Prescription Drugs: State Monitoring Programs May Help to Reduce 
Illegal Diversion (04-MAR-04, GAO-04-524T).			 
                                                                 
The increasing diversion of prescription drugs for illegal	 
purposes or abuse is a disturbing trend in the nation's battle	 
against drug abuse. Diversion can include such activities as	 
prescription forgery and "doctor shopping" by individuals who	 
visit numerous physicians to obtain multiple prescriptions. The  
most frequently diverted prescription drugs are controlled	 
substances that are prone to abuse, addiction, and dependence,	 
such as hydrocodone (the active ingredient in Lortab and many	 
other drugs) and oxycodone (the active ingredient in OxyContin	 
and many other drugs). Some states use prescription drug	 
monitoring programs to control illegal diversion of prescription 
drugs that are controlled substances. GAO was asked to examine	 
(1) how state monitoring programs compare in terms of their	 
objectives and operation and (2) the impact of state monitoring  
programs on illegal diversion of prescription drugs. This	 
testimony is based on GAO's report, Prescription Drugs: State	 
Monitoring Programs Provide Useful Tool to Reduce Diversion,	 
GAO-02-634 (May 17, 2002). In that report, the programs in	 
Kentucky, Utah, and Nevada were selected for more in-depth study 
because they were the most recently established programs at the  
time.								 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-524T					        
    ACCNO:   A09430						        
  TITLE:     Prescription Drugs: State Monitoring Programs May Help to
Reduce Illegal Diversion					 
     DATE:   03/04/2004 
  SUBJECT:   Controlled substances				 
	     Drug abuse 					 
	     Drugs						 
	     Monitoring 					 
	     Pharmaceutical industry				 
	     State programs					 
	     Law enforcement					 

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GAO-04-524T

United States General Accounting Office

GAO Testimony

Before the Subcommittee on Health, Committee on Energy and Commerce, House
of Representatives

For Release on Delivery

Expected at 1:00 p.m. EST PRESCRIPTION DRUGS

Thursday, March 4, 2004

         State Monitoring Programs May Help to Reduce Illegal Diversion

Statement of Marcia Crosse Director, Health Care-Public Health and Military
Health Care Issues

GAO-04-524T

Highlights of GAO-04-524T, a testimony before the Subcommittee on Health,
Committee on Energy and Commerce, House of Representatives

The increasing diversion of prescription drugs for illegal purposes or
abuse is a disturbing trend in the nation's battle against drug abuse.
Diversion can include such activities as prescription forgery and "doctor
shopping" by individuals who visit numerous physicians to obtain multiple
prescriptions. The most frequently diverted prescription drugs are
controlled substances that are prone to abuse, addiction, and dependence,
such as hydrocodone (the active ingredient in Lortab and many other drugs)
and oxycodone (the active ingredient in OxyContin and many other drugs).

Some states use prescription drug monitoring programs to control illegal
diversion of prescription drugs that are controlled substances.

GAO was asked to examine (1) how state monitoring programs compare in
terms of their objectives and operation and (2) the impact of state
monitoring programs on illegal diversion of prescription drugs.

This testimony is based on GAO's report, Prescription Drugs: State
Monitoring Programs Provide Useful Tool to Reduce Diversion,

GAO-02-634 (May 17, 2002). In that report, the programs in Kentucky, Utah,
and Nevada were selected for more in-depth study because they were the
most recently established programs at the time.

March 4, 2004

PRESCRIPTION DRUGS

State Monitoring Programs May Help to Reduce Illegal Diversion

GAO found that the 15 state monitoring programs in place in 2002 differed
in their objectives and operation. The programs were intended to
facilitate the collection, analysis, and reporting of information about
the prescribing, dispensing, and use of controlled substances. They
provided data and analysis to state law enforcement and regulatory
agencies to assist in identifying and investigating activities potentially
related to illegal drug diversion. The programs could be used by
physicians to check a patient's prescription drug history to determine if
the individual was doctor shopping to seek multiple controlled substances.
Some programs also offered educational programs for the public,
physicians, and pharmacists regarding the nature and extent of the problem
and medical treatment options for abusers of diverted drugs. The programs
varied primarily in terms of the specific drugs they covered and the type
of state agency in which they were housed. Some programs covered only
those prescription drugs that are most prone to abuse and addiction,
whereas others provided more extensive coverage. In addition, most
programs were administered by a state law enforcement agency, a state
department of health, or a state board of pharmacy.

