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Diversion tactics: how a sample of drug misusers in treatment obtained surplus drugs to sell on the illicit market1
International Journal of Drug Policy 9 (1997) 159 – 167
Diversion tactics: how a sample of drug misusers in treatment obtained surplus drugs to sell on the illicit market1 Jane Fountain *, Paul Griffiths, Michael Farrell, Michael Gossop, John Strang The National Addiction Centre, 4 Windsor Walk, London SE5 8AF, UK Received 31 October 1997; received in revised form 31 December 1997; accepted 30 January 1998
Abstract This paper presents some findings from a qualitative study conducted during 1995 and 1996 amongst buyers and sellers of diverted prescription drugs in London. It details the tactics sellers employed to obtain drugs surplus to their own requirements in order to sell them on the illicit market: they acquired more than one prescription (‘multiple scripting’) and/or obtained a prescription for a higher dosage and/or a wider variety of drugs than they intended to use themselves (‘overscripting’). Informants exploited the lack of a standardised prescribing policy by ‘doctor shopping’, whereby they searched out those most likely to prescribe the drugs and the quantity they wanted. The methods most commonly used to acquire a surplus were to exaggerate a habit, bargain with prescribers, give a false identity, gain the sympathy of prescribers, feign addiction, and pretend to be a temporary resident. To conclude, some costs and benefits of diversion and its control are discussed. © 1998 Elsevier Science B.V. All rights reserved. Keywords: Drugs; Illicit market; Addiction
1. Introduction In Britain, opiate addicts in treatment obtain substitute drugs—usually methadone and benzodiazepines—on prescription from National Health Service (NHS) specialist drug treatment * Corresponding author. 1 The study from which this paper was taken was funded by the Department of Health. However, the views expressed are those of the authors, and not necessarily those of the Department.
agencies, and general practitioners (GPs). Although the majority of GPs are reluctant to treat drug misusers (Department of Health, 1996), ‘shared care’, a system of support that, hopefully, will encourage more GPs to do so, is currently being debated (Deehan et al., 1997). A minority of opiate addicts are treated by private practitioners—a service for which they must pay. Those private practitioners who choose to treat drug misusers are more likely than NHS sources to prescribe drugs other than methadone and benzo-
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diazepines, in larger amounts, and in injectable formulations (Strang et al., 1996) — a prescribing policy with which informants were familiar. Whilst prescribing substitute drugs to opiate addicts is an effective method of controlling their addiction (Farrell et al., 1994), an undesirable side-effect of this policy is that some prescription drugs are diverted to the illicit market. Few studies dealing solely with prescription drug diversion have been published and the proportion of drugs diverted and the number of individuals diverting them therefore remains unknown. Data on some aspects of diversion are usually found in publications concerned with polydrug use, illicit drug markets, or the management of drug misusers in treatment, and such reports frequently end with a plea for further research. In order to highlight areas of interest and concern in relation to the distribution and use of prescription drugs outside treatment settings, a study was conducted in London during 1995 and 1996 (Fountain et al., 1996). Using qualitative research techniques — observation, conversation, and unstructured interviews — the core issues surrounding diversion were examined in detail with a small number of networks of longterm, polydrug-using, opiate addicts from several drugs marketplaces. In total, 100 drug users were accessed, via a gatekeeper (usually another drug user) who introduced the researcher to each location and to individuals who bought and/or sold prescription drugs. This sample was specially chosen for this study, and it is not suggested that their behaviour is typical of all drug users. However, as the drug-using patterns of this sample were focused around diverted prescription drugs, the issues around diversion could be fully explored with them. Thus, although the findings from the study cannot be said to apply universally, particularly as local drug markets have specific supply and demand characteristics, the project generated data which make a contribution to existing knowledge on the diversion of prescription drugs, inform diversion control measures and intervention strategies, and apprise research with larger samples. This paper describes the methods by which
the sample obtained drugs surplus to their requirements in order to sell them on the illicit market. To acquire this surplus, sellers used either or both of two methods: they had more than one prescription (‘multiple scripting’ often inaccurately known as ‘double scripting’), or obtained a prescription for a higher dosage and/or a wider variety of drugs than they used (‘overscripting’). Both were common practices among the informants, who used the proceeds from sales to buy the drugs they preferred—usually heroin—to those prescribed and/or to pay for a private prescription. There is no central policy which characterises the ‘British System’ of prescribing to drug misusers (Strang and Gossop, 1994a), and the prescribing policy of a drug treatment service can facilitate or hinder the diversion of prescription drugs. Variations between services include the frequency with which a client must collect their prescribed drugs from a pharmacy; supervision of consumption; identity checks; and testing, using methods which can variously establish whether a claim of addiction is correct, which substances are used, the appropriate substitution dosage, drug use additional to that prescribed, and changes in consumption levels. There have been calls for research to discover how drug users are presenting to doctors in order to multiple- and overscript (Darke, 1994), and the following is a contribution to the relatively sparse knowledge base. The data presented here appear to indicate that it is relatively easy for a drug user to obtain surplus drugs on prescription. However, it is important to reiterate that two of the major criteria for the selection of informants for the study was that they were over- and/or multiple scripters and longterm polydrug-using, opiate addicts. Consequently, it is to be expected that they had considerable experience of applying the ‘tricks of the trade’ to circumvent controls to prevent them procuring more drugs than they used. It should also be noted that it is not intended to suggest that prescribers are unaware of the tactics, nor that they fail to take measures to thwart them.
