Good Afternoon. My name is Jeff Kallal and I am a DEA Supervisory Special Agent in charge of an initiative called the Tactical Diversion Squad.
When we talk about Diversion we are talking about Prescription drugs…More specifically, this presentation will focus on the diversion of controlled prescription drugsObjectives next…
What do they have in common?
Theobjectives this afternoon are to help you… [paraphrase objectives]I will give an overview of the problem both here and nationwide….And then then I will talk about our squad, the TDS mission, and the resources we bring to Nevada.I’m not going to use “War on Drug” cliches and call this an epidemic… but…Make no mistake about it, this a national crisis because it affects us all[next, A national crisis]
The “Buckeye State” is in the heart of a huge destination region for controlled prescription drugs.Folks from Ohio travel down I-75 to South Florida… and more astonishingly…They travel out here to Vegas!However, South Florida is still the biggiest source destination in the country…..
….because Broward County is the pain clinic capital of the country.OPERATION PILL NATION I and II have stepped up enforcement efforts with significant successes.
This quote from an article in the Atlanta Journal-Constitution illustrates how Georgia is becoming the new Florida… and it’s only half as far from the pain pill consumer areas of Appalachia and the mid-west. [In addition to Georgia, the mid-atlantic has it’s own problems.
…In the form of skyrocketing Oxycodone abuse and pharmacy robberies.[The Hamptons aren’t the only place the well-to-do are getting hooked on pain pills…]
It’s happening in Orange County too as some of our investigators here today will tell you.And, increasingly, these kids are moving to heroin. A trend we are seeing in Northern San Diego County and Suburban Chicago as well…You may ask how bad are things at home in Nevada? Let’s take a look…[next]
PLAY VIDEO – Oxy – A Quick trip to Heroin.
Oxycontin, or synthetic Heroin as it is often call, has almost the exact same molecular makeup as Heroin.Heroin and Oxycontin both give the user an intense head rush, and then euphoria.The drug addict will use whichever drug is easiest for him to obtain, as Heroin and Oxycontin are interchangeable.Oxycontin is vastly over prescribed.Both are extremely addictive.
Circle of Addiction & the Next Generation Hydrocodone Lorcet®$5-$7/tab Oxycodone Combinations Percocet®$7-$10/tab OxyContin® $80/tab Roxicodone® Oxycodone IR 15mg, 30mg $30-$40/tab Heroin $15/bag
Here are some headlines from across the country…
The Abuser ingest these combination to increase the pills effects!
Next: Our mission
Next: What make up a TDS.
This is the current staffing of the participating agencies.
DEA enforces the controlled Substance Act (CSA)These regulations outline illegal sales and distribution of controlled substances; ordering and dispensing of controlled substances; licensing of registrants; audit/search/and forfeiture powers of the DEA and sentencing guidelines of guilty offenders.The penalty phase can include imprisonment/fines up to $10,000 per violation/and forfeiture of DEA license and real assets.
In addition to the CSA, the DEA mutually works with state and local law enforcement and licensing boards to address the problem. Here are some of the Nevada State laws that help us enforce pharmaceutical violations.
Registrant and health care providers have obligations under the CSA.One role of DEA, in addition to enforcing the Controlled Substance Act (CSA), is to educate the registrant population–including health care providers–of their obligations under CSA, as well as to educate parents, community leaders and law enforcement personnel regarding diversion trends, the scope or the problem, and how to best address prescription drug diversion in communities throughout the United States. The CFR outlines the requirements that registrants must adhere to.
Schedule II substances carry the highest penalty in sentencing guidelinesThis is a key factor since the prosecutors want to ensure the defendants meet heavy penalties.
However, because of the limited manpower, the TDS has been focusing on what we believe is the major source of supply of Controlled Prescription Drugs …Doctors and pharmacists.
As ridiculous as some of these Red Flags sound…we have observed all of these in our investigations.
Here are some headlines stemming from the Las Vegas TDS cases over the last 18 months.
