WOMEN DRUG FELONS: PRESCRIPTION DRUG
FORGERIES AND FRAUD
Nicole March Daddona
B.A., McGill University, 1991
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts
1998 by Nicole March Daddona
All rights reserved.
This thesis for the Master of Arts
Nicole March Daddona
has been approved
A. Leigh Ingram
Daddona, Nicole March (M.A., Sociology)
Women Drug Felons: Prescription Drug Forgeries and Fraud
Thesis directed by Associate Professor A. Leigh Ingram
Fusing lived experience with my educational background in social problems,
crime and deviance, and the social organization of criminal underworlds,
gave rise to the notion that a study of female prescription forgers from a
sociological perspective may present a deep, textured analysis. The topic of
prescription fraud has been reviewed mainly in the legal, medical and health
professions literature. What research has been done indicates that
prescription drug abuse and fraud is a relatively little known topic, and
therefore is one amenable to a sociological investigation. What is sociological
about this thesis will be the ways in which prescription fraud has an impact on
society as a whole, and why patterns emerge that implicate women, for
instance, as the dominant perpetrators of this crime in the United States.
Why hasnt prescription fraud been viewed as a social problem in the past?
Why is it increasing over time in frequency and seriousness? What are the
underlying reasons why women commit fraud and forgery within other arenas
as well as prescription medications? And what is it about self-medication and
the need for an instant cure in our society, that leads women to abuse
medications and commit crimes to obtain them? These and other questions
will be posed, and answers sought to address them, in the body of this report.
This abstract accurately represents the content of the candidates thesis. I
recommend its publication.
I dedicate this thesis to the Honorable Judge Paul A. Markson, Jr., for his
depth and breadth of understanding, and for giving me the freedom to
complete this work.
My thanks to Dr. A. Leigh Ingram for her guidance and support over the past
two years. Thanks also go to Boder, for her inspiration along the way. My
Mother and Father are acknowledged for their outstanding love throughout. I
also thank Jody Gingery MEd., RN, of The Colorado Prescription Drug Abuse
Task Force, for the valuable information she provided.
Purpose and Scope of the Study..................5
2. PRELIMINARY INVESTIGATION...............................7
Womens Prescription Drug Misuse/Abuse.............11
Check and Credit Card Fraud:
Traditional Types of Female Crimes...............12
Findings of Prior Researchers..................15
3. REVIEW OF THE LITERATURE...............................25
Prescription Forgeries and Fraud....................35
Colorado Prescription Drug Abuse Task Force...68
Directions for Future Research...................111
Study Limitations and Conclusion...............113
A. Cover Letter......................................120
B. Consent Form......................................124
Let's talk about living the subject. What does "living" prescription forgery
mean? It means actually having had committed the crime of prescription
forgery, and dealing with the resulting legal consequences of same. It means
not quite knowing what your future is going to hold, and how you will live your
life going forward. It means having your freedom seriously curtailed by your
criminal activities. Prescription forgery is a class 4 felony with a range of
penalties from two (2) to six (6) years in State Prison. Mind you, this is the
second time that I have committed this crime, having been arrested and
convicted. In Denver, first time arrestees are usually put through a program
known as the Denver Drug Court System which is rehabilitation based. A
person who is sentenced to the Denver Drug Court System usually has had
her case disposed of in what is known as a Deferred Judgment, (DJ). This
means that the individual, after completion of the Drug Court program will
have a clean record, that is, no Felony conviction.
The Denver Drug Court is a phased-based approach consisting of 3 phases
which last anywhere from 4-6 months each. The phases consist of random
monitored urinalysis, group drug therapy, fines and community service. You
may be court ordered to take "groups" once or twice a week for 20 weeks, do
random urine "drops" twice a week in Phase I, once a week in Phase II and
2-3 times a month in Phase III. The treatment center that I attended for the
majority of my Drug Court career was called Milestone Counseling. Just for
the record, each group session is 2 and 1/2 hours in length and costs $25.00
cash out of pocket per group. Each urine screen costs $10.00 out of pocket
for one drug, and $20.00 out of pocket for what is known as a "Poly" or a
polydrug screen. Milestone gives a random "Poly" once a month. Provisions
for random urinalysis consists of calling Milestone's telephone number every
day, between the hours of 9:00 a.m. until 5:00 p.m. Monday through Friday,
to find out if you are "on" that day. If you are on, you must go to one of
Milestone's facilities to "drop" within those hours. If you miss a U/A it is
considered "hot" by the court, and you are punished accordingly. Other court
fines and costs are in the ballpark of $2,000-$6,000 depending on what you
have been convicted of. For instance, my fines were roughly $1,500 the first
time, and $2,505 the second time. I know of someone convicted of
manufacturing drugs whose fines are $6,000. I have saved every receipt for
every drug test and every "group" that I have taken since 1995. One day I
will add it up. That coupled with fines coupled with lawyer's fees would be
some astronomical figure. Not to mention all the money that I have spent
using drugs over the years. I truly believe that I could have taken two or
more trips around the world, and had ample spending money if I added it all
up! Anyway, community service is usually 50 hours. There are other
stipulations, such as: not violating any laws during supervision; maintain
permanent residence in the State of Colorado; cannot leave the State of
Colorado without written permission from probation officer or the court; report
to the probation department; cannot possess firearms; cannot use drugs or
alcohol, and shall maintain employment. If any of these are violated, or if
"hot", that is positive, urine screens occur consistently, the court may modify
supervision to include more restrictions, drug tests, curfews, jail time, house
arrest, intensive treatment, etc. In addition to the above, Denver Drug Court
also involves FOP or ISP "mini-programs" within the larger treatment picture.
FOP stands for Female Offender Program. For me this consisted of reporting
in person to the Denver Adult Probation Department once a week, filling out a
form requesting the same information each time, (name, date, address,
employer name and address, any contact with police, how many days
worked, monthly income, car model and make, how much paid in court costs,
etc.), and meeting for roughly 10-15 minutes with my probation officer, at that
time. Her name was Renee Schledwitz, and she was a patient and
understanding. I reviewed the activities of the past week with her. Most
times it was business as usual. FOP also includes 17 weeks of Cognitive
Therapy twice a week for 2 hours. ISP, which stands for Intensive
Supervision Program, is a much more serious "mini-program" within the
Denver Drug Court System. I dont know all the details of that program, since
I was not sentenced to it, but it consists of work release from county jail,
house arrest, random visits to ones home by a Probation Officer, curfews,
etc... Now it is October, 1998. I am still embroiled in the Drug Court system,
now a client of Bl/Peregrine. At this organization I have to call a color line
seven days a week, and if my color is mentioned on the recording, I have to
go in and drop" that day. If I follow all of the rules, I should be released from
monitored supervision, sometime in February, 1999.
The Drug Court System in Denver is only 3 years old, and is modeled after
the first Drug Court that was set up in Miami, Florida. As mentioned earlier,
its rationale is to rehabilitate not punish. Most Drug Court clients would have
served jail sentences for their crimes prior to its instatement. However, the
way it really works is on a rehabilitate/punish continuum and gets its "feel"
from the personality of the presiding Judge. When I went through it the first
time, the Judge, the very first Drug Court Judge in Denver, Judge William
Meyers, was a rehabilitation-oriented personality. He would give you the
"work program" if you got a hot U/A. This would consist of reporting to the
Denver City Jail at 13th and Cherokee at 8:00 a.m. and cleaning the
lobby/bathroom area, or picking up trash on the grounds or on the highway.
You were usually released at 12:00 p.m. or 1:00 p.m. The next Judge was
Judge Coughlin, who was a punishment-oriented Judge. He gave clients jail
time for hot U/A's anywhere from 3-10 days. He was disliked organization-
wide, and stepped down in January, 1998. His replacement was the
Honorable Judge Paul Markson, Jr., who is more pro-rehabilitation oriented,
and to whom this thesis is in acknowledgment. Judge Markson is noted for
his leniency and keen insight into the dangers of drug-addiction. Interestingly,
the 15th Annual Meeting of The Society for Applied Sociology held in
Chicago, had Robert Granfield of the University of Denver giving a lecture
within Applications in Issues of Substance Abuse. The topic was 'The
Denver Drug Court: Alternatives to Judicial Treatment of Drug Offenders."
His paper was made available in May, 1998 in a journal called Law and
Policy. I spoke with Professor Granfield about his work on the Denver Drug
Court, his findings, and their policy implications. I also told Professor
Granfield about my dual role as Drug Court Client and Graduate student. He
was interested to hear my story, and asked that I keep him apprised of my
work, as it develops.
The first time that I went through the system, when I was arrested and
charged with "CRS 18-18-415 Criminal Attempt to Commit Fraud and Deceit
to Obtain a Controlled Substance", I had probably the least severe range of
penalties you could get. My Attorney and I applied for and were granted a 2-
year Deferred Judgment. Above and beyond the phased urine drops, fines
and 50 hours of community service, that was it. I only had to attend group
sessions once a week for 20 weeks. I was sentenced to the program in
February, 1996 and was discharged in January 1997. In March of 1997 I was
arrested again, for the same crime. Even though I was discharged from the
supervised portion of the Denver Drug Court Program in January, I was still
technically on probation for another year. Any violation of the law within that
period would be considered a violation of probation. Therefore, when I was
arrested in March, I violated the terms of my probation, and the penalties
could be, and were more severe. I was "on bond" from March 26,1997 until
September 22, 1997, with a motion to revoke my probation (putting me at risk
for receiving the most severe penalties), but was disposed of in a four-year
Deferred Judgment. It is amazing how lucky I was, considering that the
District Attorney was contemplating sending me to an in-patient program in
Pueblo, Colorado for 3 months, and Judge Coughlin wanted me to go to jail
for 90 days. But by the breadth of patience and understanding of Judge
Markson, and by the skill and dedication of my Attorney, David Dansky, Esq.,
and to the surprise of everyone that I spoke to who was familiar with the court
system, I was granted the Deferred Judgment (DJ). It was running
concurrently with my previous DJ, and so I have a double DJ. I am the only
individual in the entire drug court system in Denver fortunate enough to
receive a double DJ. The only other individual to have received one, died on
July 31, 1997, of an alcohol overdose. (1997, Personal Communication). It is
double the sentence I had the last time in many ways. The DJ was doubled,
the fines were doubled, the group therapy treatments were doubled.
"Sentence concessions" are what the state demands if violations of probation
occur, that insist on tougher penalties for repeat offenses. My sentence
concessions were that I was court ordered to have individual psychotherapy
twice a week, at my expense for an indeterminate period of time. I must
remain employed for the duration of the DJ as well as complete Graduate
School. I must attend Narcotics Anonymous meetings once a week for an
indeterminate period of time. Any drug violations during the course of the DJ
would mean immediate incarceration at the Women's Correctional Facility in
Canon City for up to six years.
I have spent some time revisiting the nuances of what "living" prescription
forgery has meant to me since November 17, 1995, when I was arrested the
first time. March 26, 1997, the date of my second arrest, began a new stage
of my journey as a women convicted for prescription fraud. Telling my story at
the outset will help lay the groundwork for other women's stories that are to
follow. I will admit to my drug problem that has developed and undergone
many changes over the past 10 or so years. The first time that I was
arrested, I was able to maneuver such that my job, school, etc. were not
implicated. The second time around resulted in a three (3) month leave of
absence from my job, during which time I had to attend rehabilitation, which I
did, on an outpatient basis at Columbia Hospital, Bethesda Campus in
Denver, from April-June, 1997.
Diverters rarely do time on first offense. Although each jurisdiction is
different, the trend among judges is that diverters will do more time for
distribution than for possession for personal use. Sentencing guidelines
usually do not call for incarceration and drug rehabilitation is included in
sentencing more and more often" (Antonelli-Bacon, 1991:14). It is generally
held that rehab serves a better purpose than incarceration. People who
abuse prescription drugs have a problem that requires counseling, not jail.
Over the years, I have been arrested and detained for drug and alcohol
related offenses on 6 different occasions. Possession of Marijuana in 1988,
Possession of Marijuana and Larceny to the Sixth Degree in 1991, DWAI in
1994, DUI and Reckless Driving in November, 1995, Fraud and Deceit to
Obtain a Controlled Substance, (for Valium, in the Benzodiazepine family of
drugs), in 1995 and again in 1997. My drug abuse and related criminal
activity has lead to serious run-ins with the Law, and has now reached
proportions that are affecting important areas of my life (job, relationships,
etc.), but which may have a positive outcome as well. And that is what leads
me to a more refined definition of what has been the driving force for this
research and the formulation of a topic for my masters thesis.
Fusing lived experience with my educational background in social problems,
crime and deviance, and the social organization of criminal underworlds,
gave rise to the notion that a study of female prescription forgers from a
sociological perspective may present a deep, textured analysis. The topic of
prescription fraud has been reviewed mainly in the legal, medical and health
professions literature. What research has been done indicates that
prescription drug abuse and fraud is a relatively little known topic, and
therefore is one amenable to a sociological investigation.
Purpose and Scope of the Study. My thesis addresses the issue of
prescription forgery as it pertains to women. I have looked to see "what is out
there" in terms of any sociological or other types of analysis of this particular
type of drug-use/criminal behavior among women in general, and some small
population of female offenders in the Denver Metropolitan Area, in particular.
I would like to fuse my own experiences within the criminal justice system,
and the unique perspective that I bring to this project, as a multi-faceted
individual both educated and "touched with the "sociological imagination",
and simultaneously labeled "criminal" as well. Having spent short periods of
time in city and county jails, long stints in criminal drug rehabilitation
"projects", and again currently in the system, I have created a report that has
utilized my overall perspective. To conclude, this is an in-depth study that has
explored sociologically, aspects of women and crime. The emphasis is on
felony drug convictions, specifically, prescription medications forgeries, an
area that has not been widely researched. This could be an informative area
of inquiry, one that would fuse intellectual work that has already been done
on the subject, with personal experience with the criminal justice system and
the crime itself, leading to hitherto unexplored answers to questions related to
women and drug crimes, experiences with the system, and subsequent life
In what follows, I will present a complete literature review on the subject. I
then employ survey research methods via a questionnaire design to assess
real-life experiences around prescription drug forgery and fraud. This data is
analyzed in conjunction with my own direct observation and experience within
the criminal justice system. My hope is to provide a deeper sociological
understanding of the rather unknown topic of women felons, whose
criminality stems from prescription drug forgeries. One component of this
thesis may be called experiential learning, in that I have not only experienced
what it is that I am researching and writing about, but am learning and
performing an intellectual endeavor in an area that is not well researched.
What is sociological about this thesis will be the ways in which prescription
fraud has an impact on society as a whole, and why patterns emerge that
implicate women, for instance, as the dominant perpetrators of this crime in
the United States. Why hasn't prescription fraud been viewed as a social
problem in the past? Why is it increasing over time in frequency and
seriousness? What are the underlying reasons why women commit fraud and
forgery within other arenas as well as prescription medications? And what is it
about self-medication and the need for an instant cure in our society, that
leads women to abuse medications and commit crimes to obtain them?
These and other questions will be posed, and answers sought to address
them, in the body of this report.
Based on paperwork given to me by the police upon two separate arrests, I
was able to determine that prescription drug forgery is called "Fraud and
Deceit to Obtain a Controlled Substance." Furthermore, in consultation with
my Attorney, I discovered that this is a felony offense, considered to be a
"Class 4 Felony", as mentioned earlier. Drug felonies fall on a scale of 1-5,
with 5 considered to be the least offensive, and 1 considered to be the most
offensive. Additionally, Valium or Diazepam (Generic), is in the
Benzodiazepine family of drugs, and it is the drug that I forged prescriptions
for. It is considered by law enforcement officials to be a Schedule IV
controlled substance, but one that is commonly prescribed by doctors
throughout the U.S., for such symptoms as anxiety, mania, relaxation of
muscle tension, and as an anticonvulsant.
One claim that I make in this report is that prescription drug forgeries done by
professional or paraprofessional, middle to upper-middle class, highly
educated, and white females is an anomaly in the sphere of drug-related and
property crimes. The portrait of a "typical" female drug felon is that of a poor
or working-class minority, with little to no higher education, who typically has
never earned over $6.00 per hour in the occupational arena (Chesney-Lind,
1995:110). This thesis also encompasses the claim that, atypical, white
female felons, who are from the middle to upper-middle strata of U.S. society
today, who are in most cases, highly educated professionals or
paraprofessionals, have forged prescriptions in order to "self-medicate" some
already existing mental disturbance, that has hitherto remained untreated,
with some type of mood stabilizer or antidepressant. Such mental
disturbances have been diagnosed as Bipolar Disorder (Manic-Depression).
In some cases, there is an emphasis on either the Mania or Depression,
called Unipolar Disorder, but which is a label/term not widely in use by
Psychiatrists, Psychologists, and Counselors. Other mental disturbances
might include schizophrenia, acute and prolonged anxiety, as well as various
other psychotic and neurotic disorders. Self-medication might arise to make
life more bearable for individuals living in unpleasant circumstances, such as
Somehow, by making the above claim that women who forge prescriptions
are an anomaly when looking at female offending in general, it questions
head-on, the argument that forgery in [the area of prescription medications],
is either a white-collar crime committed in an occupational setting by women
with a particular set of demographic characteristics, that have made
increases and advances in the paid labor force, or by women who live on the
fringe, who are economically marginalized, and who demonstrate the
"feminization of poverty" hypothesis (Steffensmeier, 1995:97). My claim is
that wherever the crime of prescription fraud is committed, on or off the job, it
is committed by atypical white female offenders, who don't fit the descriptions
of offenders commonly found in the literature, e.g., (Anglin and Hser, 1987;
American Correctional Association, 1990; Price and Sokoloff, 1995; Flowers,
1995). Although they may have been substance dependent at a certain time
or times in their lives, (another sort of self-medicating), they were not victims
of physical and sexual abuse, usually associated with the minority women
discussed in the literature, e.g., (Price and Sokoloff, 1995, Flowers, 1995;
American Correctional Association, 1990). Prescription drug crime can be
viewed as a combination of individual pathology and social structural forces
at work. On the surface, the crime appears to be irrational, illogical and
without meaning. But, as we shall see in the review of the literature, there are
structural, i.e., historical and perhaps socioeconomic reasons that underpin
why the crime of prescription drug fraud is on the rise.
Four (4) basic themes dominate sociological discussions of the etiology of
modern female criminality. They are classified as follows:
1) Masculinity Thesis
2) Opportunity Thesis
3) Economic Marginality Thesis
4) Chivalry Thesis
The first three themes may be applicable to a preliminary understanding of
prescription forgery and fraud. Following Simon and Landis (1991), the
masculinization thesis predicts that to the extent that womens attitudes and
behaviors become masculinized through their liberation and consequential
assumption of traditional male social roles, their rates and patterns of criminal
offending increasingly will approximate those of men (p.2). The opportunity
thesis predicts that as more women enter the labor force and move into
positions involving expert knowledge and skills, they will have more
opportunities to commit the type of employment-related crimes committed by
men'1 (p. 3). If fraud and forgery are considered to be white-collar offenses,
then this is the thesis used to explain this type of criminal behavior. Overall,
the opportunity thesis claims that as women acquire more education, enter
the labor force full-time, and assume positions of greater authority, prestige,
and technical skills, they will use the opportunities available to them to
commit white-collar property offenses in the same proportions as do their
male counterparts. Moreover, both the opportunity and masculinity theses
predict that changes in the social status of women, resulting in part from the
womens movement, will result in changes in the offending patterns of
women (p. 4).
There is dissension between the views held by Simon (1975), and Simon and
Landis (1991), and Darrell Steffensmeier (1980, 1982), regarding the validity
of the opportunity thesis. Steffensmeier holds that it is not increased
opportunity that has accounted for the increase in female white-collar arrests,
but rather that they simply reflect traditional sex role expectations, behaviors
and opportunities. According to Steffensmeier (1995), ...women are not
being arrested for fraud which are occupationally related or which tend to be
real white-collar crimes, such as false advertising, product defects and so
on." He maintains that the status of women is still lower than that of men,
and that women are still limited to traditionally female occupations providing
opportunities for traditionally female crimes (p. 97). Furthermore, self-
service marketing and credit card sales provide increasing opportunities for
petty thefts (p. 98). Steffensmeier attributes increases in female property
crime to the convergence of market consumption trends and the worsening
economic conditions of women rather than to women's liberation or changing
sex roles (Simon and Landis, 1991:7). Steffensmeiers argument is
consistent with the economic marginalization thesis. Simon maintains that
womens objective location in the occupational structure determines the
opportunities that they have to commit crimes, and if they were not in those
occupational positions, they would not have access to the means that those
positions provide" (p. 8).
Arguments have been made contending that forgery, or fraud in the areas of
"bad check passing, credit card fraud, welfare fraud, fraudulent theft of
services, and small con games", are viewed as traditionally female" crimes,
committed by all racial/ethnic groups, rich or poor, and represent extensions
of female domestic and consumer role activities, rather than new role
patterns (Steffensmeier, 1995:97). The frauds and forgeries committed by
female offenders are consistent with female gender roles and fit into the
everyday round of activities in which women engage. Forgery is something
that is learned in the normal course of things, and is usually carried out by
average, ordinary people" (p.100). Female addicts, like female criminals in
general, tend to commit crimes that are consistent with traditional female
roles (Datesman, 1981:99). Whether or not this supports or questions my
main thesis, will be an area of future research.