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2. Multiple scripting
3. Overscripting
Some of the informants who had two or more prescriptions were prescribed the same drugs by different sources, but others obtained different drugs from different treatment services: Angie2, for example:
A drug misuser in treatment can also obtain surplus drugs to divert to the illicit market by overscripting. For example: Maurice:
Well, from my own private doctor I get DFs (DF118) and temazepams. Methadone from the clinic2 . So I only get scripts for pills from my private doctor and then get methadone from the clinic. Two or three prescriptions at the same time was the norm for most of the multiple scripters of the study, although some informants had more, either currently or in the past: JF: ‘‘What’s the most prescriptions you’ve ever had at any one time?’’ Sarah: From four doctors: two private, one GP that I was getting methadone from, and one ordinary GP, and that was for Valium and temazepam. The rest was all sorta Class A drugs. But that’s a lot for one person — getting four pretty big scripts — it’s a lot. You think of every addict that could do that — that’s a lot of drugs… The number of clients who acquire multiple prescriptions is unknown, but there has been research which suggests that the practice is not uncommon (Dale and Jones, 1992; Drug Transitions Study, 1994). Although there were isolated reports during the present study that a drug treatment agency had refused to prescribe for a client discovered to be multiple scripting, it appears that, unless an individual is a persistent offender, few prescribers resort to this option (Haw, 1993).
2
All names of informants, practitioners and drug treatment agencies are pseudonyms.
I always keep my own juice (methadone mixture)—well, I sell a bit of it occasionally, but I need most of it myself, or I’d be sick (withdraw)…I do sell pills (benzodiazepines) when I get them for myself…I mean, when I get my temazi (temazepam) and Valium script, I just take a couple—like a couple with a hit (injection of heroin) or a couple to go to sleep with…I get 60 of each a month, and, like, on average, I take out of them half a dozen. Reports of individuals obtaining prescriptions for drugs they did not use at all were rare, and could not be verified, although it was widely believed by informants that some alcoholics belonged to this category of diverter: Paul: A lot of the people selling benzos…are drinkers: get the pills just to sell to get their drink—know what I mean? The tactics detailed below were used to obtain surplus drugs from GPs, drug treatment agencies, and private practitioners. Informants exploited the lack of a standardised prescribing policy by ‘doctor shopping’, whereby they searched out those most likely to prescribe the drugs and the quantity they wanted (Burr, 1983; McKeganey, 1988). Some techniques were more successful with one prescriber than another, depending on their prescribing policies.
4. Exaggerating a habit The tactic used most often by drug users of the study who obtained surplus drugs to sell was to exaggerate the amount they used: Dave: I tell you one thing and all—it’s like when anyone has told me to come to these places (drug treatment agencies), they always
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say ‘Tell them you’re using twice as much as you are using’. Andy agreed, and emphasised the financial advantage of exaggeration: …if they have a 40 mg (of methadone) a day habit then they tell the doctor it’s a 90 or 100 mg a day habit. So you’re talking about 700 mg a week, so it’s a hell of a lot of a profit at the end of the day. Sally grossly exaggerated her benzodiazepine use in order to get a prescription for them from a GP: Sally: I had no pill addiction whatsoever, but I went in there with a sob-story saying ‘I’m using ten Mogadon, eight blue Valium (10 mg) a day, and buying them off the black market, and I have to thieve to get the money, and I don’t want to do that any more, and I want to try and sort out my life’ and so forth, and what she said was ‘Out of the two drugs you’re taking, I can only prescribe one of them’. So I said to myself ‘Right, Mogadon is 5 mg, Valium is 10 mg—so I’ll have the Valium’. And when it came to the amount, I said I was using 12 blues (10 mg Valium tablets) a day, which is 120 mg a day…it’s a hell of a lot, but I said ‘I’ve managed to cut myself down to 80 mg’ and she said ‘Oh, brilliant’. So therefore, I get 56 blues of 10 mg a week, and I pick them up fortnightly, which is 112 blue tablets, take a couple myself, and the rest I sell. It should be noted here that a request for benzodiazepines from a patient who claims to be addicted to them puts a prescriber in a difficult position. If true, an abrupt withdrawal can lead to seizures.
dosage. A standard tactic was for a drug user to say that they were having to commit crimes or work as a prostitute in order to buy heroin on the illicit market, and if they were prescribed methadone, or their dosage was increased, they would not have to do so. A proposed reduction in the quantity of a prescribed drug was countered by the threat to ‘use on top’ (use extra from the illicit market). Another bargaining technique was to promise to stop injecting if oral preparations were prescribed (Rathod, 1987; McKeganey, 1988).
