   Hallucinogens   Cocaine   Legend  Drugs  
  32. 32. Drug  Fact  Over  100  People  die  from  drug  overdoses  every   day  in  the  United  States.  Many  of  the  individuals  started  therapy  with  a   valid  prescrip/on  for  pain.            
  33. 33. Drug  Fact  •  For  every  death  there  are:   – 10  treatment  admissions  for  abuse   – 32  emergency  department  visits  for  misuse   or  abuse   – 130  people  who  abuse  or  are  dependent   – 825  non-­‐medical  users  •  An  epidemic  
  34. 34. Drug  Fact  •  Most  prescrip@on  pain  killers  are   prescribed  by  primary  care  and   internal  medicine  prescribers   – Not  specialists  •  Roughly  20%  of  prescribers  prescribe   80%  of  ALL  prescrip@on  pain  killers  
  35. 35. Drug  Fact  •  Enough  prescrip@on  pain  killers  were   prescribed  in  2011  to  medicate  every   American  adult  around  the  clock  for   a  month  •  ¾  of  all  drug  overdose  deaths  in  the   US  are  due  to  prescrip@on  drugs  
  36. 36. Analy@cs  Suspicious  Ac@vity  Prac@ce  of  pharmacy  is  changing  and  pharmacists  must  be  more  aware  of  the  poten@al  diversion  of  controlled  substances  •  Prescriber  •  Pa@ent  •  Pharmacy  
  37. 37. Pharmacist’s  Corresponding   Responsibili@es  (CSA)  •  Must  consider  the   geographical  distance   PATIENT   between  the  doctor,    the   pa@ent    and  the   pharmacy     –  Would  you  fill  a   prescrip@on  for  a  pa@ent   that  resides  in  Ohio,   prescribed  by  a  physician   PHARMACY   PRESCRIBER   in  Florida  at  a  pharmacy   in  MassachuseHs?   –  NO  
  38. 38. Pill  Mill  Clinics  •  Escalated  from  Florida  •  LiHle  state  regulatory  oversight   – Doctor  dispensing   – Ques@onable  wholesalers  
  39. 39. Ten  Arrested  In  Strike  Against  Florida  “Pill  Mill”  
  40. 40. The  Migra@on  
  41. 41. Suspicious  Ac/vity  •  Pharmacists  play  an  important  role  in  the   diversion  of  controlled  substances   –  Pharmacist  can  iden@fy  suspicious  prescribers   (trends)   –  Pharmacist  can  iden@fy  suspicious  pa@ents   (PDMP)   –  Pharmacist  can  iden@fy  abuse  trends   –  Pharmacists  are  not  licensed  by  the  DEA/ pharmacies  are   –  Pharmacists  need  help  and  guidance  
  42. 42. Report  Suspicious  Ac@vity  •  Pharmacist  should   – Gather  informa@on   •  Prescriber  name   – Address   – DEA   – Descrip@on  of     suspicious  ac@vity  •  Pharmacist  should  report  trends  or   suspicious  ac@vity  
  43. 43. Pharmacy  Systemic  Approach  Chain  data  Top  Oxycodone   Pharmacy  generated  data  Stores   Prescriber  data   Reported  Top  Oxycodone  Prescribers   suspicious   Trends   Store/Site  visit   ac@vity  Pa@ent  is     Distribu@on   Cash  vs.  TP   Clinical  Protocol   Edits  iden@fied  from   threshold   Oxy  vs.  CIIs   completed  by  dispensing  data   increase  requests   member  of  field   LeHer  to   CII’s  vs.  all  RX’s   management  or   Prescriber   corporate   Edit  in  dispensing   system  to   prevent  control   prescrip@on   dispensing  for   select  prescribers  
  44. 44. Analysis  (Corporate)  •  Top  oxycodone  and  hydrocodone  dispensing   pharmacies  •  Top  oxycodone  and  hydrocodone  prescribers  •  Reported  suspicious  ac@vity  of  prescribers  •  Requests  for  distribu@on  threshold  increases  •  Percentage  of  cash  versus  third  party  payer  for   controlled  substance  prescrip@ons  for  an   individual  prescriber  •  Percentage  of  controlled  versus  non-­‐controlled   prescrip@ons  wriHen  by  a  prescriber  
