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Title: PHARMACEUTICAL DRUG CRIMES A multi-faceted problem


1
PHARMACEUTICAL DRUG CRIMES
A multi-faceted problem
2
Scope of Prescription Drug Abuse
  • Almost all regions/states state that they
    currently have a prescription drug problem.
  • Iowa, Kansas, Nebraska, and South Dakota said
    that it is not currently a problem.


Source NMCI Regional Reports
3
Prescription drugs misuse A concerning trend
  • While most people take prescription medications
    responsibly for the reasons in which the
    medications were prescribed, there has been an
    increasing trend in non-medical use of
    pharmaceuticals.
  • Video and images of prescription drugs misuse and
    abuse are increasing as the media reporting on
    the popularizing of pharmaceuticals intensifies.

4
Prescription drug abuse is only 2nd to marijuana
Out of the 20 Most Abused Drugs Only 5 Are Illicit
5
Demographics of prescription drug misusers
  • Among adolescents and young adults, prescription
    drug abuse is highest nationally among young
    adults aged 18-25 years old.
  • The National Institute on Drug Abuses Monitoring
    the Future survey in 2005 found that 12 graders
    reported using OxyContin and Vicodin without a
    prescription. Vicodin is one of the most commonly
    abused illicit drug among adolescents and young
    adults.
  • This is a concern since youth who use other drugs
    are likely to abuse prescription medications.

(National Institute on Drug Abuse NIDA, 2005)
6
ARIZONA YOUTH SURVEYS8th 12 graders
  • 2006- 14 reported using pharmaceutical drugs for
    other than approved medical purposes.
  • 2008- 22.4reported using pharmaceutical drugs
    for other than approved medical purposes.

Source ACJC Arizona Youth Survey
7
How were Prescription drug obtained
  • In 2005, the most prevalent source from which
    recently used drugs were obtained among
    non-medical users of prescription-type drugs was
    "from a friend or relative for free.
  • Among persons aged 12 or older who used pain
    relievers non-medically in the past 12 months,
    59.8 reported that the source of the drug the
    most recent time they used was from a friend or
    relative for free.

(Substance Abuse and Mental Health Services
Administration SAMHSA, 2005)
8
Teen Attitude Study on Pharmaceutical Drugs
  • 62 said Rx drugs easy to get from parents
    medicine cabinet.
  • 52 said Rx drugs are everywhere
  • 51 said Rx drugs are not illegal
  • 50 said Rx drugs are easy to get through
    peoples scripts.
  • 43 said Rx drugs are cheap
  • 35 said Rx drugs are safer to use
  • 21 said parents dont care as much if they get
    caught

2005 Partnership Attitude and Tracking Study
(PATS)
9
Demographics of prescription drug misusers
  • Prescription drug abuse affects many Americans,
    but concerning trends of increased prescription
    drug abuse can be observed among
  • adolescents
  • older adults
  • women

(National Institute on Drug Abuse NIDA, 2005)
10
Mixing Pharmaceuticals
  • Pharming
  • Pills are obtained from various sources Parents
    / Grandparents / Friends / Leftover meds.
  • Usually swallowed with alcohol.
  • The possibility of a deadly drug interaction may
    occur.

11
Commonly used prescription drugs
  • Opioids are mostly used to treat pain.
  • Some examples of opioids are codeine, morphine,
    and opium.
  • Central nervous system (CNS) depressants are used
    to treat anxiety and sleep disorders.
  • Some examples of CNS depressants are
    flunitrazepam, barbiturates, and benzodiazepines.
  • Stimulants are prescribed to treat the sleep
    disorder narcolepsy and attention-deficit
    hyperactivity disorder (ADHD).
  • Some examples of stimulants are cocaine,
    methamphetamine, and amphetamines.

(National Institute on Drug Abuse NIDA, 2005)
12
Types of RX drugs
  • Narcotics Oxycontin / Vicodin / Percocet
  • Stimulants Ritalin / Dexedrine / Adderall

Depressants Xanax / Valium
www.drugs.com
13
(Substance Abuse and Mental Health Services
Administration SAMHSA, 2005)
14
Methadone
  • Developed by the Germans during WWII to
    substitute morphine. Methadone produces many of
    the same effects as morphine or heroin.
  • Methadone primary use is to treat withdrawal
    symptoms of Heroin addicts.
  • Methadone is an opioid and you will become
    addicted if stopped abruptly you will suffer
    withdrawal symptoms.
  • Taken orally or injected and the effects last up
    to 24 hours.
  • Methadone treatment is a long term or life time
    treatment.

