Kallal presentation

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Tactical Diversion Investigationsand

The Connection to HeroinJeff Kallal

Supervisory SupervisorDrug Enforcement Administration

Las Vegas, Nevada

2012 Nevada Drug Summit

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Objectives

To understand how doctors and pharmacists contribute to the amount of prescription pills available in the illegal market

To recognize that opioid use can lead to heroin addiction

To recognize the red flags involved in this activity

To understand why it’s important to stem the tide of illegal prescription pill distribution

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Prescription Drug Abuse: A National Crisis

6.1 million Americans 12 or older were current users of prescription-type psychotherapeutic drugs without medical necessity

Prescription painkillers kill more people than cocaine, heroin, and methamphetamine combined

Seven of the top 10 drugs abused by high school seniors are sold in pharmacies

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Estimated cost of CPD diversion and abuse to public and private medical insurers is $72.5 billion a year

33 percent of all US traffic fatalities involve drug users

18 percent of motor vehicle driver deaths involve drugs

Prescription Drug Abuse: A National Crisis

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Trends from Across the

Nation

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Ohio’s Drug Epidemic

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South Florida’s Blight

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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 T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Crisis on Long Island

16 Pharmacy robberies on Long Island from October 2008 to July 2011

Armed robberies of pharmacies in NY state increased 1400% in four years

Oxycodone prescriptions filled in Nassau and Suffolk counties increased 46% from 2008 to 2010

Admissions to LI certified treatment programs are up 26% in one year

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Opioid Deaths: “The Real Orange County”

80 accidental opioid-related deaths for South [Orange] County and beach cities from 2007-2010 for people 24 and younger

“In a part of the world know for fun in the sun – and money – teens and young adults are getting wrecked on opioid-class prescriptions, and especially heroin, like never before”

David Whiting, ColumnistThe Orange County Register

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Prescription Drug Threat in Nevada

CPD abuse contributed to more drug-related deaths in Clark County than any other abused substance

The most widely available and commonly abused CPDs are opioids and depressants

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Prescription Drug Threat in Nevada

The increasing distribution and abuse of CPD pose a significant threat to Nevada

Nevadans consume about twice the national average per capita of prescription narcotics

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Prescription Drug Threat in Nevada

Las Vegas is a popular source destination for CPDs– Widely considered most prolific source destination in

Western regionCalifornia, 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 T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Drug-Related Deaths Clark County

Drug 2006 2007 2008 2009 2010 20112006 v. 2011

% Change

CPDs 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 T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Commonly Abused Opioids

Oxycodone (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 weeks Methadone (Schedule II) Morphine (Schedule II) Hydrocodone (Schedule III)

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Oxycodone

Many ways to abuse Oxycodone tablets:- Orally- Snorted- Injected- Smoked

Many 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 T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

OxyContin ® v. Heroin

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DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Cheaper heroin gives rise to new set of usersAtlanta Journal-Constitution

Heroin is mounting a comeback, appealing to a younger, more diverse audience than ever before, experts say…

They’re driven by cost, he said. Heroin is much cheaper than, say, an OxyContin 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 to heroin use.

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Delco task force tackles heroin plagueSeptember 09, 2012 By Mari A. Schaefer, Inquirer Staff Writer

Alarmed by a surge in heroin deaths, Delaware County officials joined 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, said Frederic Hellman, the county's medical examiner and a member of atask force newly appointed to address the issue.

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Southern California OxyContin Abusers Switching to Heroin

By StopOxy

Monday,February 27th, 2012

Drug treatment officials in San Diego County recently reported that the use of heroin by young adults has more than tripled since 2006. According to Susan Bower, director of San Diego County Alcohol and Drug Services, the increase in heroin use is “scary.” Admissions for heroin addiction now account for nearly one in five of all treatmentadmissions at facilities operated by the county.