These cases do not simply require undercover operations.All prosecution requires a medical expert opinion to review all aspects of the case to certify the doctor is operating out of the scope of legitimate medical practice and is an imminent threat to public safety.
We as a society have to overcome and minimize the Halo Effect.And realize that Doctors are people, just like you and me, and they are just as susceptible to vices, such as greed and lust.
Budget constraints across Federal, State, and Local Law Enforcement limit required resources to address epidemicLearning curve for investigators – complex
We must foster joint / mutual investigative efforts amongst:State Licensing BoardsDEA RegulatoryAll Federal / State / Local Law EnforcementState / Federal Prosecutors
2012 Nevada Drug SummitTactical Diversion Investigations and The Connection to Heroin Jeff Kallal SupervisorySupervisor Drug Enforcement Administration Las Vegas, Nevada DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
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ObjectivesTo understand how doctors and pharmacists contribute to the amount of prescription pills available in the illegal marketTo recognize that opioid use can lead to heroin addictionTo recognize the red flags involved in this activityTo understand why it’s important to stem the tide of illegal prescription pill distribution DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Prescription Drug Abuse: A National Crisis6.1 million Americans 12 or older were current users of prescription-type psychotherapeutic drugs without medical necessityPrescription painkillers kill more people than cocaine, heroin, and methamphetamine combinedSeven of the top 10 drugs abused by high school seniors are sold in pharmacies DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Prescription Drug Abuse: A National CrisisEstimated cost of CPD diversion and abuse to public and private medical insurers is $72.5 billion a year33 percent of all US traffic fatalities involve drug users18 percent of motor vehicle driver deaths involve drugs DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Trends from Across the Nation DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Ohio’s Drug Epidemic DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
South Florida’s Blight DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Georgia on the Mind of Drug Dealers“A worrisome new kind of drug dealer is gaining a toehold in Georgia after fleeing crackdowns in surrounding states, setting up in bedroom communities northwest of Atlanta along I-75 to serve customers near and far” Atlanta Journal-Constitution July 9, 2011 DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Crisis on Long Island16 Pharmacy robberies on Long Island from October 2008 to July 2011Armed robberies of pharmacies in NY state increased 1400% in four yearsOxycodone prescriptions filled in Nassau and Suffolk counties increased 46% from 2008 to 2010Admissions to LI certified treatment programs are up 26% in one year DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Opioid Deaths: “The Real Orange County”80 accidental opioid-related deaths for South[Orange] County and beach cities from 2007-2010for people 24 and younger“In a part of the world know for fun in the sun – andmoney – teens and young adults are gettingwrecked on opioid-class prescriptions, andespecially heroin, like never before” David Whiting, Columnist The Orange County Register DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Prescription Drug Threat in NevadaCPD abuse contributed to more drug-related deaths in Clark County than any other abused substanceThe most widely available and commonly abused CPDs are opioids and depressants DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Prescription Drug Threat in NevadaThe increasing distribution and abuse of CPD pose a significant threat to NevadaNevadans consume about twice the national average per capita of prescription narcotics DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Prescription Drug Threat in NevadaLas Vegas is a popular source destination for CPDs – Widely considered most prolific source destination in Western region California, Arizona, Utah, Colorado, Oregon, and Washington – Case intelligence also shows individuals travelling from all over the United States Alaska, Connecticut, Kentucky, Louisiana, Massachusetts, Ohio, Tennessee, and Texas DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Drug-Related Deaths Clark County 2006 v. 2011 Drug 2006 2007 2008 2009 2010 2011 % ChangeCPDs 165 336 338 262 290 364 120%Cocaine 115 58 39 44 29 68 -40%Methamphetamine 80 56 34 55 56 107 33%Heroin 35 45 17 8 5 33 -5% DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Commonly Abused OpioidsOxycodone (Schedule II) – OxyContin is a brand name of a time release version of oxycodone – Users are susceptible to dependence and tolerance within one to two weeksMethadone (Schedule II) Morphine (Schedule II) Hydrocodone (Schedule III) DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