15
Methadone
  • Low-cost pain reliever becoming more widespread.
  • A growing number of people are dying from
    methadone overdoses.
  • Commonly used as a treatment for addiction,
    especially to heroin.
  • Methadone is increasingly prescribed in pill form
    as a pain medication, leading to an increase in
    accidental overdoses.
  • Methadone remains in the body long after its
    painkilling effects wear off. As a result, even
    legal prescriptions can turn fatal when doses
    accumulate over time into overdoses.

16
Methadone Abuse
  • Methadone treatment is a strictly monitored
    program due to its high addiction abuse
    properties.
  • In some cases 50 mg taken in a single dose have
    been fatal in a non-tolerant person.
  • Methadone bloods levels continue to rise for 5
    days after starting Methadone.
  • Taken more than 120mg per day is considered very
    high even for long term addicts.

17
Fentanyl
  • A raspberry-flavored lollipop or patch that
    delivers a narcotic commonly considered to be
    80-100 times more powerful than morphine.
  • Given to Cancer patients for pain.
  • Street value for lollipops are 20 - 25.00 each.
  • Street value for patches are 10 100.00 each
    depending on strength of patch.

18
Oxycontin
  • Very beneficial for pain relief.
  • High potential for addiction / abuse.
  • High demand on the street.
  • Street names 20 / 40 / 80 / Hillbilly Heroin /
    Kicker / OCs

19
OxyContin
  • Controlled release formulation of Schedule II
    oxycodone
  • Similar to morphine in its effects abuse /
    dependence potential
  • Addiction, crime fatal overdoses reported as a
    result of OxyContin abuse
  • Controlled release method of delivery allows for
    longer duration of drug action
  • OxyContin contains larger doses of oxycodone
  • Abusers compromise the controlled release
    formulation by crushing tablets ingesting or
    injecting for a powerful morphine-like high

SOURCE 2004 Monitoring The Future Study /
Overview of Key Findings
Manufactured by Purdue Pharma
20
Non-Medical Use of OxyContin
Persons Reporting At Least One Non-Medical Use of
OxyContin During Their Lifetime (in thousands)
Source 2004 National Survey on Drug Use and
Health (NSDUH) - latest data available (formerly
the National Household Survey on Drug Abuse)
published September 2005 Dept of HHS / Substance
Abuse and Mental Health Services Administration
(SAMHSA)
21
Smoking Oxycodone
  • New trend that is quickly becoming the Hot
    Topic in media and law enforcement
  • Oxycodone tablets, typically 80 mg controlled
    release tablets are being smoked by young adults
  • There are songs about it, MTV has done a True
    Life episode about smoking oxycodone.

22
Things to look for
  • Aluminum foil
  • Lighter
  • Green marks on the shirt or socks from rubbing
    off the coating

23
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24
Smoking Oxycodone Progression
  • Taking/abusing pharmaceuticals
  • Progresses to snorting pharmaceuticals
  • Ultimately injecting or smoking pharmaceuticals
  • Oxycodone is the new drug of choice
  • When oxycodone gets too expensive (50-80/pill)
    the progression has been to go to heroin
    (50/gram)

25
Soma
  • Soma is used as a muscle relaxant
  • Incidents reported in the Phoenix metropolitan
    area involving high school students being
    suspended for using, selling, or buying Soma
  • One report indicated Soma was bought in Mexico
    and brought to the school where it was being sold
    for 5.00 per tablet

26
Effects of prescription drug abuse
  • While CNS depressants, opioids, and stimulants
    affect the body in various ways, their misuse and
    abuse can have long-lasting or deadly effects.
  • For example, opioids can produce drowsiness and
    nausea, and at large dosages, can depress or stop
    respiration.
  • As your body become use to the physiological
    affects of CNS depressants, individuals may need
    larger doses to produce the same effectsleading
    to physical dependence.