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Commonly Abused Depressants

Carisoprodol = Soma (Schedule IV)

Clonazpam = Klonopin (Schedule IV)

Diazepam = Valium (Schedule IV)

Alprazolam = Xanax (Schedule IV)

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Commonly Diverted Pills Oxycodone Xanax (alprazolam) Lortab (hydrocodone)

Methadone Valium (Diazepam)

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Pharmaceutical Cocktails

“Vegas” Cocktail- Hydrocodone- Alprazolam- Carisoprodol

Holy Trinity- Oxycodone- Alprazolam- 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 T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Methods of Diversion

Practitioners / Pharmacists- Illegal distribution- Self abuse- Trading drugs for sex

Employee pilferage- Hospitals- Practitioners’ offices- Nursing homes- Retail pharmacies- Manufacturing / distribution facilities

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

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 T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Methods of Diversion

The Medicine cabinet / Obituaries

The Internet

Rogue Pain Clinics

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

The Practice of Good Medicine

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

The Practice of Bad Medicine

No exam or brief exam where doctor may not even touch the patient

No equipment in the officeThe doctor may be the only medical staff;

other workers may be clerical staff only Doctors see excessive numbers of patients in a

work day

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Results of Bad Medicine

Increased pills on the streetsMore addicts in the communityIncreased crimes Overdoses and deathsIncreased cost of legitimate medical care

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Drug Dealers?

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Who we are!

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Tactical Diversion Mission

The 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 T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

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 T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Pills are sold on the streets or used by the addicts = Diversion

(Criminal act of illegal distribution)21 USC 841 (a)(1)

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Federal Criminal Charges Related To Prescription Drugs

Federal Criminal Code and Rules Controlled Substances Act (CSA)Title 21 – Food and Drugs Chapter 13 – Drug Abuse Prevention and ControlPart D – Offenses and Penalties § 841 through § 865

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

State Criminal Charges Related to Prescription Drugs

Nevada Revised Statutes:

NRS 453.321: Sales of Controlled Substances

NRS 453.339-5: Trafficking in Controlled Substances – Schedule II

NRS 453.331: Unlawful Acts relating to Distribution of Controlled Substances by Registrants i.e. signing blank Rx pads in advance.

NRS 453.381: Limitations on prescribing, possessing, administering, transporting, and dispensing controlled substances ** only prescribe or administer Controlled substances for legitimate medical purposes and in the usual course of professional practice.

NRS 453.333: Penalties for making available controlled substances that cause death. Imprisonment/ Fines/ Forfeitures.

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Rules and Regulations Governing Registrants

Code of Federal Regulations (CFR)Title 21 - Food and Drugs, parts 1300 – End

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

What we

look for!

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Commonly Abused

Prescription Drugs

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Oxycodone

Powerful synthetic opiate legally used in long term pain treatment

Many forms of Oxycodone: from 5mg to 80mg tablets, including immediate release to controlled release properties. Now comes in a liquid form as well

Roxies, Percocet, Big Boys, Oxies, Oxy 80s, “O” Rings

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Oxycodone

Schedule II drug – high abuse potential and high physical dependence

Schedule II substances carry the highest penalty in sentencing guidelines

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

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 10mg

Ex. 100 OxyContin 30mg weighs approx. 28 gramsand has the street value=$2,500 to $4,000

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Types of Violators

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Tactical Diversion Targets

Not all targets are DEA RegistrantsDoctors : medical and osteopathicNurse practitioners Physician AssistantsMedical AssistantsDentistsPharmaciesPharmacistsPharmacy TechniciansPatientsDrug distributors Doctor shoppers

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Cases Against Dirty Doctors and Pharmacists

Our investigations begin with information on the doctor’s and pharmacy’s practices

Intelligence from various sources

Information from database checks

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Our Sources of Information

Complaints Citizens Coroner/Medical Examiner’s OfficeLicensing boards

Documents/DatabasesPrescription reportsOther informationOrdering habits

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Additional Sources of Info

Former/current patients and customers Former/current employeesAnonymous tipsFamily members of patients who have diedOther law enforcement agencies

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Red Flags

Pill transactions taken place in pharmacy parking lot

Long lines at the office and the pharmacyGroups traveling together to appointments

and pharmacy Vehicles ‘camping out’ in parking lotOffice open for “unusual” number of hours --

either really short hours or into the night

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Red Flags

Carloads of people drive across multiple states to get pills / out of state tags in lot