GAO also found that state monitoring programs may have realized benefits
in their efforts to reduce drug diversion. These included improving the
timeliness of law enforcement and regulatory investigations. Each of the
three states studied reduced its investigation time by at least 80
percent. In addition, law enforcement officials told GAO that they view
the programs as a deterrent to doctor shopping, because potential
diverters are aware that any physician from whom they seek a prescription
may first examine their prescription drug utilization histories based on
monitoring program data. For example, as drug diverters became aware of
Kentucky's ability to trace their drug histories, they tended to move
their diversion activities to nearby nonmonitored states.

www.gao.gov/cgi-bin/getrpt?GAO-04-524T.

To view the full product, including the scope and methodology, click on
the link above. For more information, contact Marcia Crosse at (202)
512-7119.

Mr. Chairman and Members of the Subcommittee:

I am pleased to be here today and thank you for the opportunity to discuss
our work on state prescription drug monitoring programs and their use in
addressing the diversion of prescription drugs for illegal use.

The increasing diversion of prescription drugs for illegal purposes or
abuse is a disturbing trend in the nation's battle against drug abuse.1
Diversion activities can include "doctor shopping" by individuals who
visit numerous physicians to obtain multiple prescriptions, illegal sales
of prescription drugs by physicians or pharmacists, prescription forgery,
and purchasing drugs from Internet pharmacies without valid prescriptions.
The most frequently diverted prescription drugs are controlled substances2
that are prone to abuse, addiction, and dependence,3 such as hydrocodone
(the active ingredient in Lortab and many other drugs), diazepam (Valium),
methylphenidate (Ritalin), and oxycodone (the active ingredient in
OxyContin and many other drugs). According to the Drug Enforcement
Administration (DEA), increases in the extent of prescription drug abuse
and in emergency room visits related to prescription drug abuse, as well
as an increase in the theft and illegal resale of prescription drugs,
indicate that drug diversion is a growing problem nationwide.

Some states operate prescription drug monitoring programs as a means to
control the illegal diversion of prescription drugs. My remarks today will
focus on (1) how state monitoring programs compare in terms of their
objectives and operation and (2) the overall impact of state monitoring
programs on illegal diversion of prescription drugs. My comments are based
on our May 2002 report on state monitoring programs and their

1Office of Drug Control Policy, "U.S. Drug Prevention, Treatment,
Enforcement Agencies Take on `Doctor Shoppers', `Pill Mills'," Mar. 1,
2004, www.whitehousedrugpolicy.gov (downloaded Mar. 2, 2004).

2Under the Controlled Substances Act, which was enacted in 1970, drugs are
classified as controlled substances and placed into one of five schedules
based on their medicinal value, potential for abuse, and safety or
dependence liability.

3According to the National Institute on Drug Abuse, addiction is a
chronic, relapsing disease, characterized by compulsive drug seeking and
use and by neurochemical and molecular changes in the brain, whereas
physical dependence is an adaptive physiological state that can occur with
regular drug use and results in withdrawal symptoms when drug use is
discontinued.

usefulness as a tool for reducing diversion.4 For that report we reviewed
information from DEA and the National Alliance for Model State Drug Laws
on the features of existing programs. To gain a more in-depth
understanding of these programs and the challenges they face, we also
studied the programs in Kentucky, Nevada, and Utah. We selected these
three states because at the time they had the most recently established
programs.

