When the feds announced the case of a prescription pill distribution ring emerging out of Crossville, Tenn., last week, authorities again turned their spotlight on an element of criminal enterprise that has grown exponentially in the past several years, evolving from pill abusers paying friends for a hookup, to getting prescriptions by lying to doctors, to systematic TennCare fraud.
Acting on a federal grand jury indictment in Nashville, the U.S. Attorney’s Office for the Middle District of Tennessee nearly two weeks ago began rounding up 33 defendants, all from Crossville, the Cumberland Plateau city of about 10,400. By last Monday, when U.S. Attorney Jerry Martin — flanked by a dozen other law enforcement leaders from various departments — announced the indictment, 27 of the 33 had already been arrested, with possibly more to come. The defendants — ranging in age from 22 to 73 and including some family members — allegedly operated a sophisticated pharmaceutical distribution ring.
Det. Michael Donaldson has worked in the Narcotics Unit of the Metro Nashville Police Department for 13 years. For the last four, his focus has been the use of prescription drugs for illegitimate purposes. When he began that job in 2007, Metro made 184 arrests for people fraudulently obtaining prescriptions. In 2008, those arrests jumped to 300. In 2009, they doubled to 617. And in 2010, they rose again to 853.
Of course, Metro arrests across the board have risen over the past six years, prompted by former Chief Ronal Serpas’ shift in policing strategy, so the dramatic rise in arrests cannot be solely attributed to the burgeoning interests of dealers and users. But the rise in prescription fraud arrests comes as the result of a progression that ended in a more dealer-friendly drug game — one where obtaining and selling pills cuts out the overhead of selling marijuana or coke, which could require baggies, scales, guns, lawyers, and so on.
In 2008, Donaldson started seeing more dealers shift to pills. It was a rather stout progression, from an exchange between friends or acquaintances to lying to doctors for prescriptions, which led to doctor shopping — looking for multiple doctors to lie to — which brought along with it TennCare fraud, or having the state pay for a prescription that could then be sold for pure profit.
With that as backdrop, the Crossville indictment paints a picture of an organized operation that obtained prescription pills through a variety of means, sold the pills and turned a profit — all the while keeping one eye on the law.
Last Monday, authorities said so far in the case they’d seized more than 1,000 pills, $335,000 in cash and jewelry, 25 firearms and more than 40 vehicles.
At times, according to the indictment, the suspects used fake names, code words and prepaid cell phones to conduct business, shipping the drugs through the U.S. Postal Service and other couriers. The ring allegedly operated out of businesses, registered property in the names of others to avoid detection, and went as far as conducting countersurveillance on law enforcement.
Crossville Police Chief David Beaty said that as the local investigation pointed to the alleged involvement of more and more individuals, including a Cumberland County sheriff’s deputy, authorities in Cumberland County and neighboring Putnam County turned to state and federal agencies including the FBI, Tennessee Bureau of Investigation, the Drug Enforcement Administration, and the U.S. Postal Inspection Service.
On a different front in the same war against illegally obtaining prescription pills, state officials have ratcheted up prosecutions in TennCare fraud cases.
The state created the Office of the Inspector General in February 2005, coinciding with the rise of prescription fraud connected to TennCare. In June 2007, the OIG got a boost from the state when it passed legislation against doctor shopping, or going from doctor to doctor each month to rack up prescriptions. In 2008, the OIG logged 265 arrests for TennCare fraud. In 2009, the office topped 1,000.
At the local level, insurance fraud changed the way police departments investigate reported thefts of prescription medication after it became clear that people were filing bogus reports to perpetuate fraud.
Two and half years ago, when Beaty’s department noticed a rise in suspicious thefts, Crossville police stopped taking reports of stolen prescriptions they suspected as fraud. Similar to the changes at the Crossville Police Department, detectives in the Hermitage Precinct of the MNPD also changed their procedures in mid-2010 after noticing a large number of reports involving prescriptions, usually taken out of vehicles that suspiciously were left unlocked and otherwise undisturbed.
At the time, citizens were allowed to call the department’s automated Teleserve system and report thefts of under a certain amount over the phone. But that practice ended for prescription thefts after the same individuals kept calling the precinct once a month (or a 30-day period, as it were) to get a police report regarding their “stolen” pills. With a police report, pill shoppers could be reimbursed for those pills with insurance money.
While police in Hermitage still encourage citizens to report theft, including stolen prescription medications, they now scrutinize the reports more, and detectives conduct one-on-one interviews when a prescription theft is involved.
Parallel to the arc of the criminal evolution appears to be another arc of accidental overdoses.
According to Dr. Len Paulozzi, medical epidemiologist at the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control, 2007 data (the latest available) showed Tennessee’s rate of non-suicidal drug overdose deaths caused by any drug, including prescriptions as well as heroin and cocaine (but not including alcohol), was 14.2 per 100,000 people.
Of the eight states contiguous to Tennessee, only Kentucky topped it with a rate of 15.1 deaths per 100,000 people. Missouri ranked third at 10.4 per 100,000, and the remaining six fell between 7.1 (Virginia) and 10.2 (Alabama) per 100,000.
“The area seems to be affected by the recent increase in drug overdose death rates related to prescription drugs,” Paulozzi said, “so we don’t think these higher rates are because of heroin or cocaine, in this part of the country at least. And in particular among the prescription drugs, it’s the category we call opioid analgesics [painkillers] that is really driving this increase.”
Methadone, hydrocodone and oxycodone are three of the drugs commonly involved in overdose deaths, Paulozzi said.
Prescription abuse is “a national problem,” he added, which began in the mid-1990s and has continued at least through 2009, the year of the latest available data.
The big issue, he said, is pill mills: pain clinics — the illegitimate, rogue ones — that prescribe cocktails of painkillers (OxyContin) and sedatives (Valium). Florida has made a name for itself as a drug tourist’s pill-mill destination, with some clinics there known for their propensity to prescribe oxycodone in combination with Xanax in large volumes.
“The concern in Appalachian states is that residents there are going down to Florida and obtaining large quantities of pills at the so-called pill mills and returning to their home state with them,” Paulozzi said.
The Crossville defendants allegedly did exactly that. The indictment specifically lists Georgia and Florida as two states where some of those indicted went to obtain pills. Louisiana, Texas and north Georgia have also seen increases in pill-mill production, Paulozzi said.
Pain-management clinics have added more sand to the Vaseline for police, with such pill mills popping up in areas where doctor shopping is prevalent. Though some clinics certainly are legit, others — those with packed waiting rooms and hours-long waits, and doctors who ask few questions with no physical examination before prescribing cocktail prescriptions of hundreds of painkillers to “patients” who are able to walk, don’t have cancer and are packing all of their major organs — raise suspicions.
In Metro, Donaldson also sees a lot of forged signatures on stolen prescription pads that mean a “field day” for pill hunters. A close look at the patient profile of one legitimate dentist turned up prescriptions issued to 132 people he’d never seen before because someone got hold of his prescription pad.
Still, in the last eight or nine months, Donaldson noticed another evolution of the prescription game — the rise of rogue pharmacy technicians. Hired to count pills usually without certification and for low wages, some technicians have started taking advantage of their positions to rake in extra hundreds or thousands of dollars selling pills out of a drive-through window, for instance.
The driving force behind prescription abuse and fraud remains the same as in the sell of illegal narcotics: customer demand and the ability to make money. As Donaldson relates it, the rules of the pill game change as needed to be successful.
“It’s like any other crime,” Donaldson said. “Once the police figure out where you’re keeping your marijuana [for instance], you find another way to hide it. It’s the same thing with the pills.”