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Intelligence sharing to combat illicit online pharmacies

When investigating online prescription drug diversion cases, the old saying "It's not what you know, but who you know" rings true. Networking with other local, state and federal law enforcement agencies and health officials can make or break a big case, says Cesar Arias, a pharmacist who investigated drug diversion for the Florida Department of Law Enforcement for 18 years until his retirement in 2005.

Though the elements of the crime are the same as any other illicit drug case, Charlie Cichon, executive director of the National Association of Drug Diversion Investigators (NADDI), explains that federal and state involvement is essential to navigate the jurisdictional problems that naturally accompany Internet-based crime. In these operations, medications may be delivered to Kentucky but the prescribing physician practices medicine in Wisconsin, and the pharmacy may be located in Florida while the mastermind behind the operation resides in another country.

"With the Internet, you no longer need a physical pharmacy or even a physical doctor," says John Burke, NADDI president. "So [without assistance] how do you find the location when it may be in another state or even another country?" he asks.

The value of teamwork

Departments are often reluctant to cooperate with other organizations, especially outside of law enforcement, in any type of case, let alone Internet diversion inquiries, says Mark Caverly, chief of the Drug Enforcement Administration's (DEA's) Liaison and Policy Section in the Office of Diversion Control. "But we've seen many cases where a federal or local office shuts down an illicit Internet pharmacy on its own, only to have that pharmacy replaced in a matter of days by a pharmacy somewhere else. In order to effectively control this issue, cooperation is essential."

The manpower and time required to work these cases is often more than a single agency can provide. With Internet technology obscuring the source of the product, finding the Web site's true location presents a challenge, but once unearthed it's also tricky to identify the forces behind it, Caverly explains. Doing so requires investigators to carefully peel back the layers to get to the operation's core - and this takes a lot of manpower. In fact, in the DEA's Dallas-Fort Worth case, where approximately 3.5-million dosage units of controlled substances were being illegally sold each month, the entire resources of a single regional office focused on the investigation for several months.

Because the intense work generated by these cases can deplete resources, connecting with law enforcement officials who are familiar with this type of investigation can help facilitate the process, says Cichon.

In a case worked by John Marshall of the Kentucky State Police, Florida pharmacies were delivering hydrocodone to Kentucky. Burke says Marshall teamed with the regional High Intensity Drug Trafficking Area (HIDTA) in the investigation. First Sgt. Harvey Smith of the Virginia State Police drug diversion unit also recalls a case where teamwork was essential. In this investigation, anabolic steroids were coming into Virginia from several source countries, including Mexico. Virginia State Police investigators joined forces with U.S. Customs' officials to work the case. Customs would intercept the packages arriving from the source countries and open them for security reasons. They would then contact the Virginia State Police to arrange a controlled delivery of the medications. Virginia officials carried out the delivery and prosecuted on their end if detectives determined the individual obtained the drugs by fraud, such as by falsifying a medical history form.

When multiple jurisdictions are involved, Caverly recommends working with federal law enforcement, in particular the DEA, which can help coordinate the investigation. The DEA is currently increasing staffing and resources to improve its capabilities to identify and stop illicit Internet pharmacy operations; in turn, stepping up its ability to aid other organizations. Burke advises soliciting the assistance of the FBI, U.S. Immigration & Customs Enforcement (ICE) and the Food & Drug Administration (FDA) as well.

Investigating rogue online pharmacies generates a tremendous volume of evidence and information, which must be conveyed to everyone working the case. To facilitate this process, once the DEA becomes involved it acts as the information gatekeeper to house relevant case information in one place. The organization then holds regular face-to-face meetings with the other investigative agencies involved to discuss the status of the case, revise goals and share information.

Such meetings are critical to ensure one entity doesn't take action before another unit working a separate part of the case is ready. "It becomes an issue of cooperation and coordination as we move the investigation along to try to achieve the biggest impact possible," details Caverly. "We want to shut the pharmacy down, but we also want to get the doctors who write the prescriptions and Web site operators who facilitate the transactions. Everyone must work toward a common goal, communicating and making sure we don't compromise the investigation to the detriment of the other locations."

Networking with the state health department or board of pharmacies also can make a tremendous difference when building these cases, says Arias. A pharmacist in a health department is in a position to help investigators understand the law, scope and magnitude of the situation. These professionals can assist law enforcers in "walking the talk" with health care professionals, who may be difficult to interview if officers are unfamiliar with medical terminology.

Private industry partners

In order to conduct business on the Internet, illicit pharmacies require a pharmaceutical supplier and a method to ship their products all over the country. It stands to reason that networking with private industry - including shipping companies, such as FedEx, UPS or DHL, and pharmaceutical manufacturers and distributors - also helps generate leads that clinch a case. "Building relationships with wholesalers and shipping companies will shut down the whole industry," stresses Arias. "You can't do business on the Internet without these two factors."