6. False identities An aid to multiple scripting was the use one or more false identities, and some of the sample were well-practised in this, as Maurice nostalgically recalled: Do you remember in the old days with Dr Daniels and Dr Thomas2? You’d get a crowd of doctors prescribing, and the word’s out, and everyone’s fighting to be first in the waiting room. One week it’s all prim and proper, next week it’s all full of addicts. All under different names—everyone saying ‘Don’t say my real name in front of anyone’. Obtaining more than one prescription for a controlled drug by using a false identity required a certain amount of organisation to avoid detection: for instance, the individual had to remember under which name they were registered with each prescriber and pharmacy. Sharon reported the largest number of prescriptions during this study. She used false identities for all of them: I’ve got five scripts—I ain’t got a script in my own name…I just give a name off the top of my head, my date of birth backwards, so I could remember it, you know what I mean?
5. Bargaining with prescribers 7. Gaining sympathy Many of the sample bargained with prescribers in order to persuade them to prescribe, increase the quantity, or keep them on a maintenance
Several women in the sample spoke of the ‘sob-stories’ they told prescribers they judged
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likely to be sympathetic in order to get the drugs they wanted:
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8. Feigning addiction
Lucy: …you tell them what you know they want to hear, and they know it. They must know it, you can’t have worked with junkies for years and years and years and not know that half of the stuff that comes out their mouths is absolute crap. I mean, God forbid, my mother, she has died more times…she’s had car accidents, she’s died of cancer, and I’ve been grieving, ‘I’ve got to go the funeral, I need this and this and this’, and it’s amazing how quick those tears dry up when you see that pen writing the script.
Several informants had obtained benzodiazepines from a GP by professing addiction not to opiates, but to alcohol (Jones and Power, 1990). A variation of the technique was also reported: to admit to opiate addiction, but claim to be trying to abstain or reduce use, and ask for benzodiazepines to help alleviate withdrawal symptoms (Seivewright et al., 1993). A few informants claimed they could get a non-opiate user a prescription for methadone—Lucy, for example, assured the researcher that:
Sarah: Well, it’s a sob story usually, you know, ‘my mum and dad — I’ve left home because of my mum and dad fighting, my mum drinks and my dad drinks, I can’t sleep, I think I might be pregnant’ — you know, the old stories. Women getting them (prescriptions) off men doctors is the usual…especially older doctors. Not so much the young doctors—they won’t wear it — always usually the older doctors cos they’re trying to help, you know…
…I could take you to a doctor (GP) right now actually, yes now—what’s the time?—4 o’ clock—yeah, I could get you a methadone prescription…This is probably because I know him that I could refer you, but yes, you can, if you know what you’re doing and you know the spiel…I’d know exactly what to say. Because you’ve got no (needle) marks, I’d say you’ve been chasing it, and he’d give you methadone. I mean it’s ridiculously easy.
Sally gained the sympathy of her GP by presenting her life in a more positive light than Lucy and Sarah did: Basically, she’s of the understanding that I’m going to get myself into a treatment centre, so therefore she’s more accommodating. But this treatment centre lark has been going on for the last one and a half years. Every time I get close to it, something pops up — like I say I’ve got a court case or something…plus when I go in there, I do sort of feed her positive information, like I am sticking to my script, like my mum gives them to me on a daily basis, so there’s no chance of me abusing them…So when I go there, and I have a little chat with her—some of it’s a load of bullshit obviously, and some of it’s the truth-and she thinks maybe I am trying…
9. Becoming a temporary resident Emergency prescriptions were obtained by some of the sample who visited a GP and posed as a temporary resident in the locality. False identities were frequently used on these occasions. Some informants went to surgeries in their home area, whilst others travelled many miles away, as Sarah explained: I know people who travel right out to the country and do it. If they can’t do it here (in London), they go out to the country and do it, and I guarantee they get away with it there because they’ll say ‘I come from London and I’ve had this, this, and this (drugs on prescription)—I’m really sorry for being a nuisance but I can’t get back because’, say, ’my grandmother
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died last week’, and what does the doctor do? He can’t check up cos they say I’ve got no doctor, I can’t sleep blah, blah, blah, and he’s got to really do something. He can’t just say ‘Go away, you live in London’. Mike maintained it was ‘quite easy’ to get drugs from GPs in this way: I’ve actually been guilty of going into a doctor’s out of the blue and he has just gone ‘bosh’ (written out a prescription)…yeah, as a temporary resident, say from the North, and I’ve walked out with temazepam, diazepam, and DFs (DF118). That’s on the first visit…Then you walk round the corner and do it again, and you’ve got your pockets full and you’ve earned yourself a few bob — you sell them and you’ve got the money to buy your own stuff (preferred drugs). Maurice thought that persistence would eventually yield a prescription from a GP: Just take pot luck, because at the end of the day, the doctor can only say no. The chances are you are going to get something off someone.
11. Feigning symptoms In addition to the ‘sob-stories’ purporting to be leading to stress and depression described earlier, some informants feigned symptoms of insomnia in order to acquire benzodiazepines. Several had told the more liberal private practitioners that the methadone they were prescribed led to lethargy, and thus obtained an additional prescription for the stimulant dexamphetamine sulphate (Dexedrine). A more sophisticated version of this ploy-claiming to be suffering from a condition which requires treatment with opioids (Burroughs, 1953; Wheeldon, 1992) was not reported to the study, however.