In brief, we found that 15 states operated monitoring programs in 2002 as
a means to control the illegal diversion of prescription drugs that are
controlled substances.5 Although these programs were all intended to
facilitate the collection, analysis, and reporting of information about
the prescribing, dispensing, and use of controlled substances, they
differed in their objectives and operation. They all provided data and
analysis to state law enforcement and regulatory agencies in order to
assist in identifying and investigating activities potentially related to
the illegal prescribing, dispensing, and procuring of controlled
substances. Further, some programs could be used by physicians to check a
patient's prescription drug history to determine if the individual may
have been doctor shopping to seek multiple controlled substances. Some
programs also offered educational programs for the public, physicians, and
pharmacists regarding the nature and extent of the problem and medical
treatment options for abusers of diverted drugs. The operation of the
monitoring programs varied primarily in terms of the specific drugs they
covered and the type of state agency in which they were housed. Some
programs covered only those prescription drugs that are most prone to
abuse and addiction, whereas others provided more extensive coverage. In
addition, most programs were administered by a state law enforcement
agency, a state department of health, or a state board of pharmacy.

We found that state monitoring programs realized benefits in their efforts
to reduce drug diversion. These included improving the timeliness of law
enforcement and regulatory investigations. Each of the three states we

4For more details on these programs, see U.S. General Accounting Office,
Prescription Drugs: State Monitoring Programs Provide Useful Tool to
Reduce Diversion, GAO-02-634 (Washington, D.C.: May 17, 2002).

5The 15 states were California, Hawaii, Idaho, Illinois, Indiana,
Kentucky, Massachusetts, Michigan, Nevada, New York, Oklahoma, Rhode
Island, Texas, Utah, and Washington. In 1998, West Virginia terminated its
monitoring program, but began operating a program again in 2003, bringing
the total of state programs to 16. In addition, Virginia began operating a
pilot program in the southwestern part of the state in fall 2003.

studied reduced its investigation time by at least 80 percent. In
addition, law enforcement officials told us that they view the programs as
a deterrent to doctor shopping, because potential diverters are aware that
any physician from whom they seek a prescription may first examine their
prescription drug utilization histories based on monitoring program data.
For example, as drug diverters became aware of Kentucky's ability to trace
their drug histories, they tended to move their diversion activities to
nearby nonmonitored states.

Background 	The diversion and abuse of prescription drugs are associated
with incalculable costs to society in terms of addiction, overdose, death,
and related criminal activities. DEA has stated that the diversion and
abuse of legitimately produced controlled pharmaceuticals constitute a
multibillion-dollar illicit market nationwide. One recent example of this
growing diversion problem concerns the controlled substance oxycodone, the
active ingredient in over 20 prescription drugs, including OxyContin,
Percocet, and Percodan. OxyContin is the number one prescribed narcotic
medication for treating moderate-to-severe pain in the United States.6
Currently, a single 20-milligram OxyContin tablet legally selling for
about $2 can be sold for as much as $25 on the illicit market in some
parts of Kentucky.

Combating the illegal diversion of prescription drugs while ensuring that
the pharmaceuticals remain available for those with legitimate medical
need involves the efforts of both federal and state government agencies.
The Controlled Substances Act of 19707 provides the legal framework for
the federal government's oversight of transactions involving the sale and
distribution of controlled substances at the manufacturer and wholesale
distributor levels. The states address these issues through their
regulation of the practice of medicine and pharmacy.

6U.S. General Accounting Office, Prescription Drugs: OxyContin Abuse and
Diversion and Efforts to Address the Problem, GAO-04-110 (Washington,
D.C.: Dec. 23, 2003).

7Title II of the Comprehensive Drug Abuse Prevention and Control Act of
1970 (Pub. L. No. 91-513, S:S:100 et seq., 84 Stat. 1236, 1242 et seq.).