  45. 45. Analy@cs  •  Na@onal  Controlled  Substance  Ra@ng   Solu@on*     – Na@onal  database     •  Purchasing  data   •  Prescrip@on  data   •  Pa@ent  data  (de-­‐iden@fied)   •  Prescriber  reference  data  (specialty)   – Guide  to  iden@fying  suspicious   prescriber  ac@vity  *Currently  under  development  
  46. 46. Na@onal  Dashboard  •  The  Na@onal  Dashboard  will  be  color-­‐coded   based  on  the  metric  selected   –  Per  Capita  $  Spend  for  controlled  substances   –  Rx  Volume   –  Unit  Volume  (best  analysis  by  dosage  unit)   –  Change  in  Unit  Volume  (spike  in  dispensing  CDS)   –  #  of  Outlets  w/  High  Overall  Ra@ng   –  #  of  Prescribers  w/  High  Overall  Ra@ng  •  Selec@ng  a  state  will  then  drop  color-­‐code  “pins”     for  each  of  the  areas  within  a  state     where  suspicious  ac@vity  may  be  iden@fied  
  47. 47. Na@onal  Dashboard  
  48. 48. Pharmacy  Clinic  Protocol    •  Checklist  to  review  a  prescriber’s  office   –  Onsite  visit  (pictures  or  Google  maps)   –  Review  of  opera@ng  procedures  (security  guards)   –  Review  staff  and  creden@als  (sanc@ons)   –  Review  the  pa@ent  base  (similar  age)   –  Review  medica@ons  prescribed  (each  pa@ent  gets   same  medica@on  in  same  strength  and  quan@ty)   •  Oxycodone  30mg  #180  for  all  pa@ents  
  49. 49. Clinic  Protocol  •  The  protocol  is  not  only  used  for   prescribers  of  opioids  such  as   oxycodone  and  hydrocodone   –  Buprenorphine  clinics   •  Review  of  DEA  license  to  determine  number  of  pa@ents   prescriber  can  treat  (30  versus  100  pa@ents)   •  Review  the  number  pa@ents  under  treatment  or  care   by  the  prescriber   –  Weight  loss  clinics   –  ADHD  clinics    
  50. 50. Poten@al  Ac@on  Edit  in  Computer  •  LeHer  sent  to  the  prescriber  sta@ng  this   pharmacy  will  no  longer  dispense   prescrip@ons  for  controlled  substances  under   his/her  DEA  registra@on  (2  days  prior  to  edit  in   the  dispensing  system)   –  LeHer  must  be  mailed  via  Cer@fied  Mail,  UPS,   FedEx,  or  any  other  provider  that  has  shipment   tracking  and  signature  required  to  assure  delivery  •  “Corporate  policy  prohibits  dispensing   controlled  substance  prescrip4ons     wri6en  by  this  prescriber”  
  51. 51. Suspicious  Prescriber  •  Prescriber   –  Prescribed  695,811  total  dosage  units  of  oxycodone   containing  products  in  12  months   •  Prescribed  460,806  dosage  units  of  oxycodone  30  mg  tablets   in  12  months   –  Prescribed  to  several  members  of  the  same  family  at   the  same  address  with  same  diagnosis   –  Prescribed  the  same  combina@on  of  drugs  to  the   majority  of  pa@ents   –  Did  not  accept  Medicaid  pa@ents  and  did  not  accept   insurance  plans  for  office  visits   –  Ini@al  office  visit  per  pa@ent  was  $250.00  cash  only  
  52. 52. Systemic  Approach  Store  generated  data  Distribu@on   •  Pharmacy  Manager  requests  a  threshold   threshold  increase  for  oxycodone  increase  request   30mg   –  “Pharmacy  200  feet  down  the  block   is  no  longer  stocking  oxycodone   30mg.  I’ve  lost  a  ton  of  business  so  I   try  to  fill  in  the  gaps  and  aHract  new   business  however  I  can”  