12. Pretending to be an injector On the illicit drugs market, injectable methadone is more valuable than oral versions of the drug, and one informant reported that she had pretended to be an injector so that she could obtain ampoules to sell: she had made ‘track marks’ with a pin. This was in the 1970’s, however: there were no reports during fieldwork that a non-injector had used this tactic more recently.
13. ‘One-off’ tactics 10. Forgery A method which used to be commonplace, according to some older informants, was forging prescriptions after having stolen or bought blank ones. However, a tightening-up of procedures regarding the prescribing of opioids and increased security precautions at doctors surgeries have narrowed this avenue of obtaining drugs. Nevertheless, blank forms from NHS sources and letterheads upon which private practitioners write prescriptions were occasionally traded on the marketplaces of the study. Some informants also reported forging wage slips to convince a private practitioner of their ability to pay for a prescription. A variation of this tactic was to temporarily borrow money to show up in a bank or building society account.
Ploys used as one-off measures to obtain prescription drugs were reported: claiming that a bottle of methadone mixture had been dropped and smashed, in order to get a replacement filling a methadone mixture bottle with coloured water, switching it with one just dispensed and dropping and smashing it in view of a pharmacist, who, having seen the incident, replaced it professing to have lost a week’s supply of a drug, or that it had been stolen, and obtaining a replacement prescription.
14. Enjoying the game It is worth allowing Sarah, who, over- and
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multiple-scripted over a 20 year period, to point out the enjoyment to be had from outwitting prescribers: I used to enjoy doing it. I believed what I was saying. I never ever got nicked…You’re always scared, but sometimes that’s part of the fun of it. Especially if you know someone that’s already hit that doctor and you think that you can get a lot better than them and you do it: it’s quite a buzz. I mean, I always felt so clever when I came out: I’d pulled it off perfectly and thought ‘What a liar I am: that poor doctor is totally taken in by this. They’re trying to help me — there’s nothing wrong with me, I’ve just gone in with this load of lies and he’s believed this’. And what you have to do— the trick to it is that you have to believe it yourself when you go in that room, go through that door. You believe what you say and you’re so convincing ‘cos you believe every word you’re saying. If you didn’t do that, you know, if you faltered at all, you wouldn’t get it. You’ve got to be convinced that it’s true and that doctor will believe you. Nine out of ten will believe you. JF: ‘‘How do you size up the doctor?’ Sarah: Just by the way he looks up at you — the way he’ll smile at you. I mean, you know if he’s gonna be a touch or if he’s gonna be hard work. And sitting down after five minutes of talking to him — you’ve either got him or you haven’t. It’s either ‘Get up, get out of my surgery’, or ‘Is it really that bad?’ Then, I mean you go right into one, because you’ve got him in your grasp anyway, and you elaborate your story, and now it’s quite a buzz. It’s a bigger buzz walking out with a great big prescription.
15. Discussion Whilst the benefits of prescribing substitute drugs to drug misusers have been shown to be an effective method of treatment (Farrell et al.,
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1994), and the majority of clients use their prescribed drugs themselves, it is generally accepted that some diversion is unavoidable (Department of Health, 1996). Commentaries on the issue invariably end with suggestions to minimise the occurrence, but not at the expenses of making controls so rigid that drug misusers are discouraged from seeking treatment. The achievement of this aim demands a balancing of the costs and benefits of diversion, as the following comments illustrate. The energy and ingenuity which some drug misusers in treatment devote to obtaining drugs to divert to the illicit market can thwart control attempts unless all avenues are closed simultaneously. This would require not only standardisation of prescribing policies, but also co-operation between NHS drug treatment services, private practitioners, law enforcement agencies, and pharmacists. The cost would not only be financial, but would also put drug misusers and those who treat them under far greater scrutiny than at present (Cooper et al., 1993). The risk of such a policy is that fewer doctors, drugs workers, and pharmacists would be prepared to deal with drug misusers, and fewer drug misusers would seek treatment. Those who use diverted prescription drugs without the benefit and advice of treatment services take health risks. The combinations of substances polydrug users consume—particularly those which include benzodiazepines and dexamphetamine sulphate—can result in aggressive, paranoid, and reckless behaviour (Klee et al., 1993; Edmunds et al., 1996). Some drug misusers add to the substances to which they are addicted by their use of diverted prescription drugs, and some use therapeutic dosages—particularly benzodiazepines (Seivewright et al., 1993). Other risks are methadone overdose (Newcombe, 1996); the injection of formulations meant for oral use (Ruben and Morrison, 1992); and the introduction of methadone into the drug-using repertoires of young drug users (Lavelle et al., 1991). In addition, the wide variety and high dosages of drugs obtained from some private doctors can involve a patient in a cycle of increas-
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ing consumption, followed by overscripting and diversion in order to pay the fees. It has been suggested that those buying diverted prescription drugs are engaging in self-treatment (Spunt et al., 1986). However, the term should be used with reservation: it suggests that such users are mimicking the therapeutically-based decisions of treatment services, whereas the combinations and high dosages some of them use would not be available to them from legitimate sources. Nevertheless, some have assimilated the harm reduction advice emanating from drug treatment services and disseminated by the drug users’ grapevine. Ironically, the knowledge that illicit drugs and injecting are dangerous increases demand for the ‘safer’ prescription drugs (Bulla, 1993). If drug misusers in treatment — particularly those with no income and a marginal position in society—generate funds to pay for their preferred drugs by selling those they are prescribed, they are less likely to commit other acquisitive crimes (Burr, 1983). Further, as diverted prescription drugs are cheaper than illicit drugs on the illicit market, successful diversion control would mean that they would have to raise more money than at present. Whilst obtaining prescription drugs from treatment services only to exchange them for preferred drugs can be viewed as irrational, both buyers and sellers are responding rationally to a situation where they are dissatisfied with the drugs and/or the dosages prescribed by treatment services. However, the option of prescribing the preferred drugs—heroin, in particular — has been the subject of controversy for many years (Strang et al., 1994b), although trials are currently being conducted (Uchtenhagen et al., 1996). A policy which seeks to minimise diversion means striking a balance between over-prescribing (and the possibility of contributing to the supply of drugs to the illicit market) and ensuring that drug misusers in treatment are sufficiently satisfied to discourage ‘topping up’ from the illicit market. The examples above illustrate that the diversion of prescription drugs has costs and benefits, both of which impact on treatment options and the drug-using repertoires of drug misusers whether in or out of treatment. Any policy on diversion
control has the difficult task of balancing these positive and negative impacts, whilst also considering whether it is more concerned with treating drug misusers than preventing a minority selling their prescribed drugs.