Controlled Substances Act

The Controlled Substances Act established a classification structure for
drugs and chemicals used in the manufacture of drugs that are designated
as controlled substances.8 Controlled substances are classified by DEA
into five schedules on the basis of their medicinal value, potential for
abuse, and safety or dependence liability. Schedule I drugs-including
heroin, marijuana, and hallucinogens such as LSD and PCP-have a high
potential for abuse and no currently accepted medical use. Schedule II
drugs-including methylphenidate (Ritalin) and opiates such as hydrocodone,
morphine, and oxycodone-have a high potential for abuse among drugs with
an accepted medical use and may lead to severe psychological and physical
dependence. Drugs on schedules III through V have accepted medical uses
and successively lower potentials for abuse and dependence. Schedule III
drugs include anabolic steroids, codeine, hydrocodone in combination with
aspirin or acetaminophen, and some barbiturates. Schedule IV contains such
drugs as the antianxiety medications diazepam (Valium) and alprazolam
(Xanax). Schedule V includes preparations such as cough syrups with
codeine. All scheduled drugs except those in schedule I are legally
available to the public with a prescription.9

Under the act, DEA provides legitimate handlers of controlled
substances-including manufacturers, distributors, hospitals, pharmacies,
practitioners, and researchers-with registration numbers, which are used
in all transactions involving controlled substances. Registrants must
comply with a series of regulatory requirements relating to drug security
and accountability through the maintenance of inventories and records.
Although all registrants, including pharmacies, are required to maintain
records of controlled substance transactions, only manufacturers and
distributors are required to report their transactions involving schedule
II drugs and schedule III narcotics, including sales to the retail level,
to DEA. The data provided to DEA are available for use in monitoring the
distribution of controlled substances throughout the United States, in
identifying retail-level registrants that received unusual quantities of
controlled substances, and in investigations of illegal diversions at the
manufacturer and wholesaler levels. Although data are reported to DEA
regarding purchases by pharmacies, the act does not require the reporting
of dispensing information by pharmacies at the patient level to DEA.

8Section 201, classified to 21 U.S.C. S: 811.

9Some schedule V drugs that contain limited quantities of certain narcotic
and stimulant drugs are available over the counter without a prescription.

State Regulation of the Practice of Medicine and Pharmacy

  State Monitoring Programs Varied in Objectives and Operation

State laws govern the prescribing and dispensing of prescription drugs by
licensed health care professionals. State medical practice laws generally
delegate the responsibility of regulating physicians to state medical
boards, which license physicians and grant them prescribing privileges.10
In addition, state medical boards investigate complaints and impose
sanctions for violations of the state medical practice laws. States
regulate the practice of pharmacy based on state pharmacy practice acts
and regulations enforced by the state boards of pharmacy. The state boards
of pharmacy are also responsible for ensuring that pharmacists and
pharmacies comply with applicable state and federal laws and for
investigating and disciplining those that fail to comply. According to the
National Association of Boards of Pharmacy, all state pharmacy laws
require that records of prescription drugs dispensed to patients be
maintained and that state pharmacy boards have access to the prescription
records.

State prescription drug monitoring programs varied in their objectives and
operation. While all programs were intended to help law enforcement
identify and prevent prescription drug diversion, some programs also
included education objectives to provide information to physicians,
pharmacies, and the public. Program operation also varied across states,
in terms of which drugs were covered and how prescription information was
collected. Which agency, such as a pharmacy board or public health
department, was given responsibility for the program also varied across
states. Additionally, methods for analyzing the data to detect potential
diversion activity differed among state programs.

State monitoring programs are intended to facilitate the collection,
analysis, and reporting of information on the prescribing, dispensing, and
use of prescription drugs within a state. The first state monitoring
program was established in California in 1940, and the number of programs
has grown slowly. We reported that the number of states with programs has
grown from 10 in 1992 to 15 in 2002; the number of programs stands at 16
in 2004.

10The types of practitioners who prescribe drugs and may be monitored by a
state program vary among states. Physicians are the majority of covered
practitioners, but in most states many nonphysicians who also have
prescribing authority may be covered, including physician assistants,
dentists, optometrists, podiatrists, veterinarians, and certain types of
nurses, such as nurse practitioners and advanced practice nurses.