(National Institute on Drug Abuse NIDA, 2005)
27
Warning signs of potential prescription drug abuse
  • You take more pain medication than your doctor
    has prescribed.
  • You request prescriptions from multiple doctors.
  • You use alcohol or other medications to increase
    the effects of the pain medication.
  • You take pain medication to deal with other
    problems, such as anxiety or stress.
  • Your doctor, friends or loved ones express
    concern about your use of pain medication.

(The Mayo Clinic, 2006)
28
Average street prices for legitimately prescribed
controlled substances
OxyContin, 80mg -- 40 to 80 per
tablet OxyContin, 40mg -- 20 to 40 per
tablet ( on average - 1.00 per mg.) Percocet
-- 5 per tablet Vicodin ES -- 5 per tablet
Valium, 10mg -- 4 per tablet Lortab, 10mg --
5 to 6 per tablet Soma -- 2 to 5 per tablet
29
Pharmaceutical Diversion
The illegal acquisition of prescription drugs
for personal use or profit
30
Types of Diversion
  • Altered, forged,
  • Phone in prescriptions
  • Stolen Prescriptions
  • Computer generated prescriptions
  • Fraudulent security prescriptions
  • Provider diversion
  • Pharmacy diversion
  • Internet Pharmacies
  • Robbery

31
Most Common Diversion Methods
  • Most reports detail crime, burglary, worker
    theft, prescription fraud and doctor shopping
    associated with diversion.
  • An overwhelming majority also agree that the
    crime and groups associated with prescription
    diversion are generally unorganized and small
    groups.
  • There are a few references of groups taking van
    loads of homeless persons from clinic to clinic.

32
Most Commonly Diverted Drugs
  • Either all three or a combination of oxycodone,
    hydrocodone, or methadone is mentioned in every
    report.
  • Codeine is also frequently mentioned.

33
Fraud by MO
G
34
Written Prescriptions
  • Altered
  • Stolen
  • Copied
  • Forged

G
35
Altered Strength
36
2 Added to Refills
37
1 Altered to 4 Refills
38
Altered Quantity
39
Alprazolam Added
40
Computer Made Rx
41
Telephonic Prescriptions
  • Most common M.O.
  • Most difficult to identify suspect
  • Impersonates medical staff
  • Calls during off hours
  • Frequently patients or employees of victim doctor
  • Often overly friendly

G
42
Doctor Shoppers
  • How the law applies to them
  • Use of multiple doctors/pharmacies
  • Providing false information to the doctors
  • Dont tell Dr.s about other Dr.s they have seen

43
  • Physicians perceive the three main mechanisms of
    diversion to be
  • Patient doctor shopping (96 percent)
  • Patient deception or manipulation of doctors (88
    percent)
  • Forged or altered prescriptions (70 percent)

44
Modus Operandi Often Used by the Drug-Seeking
Patient
  • Feigns physical problems in an effort to obtain
    narcotic drugs
  • Example Fibromyalgia difficult to diagnose
  • Feigns psychological problems, such as anxiety,
    insomnia, fatigue or depression in an effort to
    obtain stimulants or depressants 
  • States that specific non-narcotic analgesics do
    not work or that he/she is allergic to them 

45
Modus Operandi Often Used by the Drug-Seeking
Patient
  • Contends to be a patient of a practitioner who is
    currently unavailable and/or will not give the
    name of a primary or reference physician 
  • States that a prescription has been lost or
    stolen and needs replacing   
  • Pressures the practitioner by eliciting sympathy,
    guilt, and/or by direct threats 

46
The Typical Investigation
  • Contacted by pharmacies, doctors, family, staff,
    etc.
  • A fax alert is sent out to determine the extent
    of the fraud
  • Conduct interviews with the involved parties
  • Make arrest if appropriate
  • Refer for prosecution

47
FAXNET 1
  • Organization that can report individuals who are
    doctor shopping and/or forging prescriptions to
    a number of participating pharmacies in their
    network.
  • www.faxnet1.org
  • peggy_at_faxnet1.org
  • 602-414-3648 (work)
  • 602-953-5921 (fax)

48
Administrative Referrals
  • Doctors State Medical Board, DEA
  • Nurses State Nursing Board
  • Veterinarians State Veterinary Board
  • Physician Assistants State Medical Board
  • Dentists State Dental Board
  • Pharmacists State Pharmacy Board
  • FAA-Licensed Pilots