Doctor offers to write prescriptions in pharmacy parking lot; pharmacist is asked to fill them without asking questions

Doctor 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 T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Red Flags Patients report that doctor has them fill the

prescription and bring some of the pills back to him

Doctor writes prescriptions in exchange for work or other favors

Patients bring family and friends to doctor-they all get the same prescriptions

Fee for visit ($100-$400) cash is paid directly to doctor when prescription is written

Sliding Pay Scales

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Successes

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Las Vegas doctor charged with illegally distributing prescription drugs: Las Vegas doctor who advocates medical marijuana therapy has been charged with illegally distributing prescription drugs. Federal agents arrested James Tinnell, 73, on Tuesday. He appeared Wednesday before U.S. Magistrate Judge Lawrence Leavitt and was released on his own recognizance.

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Las Vegas doctor among 3 indicted in oxycodone ‘pill mill’ case:

Federal authorities have indicted a Las Vegas doctor, his unlicensed medical assistant and an alleged conspiring pharmacist in connection with illegally distributing painkillers. Dr. Henri Wetselaar, 87, David Litwin, 52, and Jason C. Smith, 43, each have been charged with one count of conspiracy to distribute oxycodone.

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Another Las Vegas doctor arrested in prescription drugs case:Another Las Vegas physician has been arrested in a federal crackdown on prescription drug abuse. A federal indictment unsealed Wednesday charged Sebastian M. Paulin Jr. with six counts of distribution of controlled substances, four counts of money laundering and one count of structuring transactions to evade reporting requirements. The government also is seeking forfeiture of $1.2 million. Paulin, 65, was taken into custody on Wednesday and then released on his own recognizance.

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Vegas doctor arrested for illegally dispensing drugs and burglary:

A Las Vegas doctor has been arrested on numerous charges including burglary and illegally prescribing and dispensing drugs. 51-year-old Dr. James Eells was arrested last Thursday on dozens of counts for each charge. It is alleged that Dr. Eells wrote at least 41 prescriptions for his brother-in-law, Todd Hallenbec, from Jan. 2010 through June 2011. The prescriptions were for oxycodone, methylin, methylphenidate, carisoprodol, and alprazolam. Upon arrest, Eells told police he does not have a license to dispense drugs and the prescriptions were intended for the treatment of indigent patients.

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Las Vegas Doctor Accused of Selling Drugs:

The I-Team has uncovered that a prominent hospital doctor was arrested for illegally selling thousands of powerful painkiller drugs. The doctor, who at one time was the Chief of Internal Medicine at Centennial Hills Hospital, was snagged in an undercover drug sting. Federal drug enforcement agents say Dr. Vinay Bararia sold nearly $50,000 worth of oxycodone painkillers.

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

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 T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Challenges

Criminal cases against doctors are complicated, time-consuming and require much greater resources than typical drug investigations. Prescription drugs are, after all, legal.

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Challenges

“Halo Effect”Political influenceSocial standingHighly regarded professionsPowerful professional organizationsHalo Effect” results in lenient

prosecution

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

ChallengesManpower-Budget restraints across Federal, State, & Local Law Enforcement limit required resources to address epidemicComplex Investigation-Learning curve for investigatorsExpensive-Medical expert fees $300 plus an hour-Expense of multiple Undercover visits

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Our Tools for Success!

Criminal InvestigationsCivil PenaltiesAdministrative SanctionsEducation

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

We don’t want Nevada to be the next South Florida!

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

Our Goal: Put the criminals away!

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

The Way AheadFoster collaborative investigative efforts

Dismantle the practices of dirty doctors, pharmacists and their criminal networks in Nevada

DEA T A C T I C A L D I V E R S I O N S Q U A D L A S V E G A S

WWW.DEADIVERSION.USDOJ.GOVJayne Tomko-GriffinDiversion Group Supervisor(702) [email protected]

Jennifer ZavestoskiRegistration Program Specialist(702) [email protected]

Jeff KallalSupervisory Special Agent(702) [email protected]