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OxycodoneMany ways to abuse Oxycodone tablets: - Orally - Snorted - Injected - SmokedMany users go through a transition: - Other “pills” (Hydrocodone, Alprazolam, etc. are often mixed with Oxycodone to make different “pharmaceutical cocktails” based upon the abusers addiction. - Heroin (Prescription drug abusers transition to heroin because it is a cheaper and stronger ”high”) - Transition occurs because 1 oxycodone tablet costs $25 to $40 vs. 1 gram Heroin $40 DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
OxyContin ® v. Heroin DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
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Cheaper heroin gives rise to new set of usersAtlanta Journal-ConstitutionHeroin is mounting a comeback, appealing to a younger, more diverseaudience than ever before, experts say…They’re driven by cost, he said. Heroin is much cheaper than, say, anOxyContin tablet, which typically sells for $30.“A lot of young kids start on grandma’s Percocets and they get hooked.”said Lee, adding that prescription painkillers often serve as a gateway toheroin use. DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
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Delco task force tackles heroin plagueSeptember 09, 2012 By Mari A. Schaefer, Inquirer Staff WriterAlarmed by a surge in heroin deaths, Delaware County officialsjoined together for the first time Friday to attack a problem they seedevastating families and communities. There were 33 heroin-related deaths in the county in the first six months of the year.In 2011, there were 62 deaths, and in 2010 there were 50, saidFrederic Hellman, the countys medical examiner and a member of atask force newly appointed to address the issue. DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Southern California OxyContin Abusers Switching to HeroinBy StopOxyMonday,February 27th, 2012Drug treatment officials in San Diego County recently reported thatthe use of heroin by young adults has more than tripled since 2006.According to Susan Bower, director of San Diego County Alcohol andDrug Services, the increase in heroin use is “scary.” Admissions forheroin addiction now account for nearly one in five of all treatmentadmissions at facilities operated by the county. DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Commonly Abused DepressantsCarisoprodol = Soma (Schedule IV)Clonazpam = Klonopin (Schedule IV) Diazepam = Valium (Schedule IV)Alprazolam = Xanax (Schedule IV) DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Commonly Diverted PillsOxycodone Xanax (alprazolam) Lortab (hydrocodone) Methadone Valium (Diazepam) DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Pharmaceutical Cocktails“Vegas” Cocktail Holy Trinity - Hydrocodone - Oxycodone - Alprazolam - Alprazolam - Carisoprodol - Carisoprodol These dangerous combinations are highly sought after by Rx abusers and those in the night club scene. The abusers ingest the pills simultaneously, commonly with alcohol to increase the pills effects. DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Methods of DiversionPractitioners / Pharmacists- Illegal distribution- Self abuse- Trading drugs for sexEmployee pilferage- Hospitals- Practitioners’ offices- Nursing homes- Retail pharmacies- Manufacturing / distribution facilities DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Methods of Diversion Pharmacy / Other Theft - Armed robbery - Burglary (Night Break-ins) - In Transit Loss (Hijacking) - Smurfing Patients / Drug Seekers - Drug rings - Doctor-shopping - Forged / fraudulent / altered prescriptions DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Methods of DiversionThe Medicine cabinet / ObituariesThe InternetRogue Pain Clinics DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
The Practice of Good Medicine DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
The Practice of Bad MedicineNo exam or brief exam where doctor may not even touch the patientNo equipment in the officeThe doctor may be the only medical staff; other workers may be clerical staff onlyDoctors see excessive numbers of patients in a work day DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Results of Bad MedicineIncreased pills on the streetsMore addicts in the communityIncreased crimesOverdoses and deathsIncreased cost of legitimate medical care DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Drug Dealers?DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Whoweare! DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Tactical Diversion MissionThe Tactical Diversion Squad (TDS) program combines the resources of DEA with State and local law enforcement agencies in an innovative effort directed at doctor shoppers, prescription forgers, and