  53. 53. Systemic  Approach  Prescriber  Data  Trends   •  Top  6  prescribers  were  prac@cing  in  Cash  vs.  TP   Florida  (Store  is  in  New  England)   •  Oxycodone  30mg  was  the  primary  Oxy  vs.  CIIs   oxycodone  product  prescribed  CII’s  vs.  all  RX’s   •  85%  of  these  prescrip@ons  were  for   cash  payments   •  67%  of  the  CII  prescrip@ons  were  for   oxycodone  30mg   •  78%  of  the  prescrip@ons  were  for  CIIs  
  54. 54. Systemic  Approach  Store/Site  Visit  Clinic  Protocol   •  Based  on  the  informa@on  from  completed  by  member  of   the  store  generated  data  and  field   the  prescriber  data  a  Store/Site  management  or  corporate.   visit  was  not  required   •  The  request  for  a  threshold   increase  was  denied  
  55. 55. Systemic  Approach  Edits  LeHer  to  Prescriber.   •  Based  on  prescriber  analysis  a  Edit  in  dispensing   leHer  was  sent  to  suspicious  system  to   prescribers  prevent  control  prescrip@on   •  A  message  is  ac@vated  in  the  dispensing  for   dispensing  system:  “Corporate  select  prescribers.   policy  prohibits  dispensing   controlled  substance  prescrip@ons   wriHen  by  this  prescriber”  
  56. 56. Addi@onal  Technology  Tools   (under  development)  •  Poten@al  edit  through  “third  party   processor”  to  alert  for  suspicious  ac@vity   (may  include)     –  Pa@ent  demographic   –  Prescriber  prac@ce  loca@on   –  Prescriber’s  scope  of  prac@ce   –  Medica@on  and/or  therapy  prescribed   –  Prescribing  paHerns   •  All  pa@ents  get  the  same  combina@on     of  medica@ons  with  same  diagnosis  
  57. 57. Summary  •  Pharmacies  should  consider  developing  a   comprehensive  analy@cal  approach  to  iden@fy   suspicious  prescriber  ac@vity.     –  This  approach  cannot  iden@fy  all  ac@vity  and  must   be  supplemented  by  the  pharmacists  in  stores     –  Prescribers  are  reviewed  on  an  individual  basis   with  respect  to  their  scope  of  prac@ce  and  pa@ent   base   –  The  analy@cs  are  simply  an  added  tool.   Pharmacists  are  a  key  part  of  the  process  Note:  This  list  is  not  inclusive  of  all  the  inves@ga@ve  techniques  we  rou@nely  conduct,  this  is  intended  to  highlight  the  major  inves@ga@ve  steps.  
  58. 58. Pa@ent  Diversion  Behavior  •  Armed  Robberies  rose  81%  from  2006  to   2010  •  The  number  of  dosage  units  stolen  grew  from   706,000  to  1.3  million  •  Haven  Drugs  –  Medford,  NY  a  pharmacist,  a   clerk  and  two  customers  killed  in  the  robbery  •  Charlie’s  Family  Pharmacy  –  Seaford,     NY  an  ATF  agent  and  robbery  suspect     shot  and  killed  
  59. 59. Reason  Pharmacies  are  Targeted  •  Easy  to  find  and  easy  access  •  Open  extended  hours  •  Typically  carry  larger  inventory  to  sa@sfy  demand  •  Open  floor  design  to  facilitate  pa@ent  interac@on  •  Limited  barriers  •  Limited  training  for  employees  on  robbery  events  •  Sa@sfy  addic@on  and  some  converted     to  cash   –  $80/tablet  of  oxycodone  in  certain  markets  
  60. 60. Preven@on  Tips  -­‐  Training  •  Understand  and  observe  behaviors  of  poten@al  robber   1.  Purposely  wearing  mul@ple  layers  to  cover  their  face   2.  Do  not  directly  look  at  cashier  or  other  associate   3.  They  do  not  acknowledge  your  gree@ng  or  comply  with   request  to  show  their  face   4.  They  walk  directly  and  with  purpose  to  the  pharmacy   counter  •  Be  aware  of  your  surroundings  •  Controlled  safes/cabinets  must  be  locked  when  not  in   use  •  Keep  pharmacy  doors  locked  at  all  @mes  •  Never  leave  the  pharmacy  area  unaHended  