We found that state programs varied in their objectives. All states used
monitoring programs primarily to assist law enforcement in detecting and
preventing drug diversion, and but some also used the programs for
educational purposes. Programs assisted law enforcement authorities both
by providing information in response to requests for assistance on
specific investigations and by referring matters to law enforcement
officials when evaluations of program data revealed atypical prescribing
or dispensing patterns that suggested possible illegal diversion. The
programs evaluated prescribing patterns to identify medical providers who
may have been overprescribing and inform them that their patterns were
unusual. They also identified patients who may have been abusing or
diverting prescription drugs and provided this information to
practitioners. For example, the programs in Nevada and Utah sent letters
to physicians containing patient information that could signal potential
diversion activity, including the number and types of drugs prescribed to
the patient during a given time period and the pharmacies that dispensed
the drugs. Monitoring programs have also been used to educate physicians,
pharmacies, and the public about the existence and extent of diversion,
diversion scams, the drugs most likely to be diverted by individuals, and
ways to prevent drug diversion.

Monitoring programs also differed in operational factors, some of which
have cost implications. These factors included the choice of controlled
substance schedules monitored, approaches to analyzing and using data,
computer programming choices, number and type of staff and contractors,
turnaround times and report transmittal methods, and number and type of
requests for information.

State programs varied in the controlled substances they covered, in part
because of differences in available resources and other state-specific
factors such as level of drug abuse. Two of the states we studied-
Kentucky and Utah-covered schedules II through V. These states' program
officials told us that covering those schedules allowed them flexibility
to respond if drugs on other schedules became targets for diversion. Most
experts agree that covering all controlled substance schedules prevents
drug diverters from avoiding detection by bypassing schedule II drugs and
switching to drugs in other schedules.

States used different approaches to analyze the prescription information
they received. A few states used a proactive approach, routinely analyzing
prescription data collected by the programs to identify individuals,
physicians, or pharmacies that had unusual use, prescribing, or dispensing
patterns that could suggest potential drug diversion, abuse, or doctor

shopping. Trend analyses were shared with appropriate entities, such as
law enforcement, practitioners, and regulatory and licensing boards. In
contrast, most state programs generally used the prescription data in a
reactive manner to respond to requests for information. These requests may
have come from physicians or from law enforcement or state officials based
on leads about potential instances of diversion. According to state
program officials, most programs operated in a reactive fashion because of
the increased amount of resources required to operate a proactive system.

Some state programs had electronic reporting systems, while others were
paper-based. If data are reported electronically, there are ongoing
computer maintenance and programming choices and their attendant costs.
Similarly, some state programs engaged private contractors to collect and
maintain the data, while others did so in-house. If a private contractor
collects the raw data from dispensers and converts them to a standardized
format, the program pays annual contracting costs for database
maintenance. Kentucky and Nevada privately contracted with the same
company to collect data for their program databases. Utah, in contrast,
collected and maintained drug dispensing data in-house, using its own
software and hardware.

The number and type of staff a state chose to operate its monitoring
program also varied. In 2002, Kentucky's program employed four full-time
and four part-time staff to help ensure the accuracy of its reports,
including a pharmacist-investigator who reviewed each report before it was
sent. Nevada's program operated with one employee because a private
contractor collected the data. In contrast, in 2002 Utah's program, with
three full-time employees and no private contractor, had one program
administrator who collected all dispensing data, converted them to a
standardized format for monitoring, and maintained the database. The two
other staff answered requests.

If the program seeks to provide more timely responses to report requests,
such as same-day responses, the costs involved in returning the response
to the requester may increase. For example, in 2001 Kentucky spent up to
$12,000 in 1 month for faxing reports. Monitoring program officials from
Kentucky, Nevada, and Utah told us in 2002 that they estimated 3- to 4hour
turnaround times for program data requests, and all mainly used faxing,
rather than more costly mailing, to send reports to requesters. Same-day
responses may be preferable for physicians who want the prescription drug
history for a patient being seen that day and for law enforcement users
who need immediate data for investigations of suspected illegal activity.