The term "forgery", is used in tandem with the term "fraud", although forgery
can be considered to be a type of fraud. In the literature, however, I have
seen these terms used interchangeably. Fraud as defined by the FBI includes
fraudulent conversion and obtaining money or property by false pretenses. It
includes bad checks except forgeries and counterfeiting (Federal Bureau of
Investigation, 1970:61). This category also includes such offenses as postal
fraud, welfare fraud, writing insufficient funds checks, false advertising, con
games, investment and land frauds and violation of consumer protection
statutes. The majority of these crimes go undetected. According to
Sutherland and Cressey, it is probable also, that fraud is the most prevalent
crime in America (1970:42, quoted in Hoffman-Bustamante, 1973:126).
There has been little study of women who are arrested for fraud. And those
that are arrested get caught because their crimes were not well planned,
especially for larceny (shoplifting), check forgery, fraud and embezzlement
(Hoffman-Bustamante, 1973:126). Forgery is defined as the fraudulent
passing and uttering or making or altering of an instrument which is genuine,
would be of legal efficacy, or fraudulent use of credit cards. This definition
includes the knowledge on the part of the offender of the ungenuine
character of the instrument and the intent to defraud or prejudice the rights of
another" (Stanford, Vega and Morse, 1983:74).
Fraud/Forgery is considered to be a minor property crime in most cases
where the amount of a good or service taken by illegal means is relatively
small. Drug use is often seen as a "victimless crime", (as long as you don't
consider the "user" to be a victim). Both types of crimes are in violation of
criminal law, considered to be a "social wrong" or a crime against society and
the state (Price and Sokoloff, 1995:15). Additionally, since women's drug
related offenses are on the rise, a focus on prescription medications forgeries
combines the two types of crimes: minor property and drug related offenses.
Female arrest patterns are increasing due to such things as mandatory
sentencing for drug related offending, as well as (ess bias in sentencing
females who have committed minor property crimes, an example of the
Chivalry thesis, noted above (Steffensmeier, 1995:90).
In sum, one main concern of this thesis, is to describe different scenarios
involving women who have forged prescriptions and their personal situations
based on social condition. That is, the race, class and social condition of the
female offender and how she has been impacted by the legal system, in the
Metropolitan Area in and around Denver. At this stage, it will not discuss how
women's and men's crime rates differ with respect to prescription drug fraud,
although this too, may be an area of future research.
Women's Prescription Drug Misuse/Abuse
It is claimed that millions of women in the United States are abusing or are
addicted to prescription or legal drugs, including tranquilizers, sleeping pills,
amphetamines, and pain killers. There are 3.7 billion such drugs consumed
in the country each year" (Flowers, 1995:115). Many such women become
Valium junkies by collecting prescriptions from as many doctors as they
could manipulate into writing them. In addition, recent surveys have shown a
high rate of psychotherapeutic drug use (a combination of medical and
nonmedical drug use) among women. Prescription or psychotropic drugs,
such as Demerol, Seconal, Valium, and Librium are mood altering,
potentially addictive drugs that are easily misused...that is using them in
greater amounts, or for purposes other than those for which they were
prescribed and thereby developing a psychological and/or physical
dependency (p. 115, italics mine). Moreover, studies have found that
women are far more likely to receive hospital emergency room treatment for
psychotherapeutic drug abuse than males, with the number doubling in drug
overdose situations. Women who die as a result of psychotherapeutic drug
abuse are twice as likely as men to be over the age of 36, a figure attributed
to women's greater use and abuse of these kinds of drugs during these years
(p. 115). In sum, females who enter drug treatment programs are more likely
to be abusing psychotherapeutic or prescription drugs than cocaine, heroin,
methadone, or alcohol, and the typical abuser of prescription drugs is a
middle or upper-class housewife (p. 115). It appears likely that women who
use and abuse prescription drugs are multi-dimensional individuals, with
important psychological, behavioral, biochemical, and socioeconomic
components involved in their prescription drug dependency (Ogur, 1986:113).
Females who use and/or abuse alcohol or drugs are more likely than
nonusers to become involved in or continue abusive or criminal behavior.
Data indicate that female addicts are involved in a range of other criminal
activities such as violent crime, property crime, drug trafficking, and family
offenses. Eight out of every ten female inmates in state prison have used
drugs at some point, with more than one-third being under the influence of
drugs during the time of the offense for which they are incarcerated
(Flowers, 1995:75). I was under the influence of Valium and Marijuana during
my first prescription forgery offense and Valium and Methadone when I
committed my second offense.
Women who commit fraud, that is, forge prescriptions for Valium and other
drugs, may do so after legitimate means of getting the drugs are exhausted.
This can occur when as many doctors, clinics and pharmacies have handed
out as many prescriptions as could be deemed reasonable, that another
request for a refill would be denied and/or would be looked upon as a
problem of chemical dependency by the doctors and medical staff. It is
apparent that many American women are chemically dependent, both
psychologically and physically to all kinds of drugs. A view that I hold is that
this dependency can take place over the course of 2-3 days of seriously
abusing, that is, taking way over the prescribed dosages, (combined with
other drugs such as methadone tablets, marijuana, and alcohol, as in my
case). This can interact negatively with unresolved developmental issues and
a psychological state of pervasive low self-esteem, or untreated mental
conditions, such as bi/unipolar disorder. Thus a seemingly harmless drug, if
used incorrectly, can turn a basically rational individual who is coherent
before the drug abuse occurs, into a different person, who fraudulently writes
"scripts", unaware of any intent to commit the crime.
Check and Credit Card Fraud:
Traditional Types of Female Crimes.
Crimes committed by women are the outcome of five major factors.
These include differential role expectations for men and women; sex
differences in socialization patterns and applications of social control;
structurally determined differences in opportunities to commit particular
offenses; differential access or pressures toward criminally oriented
subcultures; and careers and sex differences built into the crime
categories themselves (Hoffrnan-Bustamante, 1973:117).
The importance of each factor depends on the nature of the crime and
illustrate the dynamics of womens role in crime (p.118). Women seem to
commit crimes in roles auxiliary to men, in keeping with their sex roles and for
lesser returns, often making them more vulnerable to arTest (p.131). In
addition, those acts such as forgery, for which women have received
adequate training in the normal process of growing up, are more likely to
have high rates of women arrestees.
A good place to begin would be to give a brief overview of "traditionar female
crime in the area of fraud/forgery. These crimes, as mentioned earlier, are
typically minor property crimes. Past research indicates that pink-collar
crimes", such as petty fraud and forgery, shoplifting and embezzlement, may
be looked at as occupational crimes committed on the job, by say a bank-
teller or secretary, but that fraud in its general sense is a poor indicator of
white-collar offenses. Moreover, "passing bad checks, associated with
insufficient funds and habitual offenders, is a poor indicator of white-collar
crime and is non-occupational" (Steffensmeier, 1995:97). Also, the fact that
"the United States monetary system is largely credit based, makes it easier to
detect the passing of bad checks/credit card fraud, resulting in the increasing
arrests of females" (p. 99). According to the FBI's Uniform Crime Reports
(1990), fraud accounted for 7 percent of all women arrests in 1990. The
female percentage of fraud arrests is currently about 43% (quoted in
Steffensmeier, 1995:99). This percentage may be due to less bias against
prosecuting female offenders, and the crimes they commit tending to have
higher visibility than they did in the past. Previously, lenient treatment of
female offenders by criminal justice personnel was the norm. There has
been a change in the official reaction to womens criminal behavior, rather
than changes in the behavior itself, that accounts for increased numbers of
women in official crime and prison statistics (Simon and Landis, 1991:11).
Ultimately, the discussion is framed within a "get tough on crime" ethos that
has pervaded U.S. society for a number of years. Coupled with the drug
dependency and abuse that is witnessed in [prescription medication]
forgeries, the "war on drugs" ethos also permeates any discussion of female
crime rates in this area (Steffensmeier, 1995:100).
Steffensmeiers research examined the relationship between female crime
and national developmental status. Although the present report will not
directly explore his findings, some of his thoughts are pertinent. For example,
how female social roles and crime should be seen as outcomes of complex
socioeconomic, political and historical factors, and that more so than gender
equality, greater economic insecurity or marginality for women in developed
nations is key" (Steffensmeier,1989:263).
Steffensmeier writes that;
in many industrialized nations the economic pressures on women are
aggravated by rising rates of divorce, illegitimacy, and female-headed
households, coupled with increasing segmentation of the labor market,
greater segregation of women into low-paying and female occupations,
and growing inequality of income between the sexes. In turn, the
inequality and economic insecurity increase the pressures to commit
the traditional female consumer-based crimes like shoplifting, check
forgery, theft of services, welfare fraud, etc., the opportunities which
have increased with development (p.264).
On the subject of expanding opportunities for traditional female-based
consumer crimes, as commented upon earlier;
the increased supply of goods and their self-service marketing, a
credit-based currency, consumerism, and a social welfare type of
government that accompany development have resulted in more
opportunities for traditionally "female" types of theft and fraud. A high
proportion of female crime in most societies involves minor thefts,
illegal exchange transactions, and contraband smuggling, crimes that
are an extension of traditional consumer and domestic roles
The type of criminal opportunity available to women, is defined in large part
by their roles as primary consumers in a market economy.
Studies of female white-collar criminality are few and far between. Daly
(1989:770), draws upon an earlier study conducted by Zietz (1981),
regarding the nature of female offenders convicted of embezzlement, fraud,
forgery, and theft. Some of Zietzs questions were to find out whether
typologies of white-collar criminals developed for men could be applicable to
women. She found that they were not, and that women had different
motivations for committing these crimes, like caretaker roles and love
relationships (Zietz, 1981:7). Daly examined a group of federal offenders
incarcerated for embezzlement, fraud, and forgery and found that most
womens crimes were petty. Large proportions of women were of minority
status and had no ties to the paid labor force; fewer women had a four-year
college degree. The womens socioeconomic profile combined with the
nature of their crimes questions the accuracy of the label white-collar. Her
data suggest that if womens share of white-collar arrests increases, it will
stem from (1) increasing numbers of women in highly monitored, money-
changing types of clerical, sales, or service jobs, and (2) increasing numbers
of poor or unemployed women attempting to defraud state and federal
governments or banks by securing loans, credit cards, or benefits to which
they are not legally entitled (Daly, 1989:790).
Daly (1989), supports Steffensmeiers contention that the Uniform Crime
Report (UCR) crime categories of fraud, forgery, and embezzlement are poor
indicators of white-collar offenses, particularly for women, and is a supporter
of the economic marginalization thesis. The economic marginalization thesis
states that it is the absence rather than the availability of employment
opportunity for women that seems to lead to increases in female crime
(Simon and Landis, 1991:9). A contending viewpoint found in the literature,
and mentioned earlier, as presented in Simon and Landis (1991), is that more
women are upwardly mobile into managerial, professional and technical
positions, according to census data, and that there is a positive relationship
between female upward occupational mobility and higher female property,
especially white-collar, arrest rates" (p. 11). Edwin Sutherland first coined the
term White-Collar Crime in 1939. It has been widely used ever since.
Findings of Prior Researchers. Regarding the crime of forgery, strength and
force are unnecessary, and there is only a low level of skill or expertise
required that can be learned in everyday experience. Forgery only requires a
minimum level of literacy, and is consistent with the female sex-role" (Smart,
1975:16). With offenses like fraud, forgery and theft, the likelihood of arrest is
directly related to the ability and skill of the offender. It is likely therefore that
the least able and the most petty offenders form a disproportionate number of
those arrested (p. 24). According to one study of forgery (Lemert, 1971), the
vast proportion of arrestees either had no record or only previous forgeries.
Lemert estimated that 75% of all persons convicted of forgery were naive
check forgers (p.139). The socioeconomic characteristics of forgers also
stand out in comparison with other types of criminals. They are usually of
higher intelligence, have completed more years of schooling than the average
of the population, and follow clerical, professional or skilled occupations.
Forgery is a low visibility crime" (Hoffman-Bustamante, 1973:125). Stanford,
Vega and Silverman, (1983), review findings of 32 convicted female forgers
detained at the Florida Correctional Institution at Lowell, indicating that the
majority were white, under 30, of average intelligence, single, and had prior
arrests for forgery related offenses.
Data from this study indicated that the female forger:
tends to perpetrate the crime alone, be involved in little or no planning,
use no weapons or cause no injury during the commission of the
offense, and to be motivated by a desire for financial gain. Most of the
offenders committed the crime during the day, with the crime usually
consisting of the uttering of a personal check to a business or
merchant. Monetary gain was the major motivating factor cited by the
inmates in a majority of instances. Substance abuse during the
offense was a contributing factor in less than one-half of the sample.
The forger in this sample began her career at a relatively young age
and her prior offenses tended to involve bad check charges (p.80).
Stanford, et. ai.(1983), developed a preliminary typology which included two
major categories, check bouncer and forger. They conducted a literature
review of forgers covering Berg (1944), Gillin (1946), MacDonald (1959),
Lemert (1967), McCaldon (1967), Denys (1969), and Klein and Montague
(1977). There were no studies dealing with the female forger in the United
States. Only McCaldon and Denys studies specifically dealt with the female
forger as a special category, and both were done in Canada. However
findings were consistent with those of other studies using male subjects or
mixed populations. These studies reported forgers were older when first
involved in crime, of higher intelligence, and had higher grade placement
levels when compared with other offenders. Forgers were also found to be
recidivists with prior forgery related convictions (Stanford, et. al., 1983:74).
From Zietzs (1981), typology of female offenders, the occasional offender
seemed most similar to the female prescription forger.
The occasional offender, in relation to minor property crimes, is:
generally considered to be a person who: commits one or more crimes
against property but does not violate the law at frequent intervals; does
not depend on criminal activities for her livelihood or incorporate them
into her life organization; does not perceive of herself as a criminal or
associate with known criminals; does not acquire any special
techniques for use in criminal activity; usually commits a crime only
when she feels impelled to obtain or retain something she considers
necessary and important but not available through legitimate channels;
and may react with serious emotional disturbance when apprehended
Past research has identified three major types of crime that women drug
addicts commit: prostitution (Ellinwood, Smith, and Vaillant, 1966;
Rosenbaum, 1981; Chambers, Hinesley, and Moldestad, 1970; Cushman,
1972); reselling narcotics or assisting male drug dealers (James et. al., 1979;
Inciardi and Chambers, 1972); and property crimes such as larceny, forgery,
shoplifting, burglary, and robbery (Weissman and File, 1976; Hseret. al.,
1987a, 1987b; Anglin et. al.,1987; Inciardi and Pottieger, 1986). Women
addicts may be involved in all three types depending on ?ndividual need and
opportunity, and there also seem to be racial differences in which crimes are
committed (Anglin and Hser, 1987:362). Looking specifically at property
crimes, the incidence of forgery among women was high (Inciardi and
Pottieger; 1986; Hser, Anglin, et. al., 1987a, 1987b; Datesman, 1984;
Rosenbaum, 1981; File, et. al., 1974). Regarding racial differences in
criminality, many studies found connections between race and type of crime
committed (James, 1976; File, 1976; File, et. al., 1974). Some findings
include black narcotics users being more prone than white narcotics users to
have been arrested for forgery, among other crimes. While white women had
higher incidence of drug possession, sales and liquor offenses (Anglin and
Hser, 1987:363). The Hispanic pattern is more similar to the white pattern of
narcotics use and type of crime (p.364). However, "Chicana women had
higher arrest rates and self-reported criminal involvement in drug crimes,
properly crime, and other crime, than white women" (p.364). Additionally,
Anglo women report less gang membership, less disrupted family (parental
separation and divorce), fewer problems in school, a higher grade level when
leaving school, higher socioeconomic status, and more occupational skills
than do Chicana subjects" (p. 373). Moreover, an attempt is made to review
studies that examine to what extent narcotics use and addiction precedes
property crime or vice versa (p. 367). There is much speculation over what
comes first, and it does not appear that a simple cause-and-effect
relationship exists (Datesman, 1981:100).
In their study, forgery appears to equate to check or credit card fraud,
because Anglin and Hser look at it as an income-generating crime, used to
support a heroin or cocaine habit (1987:369). Prescription drug forgeries
when done strictly for personal consumption, would not be an income-
generating crime. This lends support to the hypothesis that this type of fraud
is committed for other purposes, such as illustrating addictive behavior, or
self-medicating a pre-existing mental disturbance or to deal with hardships in
Reed (1985), defines drug abuse or dependency as the compulsive or
destructive use of many types of psychoactive substances, including heroin,
prescription drugs, over-the-counter drugs, and alcohol (p. 7). One way in
which drugs and crime appear to be connected is in a
psychopharmacological way. This refers to instances when a drug user
commits a crime due to drug-induced changes in physiological functions,
cognitive ability, and mood (Moon, et. al., 1993:46).
The Federal Governments Strategy Council on Drug Abuse (1979), as
indicated in a pamphlet distributed by the Colorado Prescription Drug Abuse
Task Force (1994), distinguishes between drug abuse and drug misuse. It
defines drug abuse as:
the non-therapeutic use of any psychoactive substance, including
alcohol, in such a manner as to adversely affect some aspect of the
users life. The substance may be obtained from any number of
sources by prescriptions, from a friend, over-the-counter, or through
the illicit market. The pattern of use may be occasional or habitual.
And defines drug misuse as:
the inappropriate use of drugs intended for therapeutic purposes. And,
a) lack of knowledge on the part of the physician; b) errors in
judgment; c) use of a prescription drug by a patient not under the
supervision of a physician; d) self-medication by a patient with a drug
(over-the-counter or prescription) inconsistent with the label
information (Colorado Prescription Drug Abuse Task Force, 1994).
In general, the elderly tend more often to be misusers and younger adults
could more often be classified as abusers" (Colorado Prescription Drug
Abuse Task Force, 1992:5).
Another reason that women are increasingly involved with drug-related
crimes is that society in general is more involved with drugs. Drug and
alcohol addiction are among the most common and serious social problems
in U.S. society. According to the NIDA 1990 Household Survey on Drug
Abuse, 37 percent (74.4 million) of Americans report some use of an illicit
drug at least once in their lifetime. Furthermore, a major study funded by the
National Institute of Mental Health finds that, alcoholism is the most
prevalent psychiatric diagnosis, while drug abuse or dependence is the third
most frequently reported disorder (Hanson, 1991, quoted in Moon, et. a!.,
1993:48). Mirroring the dominant culture (i.e. male behavior), todays
women are increasingly likely to use drugs and become active in drug-related
crime (p.48). Substance abuse may be the most serious corrections issue
of the Nineties. The correlation between women being incarcerated and
substance abuse is staggering (Bureau of Justice Statistics, 1991:49).
Nationally, female involvement with drugs has dramatically increased both in
personal consumption (abuse) and distribution and sales. This has resulted in
an increase in female conviction and incarceration (p.49).
Most research done on the relationship between drug use and crime has
been conducted on male populations. Empirical evidence showing that social
class is related to criminal behavior has been sketchy. This has not been the
case for gender, however. According to Triplett and Jarjoura, educational
expectations are one result of class and gender based dimensions of
delinquency. Although they deal in large part with differences between the
genders, my focus will be on their statements involving social class based
educational expectations amongst females, and subsequent activity in
delinquent behavior. According to these authors, "there has been relatively
little empirical research that examines the class-crime relationship within
gender categories", and that this may be due to difficulties in operationalizing
the term class (Triplett and Jarjoura, 1997:290). Their results support the
contention that gender and class are important factors shaping educational
aspirations and following criminal activity (p. 287). Moreover, these authors
call for a "criminology that acknowledges the fact that individual experiences
and structuring forces vary by class and gender" (p. 288),and rely on
research in the field of social psychology to back up their claims. Class as
operationalized by these authors, in a study conducted in two parts of the
National Longitudinal Survey of Youth, with data collected by the National
Opinion Research Center, is encompassed in five measures; Family Income,
Educational Attainment of Head of Household, Duncan Index of Occupational
Status of Head of Household, Welfare, and Head of Household Unemployed.
Educational Expectations and Delinquency were also included, as were the
control variables of race, age, and family structure, (p.295). For these
authors, a notable finding was that "educational attainment for the head of
household was the measure of class most strongly related to educational
expectations for females" (p. 299). Additionally, "for females, each measure
of class is positively related to involvement in stealing" (p. 299). The authors
believe that, "educational expectations mediate the effect of class on crime,
such that less serious forms of delinquency are more likely to occur from
middle-class youths than from lower-class families" (p.304). Finally, these
authors discuss how social structural variables like class, can be combined
with gender, to discover the ways in which they structure individual lives on a
daily basis (p. 312).