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Diversion tactics: how a sample of drug misusers in treatment obtained surplus drugs to sell on the illicit market1 Jane Fountain *, Paul Griffiths, Michael Farrell, Michael Gossop, John Strang The National Addiction Centre, 4 Windsor Walk, London SE5 8AF, UK Received 31 October 1997; received in revised form 31 December 1997; accepted 30 January 1998
Abstract This paper presents some findings from a qualitative study conducted during 1995 and 1996 amongst buyers and sellers of diverted prescription drugs in London. It details the tactics sellers employed to obtain drugs surplus to their own requirements in order to sell them on the illicit market: they acquired more than one prescription (‘multiple scripting’) and/or obtained a prescription for a higher dosage and/or a wider variety of drugs than they intended to use themselves (‘overscripting’). Informants exploited the lack of a standardised prescribing policy by ‘doctor shopping’, whereby they searched out those most likely to prescribe the drugs and the quantity they wanted. The methods most commonly used to acquire a surplus were to exaggerate a habit, bargain with prescribers, give a false identity, gain the sympathy of prescribers, feign addiction, and pretend to be a temporary resident. To conclude, some costs and benefits of diversion and its control are discussed. © 1998 Elsevier Science B.V. All rights reserved. Keywords: Drugs; Illicit market; Addiction
1. Introduction In Britain, opiate addicts in treatment obtain substitute drugs—usually methadone and benzodiazepines—on prescription from National Health Service (NHS) specialist drug treatment * Corresponding author. 1 The study from which this paper was taken was funded by the Department of Health. However, the views expressed are those of the authors, and not necessarily those of the Department.
agencies, and general practitioners (GPs). Although the majority of GPs are reluctant to treat drug misusers (Department of Health, 1996), ‘shared care’, a system of support that, hopefully, will encourage more GPs to do so, is currently being debated (Deehan et al., 1997). A minority of opiate addicts are treated by private practitioners—a service for which they must pay. Those private practitioners who choose to treat drug misusers are more likely than NHS sources to prescribe drugs other than methadone and benzo-
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diazepines, in larger amounts, and in injectable formulations (Strang et al., 1996) — a prescribing policy with which informants were familiar. Whilst prescribing substitute drugs to opiate addicts is an effective method of controlling their addiction (Farrell et al., 1994), an undesirable side-effect of this policy is that some prescription drugs are diverted to the illicit market. Few studies dealing solely with prescription drug diversion have been published and the proportion of drugs diverted and the number of individuals diverting them therefore remains unknown. Data on some aspects of diversion are usually found in publications concerned with polydrug use, illicit drug markets, or the management of drug misusers in treatment, and such reports frequently end with a plea for further research. In order to highlight areas of interest and concern in relation to the distribution and use of prescription drugs outside treatment settings, a study was conducted in London during 1995 and 1996 (Fountain et al., 1996). Using qualitative research techniques — observation, conversation, and unstructured interviews — the core issues surrounding diversion were examined in detail with a small number of networks of longterm, polydrug-using, opiate addicts from several drugs marketplaces. In total, 100 drug users were accessed, via a gatekeeper (usually another drug user) who introduced the researcher to each location and to individuals who bought and/or sold prescription drugs. This sample was specially chosen for this study, and it is not suggested that their behaviour is typical of all drug users. However, as the drug-using patterns of this sample were focused around diverted prescription drugs, the issues around diversion could be fully explored with them. Thus, although the findings from the study cannot be said to apply universally, particularly as local drug markets have specific supply and demand characteristics, the project generated data which make a contribution to existing knowledge on the diversion of prescription drugs, inform diversion control measures and intervention strategies, and apprise research with larger samples. This paper describes the methods by which
the sample obtained drugs surplus to their requirements in order to sell them on the illicit market. To acquire this surplus, sellers used either or both of two methods: they had more than one prescription (‘multiple scripting’ often inaccurately known as ‘double scripting’), or obtained a prescription for a higher dosage and/or a wider variety of drugs than they used (‘overscripting’). Both were common practices among the informants, who used the proceeds from sales to buy the drugs they preferred—usually heroin—to those prescribed and/or to pay for a private prescription. There is no central policy which characterises the ‘British System’ of prescribing to drug misusers (Strang and Gossop, 1994a), and the prescribing policy of a drug treatment service can facilitate or hinder the diversion of prescription drugs. Variations between services include the frequency with which a client must collect their prescribed drugs from a pharmacy; supervision of consumption; identity checks; and testing, using methods which can variously establish whether a claim of addiction is correct, which substances are used, the appropriate substitution