prevalent retail-level violators. Physicians and pharmacies involved in retail diversion schemes are also targeted based on information developed by the TDS. DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Las Vegas Tactical Diversion Squad Participants• Drug Enforcement Administration• Las Vegas Metropolitan Police Department• Nevada Highway Patrol• North Las Vegas Police Department• Henderson Police Department• Federal Bureau of Investigation DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Pills are sold on the streets or used by the addicts = Diversion (Criminal act of illegal distribution) 21 USC 841 (a)(1) DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Federal Criminal Charges Related To Prescription DrugsFederal Criminal Code and RulesControlled Substances Act (CSA)Title 21 – Food and Drugs Chapter 13 – Drug AbusePrevention and ControlPart D – Offenses and Penalties § 841 through § 865 DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
State Criminal Charges Related to Prescription DrugsNevada Revised Statutes:NRS 453.321: Sales of Controlled SubstancesNRS 453.339-5: Trafficking in Controlled Substances – Schedule IINRS 453.331: Unlawful Acts relating to Distribution of Controlled Substancesby Registrants i.e. signing blank Rx pads in advance.NRS 453.381: Limitations on prescribing, possessing, administering,transporting, and dispensing controlled substances ** only prescribe oradminister Controlled substances for legitimate medical purposes and in theusual course of professional practice.NRS 453.333: Penalties for making available controlled substances that causedeath. Imprisonment/ Fines/ Forfeitures. DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Rules and Regulations Governing RegistrantsCode of Federal Regulations (CFR)Title 21 - Food and Drugs, parts 1300 – End DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
What welook for! DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Commonly AbusedPrescription Drugs DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
OxycodonePowerful synthetic opiate legally used in long term pain treatmentMany forms of Oxycodone: from 5mg to 80mg tablets, including immediate release to controlled release properties. Now comes in a liquid form as wellRoxies, Percocet, Big Boys, Oxies, Oxy 80s, “O” Rings DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
OxycodoneSchedule II drug – high abuse potential and high physical dependenceSchedule II substances carry the highest penalty in sentencing guidelines DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Street Prices $2- $4 – Diazepam (Valium) 5mg $2- $4 – Alprozolam (Xanax) 2mg $3- $5 – Hydrocodone (Vicodin) 10mg $25 - $40 – Oxycodone (Oxycontin) 30mg $25 – Morphine Sulfate (MS Contin) 60mg $ 5 – Methadone 10mgEx. 100 OxyContin 30mg weighs approx. 28 grams and has the street value=$2,500 to $4,000 DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Types of Violators DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Tactical Diversion TargetsNot all targets are DEA Registrants Doctors : medical and osteopathic Nurse practitioners Physician Assistants Medical Assistants Dentists Pharmacies Pharmacists Pharmacy Technicians Patients Drug distributors Doctor shoppers DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Cases Against Dirty Doctors and Pharmacists Our investigations begin with information on the doctor’s and pharmacy’s practices Intelligence from various sourcesInformation from database checks DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Our Sources of InformationComplaintsCitizensCoroner/Medical Examiner’s OfficeLicensing boardsDocuments/DatabasesPrescription reportsOther informationOrdering habits DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Additional Sources of InfoFormer/current patients and customersFormer/current employeesAnonymous tipsFamily members of patients who have diedOther law enforcement agencies DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Red FlagsPill transactions taken place in pharmacy parking lotLong lines at the office and the pharmacyGroups traveling together to appointments and pharmacyVehicles ‘camping out’ in parking lotOffice open for “unusual” number of hours -- either really short hours or into the night DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Red FlagsCarloads of people drive across multiple states to get pills / out of state tags in lotDoctor offers to write prescriptions in pharmacy parking lot; pharmacist is asked to fill them without asking questionsDoctor and a pharmacist-in-charge agree to refer “patients” back-and-forth; patients sign agreement in doctor’s office to go to specific pharmacy (kickbacks paid to doctor) DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Red FlagsPatients report that doctor has them fill the prescription and bring some of the pills back to himDoctor writes prescriptions in exchange for work or other favorsPatients bring family and friends to doctor-they all get the same prescriptionsFee for visit ($100-$400) cash is paid directly to doctor when prescription is writtenSliding Pay Scales DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
SuccessesDEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Las Vegas doctor charged with illegallydistributing prescription drugs:Las Vegas doctor who advocates medicalmarijuana therapy has been charged withillegally distributing prescription drugs. Federalagents arrested James Tinnell, 73, on Tuesday.He appeared Wednesday before U.S. MagistrateJudge Lawrence Leavitt and was released on hisown recognizance. DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Las Vegas doctor among 3 indicted inoxycodone ‘pill mill’ case:Federal authorities have indicted a Las Vegasdoctor, his unlicensed medical assistant and analleged conspiring pharmacist in connectionwith illegally distributing painkillers. Dr. HenriWetselaar, 87, David Litwin, 52, and Jason C.Smith, 43, each have been charged with onecount of conspiracy to distribute oxycodone. DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Another Las Vegas doctor arrested inprescription drugs case:Another Las Vegas physician has been arrested in afederal crackdown on prescription drug abuse. Afederal indictment unsealed Wednesday chargedSebastian M. Paulin Jr. with six counts of distribution ofcontrolled substances, four counts of money launderingand one count of structuring transactions to evadereporting requirements. The government also isseeking forfeiture of $1.2 million. Paulin, 65, was takeninto custody on Wednesday and then released on hisown recognizance. DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Vegas doctor arrested for illegallydispensing drugs and burglary:A Las Vegas doctor has been arrested on numerouscharges including burglary and illegally prescribing anddispensing drugs. 51-year-old Dr. James Eells wasarrested last Thursday on dozens of counts for eachcharge. It is alleged that Dr. Eells wrote at least 41prescriptions for his brother-in-law, Todd Hallenbec,from Jan. 2010 through June 2011. The prescriptionswere for oxycodone, methylin, methylphenidate,carisoprodol, and alprazolam. Upon arrest, Eells toldpolice he does not have a license to dispense drugs andthe prescriptions were intended for the treatment ofindigent patients. DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Las Vegas Doctor Accused of SellingDrugs:The I-Team has uncovered that a prominenthospital doctor was arrested for illegally sellingthousands of powerful painkiller drugs. Thedoctor, who at one time was the Chief ofInternal Medicine at Centennial Hills Hospital,was snagged in an undercover drug sting.Federal drug enforcement agents say Dr.VinayBararia sold nearly $50,000 worth ofoxycodone painkillers. DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
What You Don’t See In The News Paper• Civil penalties up to a million dollars• Seizures of assets, to include real estate and financial accounts in excess of four million dollars• Revocation of DEA Registration and applicable State Licensing• Legal Fees• Embarrassment and distrust amongst your associates• Loss of livelihood DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
ChallengesCriminal cases against doctorsare complicated, time-consumingand require much greaterresources than typical druginvestigations. Prescription drugsare, after all, legal. DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Challenges“Halo Effect”Political influenceSocial standingHighly regarded professionsPowerful professional organizationsHalo Effect” results in lenient prosecution DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
ChallengesManpower-Budget restraints across Federal, State, &Local Law Enforcement limit requiredresources to address epidemicComplex Investigation-Learning curve for investigatorsExpensive-Medical expert fees $300 plus an hour-Expense of multiple Undercover visits DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Our Tools for Success!Criminal InvestigationsCivil PenaltiesAdministrative SanctionsEducation DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
We don’t want Nevada to be the next South Florida! DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
Our Goal: Put the criminals away! DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
The Way AheadFoster collaborative investigative effortsDismantle the practices of dirty doctors, pharmacists and their criminal networks in Nevada DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V
WWW.DEADIVERSION.USDOJ.GOVJeff Kallal Jayne Tomko-GriffinSupervisory Special Agent Diversion Group Supervisor(702) 759-8068 (702) 759-8111Jeffrey.G.Kallal@USDOJ.GOV Jayne.M.Tomko@USDOJ.GOV Jennifer Zavestoski Registration Program Specialist (702) 759-8202 Jennifer.N.Zavestoski2@USDOJ.GOV DEA TA C T I C A L D I V E R S I O N S Q U A D L A S V