The American Correctional Association's Task Force on the Female
Offender, surveyed adult and juvenile offenders in local jail facilities and state
correctional prisons in late 1987. The Task Force sought to ascertain the
backgrounds, attitudes and program needs of the nation's estimated 43,000
female inmates, and the policy and procedural practices of federal, state, and
local government correctional institutions responsible for their housing and
supervision (American Correctional Association, 1990:1). Some relevant
factors in their discussion regarding adult female offenders is that their survey
data found that, "a drug offender or a property offender with a serious drug
abuse problem is more likely to be sentenced to prison than be offered
community options" (1990:3). Furthermore, their profile of the female
offender looks at personal history, such as race, age, and marital status,
home life, consisting of family structure, (i.e., broken home, single-parent
household), physical abuse, alcohol/drug history, criminal history, treatment
programs, educational background, work history and program benefits. In a
nutshell, the profile looks like this:
the average adult female offender is a minority between the ages of 25
and 29 who has either never married or heads up the household by
herself. She comes from a single parent or broken home, has
relatives who are also incarcerated, and has likely been a victim of
sexual abuse. The average female offender first started using alcohol
or drugs between the ages of 13 and 14. Typical drugs used are
alcohol, cocaine, speed, and marijuana. Her criminal history reveals
that she has been arrested an average of 2 to 9 times, beginning
between the ages of 15 to 19. The most common offenses include
property crimes and crimes of violence. Less than half of all female
offenders have a high school education. Typically, she is a high
school dropout with 1 to 2 years of education and no GED. The
average female offender has previous job experience in sales, service
and clerical work. Others held 1 to 3 jobs at a time, and did not earn in
excess of $3.36 to $6.50 per hour. The majority were on welfare, but
saw the need for more educational and vocational training. During
incarceration, the female offenders felt that treatment services were by
and large, beneficial to them (American Correctional Association,
Other characteristics of females who are incarcerated are that they ran away
from home when they were young, and use drugs to make themselves feel
more emotionally balanced. On average, these women, received a sentence
of 2 to 8 years, will serve less than one-fourth of the sentence, and committed
the crimes to pay for drugs, relieve economic pressures, or poor judgment
(American Correctional Association, 1990:7). Reactions to incarceration
include disbelief, resignation and fear. The average female offender has
participated in either a drug and/or alcohol treatment program, and considers
them to be helpful. Reasons for not completing high school include boredom,
tiredness, and pregnancy. Others attended vocational school in the areas of
business and secretarial skills, medical and dental skills, and cosmetology
This profile of the typical adult female offender was based on a survey
sample of "4.0 percent of the nationwide universe of approximately 43,000
female inmates, or 1,720 inmates, and was chosen to be the minimum size
needed to be statistically reliable" (1990:46). Of interest to a study of female
criminality is the role of menstrual cycle. A number of studies have shown
that female deviant behavior occurs most often during certain phases of the
menstrual cycle, the 4 premenstrual days and the first 4 days of
menstruation (Dalton, 1961, as quoted in Flowers, 1995:77). Recent
studies on the relationship between menstruation and criminality have
centered on the effects of premenstrual syndrome on female deviance.
Currently, however, most experts see other factors as more significant in
contributing to female crime and delinquency (Flowers, 1995: 77).
The majority of female criminals and delinquents are recidivists, or repeat
offenders. In Flowers 1995 study, more than 66 percent of the women
imprisoned had prior criminal convictions as either an adult or juvenile.
Almost 50 percent of all female inmates in state prison had previously been
given prison sentences or probation at least twice; 33 percent three or more
times; and more than one in seven had prior convictions of six or more times
(p. 78). Anglin and Hser (1987), looked at narcotics use and crime among
Chicanas and Anglos, specifically, the use of Methadone was examined.
Although this differs from the particular prescription drugs under assessment,
I thought that it may provide some insights into the use of prescription drugs
and property crimes. According to these authors, "the research evidence for
a link between drug involvement and criminal activity for women is
considerable" (p. 360).
Female drug use and crime have not been considered as major social
problems because of the largely petty nature of their drug use and criminal
activity. Females are more likely to use drugs obtained legally, and therefore,
drug use among women has not evoked the same degree of public concern
as illicit drug use, with its presumed direct connection to crime. Female
crimes are commonly seen as victimless, most harmful to the offender, and
having minimal impact on the social order" (Datesman, 1981:86). The fact
that female drug use and crime have not typically been considered as social
problems has implication for the amount of research attention devoted to
these subjects (Datesman, 1981; Zietz, 1981; Ettore, 1985, 1989).
As stated previously, white-collar crime is a term that refers to offenses such
as forgery and counterfeiting, fraud, and embezzlement, which are generally
committed by persons working in white-collar professions, such as bank
employees and office workers. This is different from other crime categories
including violent crimes, property crimes, and public-order crimes (Flowers,
1995:125). Prescription drug forgeries are a combination of minor property
crime and victimless drug crime. They are both considered to be in violation
of criminal lav/, a social wrong, and a crime against society and the state. I
am of the opinion that prescription drug fraud/forgery committed outside of
one's place of employment, is not to be considered a white-collar crime, per
se. Passing a forged prescription with a false signature on it is the minor
property portion of the crime, the intent to thereby obtain drugs for personal
consumption, is the victimless drug crime portion of the crime. Although
prescription forgeries contain elements of both types of crimes, property and
victimless drug, they are distinct in many ways from strictly white-collar
crimes and crimes committed by drug abusers in general.
White-collar criminals do not have to be salaried or professional women,
because white-collar crime can be found in significant numbers in poorer,
less educated sections of the population, such as women who forge checks
or use stolen credit cards to support their children, or drug habits, etc.
(Flowers, 1995: 128). These female offenders have been referred to as
"frayed-collar" criminals (p. 129). Again, I am of the opinion that prescription
drug forgeries do not fall into this category either.
Using the Wheeler et. al., (1982, 1988) data set, Kathleen Daly determined
that "just a handful" of women fit the image of the white-collar criminal seen
as having high socioeconomic power and prestige, and to be "up there" within
a large organization. Mobility did not characterize these women, rather
marginalization did (Daly, 1989: 769). Moreover, she criticizes the focus of
studies on crime and gender that are decontextualized in official arrest
statistics such as the Uniform Crime Reports (UCR) or Offender-Based
Tra nsaction Statistics. That is, we find out about the frequency but not the
nature of white-collar crime, and that ultimately the picture is distorted in
official reporting (p.769). This work focused on the different types of white-
collar crimes committed by men and women. However, some differences in
definitions may be important for the present work.
Daly points out the disagreement in the literature about how to distinguish
between the ways one can define white-collar crime. It can either be offense
or offender based. That is, offense based crime focuses on the
characteristics of the offense, or how the crime is committed. Offender based
crime naturally focuses on the characteristics of the person or persons in
high-status or respected positions of power, who commit the crimes. Thus
according to Daly, "if one takes an offender-related approach, a Medicaid
fraud is considered a white-collar crime if it is carried out by a doctor or
nursing home owner, but not if it is carried out by a clerical worker or poor
person. If one uses an offense-related approach, that distinction is not
In her review of the literature on the nature of white-collar crime and gender,
Daly concludes that it is "long on speculation and short on evidence" (p.772).
Five hypotheses that she presents that bring together the major themes are;
1) the female sphere of corporate or organizational crime is very low; 2) the
female share of occupational crime is low; 3) women are less likely to work in
crime groups than men; 4) women's economic gains from crime are less than
men's; 5) men's and women's motives for criminal involvement differ (p.773).
Types of white-collar crimes included in Daly's study are; bank
embezzlement, income tax fraud, postal fraud, credit card fraud, false claims
and statements, and bribery. Additionally, antitrust and securities fraud was
also listed. She used Wheeler, et. al.'s offense-based approach, defining
white-collar crime as "economic offenses committed through the use of some
combination of fraud, deception, or collusion" (p.773).
Passing bad checks and credit card fraud, used to maintain a drug habit are
findings based on the activities of other drug users as well as white-collar
criminals. Prostitution, drug sales and assisting male drug dealers, although
crimes committed by drug abusing females, are not similar to prescription
fraud crimes. Prescription forgery for personal consumption is different from
those crimes traditionally regarded as white-collar such as other forgeries,
embezzlement and counterfeiting. One aim of the present research is to look
at whether or not prescription forgeries are committed by middle and upper-
middle class women, or by poor women and minorities. Prescription forgeries
may be on the rise because of the feminization of poverty, as well to
womens increases and advancements in the paid labor force. They may also
be on the rise because of increased drug use among females. Or simply,
prescription drug forgeries have nothing at all to do with questions pertaining
to white-collar crime or drug abusing females in general. The crime of
prescription fraud will differ based on the social conditions and experiences of
women, including differences based on race and class.
REVIEW OF THE LITERATURE
Its so easy to do. The doctors dont really question you."
Benzodiazepines Anonymous (Weikel, 1996: A24).
In the above quotation, Ms. Curtis is referring to how easy it is to scam
doctors for prescription medicines. One main theme of this report is that:
drug use in America is strongly influenced by the social, economic,
political, scientific and technological environments that define our
society. We are a drug-taking society whose general outlook is that
every malady has a treatment and that this solution lies mainly in the
use of medicinal agents. The availability of drug products for the
prevention and treatment of a broad array of disease problems makes
drugs a critical mainstay of medical practice in the United States.
Drugs have gained a prominent place among professionals and the lay
public (Manasse Jr., 1989:1141).
We have a social and cultural expectation that there is a pill for every ill
(Wilford 1990, p. 609; McCallister 1988, p. 2B; Manasse Jr. 1989, p. 1141;
Cooperstock 1983).The abuse of mood changing drugs is extensive,
involving ail ages and socioeconomic classes" (Brahen, 1973:13; Miller,
1990:179). Mystification surrounds the giving and taking of drugs, both legal
and illegal. It is claimed that the pharmaceutical industry, the mass media,
physicians and patients are locked into a vicious cycle of mutual mystification
in which the problems of the human condition are increasingly medicalized"
(Lennard et. al., 1971:14). Moreover:
many patients appearing in a general practitioners office do so largely
for nonmedical reasons. They come because they are lonely,
depressed, anxious dissatisfied, or unhappy. They are troubled
because they are finding it difficult or impossible to measure up to
prevailing social prescriptions and ideologies as to what one ought to
be or to get out of life. They are not as popular, successful, sweet-
smelling, thin, vigorous, or beautiful as they have been led to believe
they ought and deserve to be. In effect, they are in a physicians office
because of the premium contemporary society places upon
appearance, mood, or performance; they are there because they feel
they should be something other than what they are. There is no end to
the ways in which Americans can be manipulated and made to feel
that there is something wrong, and that whatever it is, it can be solved
by something or someone (Lennard, et. al.t 1971:42).
Furthermore, Americans have come to believe that prescription and over-the-
counter medications are okay if they are prescribed by a doctor. A legitimate
pact is rendered in the doctor-patient relationship through the giving and
taking of medications. Dynamically, through giving the drug, the physician
accepts the patients discomfort as real, and agrees with the definition of the
patients definition of herself as sick. In many cases the drug prescribed
may be a minor tranquilizer such as Valium or Librium (Lennard, et. al.,
1971:26; Mant, et. al., 1983:185). Patients have come to demand quick relief
from real or imagined physical and psychological distress. Pain and
depression are not as likely to be endured as stoically as in the past.
Instead, the societal norm now is to expect and ask for chemical relief in the
form of a prescribed medicine" (Cohen, et. al., 1982:1). Prescription medicine
seems to have a symbolic meaning for some people (p.4).
People ultimately feel victimized" by the conditions of being human, and are
given drugs, but it does not remedy the underlying problem. Prescription,
OTC, and illegal drugs are a quick fix for the dilemmas of modern humankind.
This is called the medicalization of human problems in American life, or the
issue of people treated with medications, to cure humanitis" (Cohen, et. al.,
1982:104-105). Humanitis" can be viewed as a reliance on prescription and
OTC drugs to allay discomfort and disturbed emotions (Gottschalk, et. al.,
1971:395). It is the widespread malaise in todays high-pressured society that
has been amply documented. It is what the physician may regard more as
dis-ease than disease (p. 395). For whatever reason, people are coming
to view psychotherapeutic drugs as simply another technology to be used in
the service, comfort and efficiency of individual living" (p. 395).
According to Parry, et. al. (1973), the modem demand for happiness as a
right and an end in itself leads to an unwillingness to grin and bear it. These
authors paint a gruesome picture of an overmedicated society swallowing
prescriptions to escape from the troubles that mankind is bom to. As a
backdrop to this picture, gullible physicians are pushed into overprescribing
by the machiavellian marketing techniques of the pharmaceutical industry (p.
The abuse of prescription drugs has long been a womens problem, going
back over 100 years. In the 19th century and into the early 20th century,
many women were addicted to medicines that contained impressive amounts
of morphine, opium, alcohol, and other addictive substances. These
medications were often referred to as womens friend, a description
indicative of how involved women patients were with their medicines" (Miller,
1990:180). These medicines were freely prescribed or dispensed by
physicians, and sold over the counter in pharmacies, groceries and general
stores, from traveling medicine shows, and through the mail. These
medicines were marketed under such labels as Ayers Cherry Pectoral;
Mrs. Winslows Soothing Syrup; McMunns Elixir1; and Godfreys Cordial
(Inciardi and Pottieger, 1986:91). Many were advertised seductively in all
forms of media as painkillers, womens friends, cough mixtures", and
consumption cures, while others were recommended for diarrhea,
dysentery, colds, cancer, teething, cholera, rheumatism, cramps and pelvic
ailments (Carson, 1961; Editors of Consumer Reports, 1971; Inciardi, 1977).
Cuskey, et. al., (1972), as shown by Datesman, (1981:88), reviewed a
number of studies covering the period before the Civil War to about 1920, all
showing the high ratio of female to male addicts. The typical nineteenth-
century addict was middle-aged, rural, middle-class and white. Primary
among the reasons for womens addiction, according to a report by the
Michigan state board of health in 1878, was to relieve painful menstruation
and diseases of the female organs of generation" (Terry and Pellens,
1928:96, as quoted in Datesman, 1981:88). Housewives used opium to
relieve household cares (Haller and Haller, 1974:281, as quoted in
Datesman, 1981:88). While society women used it, to calm their shattered
nerves" after a trying season of parties and social functions" (Terry and
Pellens, 1928:114, as quoted in Datesman, 1981:88). The high addiction
rate among women was also blamed on their more nervous organization and
tendency to hysterical and chronic diseases (Haller and Haller, 1974:282, as
quoted in Datesman, 1981:88).
By the turn of the twentieth century, it was estimated that women were twice
as likely as men to be dependent on these drugs (Terry and Pellens, 1928;
Datesman, 1981; Stevens, 1995). Early studies of the etiology of female drug
use maintained that the causes of addiction could be found in physician
prescribing practices and the widespread availability of non-prescription
narcotics (Datesman, 1981:88; Earle, 1880, Marshall, 1978). During the first
two decades of the twentieth century, federal legislation served to alter this
situation, resulting in a dramatic drop in the rates of drug dependence among
women (Datesman, 1981:88). In 1906, the Pure Food and Drugs Act
prohibited over-the-counter sales of opium-containing medications, and in
1914, the Harrison Act defined as criminal any manufacture, prescription,
transfer or possession of narcotics by persons not authorized to pay a tax on
them. By 1920, drug dependence, particularly narcotics addiction, was
viewed overwhelmingly as a male problem. (Oliver, 1871; Stanley, 1915;
Morgan, 1974, paraphrased from Inciardi and Pottieger, 1986:92). Narcotics
use by women was not eliminated. Although much of the female drug
dependence before these laws had its origins in self-medication and
physician prescribing practices, reports as far back as 1871 suggested that
there was a population of women addicts within the criminal subculture for
whom drug use was a part of their criminal lifestyle" (Inciardi and Pottieger,
1986:92). Hence, as dangerously addictive medicines were discontinued,
new possibilities in the domain of medical addiction were offered in
abundance to female patients; tranquilizers of the 1950s and 1960s, such as
Valium and Librium, are now being replaced by Xanax, and other new equally
addictive medicines (Miller, 1990:180).
Tranquilizers such as Valium have been used as a medical solution for the
emotional problems of anxiety, loneliness, and unhappiness. Tranquilizers
came to market in the 1960s and have become the most popular drug in
Europe and America. Over the years, they have been used to combat
stresses of any kind pressures at work, marital problems, financial worries,
poor living conditions, and bereavement. They have been treated as a cure
for anything that threatened a persons peace of mind. (Swanson, et. al.,
1973; Melville, 1984:7).
Balint, et. al., (1970), studied repeat prescriptions cases. Underneath the
traditional diagnosis, the researchers found that prescriptions provided
something that satisfied emotionally starved individuals. It seems that pills
helped people cope with their expectations of how their life should be versus
what it really was like. It was the therapeutics of disappointment, of thwarted
love, unrealized achievement, or unresolved fears (Balint, et. al., 1970:120).
Current prescribing patterns can be framed up within the classic illness
model. This view sees ail problems that are presented to doctors as related to
the biology of individuals, downplaying the social and psychological
dimensions of illness. Intervention is oriented toward the individual who is
under stress rather than toward a society in need of change" (Ettore,
1985:115). The benzodiazepines were developed during a period in which
increasing numbers of patients were presenting symptoms of anxiety and
tension related to chronic illness, social and interpersonal problems. The
medical profession accepted these symptoms as within their domain for
treatment. These symptoms are vague and immeasurable and not usually
amenable to biochemical solutions, but they were brought within the purview
of the medical establishment anyway (Cooperstock, 1983:211). Moreover,
according to Cooperstock, expansion of the bounds of medical care is seen
in female patients presenting symptoms of financial difficulties, loneliness and
disobedience of children to their physicians" (1976:761). Patients presenting
symptoms of psychological and personal distress are not ill in the
conventional sense, and there are no clear medical criteria for prescribing
drugs (Balter, et. al., 1971:386).
Diazepam (Valium) was first brought to market in 1962 (Melville, 1984:14). It
is considered to be useful in the symptomatic relief of tension and anxiety
states resulting from stressful circumstances or whenever somatic complaints
result from emotional factors. It is useful in psychoneurotic states,
manifested by tension, anxiety, apprehension, fatigue, depressive symptoms
or agitation. It is manufactured by Rocie Laboratories, Division of Hoffman-
La Roche, Inc., Nutley, New Jersey. Valium is prepared in injectable form and
in tablets. Tablets are scored and come in the following strengths and colors;
2 mg, white; 5 mg, yellow; and 10 mg, blue. Its nickname is mothers little
helper1, derived because of extensive use by housewives (Illinois Legislative
Investigating Committee, 1974:21). Benzodiazepines work by using the
brains natural mechanism for calming itself. To avoid over-excitement, the
brain transmits a chemical from one nerve to another. When someone takes
a tranquilizer this causes the chemical to flow more directly on to its target
and increases its calming effect on the brain (Melville, 1984:14). Moreover,
benzodiazepines were marketed as being effective both as daytime
tranquilizers and night-time sedation, and were believed to be more effective
and safer than Barbiturates in alleviating anxiety and stress, in dealing with
the extent of clinical anxiety in society" (Ettore, 1985:114).
The side effects of tranquilizers vary from person to person according to their
sensitivity to the drug, how long they have been taking it, and the strength of
the dose. In addition to the common adverse effects such as drowsiness and
poor motor coordination, some abnormal psychological reactions to
benzodiazepines have been reported. Rare behavioral adverse effects
include paradoxical aggressive outbursts, excitement, confusion, and the
uncovering of depression with suicidal tendencies. Other rare adverse
effects, include hypertension, gastrointestinal and visual disturbances, skin
rashes, urinary retention, headache, vertigo, changes in libido, blood
abnormalities and jaundice, have also been reported (Melville, 1984:112).
Tranquilizers can also cause physical and psychological dependence. The
longer they are taken, the more they accumulate in the body, the more likely
they are to cause problems.
Some people taking tranquilizers have shown uncharacteristic hostility and
aggression. In a 1978 study done by Gaind and Jacoby, called
Benzodiazepines Causing Aggression", as reported by Melville, (1984:118),
several patients or their relatives in the study said that the drug had caused
their behavior to change. Some individuals mentioned that this change had
come about quite suddenly and had lasted as long as they had taken the
drug. Although no decisive conclusion can be drawn as to precisely which
kind of patient is more likely to become aggressive, the authors point out the
uninhibiting effect of these drugs, even with low doses. They may tranquilize
most people, but there is the obvious risk that in the minority of cases they
may cause dangerous behavior. Other uncharacteristic behavior has been
noted. Those taking tranquilizers may occasionally react in other
uncharacteristic ways, apart from aggressively. They can sometimes
respond by becoming excessively emotional, and becoming more anxious.
Other such behavior can include sex offenses, like self-exposure. There are
also cases of shoplifting, when both men and women have taken goods off
the shelves that were of no use to them and were unable to explain why they
had done so (Melville, 1984:118, italics, mine). Tranquilizers can cause a
lack of concentration, a remoteness from what is going on, and forgetfulness.
People taking tranquilizers need to be aware of this, and if they feel it could
happen to them, should try not to go shopping alone!" (p. 119).