dosage, drug use additional to that prescribed, and changes in consumption levels. There have been calls for research to discover how drug users are presenting to doctors in order to multiple- and overscript (Darke, 1994), and the following is a contribution to the relatively sparse knowledge base. The data presented here appear to indicate that it is relatively easy for a drug user to obtain surplus drugs on prescription. However, it is important to reiterate that two of the major criteria for the selection of informants for the study was that they were over- and/or multiple scripters and longterm polydrug-using, opiate addicts. Consequently, it is to be expected that they had considerable experience of applying the ‘tricks of the trade’ to circumvent controls to prevent them procuring more drugs than they used. It should also be noted that it is not intended to suggest that prescribers are unaware of the tactics, nor that they fail to take measures to thwart them.
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2. Multiple scripting
3. Overscripting
Some of the informants who had two or more prescriptions were prescribed the same drugs by different sources, but others obtained different drugs from different treatment services: Angie2, for example:
A drug misuser in treatment can also obtain surplus drugs to divert to the illicit market by overscripting. For example: Maurice:
Well, from my own private doctor I get DFs (DF118) and temazepams. Methadone from the clinic2 . So I only get scripts for pills from my private doctor and then get methadone from the clinic. Two or three prescriptions at the same time was the norm for most of the multiple scripters of the study, although some informants had more, either currently or in the past: JF: ‘‘What’s the most prescriptions you’ve ever had at any one time?’’ Sarah: From four doctors: two private, one GP that I was getting methadone from, and one ordinary GP, and that was for Valium and temazepam. The rest was all sorta Class A drugs. But that’s a lot for one person — getting four pretty big scripts — it’s a lot. You think of every addict that could do that — that’s a lot of drugs… The number of clients who acquire multiple prescriptions is unknown, but there has been research which suggests that the practice is not uncommon (Dale and Jones, 1992; Drug Transitions Study, 1994). Although there were isolated reports during the present study that a drug treatment agency had refused to prescribe for a client discovered to be multiple scripting, it appears that, unless an individual is a persistent offender, few prescribers resort to this option (Haw, 1993).
2
All names of informants, practitioners and drug treatment agencies are pseudonyms.
I always keep my own juice (methadone mixture)—well, I sell a bit of it occasionally, but I need most of it myself, or I’d be sick (withdraw)…I do sell pills (benzodiazepines) when I get them for myself…I mean, when I get my temazi (temazepam) and Valium script, I just take a couple—like a couple with a hit (injection of heroin) or a couple to go to sleep with…I get 60 of each a month, and, like, on average, I take out of them half a dozen. Reports of individuals obtaining prescriptions for drugs they did not use at all were rare, and could not be verified, although it was widely believed by informants that some alcoholics belonged to this category of diverter: Paul: A lot of the people selling benzos…are drinkers: get the pills just to sell to get their drink—know what I mean? The tactics detailed below were used to obtain surplus drugs from GPs, drug treatment agencies, and private practitioners. Informants exploited the lack of a standardised prescribing policy by ‘doctor shopping’, whereby they searched out those most likely to prescribe the drugs and the quantity they wanted (Burr, 1983; McKeganey, 1988). Some techniques were more successful with one prescriber than another, depending on their prescribing policies.
4. Exaggerating a habit The tactic used most often by drug users of the study who obtained surplus drugs to sell was to exaggerate the amount they used: Dave: I tell you one thing and all—it’s like when anyone has told me to come to these places (drug treatment agencies), they always
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say ‘Tell them you’re using twice as much as you are using’. Andy agreed, and emphasised the financial advantage of exaggeration: …if they have a 40 mg (of methadone) a day habit then they tell the doctor it’s a 90 or 100 mg a day habit. So you’re talking about 700 mg a week, so it’s a hell of a lot of a profit at the end of the day. Sally grossly exaggerated her benzodiazepine use in order to get a prescription for them from a GP: Sally: I had no pill addiction whatsoever, but I went in there with a sob-story saying ‘I’m using ten Mogadon, eight blue Valium (10 mg) a day, and buying them off the black market, and I have to thieve to get the money, and I don’t want to do that any more, and I want to try and sort out my life’ and so forth, and what she said was ‘Out of the two drugs you’re taking, I can only prescribe one of them’. So I said to myself ‘Right, Mogadon is 5 mg, Valium is 10 mg—so I’ll have the Valium’. And when it came to the amount, I said I was using 12 blues (10 mg Valium tablets) a day, which is 120 mg a day…it’s a hell of a lot, but I said ‘I’ve managed to cut myself down to 80 mg’ and she said ‘Oh, brilliant’. So therefore, I get 56 blues of 10 mg a week, and I pick them up fortnightly, which is 112 blue tablets, take a couple myself, and the rest I sell. It should be noted here that a request for benzodiazepines from a patient who claims to be addicted to them puts a prescriber in a difficult position. If true, an abrupt withdrawal can lead to seizures.