G
49
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50
Typical Internet Pharmacy
51
Welcome Screen
52
Go to Checkout
53
Suspect pharmacies
Suspect pharmacies dispense prescription
medications - without requiring the consumer to
mail in a prescription - do not contact the
patients prescriber to obtain a valid verbal
prescription - solely based upon the consumer
completing an online questionnaire without the
consumer having a pre-existing relationship with
a prescriber and the benefit of an in-person
physical examination
54
Internet Cases
55
Customer
Pharmacy
Kingpin
Order
Distributor
Approval
Order
Consult
With Prescription
Doctor
Website/server
56
Valid patient-physician relationship
Includes, but not limited to - obtain a
reliable medical history and perform a physical
examination - have sufficient dialogue with the
patient regarding treatment options and the risks
and benefits of treatment - follow up with the
patient to assess the therapeutic outcome -
maintain a contemporaneous, readily available
medical record, and - include electronic
prescription information in patients medical
record
H-120.949 Guidance for Physicians on Internet
Prescribing - June 2003
57
ALARMING TREND
  • PHARMACY ROBBERIES

58
Pharmacy Thefts
Reported Number of Thefts Nationwide by
Pharmacies Armed Robberies and Night Break-Ins
Only January 1, 2006 December 31, 2007
NUMBER OF THEFTS
NUMBER OF THEFTS
2006
2007
Source Drug Thefts and Loss Date Prepared
03/10/2008
Drug Enforcement Administration, Office of
Enforcement Operations, Pharmaceutical
Investigations Section, Targeting and Analysis
Unit
59
Information Concerning OxyContin Robberies
  • To date approximately 70 robberies have occurred
    involving the theft of OxyContin in Maricopa
    county.
  • Approximately 5 of the pharmacies have been
    robbed twice (East valley).
  • The robberies started in Arizona in June 2005.
  • The robber spends about 25 minutes at a minimum
    in each store before approaching the pharmacy
    counter to commit the crime.
  • One robber asked for OxyContin and Promethazine
    with Codeine

60
The Arizona RepublicJan. 25, 2008 1054 AM A
fake bomb was used in a robbery at a Mesa
pharmacy on Thursday, the second time in less
than a month that the ruse was used to steal
prescription drugs, police said. A man walked
into Arizona Discount Pharmacy in the 1000 block
of North Mesa Drive around 215pm and demanded
pain pills.He placed a bag on the counter that he
claimed was a bomb and said he "would blow the
bomb if PD arrived within 3 minutes," police
said. After getting several bottles of
Oxycontin and Oxycodone, which are highly
addictive and often abused, the suspect fled on
foot. The bomb squad was called in and
determined that the bomb was a fake, police
said.In the Dec. 27 robbery, the suspect placed
a grocery bag that he said contained a bomb on
the counter and fled with multiple bottles of the
same pain pills. The bag contained only
magazines.
61
Pharmacy reports painkiller robbery The Arizona
RepublicFeb. 25, 2008 1122 AM Police are
looking for a man in connection with a
prescription drug robbery at a Mesa pharmacy
Friday night.The suspect approached the clerk
at the counter of the AZ Discount Pharmacy on the
1000 block of north Mesa Drive and demanded all
the Oxycontin and Percocet he had, police said.
The clerk told him he didn't have much but gave
him a few bottles, according to the police
report.The suspect left and headed in south,
authorities said. There is no description of the
vehicle..
62
The Arizona RepublicFeb. 27, 2008 0940 AM A
Surprise man has been arrested in the holdup of a
Walgreens pharmacy in which a bandit made off
with nearly 500 pills of OxyContin, a powerful
painkiller.Nathaniel Ray Shaw, 26, was taken
into custody Tuesday after officers received a
tip that he had been trying to use forged
prescriptions for OxyContin at local pharmacies,
police said.After reviewing surveillance
photos, detectives executed a search warrant at
Shaw's home in the 16000 block of West Yucatan
Drive, south of Cactus Road, said Sgt. Mark
Ortega, a Surprise police spokesman.
"Detectives recovered a large amount of the
prescription OxyContin, as well as clothing and a
firearm," Ortega said Tuesday.Shaw is accused
in a robbery that occurred about 10 p.m. Feb. 22
at the Walgreens, 11514 W. Waddell Road. Police
said that the bandit handed a pharmacist a note
demanding the painkiller.
63
2nd Mesa pharmacy robbed of pain pills The
Arizona RepublicFeb. 26, 2008 0348 PM A
Mesa pharmacy was robbed of an estimated 1,000
pain pills Monday morning in the second such
crime committed in Mesa in a four-day
period.Shortly before 9 a.m. on Monday a
suspect entered Community Pharmacy in the 700
block of West Southern Avenue and handed the
pharmacist a demand note for Oxycodone, police
said. Then the man removed a handgun from his
waistband, jumped the counter and followed the
pharmacist to the rear of the pharmacy. The
robbery followed a similar one on Friday night,
when a male suspect demanded pain pills from a
pharmacist at AZ Discount Pharmacy in the 1000
block of north Mesa Drive, according to police.
The suspect made off with "a few bottles," police
said..
64
PREVENTION
65
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68
Preventing prescription drug abuse/misuse
  • School-Based Prevention
  • Among school-age children and adolescents who may
    be at risk of non-medical use of pharmaceuticals,
    McCabe, Teter, Boyd (2004) suggest that
    physicians, parents, pharmacists, school nurses,
    social workers, counselors, and principals be
    educated about the prescription drug misuse.
  • Other school administrators such as school
    nurses, social workers, etc. can help monitor
    which students are prescribed medications and may
    be at risk for prescription drug diversion.