As users become more familiar with the benefits of monitoring program
report data, requests for information and other demands on the programs
may increase. In Kentucky, Nevada, and Utah, use had increased
substantially, mostly because of an increase in the number of requests by
physicians to check patients' prescription drug histories. In Kentucky,
these physician requests increased from 28,307 in 2000, the first full
year of operation, to 56,367 in 2001, an increase of nearly 100 percent.
Law enforcement requests increased from 4,567 in 2000 to 5,797 in 2001, an
increase of 27 percent. Similarly, Nevada's requests from all authorized
users also increased-from 480 in 1997, its first full year, to 6,896 in
2001, an increase of about 1,300 percent.

Additionally, as drug marketing practices change and monitoring programs
mature, the operational needs may shift as well. For example, states face
new challenges with the advent of Internet pharmacies, because they enable
pharmacies and physicians to anonymously reach across state borders to
prescribe, sell, and dispense prescription drugs without complying with
state requirements.11 In addition, if users want program reports to
reflect more timely information, dispensing entities would have to report
their data at the time of sale, rather than submitting data biweekly or
monthly, to capture the most recent prescription dispensing. If users want
to be alerted if a certain drug, practitioner, or pharmacy may be involved
in a developing diversion problem, programs would have to initiate
periodic data analysis to determine trends or patterns. Such program
enhancements would entail additional costs, however, including costs for
computer programming, and data analysis.

States that are considering establishing or expanding a monitoring program
face a variety of other challenges. One challenge is the lack of awareness
of the extent to which prescription drug abuse and diversion is a
significant public health and law enforcement problem. States also face
concerns about the confidentiality of the information gathered by the
program, voiced by patients who are legitimately using prescription drugs
and by physicians and pharmacists who are legitimately prescribing and
dispensing them. Another challenge states face is securing adequate

11For more details on Internet pharmacies, see U.S. General Accounting
Office, Internet Pharmacies: Adding Disclosure Requirements Would Aid
State and Federal Oversight, GAO-01-69 (Washington, D.C.: Oct. 19, 2000).

funding to initiate and develop the program and to maintain and modify it

12

over time.

  State Monitoring Programs Have Helped Shorten Investigation Times and May
  Reduce Illegal Drug Diversion

We found that states with monitoring programs have experienced
considerable reductions in the time and effort required by law enforcement
and regulatory investigators to explore leads and the merits of possible
drug diversion cases. We also found that the presence of a monitoring
program in a state may help reduce illegal drug diversion there, but that
diversion activities may increase in contiguous states without programs.

The ability of the programs to focus law enforcement and regulatory
investigators who are working on suspected drug diversion cases on
specific physicians, pharmacies, and patients who may be involved in the
alleged activities is crucial to shortened investigation time and
improvements in productivity. States that do not have programs must rely
on tips from patients, practitioners, or law enforcement authorities to
identify possible prescription drug abuse and diversion. Following up on
these leads requires a lengthy, labor-intensive investigation. In
contrast, the programs can provide information that allows investigators
to pinpoint the physicians' offices and pharmacies where drug records must
be reviewed to verify suspected diversion and thus can eliminate the need
to search records at physicians' offices and pharmacies that have no
connection to a case.

In each of the three states we studied, state monitoring programs led to
reductions in investigation times. For example, prior to implementation of
Kentucky's monitoring program, its state drug control investigators took
an average of 156 days to complete the investigation of alleged doctor
shoppers. Following the implementation, the average investigation time
dropped to 16 days, or a 90 percent reduction in investigation time.
Similarly, Nevada reduced its investigation time from about 120 days to

12Federal grants are available to states to establish new monitoring
programs and to enhance existing programs under the Harold Rogers
Prescription Drug Monitoring Program. DEA's Office of Diversion Control,
in collaboration with the Department of Justice's Bureau of Justice
Assistance, provides grants to states to establish new programs and to
enhance existing monitoring programs through the Harold Rogers
Prescription Drug Monitoring Program. The fiscal year 2003 grantees are
Alabama, Florida, Maine, New Mexico, and Wyoming for new programs, and
California, Idaho, Nevada, and New York for enhanced programs. The
grantees in fiscal year 2002 were Ohio, Pennsylvania, Virginia, and West
Virginia for new programs, and California, Kentucky, Massachusetts,
Nevada, and Utah for enhanced programs.

about 20 days, a reduction of 83 percent, and a Utah official told us that
it experienced an 80 percent reduction in investigation time.