dosage. A standard tactic was for a drug user to say that they were having to commit crimes or work as a prostitute in order to buy heroin on the illicit market, and if they were prescribed methadone, or their dosage was increased, they would not have to do so. A proposed reduction in the quantity of a prescribed drug was countered by the threat to ‘use on top’ (use extra from the illicit market). Another bargaining technique was to promise to stop injecting if oral preparations were prescribed (Rathod, 1987; McKeganey, 1988).
6. False identities An aid to multiple scripting was the use one or more false identities, and some of the sample were well-practised in this, as Maurice nostalgically recalled: Do you remember in the old days with Dr Daniels and Dr Thomas2? You’d get a crowd of doctors prescribing, and the word’s out, and everyone’s fighting to be first in the waiting room. One week it’s all prim and proper, next week it’s all full of addicts. All under different names—everyone saying ‘Don’t say my real name in front of anyone’. Obtaining more than one prescription for a controlled drug by using a false identity required a certain amount of organisation to avoid detection: for instance, the individual had to remember under which name they were registered with each prescriber and pharmacy. Sharon reported the largest number of prescriptions during this study. She used false identities for all of them: I’ve got five scripts—I ain’t got a script in my own name…I just give a name off the top of my head, my date of birth backwards, so I could remember it, you know what I mean?
5. Bargaining with prescribers 7. Gaining sympathy Many of the sample bargained with prescribers in order to persuade them to prescribe, increase the quantity, or keep them on a maintenance
Several women in the sample spoke of the ‘sob-stories’ they told prescribers they judged
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likely to be sympathetic in order to get the drugs they wanted:
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8. Feigning addiction
Lucy: …you tell them what you know they want to hear, and they know it. They must know it, you can’t have worked with junkies for years and years and years and not know that half of the stuff that comes out their mouths is absolute crap. I mean, God forbid, my mother, she has died more times…she’s had car accidents, she’s died of cancer, and I’ve been grieving, ‘I’ve got to go the funeral, I need this and this and this’, and it’s amazing how quick those tears dry up when you see that pen writing the script.
Several informants had obtained benzodiazepines from a GP by professing addiction not to opiates, but to alcohol (Jones and Power, 1990). A variation of the technique was also reported: to admit to opiate addiction, but claim to be trying to abstain or reduce use, and ask for benzodiazepines to help alleviate withdrawal symptoms (Seivewright et al., 1993). A few informants claimed they could get a non-opiate user a prescription for methadone—Lucy, for example, assured the researcher that:
Sarah: Well, it’s a sob story usually, you know, ‘my mum and dad — I’ve left home because of my mum and dad fighting, my mum drinks and my dad drinks, I can’t sleep, I think I might be pregnant’ — you know, the old stories. Women getting them (prescriptions) off men doctors is the usual…especially older doctors. Not so much the young doctors—they won’t wear it — always usually the older doctors cos they’re trying to help, you know…
…I could take you to a doctor (GP) right now actually, yes now—what’s the time?—4 o’ clock—yeah, I could get you a methadone prescription…This is probably because I know him that I could refer you, but yes, you can, if you know what you’re doing and you know the spiel…I’d know exactly what to say. Because you’ve got no (needle) marks, I’d say you’ve been chasing it, and he’d give you methadone. I mean it’s ridiculously easy.
Sally gained the sympathy of her GP by presenting her life in a more positive light than Lucy and Sarah did: Basically, she’s of the understanding that I’m going to get myself into a treatment centre, so therefore she’s more accommodating. But this treatment centre lark has been going on for the last one and a half years. Every time I get close to it, something pops up — like I say I’ve got a court case or something…plus when I go in there, I do sort of feed her positive information, like I am sticking to my script, like my mum gives them to me on a daily basis, so there’s no chance of me abusing them…So when I go there, and I have a little chat with her—some of it’s a load of bullshit obviously, and some of it’s the truth-and she thinks maybe I am trying…
9. Becoming a temporary resident Emergency prescriptions were obtained by some of the sample who visited a GP and posed as a temporary resident in the locality. False identities were frequently used on these occasions. Some informants went to surgeries in their home area, whilst others travelled many miles away, as Sarah explained: I know people who travel right out to the country and do it. If they can’t do it here (in London), they go out to the country and do it, and I guarantee they get away with it there because they’ll say ‘I come from London and I’ve had this, this, and this (drugs on prescription)—I’m really sorry for being a nuisance but I can’t get back because’, say, ’my grandmother
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died last week’, and what does the doctor do? He can’t check up cos they say I’ve got no doctor, I can’t sleep blah, blah, blah, and he’s got to really do something. He can’t just say ‘Go away, you live in London’. Mike maintained it was ‘quite easy’ to get drugs from GPs in this way: I’ve actually been guilty of going into a doctor’s out of the blue and he has just gone ‘bosh’ (written out a prescription)…yeah, as a temporary resident, say from the North, and I’ve walked out with temazepam, diazepam, and DFs (DF118). That’s on the first visit…Then you walk round the corner and do it again, and you’ve got your pockets full and you’ve earned yourself a few bob — you sell them and you’ve got the money to buy your own stuff (preferred drugs). Maurice thought that persistence would eventually yield a prescription from a GP: Just take pot luck, because at the end of the day, the doctor can only say no. The chances are you are going to get something off someone.