69
Preventing prescription drug abuse/misuse
  • Increasing the role of the physician
  • Prescription drug abuse prevention is a is an
    important part of patient care.
  • Nearly 70 percent of Americans (191 million
    people) - visit a health care provider, such as a
    primary care physician, at least once every 2
    years.
  • Accurate screening and increases in medication
    should be careful monitored by physicians as well
    as the patient receiving the medication.

(National Institute on Drug Abuse NIDA, 2001)
70
Preventing prescription drug abuse/misuse
  • Increasing the role of the patient
  • Patients can be challenged to provide a complete
    medical history and a description of the reason
    for the visit so that their physician be accurate
    in the assessment and treatment of any illness.
  • Patients should also try to thoroughly read and
    follow the directions for careful use of
    pharmaceuticals. Become familiar with any side
    effects of common to the use a particular
    prescription drug.
  • Also, ask your pharmacist or physician of any
    adverse potential interactions among the
    medications you take and as always, do not change
    or disrupt dosages unless discussed with your
    health care provider in advance.

(National Institute on Drug Abuse NIDA, 2001)
71
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72
Improper Disposal into Water System
73
A timely topic
Drugs Are in the Water. Does It Matter? New York
Times, April 3, 2007
74
Pharmaceuticals
  • Antibiotics
  • Anti-inflammatories
  • Beta-blockers
  • Anti-depressants (SSRIs)
  • Steroids
  • Hormones, estrogen replacements, BC pills
  • Chemotherapeutics
  • Stimulants
  • Etc.

75
Pharms enter the environment through use and
disposal
  • Probably most result from use, passing through us
    un-metabolized, then going through wastewater
    treatment systems
  • Unused/unwanted quantities could be huge, as much
    as 50 of many
  • prescriptions (80 for
  • antibiotics)
  • Common/historical
  • recommendation was to
  • flush

76
Pharms are present in wastewater treatment systems
  • EPA, USGS and other studies are finding
    pharmaceuticals in all systems sampled
  • 5-POTW study in NE found 38 pharms naproxen,
    ibuprofen, acetaminophen,
  • 10-POTW study in U.S.
  • found 78 of 110, found
  • pharms in effluents and
  • downstream

77
We need to be proactive in the face of uncertainty
  • It will be years before the pharmaceutical EDC
    and other effects are clearly known
  • Precautionary approach should apply
  • Capture unused meds to minimize dumping into
    wastewater systems
  • Promote source control
  • while working with others
  • to better understand the
  • long-term impacts.
  • Product stewardship solution

78
Office of National Drug Control Policy
  • In February 2007, the White House Office of
    National Drug Control Policy issued the first
    consumer guidance for the Proper Disposal of
    Prescription Drugs. Proper disposal of drugs is a
    straightforward way for individuals to prevent
    pollution.