Withdrawal symptoms have occurred following abrupt discontinuation of
diazepam; (convulsions, tremor, abdominal and muscle cramps, vomiting and
sweating). These symptoms are usually limited to individuals receiving
excessive doses over extended periods of time. Particularly, addiction-prone
individuals such as dmg addicts or alcoholics should be under careful
surveillance when receiving this drug or other psychotropic agents because
of the predisposition of such patients to habituation and dependence (Illinois
Legislative Investigating Committee, 1974:21, italics, mine). Since this dmg
has a central nervous system depressant effect, patients should not use
alcohol and other drugs while they are using diazepam. Manifestations of
overdosage include somnolence, confusion, coma and diminished reflexes"
(p. 21). It has been claimed that the use of benzodiazepines should be
considered a social issue worthy of critical attention, due to the sheer volume
of drugs used and the money spent on such drugs. Hidden costs to womens
lives has been documented (Ettore, 1985:114; Skegg, Doll and Perry, 1977).
For instance, the use of benzodiazepines may impair intellectual functioning,
judgment and social skills (Cooperstock, 1983:210).
Advertisements that appear in medical journals, magazines, and advertising
literature sent to doctors could be open to criticism, by showing particular
stereotypes of womanhood. Drugs that relieve anxiety, stress, hypertension,
sleeplessness and depression may portray women more than men. Drug
advertisements which show the harassed drudgery of housewives, the
depressed mother of children who have left home, the tired and anxious
career woman, may influence the way doctors (male or female) view the
problems brought to them by female patients (Melville, 1984:70; Ettore,
1985). The pejorative attitudes toward female patients in medical
advertisements have been documented" (Cooperstock, 1976:761). Valium
has been available illegally on the street for some time now, but no matter
how it is obtained, either with or without a prescription, women choose to
escape through self-medication via the use of tranquilizers.
Sociostructural, cultural, and historical changes have had far-reaching
impacts in womens lives. Specifically, womens movement into the paid labor
force, liberalization of the definitions of femininity, (i.e., working mother), and
the rise of unemployment/underemployment, (i.e. part-time work, female
ghetto jobs), have contributed to depression, to becoming welfare
consumers, or to drug use, among women. (Ettore, 1985:110).
Research has shown that medical-psychiatric symptoms in women are
related to isolation in the home, stress produced by poverty and lack of
employment, as well as stressful life-events. In a society supposedly
based on social welfare, public health and individual well-being, the
occurrence of depression, mental stress, anxiety or any other
symptom which may lead to mental illness is frowned upon. Yet,
womens social position and the nature of the female role as it is
constructed is conducive to mental illness. Women are categorized
more often than men as depressed, psychoneurotic, psychotic, or
suffering from non-specific disorders (Ettore, 1985:110).
Ettores (1985) feminist slant positions the pill-dependent woman as inferior
inside of her social relations. In her view, pills are sanctioned by the State,
promoted by the pharmaceutical industry and demanded by the female
patient in a vicious circle (p. 115). As passive consumers within society,
women are at a disadvantage. The use of both licit and illicit drugs involves a
socially constructed hierarchy, ranging from good drugs at the top of the
hierarchy, to bad drugs" at the bottom. On the hierarchy of addictions,
tranquilizers are seen as good and socially necessary to maintain domestic
bliss or the stability of the family" (Ettore, 1985:117). The alcoholic or
chemically dependent woman has always been viewed as unnatural or not
representative of the female species. Women who are problem drinkers or
use illicit drugs have been constructed socially as different or more abnormal
than men who engage in the same behavior. Broom and Stevens, (1995),
conceive of women who are doubly deviant." Not only do they break the law
by using drugs, but social convention is also transgressed by such behavior.
Women with drug and alcohol problems are viewed as profound threats to the
social order (p.412). One theme running throughout the literature is that to
escape their inferiority, women rebel by using drugs (Miller, 1990:180)
Addiction to drugs and alcohol is a form of self-medication against the pain
of powerlessness and subordination" (Miller, 1990:180). According to Broom
and Stevens, "we as sociologists, need a logic that connects womens alcohol
and other drug use to womens social relationships and the social structures
that govern them" (1995:413).
Miller (1990) and Ettore (1985), blame the medical establishment and
patriarchy for enabling the addiction of women, who prescribe medications
that either provide the source of addiction or add to the female patients
problem of chemical addiction. These authors believe that for women in
society mental illness is prevalent because of their social roles. And, there
have been few studies on the use of self-medication by women at the larger
societal level." (Miller, 1990:183). According to Miller, the pattern of female
substance abuse can be conceptualized as a recursive loop of invasion and
control experienced as physical, sexual or psychological abuse, and
pervasive low self-esteem, in childhood as well as maturity" (p. 186). Female
substance abuse can be described as an attempt to control the perceived
invasion of physical or psychological boundaries. Women self-medicate
themselves to ease the pain by using substances. This use engenders
shame, thoughts of loss of self-control, and then cycles back again to pain
(Miller, 1990:186; Moon et. al., 1993:47).
Substance abuse and self-medication allow the user to distance herself from
painful situations, control access to information about herself, via secrets",
and control her anger. As Reed (1985) indicates, women more often report
using drugs to cope with life, hide from unpleasant emotions and isolate.
Additionally, research on female use of prescribed medication indicates that
certain forms of substance use and/or abuse among women are supported
and even encouraged by society (Quoted in Moon, et. al., 1993:47). Women
may distance themselves through social withdrawal or through diminished
emotional connectedness. The distance created by the substance abuse
allows women to feel less acute pain, fear, and anger (Miller, 1990:187).
Structural issues such as legal and illegal substances being beneficial to the
prevailing economic structure, and the growth of the pharmaceutical industry
are little researched. That our society is dependent economically, politically
and culturally on a 'cushioning process' provided by a variety of chemical
comforts indicates the extent to which addiction and stress have become
established facts of life (Ettore, 1989:595).
Numerous studies in the literature have demonstrated that women exceed
men in their consumption of psychotropic drugs in a consistent ratio of 2:1.
(Cooperstock, 1976:760; Manheimer, et. al.,1968, p. 445; Parry, 1971, p.
270; Balter, et. al., 1971; Parry, et. al., 1973; Ettore, 1985). And, the findings
from many European and American studies suggest that overall rates are
similar in most Western industrialized nations and that the female-male
differential generally applies" (Parry, et. al. 1973, p. 776). It is claimed that,
prescriptions for mood-modifying drugs are overwhelmingly prescribed to
women" (Cooperstock, 1971:1012). Clayton and colleagues (1987), report
that men in a 1982 National Institute on Drug Abuse (NIDA) national survey
had a higher lifetime prevalence than women for use of all types of drugs -
except for prescribed drugs" (Quoted in Moon, et. al., 1993:47).
One reason why more women than men are prescribed tranquilizers is
because they are more likely to be at the doctors than men. Women
complain more often than men because they are allowed by society to fall
back into a fragile role and respond to their nerves'" (Melville, 1984:72).
Mant, Broom and Duncan-Jones, (1983:185), examine why more women
than men get prescriptions, a subject that has been widely researched (Parry,
et. al., 1973; Skegg, Doll, Perry, 1977). The authors look at five (5) different
hypotheses; the morbidity hypothesis: more women than men suffer from
psychiatric disturbance; the consulting hypothesis: it is more socially
acceptable for women to go to the doctor than for men; the reporting
hypothesis: it is more socially acceptable for women to admit having
symptoms than men, especially symptoms of emotional distress; the
stereotyping hypothesis: doctors are predisposed to diagnose neurotic
disturbance in women; and, the social control hypothesis: that doctors are
predisposed to medicate women who are experiencing psychosocial
disturbance (Mant, et. al., 1983:187). The authors paper sought to test these
hypotheses with data from a survey of psychiatric illness in general practice
conducted in Sydney, Australia in 1976. They found tentative support for the
morbidity hypothesis and the consulting hypothesis, but not for the others (p.
Svarstad and colleagues, (1987), discuss the assumption that women receive
more prescribed drugs because they have different attitudes towards illness
and medical care, higher anxiety, and more time to visit physicians, or
because physicians are biased. Their study examined an alternative
explanation, that is, much of the excess is associated with womens
reproductive role. Further analysis showed that the gender differences were
practically eliminated after excluding women with female-specific diagnoses
and excluding the drug categories used to prevent or treat female-specific
conditions. Previous studies based on gross measures of self-reported drug
use seem to have underestimated the importance of factors that relate to
womens role (p. 1089).
As has been seen in the literature reliance on drugs for individual solutions
to problems of living is indicative of the mental health professions and
pharmaceutical industries promoting drug-taking, and a medical model that
has contributed significantly to the medicaiization and technocratization of
human existence" (Cooperstock, 1976:761). Cooperstock reported that
women feel more discomfort and other symptoms than men, and try to
alleviate them by seeing a doctor or self-medicating. She suggests as does
Parry, et. al., (1973:782), tentative explanations for differences among
women who obtain prescriptions. These include more doctor visits,
differences associated with reproductive and social roles, and less use of
alternative coping mechanisms (p. 761).
Prescription Forgeries and Fraud
Ordinarily, the community does not view prescription fraud with the same
concern as it does cocaine or heroin abuse. The pharmaceutical drug abuser
who is addicted to a licitly manufactured drug is not thought of in the same
manner as a cocaine or heroin addict. (Hall, 1996:B3). The hardened street
addict using chemicals purveyed by criminal means receives major attention.
The public is largely unaware of the prescription drug abuser who eludes
recognition by justifying his drug habit with some medical explanation, real or
imagined (Swanson, Weddige, and Morse, 1973:359). Furthermore,
illness is often accepted by the individual, medical personnel and his or her
family, and is hidden by the extensive use of prescription drugs in our society
There is a different perception about pharmaceutical abuse because it
doesnt carry with it the violence and crime associated with other drugs
(Antonelli-Bacon, 1991:10; Colorado Prescription Drug Abuse Task Force,
1992:17). About 2.6 million people in the United States use prescription
painkillers, stimulants, tranquilizers and sedatives for nonmedical reasons,
more than the estimated use of heroin, crack and cocaine (Weikel, 1996:A1).
According to surveys by the National Institute of Drug Abuse (NIDA), only
marijuana is more popular (Adams, 1991:32). Like all drug abuse,
prescription abuse has a grave impact on individuals, the community and
society as a whole (Beary, et. al., 1996:35). Drug enforcement has been
viewed by many as glitzy SWAT team raids on big time drug dealers, not on
prescription fraud (McCauley, 1993:92).There is no glory, no guns, no piles
of coke and no bundles of cash to stack up for the TV cameras, just token
enforcement' of lenient narcotics laws when it comes to the illegal trafficking
of pharmaceuticals by doctors and others (Weikel, 1996:A1).
According to data collected by the IJ.S. Congress, the National Institute on
Drug Abuse, and the Federal Drug Enforcement Administration, prescription
drug abuse is the cause of more injuries and deaths than all illegal drugs
combined (Hall, 1996:B4; Beary, et. al., 1996:33). Specifically, prescription
drugs are involved in more than half of all drug-related emergency room visits
and deaths reported throughout the federal Drug Abuse Warning Network
(DAWN),(Hall, 1996.B4, Bristol-Herald Courier, 1996.3A). Perhaps some of
these deaths are attributable to the fact that users often boil prescription
drugs to liquid form and inject them (Jalon, 1986:11). Additionally,
prescription drug abuse is the second most common cause for female
psychiatric hospital admissions (Colorado Prescription Drug Abuse Task
Force, 1992:9). Legitimately manufactured controlled substances account for
13 of the top 20 controlled drugs, and about three out of every ten drugs
mentioned to emergency room personnel" (Beary, 1996:33). The network
surveys emergency rooms in 43 metropolitan areas to measure the
consequences of drug use. It does not determine if the prescription drugs
were obtained illegally (Weikel, 1996.A24).
According to the Drug Enforcement Administration, the majority of these
drugs are diverted from the more than one half million physicians, dentists,
veterinarians, podiatrists, pharmacists and other health professionals who
provide health care to the American people. Although such diversion occurs
at multiple points in the drug distribution chain, the Drug Enforcement
Administration estimates that 80% to 90% takes place at the local level -
from individual hospitals, practitioners and pharmacies (Skom and Wilford,
Statements regarding the ubiquitousness of the illegal sale of prescription
drugs abound in the literature. For instance, one third of all illegally sold
drugs are prescription drugs. Of the top twenty (20) most abused drugs,
fifteen are prescription drugs, with diazepam (Valium) being the 4th on the
list" (Colorado Prescription Drug Abuse Task Force, 1992:10). Drug abuse
as a whole represents a complex issue for society. Using an analogy from
economics, there is both supply and demand for drugs. Foreign countries
supply the drugs, as does the manufacture of drugs inside U.S. borders. On
the demand side, are an array of interrelated physiological, psychological
and sociological variables that motivate and perpetuate drug abuse and
dependence (Colorado Prescription Drug Abuse Task Force, 1992:5).
Psychoactive drugs include stimulants, sedatives, tranquilizers and
antidepressants. They not only alter body processes but affect a whole
complex of psychological and social processes connecting the individual with
his/her physical and human environment. Thus, these agents whether
prescribed or self-administered, tend to elicit a broader range of unanticipated
and unintended side effects, consequences or costs than do other drugs
(Lennard, et. al., 1971:2). These drugs impact the individual both
physiologically and psychically, changing moods and bodily states. The
popularity of many over the counter sedatives and tranquilizers may in large
measure be due to the ease with which drowsiness, lassitude, and general
physiological slowing can be interpreted and labeled as psychic tranquillity
People who are under the influence impact the broader social system of
which they are a part, affecting not only themselves but all others with whom
they come into contact. Psychoactive drugs, such as prescription, OTC, and
illegal drugs, are pervasive in modem life. They will continue to be
manufactured, prescribed, marketed and advertised. Psychoactive drugs
have exceedingly diffuse effects and immediate as well as long-range
consequences, many of which are not visible for a considerable length of time
after drug ingestion (Lennard, et. al., 1971: 106). Also, in addition to their
abuse, prescribed drugs can become agents for self or other-destruction,
including accidental death (Cohen, et. al., 1982:6).
Prescription fraud has been referred to as the quiet little drug war that no
one talks about (Antonelli-Bacon, 1991:10), and has perplexed legal and
medical experts (Bristol-Herald Courier, 1996:3A). In fact, the American
Medical Association states that prescription drug abuse is the hidden drug
abuse problem in our nation" (Colorado Prescription Drug Abuse Task Force,
1992:9). There is much evidence that prescription fraud is largely ignored in
the fight against drugs. Nationally, the federal government spends $13 billion
to $14 billion annually on the war on drugs. But only $70 million goes to the
DEA to investigate prescription drug offenses (Weikel, 1996:A25). An
estimated 3% of the United States population deliberately misuse or abuse
psychoactive medications. A federal survey done in 1994 of the U.S.
population estimates that nonmedical use of prescription drugs is
widespread. Nonmedical drug use means: using more than prescribed,
more often than prescribed, for reasons other than prescribed, or without a
prescription (Weikel, 1996: A24). Wilford (1990), outlines from the
perspective of the health care system and clinicians, three variants of
prescription drug abuse: patients who present with an established
dependence on a prescription drug; those whose dependence develops from
poor prescribing practices of doctors, through doctor shopping, self-
medication, and; patients who seek drugs to divert them and sell on the
street (p. 609).
Abuse of over-the-counter (OTC) drugs may have parallels to abuse of
OTC drugs are advertised and sold as tranquilizers, sleeping pills and
stimulants and are used to satisfy essentially the same needs as their
counterparts among the more potent prescription drugs. They may
also serve as an alternative way of coping with these needs. Although
not as powerful as prescription drugs, they are more readily available
and serve a useful function for some users. Those who take OTC
drugs may be less willing to accept the role of physician as
gatekeeper" in the distribution of drugs. OTC drugs bypass the
physician most simply and easily of all alternate channels (Parry, et.
My literature review uncovered two articles pertinent to OTC drug use in the
late 1960s, and early 1970s. The authors data suggest that respondents
found them to be of little or no help (Parry, et. al., 1973:780). Drug prescribing
is related to the social characteristics of patients as well as to those of
doctors. Physicians are more likely to prescribe psychoactive drugs for
women than for men, and women are more likely to medicate themselves
than men (Lennard, et. al., 1971:36). But physicians can prescribe drugs
only to those who seek and have access to their services. Manheimer, et. al.,
(1968), did not distinguish between OTC and prescription drugs. In the
1960s and 1970s, it was a commonly held assumption that poorer, less
educated people use OTC or nonprescription drugs, while wealthier
individuals who have greater access to professional medical care, use more
prescription drugs (Manheimer, et. al., 1968:447; Parry, 1971:270). Sources
of psychotropic drugs are over-the-counter drugs bought and self-prescribed
by the user, prescription drugs prescribed by a physician, and prescription
drugs obtained via alternate channels, such as those acquired from friends
and relatives (Parry, 1971:269; Edwards, et. al., 1983:11). According to a
survey conducted by Parry (1971), younger respondents, respondents living
in the West, and marijuana users were likely to have higher than average
incidence of use of OTC drugs and prescription drugs acquired through non-
medical channels (p. 269).
According to Beary, et. al., (1996), "it is estimated that over 231 million
prescriptions for controlled substances (not including hospital dispensing),
are written each year. Assuming an average of 30 dosage units (du) per
prescription, this would account for 7 billion du per year (p. 33). And, U.S.
doctors wrote over 2.5 billion prescriptions in 1997 thats about ten for every
person in the country" (Fitness Magazine, 1998:52). An estimated 5% or 350
du of drugs are diverted through some sort of prescription fraud each year
(Beary, et. al., 1996:33, Keown, Gumbhirand Vaughn, 1981:15). Although
the problem seems enormous, it is largely ignored by law enforcement, who
are busy fighting what they perceive to be more serious drug wars (Weikel,
Abuse of prescription drugs is a serious problem in our society, but nobody
pays attention until somebody big and powerful be it Betty Ford, Elizabeth
Taylor or superstar film producer, Don Simpson drops dead (Weikel,
1996:A1). Or when a well-known athlete such as Green Bay Quarterback
Brett Favre announced he had become hooked on painkillers while
recovering from surgery" (Hall, 1996:B4). Prescription fraud cases arent
usually headline catchers (Hall, 1996.B4). The death of Simpson, whos well
known films include 48 Hours, Top Gun, and Beverly Hills Cop, is portrayed
in Weikels Los Angeles Times article on prescription fraud. Simpson died in
January, 1996, of a lethal overdose of 20 prescription medications and
cocaine. (Weikel, 1996:A1). Weikels article focuses on the nations illicit
prescription pill market, with a focus on the State of California. Another
interesting little tidbit concerns Dexter Coffin III, the son of the family who
created the Flo-Thru tea-bag, who was convicted of trying to obtain
painkillers fraudulently. His record dates back to 1972, which includes
prescription fraud and worthless check offenses in Florida and Virginia.
Coffin was convicted of calling a pharmacy in September, 1995 by posing as
a doctor wishing to prescribe 40 tablets of Lorcet, a narcotic painkiller (The
Washington Post, 1995:B4). Elvis Presley's doctor, George Nichopoulos lost
his medical license in 1995 because of over-prescribing addictive drugs to
patients. Singer Jerry Lee Lewis also received addictive drugs from
Nichopoulos without a legitimate medical purpose, as recently as March,
1990 (Richmond-Times Dispatch, 1995:C3).
Users run the gamut from street addicts to senior citizens who mix
afternoon cocktails of tranquilizers, to teenagers who sell their doses
of Ritalin to classmates. Some combine prescription drugs with illicit
narcotics to enhance the high. Others use tranquilizers to soften the
crash from cocaine and heroin, helping them sustain their habits. For
many others, pharmaceuticals simply are their drug of choice (Weikel,
As has been seen throughout the literature, pharmaceuticals used either
legally or illegally are rampant in the (J.S. today. Specifically, much of this
drug use occurs in the suburbs, according to law enforcement officials (Hall,
1996:B3; Bristol-Herald Courier, 1996:3A; Bemsen, 1990.A 18). Think of the
stereotype of the suburban junkie found in public service advertising, or the
well-to-do, well-educated housewife (Parry, et. al., 1973:779). Classic
middle-class drug abuse follows some simple steps. You go to the doctor
and get a bogus prescription. Then you get the pharmacy to fill it, and have
your insurance company pay for it all. No one suspects anything" (Hall,
During an eight-month period in 1990, Vicki J. Renaldo of Oceanside, CA,
duped 42 San Diego area doctors and 26 pharmacies into giving her
thousands of codeine tablets, all paid for by Medi-Cal. She was convicted
and sentenced to two years in state prison.
Another doctor-shopper in the Midwest managed to scam 134 physicians.
For almost 20 years, Barbara Curtis went to three or four doctors to
secure supplies of two painkillers Vicodin and Fiorinal with codeine.
Migraine headaches was all Id have to say.
Karen L. Moran repeatedly swindled Valium out of local pharmacies by
phoning in fake prescriptions. Records show that over several years she
used a physicians code and called in at least 50 prescriptions for
painkillers to local pharmacies during evening hours, when pharmacists
could not check the prescriptions with the physician. Moran pleaded guilty
and was sentenced to 60 days in jail for prescription fraud and spent 10
days in a drug treatment unit (Hall,1996:B4).
A young mother in Henrico County, Virginia takes her 7-year old son out
of school 26 days within the school year. Each day, she visits a different
doctor, sometimes driving great distances, and gives a medical history
consistent with that of a hyperactive child. Each time, she leaves the
doctors office with a prescription in the boys name for Ritalin, which she
takes for its cocaine-like high.