Officials from Kentucky, Nevada, and Utah told us in 2002 that their
programs may have helped reduce the unwarranted prescribing and subsequent
diversion of abused drugs in their states. In both Kentucky and Nevada, an
increased number of program reports were being used by physicians to check
the prescription drug use histories of current and prospective patients
when deciding whether to prescribe certain drugs that are subject to
abuse. Law enforcement officials told us that they view these drug history
checks as initial deterrents- a front-line defense-to prevent individuals
from visiting multiple physicians to obtain prescriptions, because
patients are aware that physicians can review their prescription drug
history. For an individual who may be seeking multiple controlled
substance prescriptions, the check allows a physician to analyze the
prescription drug history to determine whether drug treatment appears
questionable, and if so, to verify it with the listed physicians. In
Kentucky, a physician could request a drug history report on the same day
as the patient's appointment, and usually received the report within 4
hours of the request. In 2002, Kentucky's program typically received about
400 physician requests daily, and provided data current to the most recent
2 to 4 weeks.

The presence of a monitoring program may also have an impact on the
prescribing of drugs more likely to be diverted. For example, DEA ranked
all states for 2000 by the number of OxyContin prescriptions per 100,000
people.13 Eight of the 10 states with the highest numbers of
prescriptions- West Virginia, Alaska, Delaware, New Hampshire, Florida,
Pennsylvania, Maine, and Connecticut-had no monitoring programs, and only
2 did- Kentucky and Rhode Island. Six of the 10 states with the lowest
numbers of prescriptions-Michigan, New Mexico,14 Texas, New York,
Illinois, and California-had programs, and 4-Kansas, Minnesota, Iowa, and
South Dakota-did not.

13OxyContin, Hearings Before the Subcommittee on the Departments of
Commerce, Justice, and State, the Judiciary, and Related Agencies, House
Committee on Appropriations, 107th Cong. Part 10., pp. 21, 22 (2001)
(Statement of Asa Hutchinson, Administrator of the Drug Enforcement
Administration).

14New Mexico's monitoring program was terminated in June 2000.

Another indication of the effectiveness of a monitoring program is that
its existence in one state appears to increase drug diversion activities
in contiguous states without programs. When states begin to monitor drugs,
drug diversion activities tend to spill across boundaries to states
without programs. One example is provided by Kentucky, which shares a
boundary with seven states, only two of which had programs in 2002-Indiana
and Illinois. As drug diverters became aware of the Kentucky program's
ability to trace their drug histories, they tended to move their diversion
activities to nearby nonmonitored states. OxyContin diversion problems
worsened in Tennessee, West Virginia, and Virginia-all contiguous states
without programs-because of the presence of Kentucky's program, according
to a 2001 joint federal, state, and local drug diversion report.15

Although monitoring programs can enhance the ability of states to detect
and deter illegal diversion of prescription drugs, the number of states
with such programs has grown only slightly over the past 12 years from 10
in 1992 to 16 in 2004. A lack of awareness of the magnitude of the
problem; concerns about confidentiality on the part of patients,
physicians, pharmacists, and legislators; and difficulty in accessing
funding have kept the numbers of monitoring programs low. Cooperative
efforts at the state and national levels are seeking to overcome these
challenges and increase the number of states with programs.

                                   Concluding

                                  Observations

Mr. Chairman, this concludes my prepared statement. I would be pleased to
respond to any questions you or other Members of the Subcommittee may
have.

Contact and 	For more information regarding this testimony, please contact
Marcia Crosse at (202) 512-7119. Individuals making key contributions to
this

Acknowledgments 	testimony include Martin T. Gahart, Roseanne Price, and
Opal Winebrenner.

15Appalachia High Intensity Drug Trafficking Area Investigative Support
Center, with the assistance of the National Drug Intelligence Center, The
OxyContin Threat in Appalachia (London, Ky.: Aug. 2001).

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