http//www.whitehousedrugpolicy.gov/drugfact/facts
ht/proper_disposal.html
79
Federal Guidelines
  • The new Federal prescription drug disposal
    guidelines urge Americans to
  • Return unused, unneeded, or expired prescription
    drugs to pharmaceutical take-back locations.
  • If no take-back programs are available
  • Take unused, unneeded, or expired prescription
    drugs out of their original containers
  • Mix the prescription drugs with an undesirable
    substance, like used coffee grounds or kitty
    litter, and put them in impermeable, non-descript
    containers, such as empty cans or sealable bags,
    further ensuring that the drugs are not diverted
    or accidentally ingested by children or pets
  • Throw these containers in the trash
  • Flush prescription drugs down the toilet only if
    the accompanying patient information specifically
    instructs it is safe to do so

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82
BUY BACK/TAKE PACK PROGRAMS
  • IMPLEMENTING A PROGRAM FOR EXPIRED AND UNUSED
    PRESCRIPTION DRUGS

83
Goal
  • Remove unneeded prescription drugs from
    circulation
  • Disposal in compliance with applicable state and
    federal laws and sound environmental practices

84
DEA
  • The DEA is aware of pharmacy take-back programs.
  • The DEA acknowledges that regulations authorize
    law enforcement officials to handle controlled
    substances.
  • However, many law enforcement organizations do
    not want this responsibility or expense.
  • To correct this, the DEA is drafting regulations
    to permit ultimate users to surrender their
    controlled substances for destruction via other
    methods.

http//www.productstewardship.us/associations/6596
/files/DEA_Take-Back_Letter.pdf
85
Drug Inventory Disposal
  • Compliance with Drug Enforcement Administration,
    Department of Environmental Protection and local
    law enforcement.
  • 2 law enforcement officers (double verification)
  • Secure consolidation facility.
  • Repeat count of number of pills
  • Proper disposal of all drugs collected

86
Drug Collection Benefits
  • Prevent environmental exposure
  • -aquatic ecosystem
  • Minimize accidental overdoses and poisonings
  • people, pets and wildlife
  • Limit pharming and drug-related theft
  • Provide alternative to drug stockpiling

87
Pharmaceutical Enforcement Strategy
Yesterday-Today -Tomorrow
  • Yesterday-Uncoordinated or minimal response by
    individual agencies to a growing pharmaceutical
    diversion problem.
  • Today-Pharmaceutical Crimes Working Group to
    promote and develop multi-agency cooperation,
    intelligence and resources sharing that can aid
    in the investigation of pharmaceutical crimes.
  • Tomorrow-Efficient multi-level proactive
    Pharmaceutical Tactical Diversion Task Force
    sufficient in size and participation to impact
    the problem.

88
PHARM CRIMES WORKING GROUP
  • Phoenix PD DEB
  • MCSO
  • DEA Diversion
  • AZ Pharmacy Board
  • Scottsdale PD
  • Tempe PD
  • Veterinarian Board
  • CVS Pharmacy Manager
  • CVS Loss Prevention Manager
  • AZ DPS
  • Dental Board
  • AZ Attorney General
  • Maricopa County Attorney
  • US Postal Services
  • Medical Board
  • HIDTA SW Regional Initiative
  • AZ Drug Intelligence Task Force
  • AZ Homeopathic Board

89
MODEL COMMUNITY PROGRAM
  • Change the policies and perceptions surrounding
    over-the-counter and prescription drug abuse.
  • 2. Create and distribute awareness materials and
    provide trainings to targeted regions.
  • 3. Implement policy change requiring proper home
    locking procedures and disposal guidelines to
    communities and supporting retailers.
  • Effect change with related product manufacturers,
    distributors, and the home building industry with
    regard to medicine cabinet locking mechanisms.
  • Solicit pharmaceutical stores to implement policy
    change requiring these locations to house un-used
    pharmaceuticals drop-off boxes, and publicly
    recognize participating retailers.
  • Develop alternative option strategy for home
    pick-up of unused pharmaceuticals for the elderly
    and other special situations.
  • 7. Support the hosting of prescription and
    over-the-counter forums in targeted communities.

90
HIDTAs Southwest Methamphetamine
Pharmaceuticals Initiative (SWMPI) Rich Rosky
Coordinator southwest_meth_at_yahoo.com (602)
664-5623
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