Two nurses in a Chesterfield, Virginia hospital are assigned to count
narcotics in their unit. One counts and calls out the number while the other
records it. While the recorder isnt looking, the nurse counting the pills
slips two in her pocket and fails to call them out to the recorder.
(Antonelli-Bacon, 1991, p. 10).
At age 58, Edith Houchfelder didn't consider herself an addict, even
though she had been taking Valium for several years. But she was so
desperate to obtain the drug that she forged a prescription and took it to
Rite-Aid for filling. Suspicious that the script had been forged or altered,
the pharmacist phoned the doctor whose name was on it. The doctor said
he didnt write it. Investigations revealed that Houchfelder had been to
another pharmacy with a false prescription for Xanax. When she was
arrested last year, she was carrying a book entitled, A Pill Users Guide
to Staying Alive. It was marked to the section on Xanax.
Stephanie Walmsleys coworkers became suspicious that she was
stealing syringes containing Demerol and Morphine from her unit on the
9th floor of the hospital where she worked. When confronted by police,
she admitted that she had been diverting Percocet for several years
before she had begun diverting the injectibles. She said she had been
taking the drugs while on duty as well as in off hours. She was sentenced
to eight years.
Shirley Ferguson, 26, had stolen enough sheets off of prescription pads to
secure Valium, Percodan, and Decadron. When she had paid for some
with her Medicaid card, authorities were tipped off. She was charged with
14 counts of obtaining drugs by forged prescriptions (Antonelli-Bacon,
Ms. X filled 397 prescriptions in the last two years of her life. She saw
29 different doctors, receiving services from one physician on 79
occasions. One hundred fourteen of her prescriptions were filled at the
same pharmacy and reimbursed by Medicaid. On her death from a drug
overdose at age 22, her body contained near-toxic levels of two
benzodiazepine products i.e., Valium and Librium, phenobarbital and
other barbiturates, three tranquilizers, opiates and cocaine.
(Detroit News, 10/10/82. Quoted in Antonelli-Bacon, 1991:12).
Mrs. Y, aged 73, is driven to a pharmacy to fill a prescription for the
analgesic Dilaudid. She gives the bottle of 40 tablets to her driver, who
hands her $100 cash and drives her to four additional pharmacies. At the
end of the day, Mrs. Y has passed six forged prescriptions and earned
$600. Her driver has obtained 240 tablets of Dilaudid, with a street value
(CBS Morning News, 2/27/85. Quoted in Antonelli-Bacon, 1991:13).
The subject matter of John Halls (1996) Washington Post article takes place
in Arlington, Virginia, where prescription drug fraud and the middle-class
woman is the major theme. Prosecutions for prescription fraud have tripled
in Virginia in the last 10 years." Although this may not indicate a higher
incidence of fraud, just more cops enforcing the laws. As is common in the
literature, Karen was treated with painkillers for a back injury when she fell
off a horse. When she couldnt get her hands on any more pills, she decided
to obtain them fraudulently (p. B4). Much of the debate about prescription
fraud stems from the fact that it is so different than the street drug market
(Hall, 1996:B4). Prescription fakers tend to be individuals rather than
members of organized rings, and they are predominantly female, according to
the DEA (Bristol-Herald Courier, 1996:3A). Fakers tend to become addicted
after getting legal prescriptions. As will be seen, the most common forms of
prescription drug abuse by individuals not in health care are; doctor shopping
(visiting more than one doctor in the same time frame in an effort to obtain
drugs); forging prescriptions; and posing as a health care professional when
phoning in prescriptions (Antonelli-Bacon, 1991:10).
No one really sees individuals committing prescription forgery as a crime, and
it is not yet viewed as a social problem. Law enforcement, medical officials
and police departments disagree, both nationally and locally, on how
seriously to take the problem. Pill addiction is the hardest withdrawal, harder
than other drugs. People do not come into treatment because they want to
get better, but because they fear arrest, says Janieth Wise, medical director
of Arlington Hospitals addiction treatment program. (Quoted in Hall,
1996.B3). Prescription drug abuse is not associated with violence, as are
other illegal drugs, however, it is commented that if police dont enforce
prescription laws, more addicts will get caught in a debilitating cycle that
often starts when a doctor prescribes drugs for a legitimate medical purpose
(p. B3). No one knows how widespread the problem of prescription fraud is,
because most local jurisdictions do not keep statistics on it, and the very few
that do say that arrests vary directly with the resources devoted to the
problem" (p. B4).
An outdated, cliched picture of the middle-class suburban housewife reliant
upon mother's little helper to get her through the boring, hum-drum day,
may, in the late 1990s make us chuckle. However, the image is an insightful
one into the history of female drug abuse in the United States. According to
Brahen (1973), the typical woman who uses legal drugs to cope with life is a
housewife whose experiencing emptiness and despair for a number of
reasons. These might be stress, child-rearing, marital and financial
problems, or that her children have left home. In the 70s women used drugs
such as marijuana, cocaine, heroin, LSD and other substances less than
men, but their use of pharmaceuticals was greater than that of men, and
since women comprised 53% of the population, were overrepresented in
their use of such drugs (p. 14).
Only infrequently over the last 25 years has it been acknowledged
that drug abusers in the population often come from the middle-class;
moms who take their childrens uppers for diet control or a high, and
many middle to upper-middle class people who take drugs because
they like them or have become addicted to them, and who will take
illegal measures to obtain them. Surveys reveal that the abuse of
highly addictive drugs like coke and heroin are on the decnne, and
prescription drug abuse is on the rise (Antonelli-Bacon, 1991:10).
Prescription drug abuse is not just a developing trend, but, as shown by
Brahen (1973), has been happening for some time. Perhaps the use and
abuse of prescription drugs is a carry over" from the hippie days" of the
1960s, illustrative of the substitution of say Valium for Marijuana and LSD.
Statistics can be misleading due to the fact that there is an evolving
awareness of the problem, and more law enforcement dedicated to
combating it, as well as health regulatory boards, and insurance carriers
joining the fight. Another obstacle in the past was identifying drug abusers
and diverters. They are hard to profile because youve got young people, old
people, thieves, pushers, addicts, business people and health professionals"
(Antonelli-Bacon, 1991:12). Experts agree that there is no clear profile of the
prescription drug abuser, but some indicators offer a sketch of who the
primary abusers are. State of Virginia arrest records reveal that most
prescription drug abusers are white, are between the ages of 31 and 40, and
are females, but maybe they are just the ones that get caught (Antonelli-
Bacon, 1991:12. italics, mine).
Swanson, et. al., (1973), examined 225 patients who had been hospitalized
for prescription drug abuse. The patient population was characterized by
high levels of academic-occupational achievement, complicated medical
histories, and the abuse of alcohol or multiple drugs. Abuse had its onset
prior to middle-age, went on for years before it was recognized, and was
concealed behind a facade of medical disorders (p. 359). Most patients did
not experience deprivation or neglect in their early years, a characteristic
commonly associated with mental illness, and most had the advantage of an
advanced education and professional status. Prior to drug abuse, the
patients did not demonstrate the pleasure-oriented, irresponsible and
psychopathic traits generally associated with the designation addict (p.
365). Many patients blamed their drug abuse on their prescribing physician
(Personal Communication, 1997).
Moreover, abusers often manipulate practitioners into prescribing their drug
of choice. These people tend to be above average intelligence, they know a
lot about pharmaceuticals, and they know what buzz words to use. They
dont ask for a particular drug, but they steer the doctor to what they want by
saying theyre allergic to some things, for example. They wont say they
want Vicodin, theyll say they are allergic to non-Vicodin drugs (Antonelli-
Bacon, 1991:13). Dr. Keith Crossen, quoted in Antonelli-Bacons article says
that, when someone says that the only thing that will help my pain is XYZ,
its a red flag. And, while most people say that the doctor gave me
something to sleep, the abuser can usually elaborate on drug classes, doses,
and makers, and when a patient requests a refill of something they should
already have (p. 14). Most diversions occur in facilities such as hospitals,
pharmacies and doctors offices, located in urban areas, where most of the
arrests tend to occur, although the offenders themselves may live in outlying
areas (p. 14). Additionally, drug diversion doesn't always involve a ruse or
scam. Evidence throughout the literature, shows that, some doctors allow
patients to self-prescribe. They say, I want this or I want that, and the
doctor writes the prescription for them. The more ethical doctor is going to be
at a business disadvantage because people who want controlled substances
are going to gravitate toward doctors who will freely prescribe" (p. 14). Unlike
those who deal in illicit drugs, prescription drug diverters are mainly
interested in their own supply. Drug diversion for money often involves the
drug Dilaudid, known as the Cadillac Drug, and said to be stronger than
heroin and morphine, which costs .50 cents per pill by prescription, and
$60.00-$100.00 per pill on the streets (Skom and Wilford, 1988:2).
Virginia State Polices prescription fraud unit, headed up by Captain William
R. Bess is described in Halls article, and appears in Antonelli-Bacons article,
as well as a few others. (I wrote to Bess at the recommendation of Tom
Wyatt, former head of the National Association of Controlled Substances
Authorities. He forwarded to my attention a number of pertinent articles
appearing in this literature review, but declined to answer a question in my
letter pertaining to his involvement in the arrest of Karen Moran above). Mr.
Bess has received a lot of press. (Hall, 1996:B3; Antonelli-Bacon,
1991;0Dell, bibliographic information unknown). Since 1988, Besss
prescription fraud unit has grown from four to 12 investigators and arrests
have risen dramatically from 61 in 1988 to 183 in 1995 (Hall, 1996.B3).
According to Antonelli-Bacon (1991), another way to document the rise in
pharmaceutical drug abuse, at least in the state of Virginia, is the disciplinary
actions taken against health care providers, ranging from reprimands to
license revocations, which jumped nearly 50 percent between 1990, and
1991" (p. 10).
Women looking for prescription medications oftentimes con doctors and set
them up. Drug addicts are particularly manipulative in their need for drugs,
and narcotics addicts are shrewd and excellent actors/actresses. (Wilson
and Gilmore, 1974; Wick, 1995; Wilford, 1990). Manipulative behaviors used
by abusers is not usually part of the standard coursework for doctors and
pharmacists (Wick, 1995:33; Wilford, 1990:609). Moreover, prescription drug
abuse involves "long-term drug abusers who approach physicians for the
specific purpose of securing drugs to support their dependence. In the drug
culture this approach is known as 'working or making a doctor. This
individual can be referred to as an "Easy Doctor (Personal Communication
1997; Cohen, et. al., 1982). Manipulative approaches used by such conning
patients are; migraine headaches, tic doulouroux, back pain, colitis, renal
colic, acute or chronic pain from orthopedic surgery, toothache, bronchitis,
psychological anxiety, narcolepsy, and obesity" (Wilford, 1990:610).
Deception involves the manipulative techniques found in the literature, used
to deceive physicians such as prescription theft, forgery and alterations,
concealing or pretending to take medications, and requesting refills in a
shorter period of time than originally prescribed often with the excuse that
the medication was lost or stolen (Wilford, 1990:610, Cohen, et. al., 1982).
"Patients with pseudologica fantastica or Munchhausen's syndrome, or those
who are adept at deceit, can be persuasive to a degree that is unusual in
comparison with ordinary clinical encounters. The patient who has no interest
in diagnosis, fails to keep appointments for x-ray films or lab tests, or refuses
to see another physician for consultation should be suspected" (Wilford,
Feigning physical problems can be convincingly portrayed by drug-seeking
patients. Patients have even been known to mutilate themselves in order to
secure prescriptions. These run the gamut from bleeding, (Colorado
Prescription Drug Abuse Task Force, 1995:3), often stimulated by the use of
anticoagulants and self inflicted skin lesions, to gastrointestinal and
musculoskeletal disorders (Wilford, 1990:610). Additionally, If the doctor
asks for a urine specimen, the patient might even prick his or her finger and
drop a little blood into the urine" (Lindberg, 1984:240). Tic douloureaux is a
favorite approach among patient "hustlers" because it has no clinical or
pathologic signs. Patients complain of recurring, intense episodes of facial
pain lasting several seconds to several minutes. Some patients are able to
contort their faces to simulate an attack of pain" (Wilford, 1990:610).
Feigning psychological problems is also very common. There is no foolproof
way that the physician and pharmacist can be certain that a specific
prescription for a controlled substance is really written for a valid medical
reason. Patients can fake illness, to get the physician to write a prescription
for drugs to treat a nonexistent disease (Keown, Gumbhir and Vaughn,
1981:16). "Most drug seekers who feign psychological problems are
attempting to obtain stimulants or depressants rather than analgesics. The
psychological symptoms most often presented include anxiety, insomnia,
fatigue and depression" (Wilford, 1990:610).
Pressure tactics can be predicated on a guilt-induction technique, that when
applied to doctors are varied and creative. (Wilson and Gilmore, 1974:81;
Wilford, 1990:610). Some approaches used by female addicts to extract a
prescription from a male physician include trying to seduce the doctor by
wearing sexy clothes, or relate to the doctor as a daughter relates to her
father. Her plea is that of confidentiality and distress as she subtly frustrates
all of the doctor's suggestions of help except an immediate prescription
(Wilson and Gilmore, 1974:84). The idea of collusion between the doctor and
drug-seeking patients is well documented (Balint, et. al. 1970; Wilson and
Gilmore, 1974; Ettore, 1985; Wilford, 1990). Prescription medications can be
viewed as an expected medium of exchange between doctor and patient.
Relief of symptoms is a legitimate goal of medical practice. Sometimes,
though, the doctor is coerced into prescribing, and does so against his or her
best judgment. The doctor might be too busy to talk about other non-drug
alternatives. Historically, the relationship between women and the medical
profession can be seen as one of social control, and has been amply
documented in the literature (Ettore,1985:116; Wilford, 1990:609; Manasse,
Jr., 1989:1141; Keown, et. al., 1981:16; Cohen, et. al., 1982:4).
Unprovable symptoms covered up via ruses, demands, lies and scams, put
doctors, who truly want to relieve symptoms, in a real bind. (Wilford,
1990:609; Wilson and Gilmore, 1974:87; Wilford, 1990:610; Antonelli-Bacon,
1991:12). The manipulative techniques employed, may be either covert
(seduction or coercion) or overt (intimidation), or both. Drug seekers can put
the heat on doctors to push them into prescribing their drug of choice. This is
an example of the "spell binding" patient (Wilford, 1990:611). "Coercive
tactics include eliciting sympathy or guilt, such as by suggesting that medical
treatment caused the patients drug dependence, direct threats of physical or
financial harm, the offer of bribes, or using the names of family members or
friends" (p. 610). Conning tactics may be encountered by a physician
whether he/she is in private practice, in a clinic setting, in a neighborhood
health center, a busy emergency room, or a large metropolitan hospital (p.
611). Certain behaviors are common among drug seekers, and abusers
share certain characteristics. Most have multiple addictions, and frequently
are addicted to caffeine, nicotine or both. Those mechanisms of deceit which
are most successful become a pattern amongst drug seeking patients (Wick,
1995:35; Wilford, 1990:609, 611). Drug seeking behavior may be identifiable
in prescription forgers, addicts and others. Signs of these behaviors as
documented in the literature include, altering or forging prescriptions; claims
that prescriptions are lost or damaged; seeking care from multiple facilities;
providing fraudulent information; visiting ER or clinic frequently; visiting
nights, weekends, or closing hour; changing doses without consultation;
selectively filling prescriptions; being threatening or abusive; using multiple
names; unusual knowledge of medications and brand names that may
important for street recognition (Wick, 1995:36; Antonelli-Bacon, 1991:12;
Illinois Legislative Investigating Committee, 1974).
Other breeds of "legitimate" addicts found in the literature, are those who
claim that they became addicted while hurt on the job, or in a severe accident
with multiple injuries. Although prescription fakers are crafty, there are ways
that a doctor can tell that a patient is feigning illness to secure drugs:
Ordinary clinical intuition will alert the physician that there is a large
discrepancy between the patient's report of the severity of the pain and
the level of pain actually being experienced. Some patients
manipulativeness can be detected by observation. The ordinary patient
does not scan the physician for responses in the same way in which
those trying to con may. When the physician has the feeling that the
patient has extraordinary persuasive and dramatic powers, suspicion
that a manipulator may be present is justified (Wilford, 1990:611).
If the doctor has identified a manipulative patient, he or she should try to
maintain control of the interaction, realizing that the patient may be addicted
to drugs. "Drug seekers who are frustrated in their attempts to obtain drugs
often become angry. This response is so typical that some clinicians
consider it diagnostic of drug seeking behavior (Wilford, 1990:612).
Additionally, a person can claim either a medical or dental condition for which
she is being treated in another city, and in a busy office where it is hard to
verify. The transient patient" occurs when the patient is from out of town and
has either run out of the medication or has had it lost or stolen (Wilford and
Wilson, 1974; McCallister, 1988). Addicts can use these ploys many times
without being discovered (Wilford and Wilson, 1974:86; Wilford, 1990:610,
Patients presenting with a toothache often claim to be from another
town and have left at home the medications prescribed by their dentist.
Should the physician wish to verify this claim, the telephone number
supplied for the hometown dentist is often that of an accomplice. If the
person actually had an abscessed tooth, he or she usually makes full
use of it by visiting a series of physicians and dentists to ask for pain
medicine (Wilson and Gilmore, 1974).
The patient tries to crate a sense of urgency and pressures the physician for
an immediate response by claiming intense pain. (Wilford, 1990:611). The
tricks used by a drug abuser to dupe an unsuspecting doctor, dentist or
pharmacist are endless (Keown, et. al.,1981:16). As has been shown
throughout the literature, "health care professionals are exploited by those in
search of mind alteration (Cohen, et. al., 1982:ix). Other examples could
include coming into a doctor's office late on a Friday afternoon, complaining
of pain that cannot easily be verified, such as low back pain. Requests for
narcotic pain killers are common. No", is usually the answer the doctor will
get when asked if the female patient has a regular doctor to call back home.
She fits the profile of a prescription drug abuser, according to guidelines
developed by the Colorado Prescription Drug Abuse Task Force. This female
prescription abuser made a last-minute appointment before a weekend, she
knew what drug she wanted, she had pain that cannot be measured, she was
transient and she could not provide background information (McCallister,
Prescription medications offer a measure of safety not available in street
drugs. They offer label confidence and purity while achieving the same effect
as other street drugs (Cohen, et. al.,1982; Beary, et. al., 1996; Wick, 1995;
Brushwood and Warren, 1981). The pharmacy is a place to acquire
unadulterated, high-grade drugs at reasonable prices through forged or
altered prescriptions" (Brushwood and Warren, 1981:2). What makes pills
so attractive to abusers and purveyors are their purity, predictable effect and
low cost compared to illicit drugs" (Weikel, 1996:A24).
Self-medication is a concept running throughout the literature. It happens in
larger cities and small towns. It can be assumed that forgeries are indicative
of addicts trying to self-medicate (Wick, 1995:35; Wilford, 1990). Self-
treatment or self-medication is a daily, acceptable activity for most people.
For example, if you have a headache, you may take a couple of aspi:;n to
reduce your discomfort. Self-medication is more common than the use of
prescribed drugs (Skegg, Doll, Perry, 1977:1563). And, self-medication is
appropriate for many ailments. The symptomatic relief of common aches and
pains with home remedies, taken infrequently over short periods, seems the
appropriate role of self-medication. Possible dangers are misdiagnosis and
misuse. People may self-treat conditions which need medical intervention,
and tend to use self-medication as an alternative to medical consultation and
some adults may turn to self-treatment when medical consultation has been
found unsuccessful (Dunnell and Cartwright, 1972:120). Pill swapping and
sharing is also common in our culture (Swanson, et. al., 1973; Cohen, et. al.,
Many patients are noncompliant with a physician's directions. Compliance
with a prescribed drug regimen is also an issue common throughout the
literature; especially when the drug in question has a high potential for abuse.
Deviating from a physician's directions is common:
Many patients have done the following; never obtaining a prescribed
drug; never taking the prescribed drug; taking the prescribed drug
improperly; involving taking an incorrect quantity per dose or an
incorrect number per day; omitting, doubling, tripling, quadrupling
doses or discontinuing medications prematurely; or taking
nonprescribed drugs or discontinued medications in addition to or in
place of the prescribed drug (Wilford, 1990: 610).
Addicts are drug abusers. Despite the fact that a doctor may prescribe
medication to be taken three or four times each day, the addict will take the
medication when she feels she needs it, as much as she wants, and as often
as she wants. Patients are often in noncompliance due to lack of information,
insufficient motivation, or drug abuse This example of exceeding prescribed
dosages is found throughout the literature (Swanson, et. al., 1973; Cohen, et.
al., 1982). The term abuse has been used to mean use in excess of
prescribed dosages and duration of time (Brahen, 1973: 15). Drugs that
accumulate in the medicine cabinet at home, can supply a regular source of
prescription drugs for addicted family members. Unused or partially used
medicines can provide an initial supply (Cohen, et. al., 1982:1). Patients
contribute to drug misadventuring by not complying with the instructions for
proper use of a prescription, combining the use of prescription medications
with other substances, foods and chemicals when these are specifically
contraindicated, and by using medications indicated for use by others"
(Manasse, Jr., 1989:1144). Patient compliance is enhanced when open
communication is the rule between doctor and patient.