Arias suggests establishing key contacts with security officials at common carriers. By alerting these individuals about prescription drug abuse and maintaining a strong relationship with them, they may cooperate more readily when they notice large quantities of prescription meds being shipped to the same address.

Caverly recommends officers tap into the knowledge of delivery officials in the field as well. "The folks on the street know who their customers are, how frequently they are going to a specific residence, and are a tremendous resource for the local police officer seeking that type of information," says the former section chief of the DEA's pharmaceutical and chemical Internet coordination section.

The U.S. Postal Service (USPS) offers another source of assistance. People used to shy away from the USPS to avoid mail fraud charges, but Marc Gonzalez, director of security for prescription drug manufacturer Purdue Pharma's Law Enforcement Liaison and Education Program, says he's noticed a resurgence of USPS use because common carriers have been cooperating with law enforcement.

Networking with distributors also pays off as online pharmacies must obtain controlled substances from somewhere. Their sources are often legitimate companies that either don't know - or don't care - if the pharmacy is involved in illegal activity. Arias calls to mind a case where a Florida wholesaler delivered pallets of hydrocodone daily to what its officials believed was a licensed pharmacy, but in actuality the licensing was forged. Today that wholesaler is under severe scrutiny, he says. He proposes officers introduce themselves to pharmaceutical wholesaler and distributor security officials and ask them to contact the department if they notice continuing large orders of specific drugs. "If they are a legitimate company and they know you are interested in making these cases, then their liability kicks in," Arias explains. "They've been made aware that this is a potential situation and they need to cooperate."

However, sometimes the wholesalers supplying the pharmacies are located off-shore, bringing a different set of laws and regulations into play. The Kentucky State Police case involved Florida pharmacies that received their drugs from a foreign wholesaler. "It's hard enough doing these cases when they are inside the country, let alone if they are sourced outside the country," says Burke.

Still, working with carriers and manufacturers helps agencies move up the chain fairly quickly, says Caverly. In one case, the original complaint DEA officials received came from a common carrier who notified police when workers noticed a number of suspicious packages coming through a sorting facility. They contacted a local police detective with whom they had a relationship, and this call became the start of a major Internet investigation. Law enforcement officials were then able to determine the source of the packages and used that as a nexus to work up the line. "We want to focus on the highest level violator we can," he stresses, "just as we would with marijuana or cocaine trafficking."

Getting the masses on board

There are people out there who presume purchasing medications without a prescription is OK, says Burke. Many individuals falsely believe the drugs are legal since they come from a pharmacy.

"There's very little stigma associated with being caught abusing prescription drugs," says Smith. "The population as a whole isn't aware of how widespread the problem of prescription drug abuse is in this country."

But without a legitimate doctor-patient relationship, it is illegal for individuals to possess the drugs and criminal for the pharmacy to ship the prescriptions to them, according to Burke, who believes greater public awareness is sorely needed to help combat this problem.

By the nature of its status in the community, law enforcement agencies are in the perfect position to dispel some of the public's misconceptions concerning prescription medications, he emphasizes. Many agencies already speak in schools and to community groups about the dangers of drugs. It would be a logical extension of this to relay the risks of pharmaceutical abuse and Internet pharmacies.

Many resources exist to help law enforcement agencies incorporate prescription drug abuse education and the threat of illicit pharmacies into their existing drug awareness programs. By contacting NADDI through its Web site, law enforcement agencies can acquire educational materials to help them develop presentations for the community.

The FDA's "Buying Rx Drugs Online" education program also offers resources through a multi-media campaign found on the FDA Web site at www.fda.gov/oc/buyonline/default.htm. This Web page includes information on how to spot health fraud and where to report suspected illicit Internet pharmacies. In addition, the site supplies information on how to safely purchase drugs online.

Educational materials are also available through Purdue Pharma, which offers free training in pharmaceutical diversion and a program called "Painfully Obvious," that provides lesson plans to help officers train children early to prevent prescription drug abuse. (For more information visit www.painfullyobvious.com.)

Another way to get the message out - and quickly - is to talk to the press, says Caverly. Sharing information with the media spreads the word about the dangers prescription drug abuse poses to individual and community health.

"This is a public health issue," Caverly stresses. "We're trying to put these traffickers in jail because that's all they are - traffickers. They are no different than the street corner pusher. And this fact is something the public needs to be made more aware of."

Public school officials often make the comment that it takes a whole village to raise a child. In the case of online prescription drug diversion, it takes a nation to fully address the problem. Teamwork among law enforcement, health officials, the private industry and public will be needed to address the growing problem of rogue Internet pharmacies. As Gonzalez says, "It's all a matter of networking with other agencies and organizations that helps crack a big case."

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