  61. 61. Preven@on  Tips  -­‐  Training  •  Wipe  counters  and  front  doors   – Finger  prints  •  Stage  par@ally  filled  boHles  for  a   robbery  event  •  Mark  your  boHles   – Provides  a  link  for     law  enforcement   – Iden@fies  point     of  origin  
  62. 62. During  an  Event  •  Primary  concern  –  Safety  of  coworkers  and  customers  •  Do  not  resist  •  Remain  calm  –  no  sudden  movements  •  Cooperate  and  follow  instruc@ons  given  by  the  robber   –  Do  exactly  what  you  are  told,  nothing  more,  nothing  less,  do   not  argue  •  Make  mental  notes  of  the  robber  –  hair,  clothing,   shoes,  taHoos,  scars,  etc.  •  Do  not  aHempt  to  apprehend  the  criminal  •  Goal  is  to  get  the  robber  out  of  the     building  quickly  
  63. 63. For@fica@on  Sugges@ons  Based  on     Risk  Level  •  Height  Strip  Cameras   •  Public  view  monitor  •  Capture’s  height  of   at  the  pharmacy   robbery  suspect   drop  off  window  •  BeHer  facial  image   •  In@mida@on  
  64. 64. Exterior  Ligh@ng  and  Cameras  •  Increasing  the  foot  candles  of  exterior  ligh@ng  •  Exterior  cameras  for  parking  lots  and  store   entrance   –  Some  suspects  do  not  wear  their  disguise     in  the  car  or  parking  lots   –  Capture  car  make  and  model,  may  capture     license  plates   –  Direc@on  the  suspected     headed  
  65. 65. Robbery  Poster  •  Overt  warning  to   the  suspect  and   customers  for   awareness  •  Trained  associates  
  66. 66. Reward  Offers   Asking  concerned   ci@zens  for  their   help  to  resolve  a   crime.  
  67. 67. “Bait  BoHles”  
  68. 68. Tracking  Devices  •  GPS  tracking  system  •  Law  Enforcement  Tool  •  Immediate  no@fica@on  of  robbery  events  to  a   mobile  device  and  law  enforcement  •  Provides  law  enforcement  accurate  loca@on   data  on  the  suspect  •  Aids  in  the  apprehension  of  the  robbery   suspect  and  recovery  of  stolen  drugs  
  69. 69. Tracking  Devices  •  Hidden  within  the  inventory  •  Fully  automa@c  •  Updates  GPS  loca@on  every  6  to  8  seconds  •  Track  via  secured  website  (law  enforcement)  •  Device  is  silent  •  Seamless  to  day  to  day  pharmacy  opera@ons  •  Tip:  Give  staged  par@ally  filled  boHles  with  the   tracker  
  70. 70. Tracking  Points  •  9:27  PM  –  Device  ac@ve  on  Server  •  9:29  PM  –  Unit  gains  GPS  and  is  SW  on  Roosevelt  Blvd    •  9:33  PM  –  Subject  turns  leh  traveling  SE  on  Tyson  Ave  •  9:34  PM  –  Vehicle  crosses  over  Frankford  Ave  s@ll   moving  SE  •  9:36  PM  –  Subject  turns  right  on  to  Torresdale  Ave   traveling  SW  •  9:39  PM  –  Subject’s  vehicle  is  stopped  by  Police  
  71. 71. Outcome  •  Police  arrested  2  subjects  at  the  scene  •  Recovered  weapons  and  evidence  of  the  event   –  Clothing  and  drugs  •  They  were  connected  to  20+  open  cases   against  chain  and  independent  pharmacy   robberies  This  list  of  suggested  tac@cs  is  not  all  inclusive.  All  factors  should  be  considered  when  implemen@ng  any  tac@c  or  combina@on  of  tac@cs  including  threat  level,  design  of  building,  method  of  robbers  in  the  geographic  area,  etc.    
  72. 72. QUESTIONS  •  Thank  you  •  Dr.  Michael  O’Neil  •  Janet  Hart  R.Ph.  

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