Addicted physicians, pharmacists, nurses and other medical and health
practitioners is a major theme running through the literature. Doctors who
enable the addiction of patients with pharmaceuticals are treated less harshly
than drug traffickers and dealers, although with similar negative
consequences to society (Illinois Legislative Investigating Committee, 1974;
Cohen, et. al., 1982; Beary, et. al, 1996; Weikel, 1996). Some see a double
standard in leniency toward doctors and the rich and powerful who overuse
drugs (Weikel, 1996:A24). Because of the nature of the field, the bizarre
working hours, and proximity to drugs, many of these people become addicts
(Wilson and Gilmore, 1974; Beary, et. al, 1996; Wilford, 1990). Examples
are, a nurse asking a doctor off the record for a prescription for cramps or
backache, or a hospital employee asking a resident physician for a
prescription, because it takes too much time to see the employee physician
(Wilson and Gilmore, 1974:86). Physicians who contribute to the problem of
prescription drug abuse are singled out in the literature, as those who
consciously misprescribe for profit. These doctors are also referred to as
scrip docs (Illinois Legislative Investigating Committee, 1974; Keown, et.
al.,1981:15; Cohen, et. al., 1982:2; Beary, et. al., 1996; Weikel, 1996:A1;
Wilford, 1990: 609). These doctors have been described by the American
Medical Association as "dishonest; disabled by personal problems with drugs
or alcohol; dated in their knowledge of current pharmacology or therapeutics;
or those who allow themselves to be deceived by patients" (Wilford,
1990:609). These doctors also inadequately safeguard their prescription
forms and drug supplies. Since the 1970s, careless prescribing of drugs has
been a focus of attention (Brahen, 1973:14; Illinois Legislative Investigating
Committee, 1974; Cohen, et. al., 1982). By American Medical Association
estimates, 1% to 1.5% of physicians dishonestly prescribe drugs, and another
5% are grossly negligent in their prescribing" (Cohen, et. al., 1982:2). And in
California, that represents 4,500 to 4,875 doctors" (Weikel, 1996:A24).
The Council on Scientific Affairs of the American Medical Association clearly
defined the sources of prescription drug abuse in its 1981 report, Drug
Abuse Related to Prescribing Practices."
Doctor's contribute to drug abuse by acceding to the inappropriate
demands for medication by patients, through injudicious prescribing
practices whereby they acquiesce to the demands of certain patients
to instant chemical solutions to all of their problems. Furthermore, the
Council also identified patient manipulation of prescription orders by
theft, alteration or forgery and theft of drugs as major elements of
concern (Wilford, 1990:609).
Cases are presented throughout the literature on doctors and others who
illegally traffick in prescription medications. All types of medical personnel
realize there are profits to be made by illegally selling prescriptions and
pharmaceutical drugs to individuals who abuse them in a non-medical fashion
and at an inflated price (Beary, et.al., 1996:33). The mega-profits such
unscrupulous professionals warrant are enormous. Doctors, dentists and
pharmacists have made millions by turning their practices into lucrative pill
mills, where fraudulent prescriptions written in minutes have sold for $200
to $600 apiece, depending on the substance" (Weikel, 1996: A24).
Furthermore, price markups are enormous for prescription drugs sold on the
illicit market several thousand percent in some cases" (Beary, et. al.,
1996:33). Pharmaceutical diversion and abuse involving controlled
substances criminal activity involves cases of professional laxity and deceit
(Keown, et. al., 1981:16; Cohen, et. al., 1982). Millions of pills are being
illegally resold on the streets. And although some of the drugs are smuggled
into the country or stolen from distributors, a large portion comes from
medical offices, clinics and pharmacies. Doctors see many patients in a day,
do not perform medical examinations and bill Medicaid for extended visits.
(Beary, et. al, 1996:34; Weikel, 1996: A1). Moreover, "the motivational factors
causing health care professionals to become involved in the diversion of
legitimate drugs include greed, failing medical practice, seif-addiction, senility
and rationalization" (Beary, et. al, 1996:34). Greedy health-care providers
know that pharmaceutical prices are a fraction of the cost that they sell for on
the street. Sometimes they trade pills for sexual favors or other merchandise.
Older doctors whose practices are withering away may lead them to divert
drugs. New doctors right out of medical school might sell pills to pay off
debts accrued while at school. Drug addiction is common amongst health-
care professionals, due in part to long working hours and easy access to
drugs. Addicted professionals often turn to diversion to support or finance
their own habits. In some older professionals, senility has led to improper
prescribing by giving in to the demands of drug abusers. Cases exist where
office personnel or family members take over the practice on behalf of the
older professional, allowing prescriptions to be written without his or her
knowledge. Some health professionals rationalize that selling pills to drug
abusers will keep them from resorting to street drugs, and the crime
associated with buying on the street.
The relationship of this occupational status to the initiation of prescription
drug use is not clear, but availability, job stress, overwork and fatigue are
given as justifications, excuses and rationalizations (Swanson, et. al.,
1973:366). Doctors who sell pills or self-prescribe to abusers are known as
respectable pushers" (Lane, 1991:10). Since many drug diverters are
people within the health care industry, there is always the fear that a nurse or
technician assigned to your hospital is at best, diverting pain killers
prescribed for you, at worst, working while impaired" (Antonelli-Bacon,
1991:10). Robberies or break-ins are another avenue for diversion, resulting
in the destruction of prescription files and records used by the DEA to
document pill shortages (Beary, et. al, 1996:34; Keown et. al., 1981:15).
According to the Medical Practice Act, 12-36-117 (1)(X), unacceptable
physician prescribing procedures include:
a) Prescribing for personal or family use is unprofessional and is subject to
disciplinary action against license to practice medicine.
b) Prescribing a narcotic analgesic for a patient simply because the patient
tells you another physician has been prescribing one. Consult the
physician or hospital records or examine patient deciding which controlled
drug product should be prescribed.
c) Signing prescription blanks in advance.
d) Using blanks that are preprinted with the name of a proprietary narcotic
preparation (Colorado Prescription Drug Abuse Task Force, 1992:52).
The Four Ds include dishonest, disabled, deceived and dated health care
practitioners who are sources of drug diversion, according to the Colorado
Prescription Drug Abuse Task Force.
Dishonest or scrip doctors or pharmacists, willfully and knowingly
dispense controlled drugs for purposes of abuse and usually for profit.
Disabled or impaired physicians/pharmacists, practice while their
professional judgment is impaired by drug abuse, alcoholism or other
physical or mental disorders. Deceived physicians and pharmacists,
unwittingly fall victim to the conning tactics employed by patients
who seek drugs to support their own dependence or for sale to others.
And, dated physicians/pharmacists, misdispense unintentionally
because they have not kept pace with developments in pharmacology
or drug therapy (Derived from the American Medical Associations
Four Ds. Colorado Prescription Drug Abuse Task Force, 1994).
Pharmacists contribute to the problem of prescription forgery by not reporting
suspected forgers. Catching offenders is difficult because the illegal activity
occurs in the midst of legitimate business, when pharmacists are busy filling
orders. Arrests often depend on a pharmacists sixth sense that something
is wrong with a prescription (Hall, 1996.B4). They tell you too much or keep
calling back to ask if their orders are ready (Bristol-Herald Courier, 1996:3A).
Brushwood and Warren (1981), are both lawyers who are concerned with
prosecuting the prescription forger. They believe that the pharmacist and the
prosecutor need to work in tandem to bring the prescription forger to justice:
The prosecutor must prove beyond a reasonable doubt that the
defendant committed a criminal act and acted with criminal intent.
Each state jurisdiction has different forgery statutes. In jurisdictions
where an attempt to obtain a narcotic drug by fraudulent means is a
crime, the prosecutor may charge the defendant with attempt.
Additionally, the law imposes procedural requirements. Soon after
formal charges are filed, the defendant must be allowed an initial
appearance before a judge. The next formal step is either a
preliminary hearing, a trial, or, in some states, a grand jury indictment.
In any one of these proceedings, the pharmacist could be called to
testify (p. 23).
Brushwood and Warren, as lawyers (Warren is a prosecutor), are concerned
with ensuring prosecution of the prescription forger. They emphasize the
ways that pharmacists can provide law enforcement officials with the best
opportunity for arrest, and prosecutors with the best basis for conviction. One
key point is that the pharmacist keep his or her facts straight (p. 24). For
instance, the pharmacist can verify whether the prescription is genuine or a
forgery by contacting the prescriber or determining that no such prescriber
exists. He or she should stall the suspect or delay dispensing the
prescription, call the police, describe the situation, and try to have the arrest
made outside the pharmacy after the transaction is completed" (p. 24). A
case is often disposed of in other ways besides a trial. For instance, the
defendant might plead guilty, the prosecutor could drop all charges, or the
initial charge can be plea bargained down to a lesser charge. The authors
emphasize the importance of cooperation with the police, in identifying the
forger and provide as much detail as possible in the police report:
The first step for the pharmacist is to familiarize him or herself with
local laws, prosecutors and police. The pharmacist should
immediately commit to writing all the details of the events including
date, time, names of witnesses, how the verification of the prescription
was handled, conversation with the suspect, what was dispensed and
how the arrest was made. The pharmacist should be certain that
he/she can identify the physical characteristics of the suspect. He/she
should retain evidence of the written prescription, make him/herself
available to the prosecutor for pretrial interviews or hearings, and keep
track of the court docket in order to be available to provide important
testimony in the conviction of the suspect (p. 24).
If pharmacists and law enforcement agencies cooperate, a reduction of
prescription forgeries and other pharmacy crimes is likely (Warren and
Brushwood, 1981; Keown, et. al. 1981:18; McCauley, 1993:94; Colorado
Prescription Drug Abuse Task Force, 1994:7). Communication and
information sharing between the police and pharmacists is the key to busting
more people engaged in prescription fraud. Law enforcement officials are not
particularly savvy when it comes to this kind of crime. Therefore any help
from pharmacists would aid in bringing these people to justice. In this age of
escalating prescription fraud, local law enforcement and the community of
pharmacy professionals have much to offer one another (McCauley,
1993:94). In Colorado, a pharmacist who suspects prescription fraud can call
the PharmAlert Hotline at: (303) 784-6300, or the Prescription Drug Abuse
Hotline at: (303) 739-1112. This hotline is staffed by pharmacists organized
to assist professionals in dealing with situations related to prescription drug
abuse (Colorado Prescription Drug Abuse Task Force, 1994).
In Abington Township, Pennsylvania, a system of alert bulletins" was set up
to share information between pharmacists and the narcotics unit of the local
police department. Once information regarding a scam is verified, it is turned
into a flyer and circulated in the local pharmacies. Typically, the flyers
describe the scam and contain either a picture of the suspect or a copy of the
bogus prescription being used. This way, pharmacists are forewarned about
active fraud artists who may attempt to pass bad prescriptions at their store.
Prior to 1991, the police department averaged one prescription fraud arrest
per year, now it is one to two per month (McCauley, 1993:94). Lane (1991),
states that, pharmacists can be either of great value or a hindrance to the
investigation (Lane, 1991:13).
Keown, Gumbhir and Vaughn (1980), pharmacists themselves, initiated a
research effort, which was motivated by an interest in learning more about
prescription forgeries and what to do about them. An effort was made to
determine how pharmacists authenticate prescriptions for controlled drugs,
what steps they take when the prescription is determined to be fraudulent,
and what they would suggest to improve the situation (Keown, et. al.,
1981:15). Seventy-five pharmacies located in central and western Missouri
and eastern Kansas were contacted, and questionnaires hand-delivered to
each of them. Questions in the questionnaire included pharmacists estimates
of the number of fraudulent prescriptions received by them each day. In this
study, the mean was 1.6 per day. The authors ask if this number is a
function of the pharmacy's location, the prescribers in the area, the general
attitude of the pharmacists toward abuse of controlled drug products, or other
factors (p. 15). They believe that fraudulent prescriptions are a problem.
According to these authors, back in 1981, there were no comparable
statistics in the literature on this subject and that a nationwide study is
warranted to obtain reliable estimates. In the questionnaire, pharmacists were
then asked to rank the drug class for which most of the forged prescriptions
were received. In this study, narcotic analgesics (pain killers) were the most
frequent. The survey participants were asked to indicate the steps taken to
ascertain whether a prescription is genuine or fraudulent. These include,
calling the prescribers office, checking the prescription format, familiarity with
patient and/or physician, correct DEA number, subjective observation of
patient, and patient identification" (p. 19).
When asked if pharmacists were doing their best to curb the dispensing of
fraudulent prescriptions, less than half surveyed thought so" (p. 17).
Pharmacists were also asked about the efforts that all members in the health
care system need to make in order to lower the incidence of prescription
fraud in the pharmacy. Responses included, taking legal action against
pharmacists and physicians who participate in fraud; educating doctors who
write repeat prescriptions when alternative treatments are available; arrest
doctors who overprescribe or sell addictive medicines; and compile a list of
people in their area who work doctors by getting multiple prescriptions.
Other responses included compiling a list of doctors whose licenses have
been revoked for bad prescribing practices. It was also thought that cameras
should be available to take pictures of patients presenting prescriptions for
controlled substances, reducing the number of innocent looking abusers in
the pharmacies" (Keown, et. al., 1981:18).
Examples of illegally telephoning in a prescription by impersonating a
physician appear throughout the literature (Illinois Legislative Investigating
Committee, 1974; Brushwood and Warren, 1981; Keown, et. al., 1981). As
does the notion of professional patients, who visit doctors to get
prescriptions which are then sold on the street. Two such cases of diversion
of drugs for huge profits occurred in New York and Texas (Beary, et. al,
The problem of prescription forgery and fraud is widespread (Brushwood and
Warren, 1981:22; Wick, 1995:33; Keown, et. al., 1981:15), and is indicative of
the serious problem of prescription drug abuse, that is sometimes overlooked
(Lane, 1991:12). Forging prescriptions can be accomplished either by altering
a prescription written by a physician or forging prescriptions from scratch.
Using the same color ink pen, a forger can alter Arabic numerals, or those
written in longhand. Some drug seekers alter the number of refills on the
prescription (Wilford, 1990: 610). Some prescription blanks have number of
refills printed on them. Some drug seekers circle a number not prescribed by
the physician (1997, Personal Communication). When involved with forging
prescriptions from scratch:
the forger begins with either a blank piece of paper or a legitimate
prescription blank form a practicing physician. In the former case, the
forger stencils a physicians name and address (as well as the
telephone number of an accomplice), in black lettering onto a blank
page and then uses a photocopier to reduce the sheet to the usual
size of a prescription. Because the Drug Enforcement Agency (DEA)
registration number is now valid for three years, drug seekers are
always on the lookout for the names of physicians who have retired,
left the state or died. Some drug seekers use desktop publishing to
produce clever forgeries using assumed identities (Wilford, 1990:611).
Others obtain legitimate prescriptions, white out the pertinent details, and
make photocopies for forgeries. (Swan, 1985:15). Pharmacy prescription files
may contain phony prescriptions that contain prescribed quantities that are
frequently altered (Illinois Legislative Investigating Committee, 1974; Beary,
et. al, 1996:34).
The concept of diversion is well documented in the literature. Diversion is big
time" prescription fraud, when physicians and pharmacists are out to dupe
Medicare, Medicaid, or insurance companies, for instance (Beary, et. al,
1996; Wick, 1995; Jones, 1992; Rosenberg, et. al., 1991).
In illegal diversion, a person eligible for Medicaid obtains a
prescription from a physician participating in the scheme. The
doctor bills Medicaid for the unnecessary visit. The patient has the
prescription filled by a pharmacist, who also bills Medicaid. The
patient then sells the drug on the street. In some cases, the drug
has been sold back to pharmacies for profit (Jones, 1992:7).
Reliable estimates for the total national cost for prescription drug diversion
are lacking, according to the American Medical Association. Fraudulent drug
claims may cost the state Medicaid programs alone an amount equal to one
percent of all claims benefit costs, or 10% of Medicaid drug claims costs
(Skom and Wilford, 1988:2). Some interesting statistics form the basis for
concluding that diversion is a serious issue. The U.S. Drug Enforcement
Administration has estimated that about $25 billion in prescription drugs were
sold on the illicit street market in 1993, compared to a government estimate
of $31 billion spent that year on cocaine, including crack (Weikel, 1996:A24).
To underscore the breadth of the problem, it is claimed that, "nearly half of all
the legally manufactured controlled substances that are diverted to illegal use
are diverted by prescription fraud (Keown, et. al., 1981:8). Operation
Goldpill", was the largest undercover health care fraud operation ever
undertaken by the FBI. In it authorities arrested over 100 people, including 82
pharmacists and one physician. In this crackdown, two types of fraud were
targeted, illegal diversion of prescription drugs and fraudulent billing by
pharmacists (Jones, 1992:7). These forms of fraud take money from
Medicaid and private insurance earners and include; filling prescriptions with
generic drugs and billing for the brand-name product; billing several times for
the same prescription; billing for prescriptions never written or filled; filling
only a portion of the prescription, thus forcing patients to return and thereby
reaping two dispensing fees. Health care fraud is estimated to cost the
nation tens of billions of dollars a year, and it is plain to see that the
motivation for these illegal acts was pure greed (Antonelli-Bacon, 1991:10).
Another major sting taking place in the mid-1980s, called Operation Rx, has
been described as urban espionage leading to the convictions in federal
CGwirt of seven doctors, five clinic owners, three independent drug dealers and
a pharmacy owner (Jalon, 1986:10). The story as told in the Los Angeles
Times Magazine, involves a pharmacist who goes undercover to bring these
health care crooks to justice, while highlighting the drug distribution network
in southern California. The doctors patients were usually unemployed street
people known as runners, who worked for entrepreneurs called transporters.
The transporters were independent dealers who financed the whole thing,
and who paid the clinic a fee to deal with the doctor. They paid the doctor
for the prescription, and they paid the runners. They then sold the drugs to
users (p. 15).
Medicaid now monitors the frequency of prescription drug purchases with a
computerized system called Client Medical Management. Under the program,
cardholders are restricted to one doctor, one pharmacy" (Antonelli-Bacon,
1991:14). In sum, prescription drug diversion is the securing of prescription
drugs by fraud, deceit, misrepresentation, subterfuge, giving of a false name
or false address or by the concealment of a material fact (Antonelli-Bacon,
Rosenberg, et. ai., (1991), recommend that emergency physicians and
nurses be aware of fraudulent prescription requests, because the issue is
largely undiscussed in the emergency medicine literature (p. 159). The
authors letter in the correspondence section of the Annals of Emergency
Medicine, state that they noted a rise in patients presenting for prescription
refills, requesting medications not thought to have significant abuse potential.
The authors add that, they have long suspected that the patients in question
were using their Medicaid cards to obtain expensive medications, which they
would then sell back to dishonest pharmacists (p. 159). They have also
speculated that these medications are taken to soften the come-down or
reactivate the high of illicit drugs and alcohol. Society pays the bill for
diverted drugs that are paid for by state Medicaid programs and insurance
companies. Prescription fraud may occur through a customer who passes a
bogus prescription at the local pharmacy, a pharmacy technician who
changes prescriptions for non-controlled drugs to more potent controlled
drugs in the pharmacy computer, or pharmacist who dispenses unauthorized
refills or alters individual prescriptions and steals from his/her inventory
(Beary, et. al., 1996:33). Diversion may also occur at the physician's office,
where office help write unauthorized prescriptions either by forging the
doctor's signature or by telephoning prescriptions to the local pharmacy.
Fraud may exist in situations where prescriptions are presented that are
written by individuals who are not legitimate physicians or for individuals who
are not legitimate patients" (p. 33). Most diversion occurs at the retail level,
and involves physicians, pharmacists and other health-care professionals
(Beary, et. al, 1996:33; Weikel, 1996:A24; Keown, et. al., 1981:16). Federal
authorities, on average, convict 240 people a year for federal drug diversion
offenses, or about five per state (Weikel, 1996: A25).
Diversion, means illegally leaking pharmaceuticals out to the street for sale.
Drugs that have a high abuse rate in this area are the benzodiazepines,
steroids, sedative-hypnotics and anxiolytics. However, antibiotics, insulin
syringes, high-potency multiple vitamins, clonidine and drugs that look
potent have been identified as drugs of abuse (Wick, 1995:33).
Furthermore, an estimated 5% of all legally manufactured prescription drugs
are diverted through pharmacy thefts and stolen from truck shipments, but
the vast majority are diverted via prescription fraud" (Beary, et. al, 1996:33).
New opportunities for diversion have arisin as a result of transformations in
the health care field, such as the introduction of mail-service pharmacies,
HMOs, preferred providers and the computerization of medical records"
(Beary, et. al, 1996:34). Consumers ultimately pay higher premiums as a
result of this type of health care crime. According the Colorado Prescription
Drug Abuse Task Force, most prescription drug diversion comes about as a
result of dated or dishonest prescribing practices (Colorado Prescription Drug
Abuse Task Force, 1992:4).
In the past, it was believed that as long as a person had face-to-face contact
with a doctor, the person could get as many prescriptions from as many
doctors as one fancied. Doctor shopping, is Taking the same real or
imaginary ailment to multiple physicians simultaneously" (Hall, 1996:B4). It is
also a major theme found throughout the literature on prescription fraud
(Swanson, Weddige and Morse, 1973; Wilson and Gilmore, 1974; Cohen, et.
al., 1982; Wilford, 1990; Antonelli-Bacon, 1991; Wick, 1995; Hall, 1996;
Weikel, 1996), It is illegal for someone to fraudulently obtain prescription
drugs, when the fact is concealed that youre getting the same drug over the
same concurrent time period from multiple doctors" (Antonelli-Bacon,
1991:12). Doctor shoppers trick physicians and pharmacists with self
inflicted injuries, forged prescriptions and stories about back pain or old war
wounds (Weikel, 1996: A24). Addicts often make the rounds of physicians
offices to get a supply of prescriptions from easy doctors. "When the
physician has the impression that his or her responses are being studied by
the patient as intensely as the physician is studying the patients situation, the
physician should be suspicious that a doctor shopper or conning patient is at
hand" (Wilford, 1990:611). Doctor-shopping was a phenomenon identified in
the 1970's by researchers such as Dr. Leonard Brahen, who wrote of middle-
class housewives who shop from physician to physician to maintain a drug
regimen no one physician would prescribe (Brahen, 1973:13). Multiple
hospitalizations are another devious method by which prescription drug
abusers obtain their drugs (Swanson, et. al., 1973:363).
Scenes of prescription medication fraud have been described throughout the
literature, where individuals present bogus prescriptions, and when
confronted by the pharmacist, quickly leave the pharmacy (Illinois Legislative
Investigating Committee, 1974; McCauley, 1993; Wick, 1995). McCauley who
is a Detective, presents a scenario where a ringleader of a group of
prescription fraud artists spanning two states, is arrested after a stakeout in
the pharmacy (1993:94).
The prescription pad is worth its weight in gold to the drug-dependent
person (Cohen, et. al., 1982:2). Drug seekers will seize any opportunity to
steal prescription blanks from the consultation room, examination room, etc.,
and may make appointments just to steal pads (Antonelli-Bacon, 1991:14).
Therefore, it is best to keep prescription pads away from patients and never
leave a suspected addict alone in an examining or consultation room. It is a
good idea to have prescriptions numbered and use only one prescription pad
at a time (Illinois Legislative Investigating Committee, 1974; Wilford and
Gilmore, 1974:87). Suggestions to doctors by the U.S. Drug Enforcement
Administration and others on reducing the risk of having their names used in
prescription forgeries are found throughout the literature (Wilson and Gilmore,
1974:86; Wick, 1995; Wilford, 1990:611). Doctors should see that
prescription pads are not left temptingly on his or her desk when he or she
pops out of the room for a moment! (Brahms, 1988: 838).
From a media ethics slant, a highly publicized prescription forgery case
involved University of Texas football players who were forging prescriptions
for anabolic steroids, allegedly written by a doctor named David L. Hubler."
The media picked up on this and ran it nationwide. Even Sports Illustrated ran
the story. As it turns out, the real doctor named L. David Hubler, M.D., from
Duncansville, Texas, was not responsible for the forgeries. After having read
the stories, the doctor worried about his reputation and decided to take
measures to set things straight. He took legal counsel, and wrote to the
Texas State Board of Pharmacy and the Texas Pharmaceutical Association.
He also wrote to Sports Illustrated telling the editor that he was not
responsible for the forgeries. The real doctor Hubler was correct in taking a
proactive stance with the media, which oftentimes does not give an accurate
and balanced picture of events. Interestingly, almost one year after the
articles, the doctors office was still getting calls from young men seeking
steroids (Texas Medicine, 1991:54).
Investigation and prosecution of perpetrators of prescription drug fraud is
difficult due to the problem of obtaining hard evidence that diversion has
occurred. Lots of paperwork involve closing cases having to do with private
insurance companies, Medicare and Medicaid (Beary, et. al., 1996:34).
Prosecutors are reluctant to file charges in prescription fraud cases because
they believe that their limited resources are better spent fighting street drugs.
The resolve of regulatory agencies to get tough with those who violate
criminal and professional codes is questionable (Weikel, 1996.A25). Lane
(1991), looks in detail at two basic methods of investigation; undercover
operations and documentary investigations. Most investigators lack the
requisite knowledge and are unsure about how to pursue prescription fraud
(p. 14). Investigation and prosecution involves examining appropriate
professional conduct, trials involving professionals and controlled substances.
Standards of community and professional practice are violated when
pharmacists violate the public trust if involved in prescription fraud (Keown,
et. al., 1981:16). Prosecuting doctors who have high regard in a community is
difficult. No more than two dozen doctors, dentists and pharmacists are
prosecuted annually for prescription drug offenses, case records show. Most
get probation and stay in practice, largely because it is harder to prosecute a
professional in a white coat than a street comer pusher (p. 16).
Doctors and other health-care professionals dont seem to get as much
punishment as other drug dealers and users. There seems to be two different
kinds of justice at work in our legal system. In California, about three of four
physicians convicted of a prescription drug crime keep their licenses. Users
often do more time in jail. Often it seems that, if you have a professional
license, it can be a ticket to immunity from criminal prosecution" (Weikel,
1996:A24). Prosecutors and others say that the laws are written differently for
professionals in health care. In California, like the rest of the nation, there
are few law enforcement officials with specialized training in prescription drug
abuse" (Weikel, 1996:A25). Although, many departments in other states,
have established special squads familiar with unique prescription crime units,
called PCUs or Pharmaceutical Crime Units (Beary, et. al, 1996:35).
Regulatory boards in the health care professions are tough on criminal
professionals though. Doctors can be placed on probation with restrictions
on their licenses. The can be barred from prescribing all drugs in a certain
schedule group. Their licenses can also be revoked, but harsher penalties
can be mitigated by voluntary rehab (Antonelli-Bacon, 1991:14).
Looking at cross-cultural comparisons regarding prescription fraud, Bergman
and Dahl-Puustinen (1989), report data on forged prescriptions in Sweden
during the years of 1982-1986. Epidemiologically, they view prescription
forgeries as an indicator of prescription drug abuse in Sweden. It is
suggested that the data on forged prescriptions can be used as a signalling
mechanism in the surveillance of medication abuse, aimed at detecting
changes in the prevalence as well as in the pattern of abuse, and at present
is not available in most countries (p. 622). The authors report that the number
of prescription forgeries doubled in the 5-year period, reflecting increased
awareness and reporting of forgeries, as well as an increase in the number of
prescription forgeries. Psychotropic drugs accounted for 62% and analgesics
for 25% of all forgeries during the period. Interestingly, the major
benzodiazepines on the market in Sweden, (diazepam, oxazepam,
nitrazepam and flunitrazepam) were the subject of the largest number of
forgeries (p. 621). Bergman and Dahl-Puustinen conceive of a drug abuse
surveillance network in Sweden, combining prescription forgeries from out-
patient pharmacies as an indicator of drug abuse which are then reported to
the Department of Drugs, National Board of Health and Welfare. They point
out that no exact data on the rate of detection and reporting of prescription
forgeries are available, and the detection of prescription forgeries is likely to
be underestimated (p. 622). In their study, the majority of forgeries stemmed
from the three regions in which major cities, (Stockholm, Gothenburg and
Malmo), are located. Since there are more people living in these cities, there
are more drugs used and dispensed, and therefore, more related drug
forgeries, leading the authors to suggest that prescription forgery has a lot to
do with the characteristics of an urban population.
The UK government is out to do more in its efforts to tackle prescription
fraud (Pharmaceutical Journal, 1994:526). This headline indicates that the
ways that British doctors and pharmacists scam the health care system is
similar to the way it is done in the U.S. Both the consumer and the National
Health Service were losing millions of Pounds a year in fraudulent claims.
The problem of individual patients falsely claiming exemption from
prescription charges is also noted. A 1997 article in the British Medical
Journal describes more rigorous checks on prescribing practices of family
doctors, following a case in Leeds where a doctor and a pharmacist were
jailed for fraud amounting to about 1 million pounds. A 1991 article appearing
in the Chemist & Druggist describes the illegal activities of a doctor and
pharmacist, husband/wife team in West London, stating that the two
defrauded the government out of 200,000 Pounds, by writing prescriptions for
drugs which patients did not get. They made incredible profits by furnishing
false information to the Prescription Pricing Authority.
Penalties for doctors who write prescriptions that are illegible, is a practice
which is frowned upon both internationally and domestically. For instance, the
New York State legislature has proposed making only printed or computer
generated prescriptions legal. Pharmacists would not be allowed to fill orders
that didnt comply. Prescriptions that are often completely illegible,
jeopardize patients safety and result in patients not getting the care they
need (Patient Care, 1995:6). Computerized entry would do away with
legibility dilemmas and perhaps, prescription forgery as it is found throughout
the literature. Awareness of health care fraud in the UK has led to new
measures to fight the problem that are similar to those found here in America.
In a study published in 1981, and conducted in 1977 in West London, Murray,
et. al., examined factors affecting the consumption of psychotropic drugs. As
expected, the authors found that in every age group, the rate of drug
consumption was twice as high in women as in men, and that this difference
holds across all age groups surveyed (p. 552). Ruth Cooperstock, a
Canadian researcher working in the 1970s, pointed out that sex differences
in the consumption of mood modifying drugs cannot be accounted for solely
by the fact that women are more ill (1971:1007). Murray et., al.s data
confirm this finding, since it appears that when age, psychiatric well-being,
and self-assessment of health are controlled, a sex difference in
consumption remains" (Murray, et. al., 1981:558). Moreover, women of a
given age and health status are more likely to be drug consumers than men
of the same age and health status, so that the explanation of the sex
difference must be sought in areas other than illness. This could mean many
things, such as the culturally accepted activity of women taking pills to make
them feel better. Cooperstock advanced a model based on social
expectations of doctor and patient, but she concluded that more research
was needed to make any determinations on the issue.
The following section provides information on pertinent laws impacting the
topic under review. Prescription drug abuse was recognized by the U.S.
Congress with the passage of the Harrison Narcotic Act of 1914. In 1970, it
passed the Comprehensive Drug Abuse Prevention and Control Act (CSA).
This Act controls the distribution of pharmaceuticals from the manufacturer all
the way down to a local pharmacy. At the time of the CSA's enactment, the
abuse of diverted drugs was rampant, it was estimated that nearly 50% of all
legally produced amphetamines and barbiturates were being diverted into
illegal traffic (Beary, et. al, 1996:33). Since the comprehensive Act was
passed, most states have their own laws dealing with diversion that are
oftentimes more strict.
The Controlled Substances Act of 1970 puts prescription drugs of abuse into
Schedules. Prescription drugs are classed according to potency, likeliness
for abuse and degree of regulation (Antonelli-Bacon, 1991:12). Schedule I
drugs include heroin, marijuana and the hallucinogens and are prohibited.
They may only be produced for investigational use, as in the case of
tetrahydrocannabinol (THC) for the treatment of nausea in cancer patients
and for glaucoma. Schedule II drugs have been tightly controlled through
manufacturing quotas set by DEA, based on medical need, current
inventories, and potential for diversion (Keown, et. al., 1981:16).
Schedule lls include narcotics, and must have a written copy every time the
prescription is filled (no refills). Schedule lls include Percodan, Percocet,
Tylox, Dilaudid, and Ritalin. Schedule Ills include Tussionex, Hydrocodone,
and Codeine/Tylenol combinations. Schedule IV's include Xanax, Valium,
Halcion and Darvon, and Schedule Vs include cough medications. At the
other end of the scale, Schedule Vis include antibiotics and contraceptives,
and are the least likely to be abused, and therefore most easily obtained,
with unlimited refills for up to two years(Antonelli-Bacon, 1991:12).
Federal statutes apply to medical practitioners when they prescribe controlled
substances. Medical practitioners get licensed in the States in which they
practice, and must be registered with the DEA in order to prescribe drugs.
According to Title 21, Code of Federal Regulations, Section 1306.04 of the
CSA, practitioners must issue prescriptions in the usual course of a
professional practice", after good-faith medical exams" are performed, and
these prescriptions must be issued for a legitimate medical purpose"
(Keown, et. al., 1981:16; Lane, 1991:10; Weikel, 1996:A24). The Health Care
Financing Administration utilizes computerized billing systems to review drug
use nationally (Wick, 1995:36). Nationally, 11 states are trying to halt fake
prescriptions by using a computerized registry of prescriptions for addictive
drugs. It makes it easier for investigators to spot unexpected surges in
prescriptions from individual doctors or pharmacies" (Hall, 1996:B4). Before
the wide use of computers, it was tough to track prescription drug diversion
(Antonelli-Bacon, 1991:10). Both pharmacists and physicians are liable if they
continue to prescribe and dispense drugs when they are no longer needed,
or if an assessment is not made that treatments other than with prescribed
drugs could be used. It is difficult to question prescribing and dispensing
practices, though. Most statutes do not specify what types and quantities of a
drug that a doctor can prescribe (Beary, et. al, 1996:34). It is critical that a
doctor/patient relationship is created (Weikel, 1996:A24; Lane, 1991:11).
Pharmacists are required to account for every dose of controlled substances
ordered on a prescription. If the pharmacist doubts the genuine nature of a
prescription, he or she cannot dispense it. It is a felony to intentionally
dispense a forged prescription, and pharmacists can lose their licenses if they
do so. It is assumed that professional judgment will always be used (Keown,
et. al., 1981:16). Laws now require the automatic suspensions of medical,
dental and pharmacy licenses for someone convicted of a felony" (Weikel,
Throughout the discussion on prescription drug abuse and fraud in the
literature, multiple-copy or triplicate prescriptions was discussed. In January,
1989, New York was the first state to put this into law, to curb the abuse of
benzodiazepines. The Department of Health predicted that this rule would
regulate abuse without negatively impacting those with a legitimate need for
the drugs. This law spawned a hot debate over government involvement in
the sphere of medical practice. It was claimed that regulatory agencies may
deprive patients of appropriate, legitimate and helpful treatments" (Schwartz
and Blank, 1991:219). Multiple-copy prescription programs are currently in
play in nine states. Special prescription forms supplied by the state are used
by doctors. The physician keeps one copy, the pharmacy another, with the
pharmacy sending the third copy to the state agency. The state can use its
computerized prescription records to detect substance abusers, drug
diverting pharmacies and questionable prescribing practices. This
information may be used in regulatory actions and prosecutions" (p. 219).
The reaction to all of this legislation within the medical arena, is that doctors
are underprescribing medications that are vital for treatment, or prescribing
stronger drugs in lieu of drugs that are monitored by the state. It is claimed
that it is the patients who ultimately suffer, not the small fraction of drug
abusers to whom these laws are aimed (Antonelli-Bacon, 1991:10, Schwartz
and Blank, 1991:223). Ulterior motives such as saving money on prescription
claims for Medicaid has been put forward (Schwartz and Blank, 1991:223), as
has the claim that triplicate prescription programs may be a spurious battle in
the war on drugs (p. 223). Some see the diversion scare as hysteria.
Simply put, doctors are afraid of Big Brother (Hall, 1996:B4).
Similar to the triplicate program, another system found in Oklahoma is
OSTAR (Oklahomas Schedule Two Abuse Reduction System). This
program requires practitioners to record the patients drivers license number,
the National Drug Code identification number, date of fill, number of pills,
strength, and the pharmacy and prescriber identification number. This
information is sent bi-monthly to a central repository that generates monthly
reports for the Oklahoma State Bureau of Narcotics and Dangerous Drugs
Control (Antonelli-Bacon, 1991:15).
Anecdotally, in the case of Illinois vs. Jordan, decided Feb. 4, 1993, an
individual was arrested in possession of 1,500 blank, preprinted prescription
forms along with other drugs and paraphernalia. Illinois charged Jordan with
possession of counterfeit prescription forms, because unauthorized
possession of the forms, counterfeit or not is illegal. What is of note in this
case was that the jury found the defendant guilty, but the decision was
overturned because an expert pharmacist was not present to testify for the
prosecution. No one was available to identify the blank forms as true
prescription forms. However, the person still went to jail for illegal possession
of drugs (Drug Topics, 1993:1). This may support the contention that
pharmacists should be available to testify at criminal hearings.
Denver police say they are having problems keeping up with an increasing
number of investigations into prescription drug fraud. Local police and
federal agents brought 80 prosecutions for prescription abuse in 1994, but
that number was limited by resources." According to Detective John Gray, a
Denver police officer assigned to work with the DEA, rarely a day goes by
that doesnt bring three or four new cases (Drug Enforcement Report,
Many of the Denver cases involve the painkiller Vicodin, a mix of
hydrocodone and acetaminophen, frequently prescribed for pain by
doctors and dentists. The frequency of Vicodin's use makes it easier
to abuse than more obscure drugs, and it can be phoned in. Other
frequently abused prescription drugs are the painkillers Percodan and
Dilaudid, the muscle relaxant Xanax, and the sedative, Valium,
according to Drug Enforcement Administration officials in Denver.
Detective Gray mentions that prescription drug addiction can arise from a
patient legally seeking relief from pain, but that drug addicts and dealers are
also involved, because the purity of pharmaceuticals cant be found in street
drugs. In the words of Detective Gray:
the abusers are more to be prosecuted than pitied. These offenders
are often perceived as poor unfortunate people who accidentally
become hooked. But the target population also includes dealers and
hard-core addicts who are just switching addictions. Theres a
misconception that this is a different class of drug user- a higher class
of people. Thats not usually the case. This is a felony, these people
are criminals. And were police, not social workers.
Moreover, police note, its the lying that makes the crime." Prosecutions
involving prescription abuse are for criminal fraud and deceit, which can carry
a four-year prison sentence in Colorado (Drug Enforcement Report, 1995.
Colorado Prescription Drug Abuse Task Force. In 1982, Colorado ranked
among the top 15 states in per capita consumption of nine commonly abused
prescription drugs, and these statistics were among the worst in the United
States. The Colorado Prescription Drug Abuse Task Force was organized in
1984 to prevent and eliminate prescription drug abuse in Colorado. This
non-profit corporation is a consortium of over 30 private and public agencies
including the Colorado Pharmacists Association, Colorado Medical Society,
Denver Medical Society, Colorado Department of Health, Colorado Nurses
Association, Colorado Veterinary Medical Association, Colorado Hospital
Association, U.S. Drug Enforcement Administration and the state regulatory
boards for professional practice. Director, Jody Gingery, MEd., R.N., is
responsible for Task Force operations and completion of the goals
established by the Board of Directors (1994, Colorado Guidelines of
Professional Practice for Controlled Substances. Pharmacists. Introduction,
and 1995, About the Colorado Prescription Drug Abuse Task Force,
The purpose of the Colorado Prescription Drug Abuse Task Force is to
prevent the diversion of abused prescription drugs from individual
practitioners, pharmacies, hospitals and clinics through the provision of
a statewide resource for problem identification and program
development. The philosophy of the Task Force is that existing federal,
state and local agencies, working cooperatively with professional
associations, have the ability to resolve the problem of prescription
drug abuse in Colorado through effective programs of prevention and
As indicated in the informational literature describing the Task Force, its goals
are to develop guidelines, implement educational programs, improve
communication between the public and private sectors concerned with drug
abuse, monitor prescription drug abuse in Colorado, and evaluate public
policy related to controlled substances (1994, Colorado Guidelines of
Professional Practice for Controlled Substances. Pharmacists. Introduction,
and 1995, About the Colorado Prescription Drug Abuse Task Force,
1992:19). Other accomplishments of the Task Force include published
compilations of drug scenarios and scams which are commonly used by
prescription drug abusers; prevention and intervention strategies including
the statewide PharmAlert Hotline; a newsletter; and a hotline for health care
providers, law enforcement and regulatory agencies providing answers to
questions pertaining to substance abuse problems. Additionally, the Task
Force provides a National Information Resource Directory (NIRD), to increase
awareness about national organizations which are concerned about
prescription drug abuse issues. It also offers awards to those who have made
outstanding contributions to prescription fraud prevention and intervention.
(1994, Colorado Guidelines of Professional Practice for Controlled
Substances. Pharmacists. Introduction, and 1995, About the Colorado
Prescription Drug Abuse Task Force, 1992:19).
The word, scam" is defined by Webster as to cheat or swindle, as in
a confidence game. The Scam of the Month project is an effort
instituted by the Missouri Task Force on Misuse, Abuse and Diversion
of Prescription Drugs, to alert physicians, dentists, veterinarians and
pharmacists to tactics being used to dupe health care professionals.
The Missouri Task Force has also published various scams and scenarios
intended to educate health care professionals. Some interesting Future
Shock Scans" are highlighted. These include the possibility of con artists
tampering with telephone lines and computer networks. It is questioned
whether or not it is possible to tinker with fraudulent entries linking a group of
pharmacies such that, "phantom patients, fake information, and false
prescriptions could be added to the data banks, for swindlers to improperly
acquire whatever drug desired (Minnesota Pharmacist, 1987:10).
The American Medical Associations PADS and PADS II programs were set
up to identify and classify sources of drug diversion, and set up intervention
strategies to deal with it (American Medical Association, 1988:3; Ohio State
Medical Journal, 1986:33). PADS stands for Prescription Abuse Data
Synthesis, and was developed in 1982 by a group of state experts and a
representative of the federal Drug Enforcement Administration. Its mission
is to develop prevention programs that support state conference, task forces,
and publications to increase awareness of the diversion problem and to
sponsor research" (Colorado Prescription Drug Abuse Task Force, 1992:20).
It has been adopted by 26 states and the District of Columbia. (American
Medical Association, 1988:5). The AMA has outlined 5 pressure points", that
will lead to continued problems with drug diversion now and in the future, and
refined PADS with PADS II to deal with them. They are:
1. Fear of Aids addicts are looking for ways to minimize their risk of
2. Reaction to mandatory drug testing the possession of a prescription drug
may exempt an employee from testing.
3. The growing sophistication of drug abusers pharmaceuticals are
predictable in terms of purity, potency, onset and duration.
4. Less severe penalties for diverting pharmaceutical agents than for
trafficking in illicit drugs in some states it is only a misdemeanor.
5. Possibility of reimbursement of drugs through state medical assistance
Elements of PADS II include: access to databases providing the ability to
conduct detailed profiles of practitioners targeted for investigation; information
on all drugs, scheduled and non-scheduled; information reported by product
name and dosage unit; on-line access to data such as drug distribution
during the first calendar quarter of a year; and low cost (American Medical
The goals of the PADS II process is to get the private sector to support the
work of law enforcement and regulatory agencies enhancing their ability to
limit drug diversion in health care (AMA, 1988:6). According to Dr. Robert
McAffee of the AMA, the street market will continue to place high value on
pharmaceutical products which have established widespread and legitimate
use in Americas health care system. Thus, we can be certain that the
problem of prescription drug abuse will not go away (Colorado Prescription
Drug Abuse Task Force, 1992:27).
As has been seen in the literature review, prescription fraud is accomplished
by everyday people in and out of health care. It is large scale, as in the case
of diversion, and small-scale, in the case of individual women forging
prescriptions because of drug dependence, insecurity and cultural values,
among other things. According to the Director of the National Association of
Drug Diversion Investigators, prescription drug abuse may foreshadow other
problems. All of what we call street drugs today heroin, cocaine, and PCP,
used to be prescription drugs. Perhaps todays prescription drugs will be the
street drugs of tomorrow (Hall, 1996:B4). The debate on how seriously to
take the problem of prescription fraud and abuse is lively, with some saying it
was worse in the 1970s and others saying that it is a serious and growing
problem. In the big picture, prevention of prescription fraud will benefit all
people who utilize the health care system. Hopefully, studies of this kind will
also raise awareness that dependence on prescription drugs, and illegal
means to obtain them has implications for the broader social landscape.
Table 3.1 Psychotropic Drugs and Their Effects.
Minor Tranauiiizers Major Tranauiiizers Anti'deoressants Amphetamines I Controlled Narcotics fODiates)
Reduce Modify Alleviate serious Stimulate Powerful
anxiety, react psychotic depression. Central analgesics
with and symptoms; Some may Nervous that relieve
boost effects reduce fear and interact System (CNS), pain,
of alcohol. hostility. They dangerously with create feelings produce
Abuse can may be alcohol. of confidence euphoria.
lead to dangerous in amphetamines. and prevent Abuse
dependence. combination sedatives. Side fatigue. High causes
Examples: with alcohol effects include doses can addiction.
Atarax, and other blurred vision cause Examples:
Equanil, sedatives, and and dizziness psychosis. Opium.
Librium, are rarely Abuse can morphine.
Mepretabs, abused due to produce codeine,
Miltown, unpleasant side psychic Demerol,
Valium. effects. dependence. Dilaudid,
Examples: and addiction. Percodan.
Frenquel, Benzedrine and
Table 3.2 Fraud and Deceit. Colorado Revised Statute 18-18-415.
1. (a) No person shall obtain a controlled substance or procure the
administration of a controlled substance by fraud, deceit,
misrepresentation, or subterfuge; or by the forgery or alteration
of a prescription or of any written order, or by the concealment
of a material fact; or by the use of a false name or the giving of
a false address.
(b) Information communicated to a practitioner in an effort to
procure a controlled substance other than for legitimate
treatment purposes or unlawfully to procure the administration
of any such controlled substance shall not be deemed a
(c) No person shall willfully make a false statement in any
prescription, order, report, or record required by this article.
(d) No person, for the purpose of obtaining a controlled substance,
shall falsely assume the title of, or represent himself to be, a
manufacturer, wholesaler, pharmacist, practitioner, or other
person authorized by law to obtain a controlled substance.
(e) No person shall make or utter any false or forged prescription
or false or forged written order.
(f) No person shall affix any false or forged label to a package or
receptacle containing a controlled substance.
2. Any person who violates any provision of this section commits:
(a) A class 5 felony and shall be punished as provided in Section
(b) A class 4 felony, if the violation is committed subsequent to a
prior conviction for a violation to which this subsection (2)
applies and shall be punished as provided in Section 18-1-105,
_______C.R.S. (Colorado Controlled Substances Act, 1981)._____________
Table 3.3 Fraud and Deceit Cases. 1995-1996. Denver, Colorado.
Number of Arrests Men Women Total
1995 24 29 53
1996 27 29 56
1997 1 6 7
(Lisa Wultich, Investigator. Drug Enforcement Agency).
Table 3.4 Average Age and Recidivism Rate. Arrests: 1995-1996
Recidivism Rate: 15.5% 21.5%
Average Age: 1995 1996 39.9 37.6 37.8 37.2
Prior Criminal History: 23.3% 20.7%
(Lisa Wultich, Investigator. Drug Enforcement Agency).
Table 3.5 Fraud and Deceit Cases Involving Health Care
3rofessionals. 1995-1996. Denver, Colorado.
Cases Involving Health Care Number
Employees of Above 14
*Drug of choice for Health Care
professionals is Demerol/Morphine.
Approximately 70% of the Fraud and Deceit cases also
have possession of controlled substances charges filed as
(Lisa Wultich, Investigator. Drug Enforcement Agency).
Table 3.6 Drug of Choice Among Health Care Professionals
involved in Fraud and Deceit. 1995-1996. Denver, Colorado.
Drug of Choice Percent
(Lisa Wultich, Investigator. Drug Enforcement Agency).
Table 3.7 DEA Statistics. 1995-1996. Denver, Colorado.
An average doctor shopper, one who does nothing but go from
physician to physician for the only purpose of obtaining
controlled substances, hits at least 7-10 doctors per week.
Drug scammers who cold call physicians, are able to obtain
drugs 80% of the time.
Low numbers of arrests and case filings due to:
1 investigator to work these cases
3-5 calls received by the DEA per day
Prescription drug fraud is one of Americas least understood
crimes. Prescription fraud cases usually lead the law
enforcement officer through a twisting maze of;
Stolen prescription pads
Variety of scams and scenarios.
(Lisa Wultich, Investigator. Drug Enforcement Agency).
Table 3.8 DEA Statistics. 1995-1996. Denver, Colorado.
l ji_i_ i- i,
Usually the officer has to follow up on;
Dozens of drug stores
Rphs are willing to cooperate but suspicious about the criminal justice system commitment to follow through
Working with many agencies
Hand writing experts
Other local departments
Attorney Generals Office
District Attorneys Office
Creates a huge paper trail
(Lisa Wultich, Investigator. Drug Enforcement Agency).
Table 3.9 Denver Police Department. Arrest Statistics.
Rx Drug of Choice Percent
(Lisa Wultich, Investigator. Drug Enforcement Agency).
Table 3.10 Examples of Health-Care Professional Pill Abuse.
Prescribes controlled drugs and picks up the drugs for delivery to the patient.
Purchases controlled drugs for office use with increasing frequency and quantity.
Purchases new types of drugs not typically used in the professionals specialty.
Purchases cocaine in a form other than a solution.
Prescribes for self, family members, or staff.
Calls in emergency prescriptions for patient and picks up drug for office administration to patient.
Frequents the office at odd hours.
Entertains friends at the office.
Sleeps in office at odd hours.
Makes frequent trips to bathroom with associated mood changes, slurring of speech, excitability.
Demonstrates mood changes with or without slurred speech, dilated pupils.
Work history shows chronic tardiness and sporadic absences, especially on Mondays and Fridays.
Is involved in excessive administration of narcotics.
Is associated with missing prescription blanks.
Is associated with incorrect narcotic counts.
(Colorado Prescription Drug Abuse Task Force, 1994).
Table 3.11 Common Diversionary Practices.
1. Alteration of an authentic prescription to increase the number
and/or strength (known as kiting"), or the addition of a second
2. Presentation of forged prescriptions using stolen, bogus (printed to
appear authentic), or photocopied prescription blanks._________________
3. Use of fictitious patient, prescriber, clinic and hospital names,
addresses, and telephone numbers.
4. A person other than the patient or authorized agent of the patient
picking up a filled prescription.__________________________________________
5. Presentation of a prescription written by an out-of town prescriber
making it difficult to verify.____________________________________
6. Presentation of prescriptions after office hours or during weekends
and holidays when verification is difficult._____________________________
7. Physician prescribing Schedule II drugs for self or family members.
8. Physician picking up filled controlled substance prescription for
delivery to a patient.
Frequent presentation of prescriptions for large amounts of the
same or similar drugs more often than necessary if the drug were
being taken according to directions.______________________________
10. Requests for refills more often than would be required if the
directions for use were being followed.___________________________
11. Presentation of prescriptions by the same person for several
different patients over a short period of time. Presentation of
several prescriptions from the same practitioner by different patients
over a short period of time.
12. A sudden and dramatic increase in the number of prescriptions from
a given physician or clinic indicating a recent theft of prescription
13. Excessive telephoned prescriptions for controlled substances.
Recontact the prescriber to verify the call. Look up the telephone
number in a directory. ___________________________________
14. Suspect prescriptions that are incongruent with the general pattern
of the prescriber or the specialty of the prescriber.____________________
15. Suspect the authenticity of prescriptions for controlled substances
when two or more prescriptions are presented at the same time by
the same prescriber for antagonistic drugs._____________________________J
(Colorado Prescription Drug Abuse Task Force, 1994:5-6).
Table 3.12 Guidelines to Pharmacists On How To Detect
1. Know the prescriber.
2. Know the prescribers signature.
3. Know the prescribers DEA number.
4. Know the patient or agent or require identification.
5. Check combinations of medications.
Verify the DEA number authenticity via the use of the following
Write down the DEA number. 1234563.
Add the first, third and fifth numbers together:
Add the second, fourth, and sixth numbers together, then
multiply that sum by two:
Add the sum of these two operations. The last digit of the
result will be the same as the last digit of the DEA number, if
the DEA number is valid:
7. Confirm suspicious prescriptions with prescriber using
telephone numbers from the directory, not from the
8. Check the date on the prescription order.
9. Report prescription pad theft to local pharmacies and the
state board of pharmacy.
(Colorado Prescription Drug Abuse Task Force, 1994:6).
Table 3.13 The Scamming Patient.
Must be seen right away.
Make late afternoon appointments.
Call or come in after regular hours.
Must have a specific narcotic right away.
Gives vague or evasive medical history.
Is reluctant to provide references.
Does not give a referring/primary M.D.
Is not a permanent resident of the area.
Refuses lab tests or specialty evaluation.
Complains that non-narcotic analgesics dont work or is allergic to them.
Reports characteristic types of pain: low back, root canal, migraine, abdominal.
States lost or stolen prescription needs replacing.
Reports increasing pain with little relief from prescribed amounts of medication.
Describes same pain in various parts of the body.
Demonstrates pain behavior by distorting the bodys natural movements.
Centers conversation on pain.
(Colorado Prescription Drug Abuse Task Force, 1994).
Table 3.14 Characteristics of Forged Prescriptions.
1. Prescription looks too good.________________________________
2. Quantities, directions or dosages differ from usual orders
3. Prescription has directions written in full or with
4. Prescription blank is photocopied._________________________
5. Prescription has different ink colors, different handwriting,
erasures, deletions or alterations in amounts and strengths.
6. Prescription contains orders for more than one controlled
7. The date prescribed is blank or is several days old________
. (Colorado Prescription Drug Abuse Task Force, 1994:7).
able 3.14 Recommendations to Assess Prescription Validity.
1. Is the prescribed drug a commonly abused substance?
2. Can the prescribed drug be used in conjunction with another
drug to produce an effect similar to that produced by a
commonly abused substance?_________________________________
3. Is the patient receiving unusual combinations of drugs or
antagonistic drugs in light of the patients condition?_____
4. Is the quantity of the prescribed drug unusually large for the
patients condition and/or inconsistent with the patients
previous dosage history?___________________________________
5. Is the patient presenting the prescription for a drug obviously
not appropriate for his/her condition?_____________________
6. Is the patient one of a significant number of patients who
appear simultaneously or within a short time, bearing similar
prescriptions for commonly abused substances from the
7. Is the prescription identical or similar to the prescriptions
consistently written by the same prescriber for the same
commonly abused substance?_________________________________
8. Does the prescription involve a geographical relationship of
the pharmacy, patient and prescriber which is unusual and
for which no plausible explanation can be obtained?________
9. Do people appear at the pharmacy bearing numerous
prescriptions in the names of other patients for commonly
(Colorado Prescription Drug Abuse Task Force, 1994:13).
Table 3.15 Guidelines to Pharmacists: How To Deter
| Keep prescription blanks in a safe place where they can't be | stolen easily. Minimize the number of Rx pads in use
Limit the number of pads in use at one time
Number prescription blanks so that missing blanks may be detected easily
Write Rxs for Schedule II drugs in ink or indelible pencil. They must be signed by a physician.
Write out the actual amount prescribed in addition to giving an Arabic number or roman numeral in order to discourage alterations in written prescriptions.
Avoid writing prescriptions for large quantities of controlled drug products unless it is absolutely determined that such quantities are necessary.
Be cautious when a patient tells you that she is being treated by an out of state doctor, consult the physician/hospital records if possible.
! Never sign prescription blanks in advance.
I Prescription blanks should only be used for writing prescriptions, not for notes or memos. A drug abuser could easily erase the message and use the blank to forge a prescription.
Maintain an accurate record of controlled drug products you have dispensed, as required by the Controlled Substances Act of 1970.
Assist the pharmacist when he/she calls you to verify information about a prescription that you may have written. |
(Keown, et. al., 1981, p. 18).
Table 3.16 Suggested Nationwide Implementation Plan:
Expand the Pharmacy Theft Program and pharmacy alert
systems to cover most communities in the country.________
Install a limited access telephone system for reporting and
retrieving information on prescription fraud.____________
Improve cooperation between the DEA and local law
Publish the names of drug-related, convicted offenders in a
national register and read news bulletins and journals.
Improve inventory control methods for scheduled drugs to
help detect drug abusers.________________________________
Recognize and reward those practitioners who perform
their duties efficiently and honestly and who assist in
curbing the prescribing and dispensing of fraudulent
Display the DEA warning on forged prescriptions._________
(Keown, et. al., 1981, p. 18).
Table 3.17 Methods Used by Pharmacists to Decline Filling
Controlled substances should be stocked by only a limited
number of pharmacies._____________________________________
Ask for identification.___________________________________
Inform the person that the medication is not in stock
(whether it is or isnt)._________________________________
Inform the person that the prescription will take time (an
hour or more) and contact the police to apprehend the
suspect when he or she returns.___________________________
Tell the person that you checked with the physician and
know that the prescription is a fake and warn the person of
I the legal penalties of this crime.__________________________
Call all pharmacies in the area and alert them to the
The research design used in this study employs a mailed self-administered
questionnaire using both open and closed-ended questions. Closed-ended
questions address background and general information, and open-ended
questions pertain to the specific case that subjects have been convicted of.
An inquiry into similarity and differences of responses of four surveys will be
undertaken to determine patterns across variables. These variables include
socioeconomic, demographic and background information, how prescriptions
were obtained and the use of over-the-counter drugs, prescription drug
abuse, offense profile, circumstances preceding offense, attitudes toward
crime and criminality, attitudes toward doctors and the medical profession,
and assessment of overall health and well-being. Requirements for
completion of questionnaire and a comments section are also included. My
intent is to glean from the self-reports from these women, the following
information; socioeconomic status (income and level of education), details
leading up to arrest, impact of legal consequences, sentencing, legal
representation (or lack thereof), and other pertinent details. The surveys are
examined to provide details into prescription forgery and fraud. Comparisons
and contrasts are highlighted and conclusions are drawn, leading to areas for
Please recall that l am interested in women who have committed CRS 18-18-
415, Fraud and Deceit to Obtain a Controlled Substance, a Class IV felony.
The total number of women arrested for fraud and deceit to obtain a
controlled substance in metropolitan Denver is approximately 64 since 1995.
(Source: Lisa Wultich, Drug Enforcement Administration. Statistics compiled
for the Colorado Prescription Drug Abuse Task Force). In order to discover
whether or not the names and addresses of such women could be obtained
via public record, I contacted the following agencies: The Colorado District
Attorneys Council, the Denver District Attorneys office, The City and County
of Denver District Court Clerks Office, The Denver Drug Court Coordinators
office, The Colorado Bureau of Investigations, The Denver Police
Department, Department of Records, Adams County District Court, Adams
County Police Department, Department of Records, Arapahoe County District
Court, Arapahoe County Police Department, Department of Records, and
finally, the Lakewood Police Department, Department of Records.
Only one agency had the ability to run a records search based only upon the
Colorado Revised Statute 18-18-415, and that was a metropolitan Police
Department, specifically, its Department of Records. The parameters that I
was interested in were names, date of arrest, case number, charge, and date
of birth. I requested that the records department search for the time interval
of 1993-1998, or a 5-year span. For $25.00, I was able to obtain a list of 27
names with the above pertinent details. The subject pool is derived from the
public record, and does not involve police officers or agents of law
enforcement. Having been provided with such a list, I then scanned the white
pages of many phone books published by US West, in order to obtain
addresses of the women on my list. I also called information, and spent a
number of hours trying to find out whether or not these women were still living
in the Denver Metropolitan Area. Out of the list of 27,1 was able to find 10
addresses and telephone numbers that were used, identifying those women
who have been arrested and convicted for prescription forgery/fraud in the
past five (5) years. The first mailing was in July 1998.1 did a second mailing
of the questionnaires in August, 1998. The response rate was 40%, as four
completed questionnaires were returned to me, and thus form the analysis
that is to follow.
Subjects are assured voluntary participation both in the Consent Form and in
the Cover Letter attached to the Questionnaire. For instance, a sentence
from the cover letter reads: Your participation is strictly voluntary, and you
will in no way be forced to participate against your will." A $50.00 incentive
was awarded to those subjects who completed and sent in their
The criteria for including subjects was that they had to be female, arrested for
prescription drug forgery and fraud within the last five (5) years, and still
residing in the Denver metropolitan area. This way, subjects would be able to
receive the questionnaire. The following considerations were put in place to
determine who sent in their questionnaire, and who should receive their
incentives: 1.) Respondent sends in completed questionnaire without any
identifying information on it, but also encloses a signed consent form, and
mails it to the Department of Sociology, to my attention; 2.) Dr. A. Leigh
Ingram, my Professor who has guided this work, receives the mail, opens it,
and separates the two documents, without looking at the questionnaire. 3.)
Leigh advises me of how many questionnaires have arrived, and sends out
the $50.00 money orders to the names on the consent forms. 4.) Leigh
immediately destroys the consent forms, and I never see the consent forms
that arrived with the questionnaires, to maintain confidentiality. The
questionnaires, having no identifying information on them, have been mixed
up and are ready to code for analysis.
The method for including subjects was via convenience sampling techniques.
This technique is also called haphazard, fortuitous", or accidental"
sampling (Singleton, Straits and Straits. 1993: 159). According to Singleton,
et. al., the researcher simply selects a requisite number of cases that are
conveniently available (p. 159). The women in my sample are not considered
to be a protected or vulnerable class of individuals. Individuals who may have
a felony on their record, are afforded no special protections. There is a
minuscule amount of risk involved in participating in the research, and the
subjects have the right to refuse participation if they so choose. Given the
exploratory nature of the research, it is critical that these subjects were
contacted and an attempt to have them complete the questionnaire
undertaken, in the hopes that their experiences would shed light on the
incidence of women who forge prescriptions, and who fraudulently acquire
Study location was, I assume, in the subjects home, or at a location most
comfortable to them. The principal activity involving subjects was completing
a self-administered questionnaire, and then mailing back to me at the
University, in a self-addressed stamped envelope. The frequency and
duration of each activity included completion of the questionnaire taking no
longer than 60 minutes. Folding it, enclosing it in the envelope, and dropping
it in the mail should have taken approximately 5 minutes. The method of data
collection, as previously stated, was via a questionnaire. The method of data
recording was via computer entry.
The procedures used to maintain confidentiality were carefully planned.
There are no questions pertaining to crimes that the individual has not
already been arrested and convicted of, addressing the issue of risk, by not
confessing to any crimes not already punished for. I have not included
questions regarding other crimes, and issues surrounding the illegal use of
drugs. Issues of guarantees of confidentiality, with respect to research
records being subpoenaed, and disclosure of criminality activity have been
accounted for in the questionnaire. For instance: a) respondents cannot be