11. Feigning symptoms In addition to the ‘sob-stories’ purporting to be leading to stress and depression described earlier, some informants feigned symptoms of insomnia in order to acquire benzodiazepines. Several had told the more liberal private practitioners that the methadone they were prescribed led to lethargy, and thus obtained an additional prescription for the stimulant dexamphetamine sulphate (Dexedrine). A more sophisticated version of this ploy-claiming to be suffering from a condition which requires treatment with opioids (Burroughs, 1953; Wheeldon, 1992) was not reported to the study, however.
12. Pretending to be an injector On the illicit drugs market, injectable methadone is more valuable than oral versions of the drug, and one informant reported that she had pretended to be an injector so that she could obtain ampoules to sell: she had made ‘track marks’ with a pin. This was in the 1970’s, however: there were no reports during fieldwork that a non-injector had used this tactic more recently.
13. ‘One-off’ tactics 10. Forgery A method which used to be commonplace, according to some older informants, was forging prescriptions after having stolen or bought blank ones. However, a tightening-up of procedures regarding the prescribing of opioids and increased security precautions at doctors surgeries have narrowed this avenue of obtaining drugs. Nevertheless, blank forms from NHS sources and letterheads upon which private practitioners write prescriptions were occasionally traded on the marketplaces of the study. Some informants also reported forging wage slips to convince a private practitioner of their ability to pay for a prescription. A variation of this tactic was to temporarily borrow money to show up in a bank or building society account.
Ploys used as one-off measures to obtain prescription drugs were reported: claiming that a bottle of methadone mixture had been dropped and smashed, in order to get a replacement filling a methadone mixture bottle with coloured water, switching it with one just dispensed and dropping and smashing it in view of a pharmacist, who, having seen the incident, replaced it professing to have lost a week’s supply of a drug, or that it had been stolen, and obtaining a replacement prescription.
14. Enjoying the game It is worth allowing Sarah, who, over- and
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multiple-scripted over a 20 year period, to point out the enjoyment to be had from outwitting prescribers: I used to enjoy doing it. I believed what I was saying. I never ever got nicked…You’re always scared, but sometimes that’s part of the fun of it. Especially if you know someone that’s already hit that doctor and you think that you can get a lot better than them and you do it: it’s quite a buzz. I mean, I always felt so clever when I came out: I’d pulled it off perfectly and thought ‘What a liar I am: that poor doctor is totally taken in by this. They’re trying to help me — there’s nothing wrong with me, I’ve just gone in with this load of lies and he’s believed this’. And what you have to do— the trick to it is that you have to believe it yourself when you go in that room, go through that door. You believe what you say and you’re so convincing ‘cos you believe every word you’re saying. If you didn’t do that, you know, if you faltered at all, you wouldn’t get it. You’ve got to be convinced that it’s true and that doctor will believe you. Nine out of ten will believe you. JF: ‘‘How do you size up the doctor?’ Sarah: Just by the way he looks up at you — the way he’ll smile at you. I mean, you know if he’s gonna be a touch or if he’s gonna be hard work. And sitting down after five minutes of talking to him — you’ve either got him or you haven’t. It’s either ‘Get up, get out of my surgery’, or ‘Is it really that bad?’ Then, I mean you go right into one, because you’ve got him in your grasp anyway, and you elaborate your story, and now it’s quite a buzz. It’s a bigger buzz walking out with a great big prescription.
15. Discussion Whilst the benefits of prescribing substitute drugs to drug misusers have been shown to be an effective method of treatment (Farrell et al.,
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1994), and the majority of clients use their prescribed drugs themselves, it is generally accepted that some diversion is unavoidable (Department of Health, 1996). Commentaries on the issue invariably end with suggestions to minimise the occurrence, but not at the expenses of making controls so rigid that drug misusers are discouraged from seeking treatment. The achievement of this aim demands a balancing of the costs and benefits of diversion, as the following comments illustrate. The energy and ingenuity which some drug misusers in treatment devote to obtaining drugs to divert to the illicit market can thwart control attempts unless all avenues are closed simultaneously. This would require not only standardisation of prescribing policies, but also co-operation between NHS drug treatment services, private practitioners, law enforcement agencies, and pharmacists. The cost would not only be financial, but would also put drug misusers and those who treat them under far greater scrutiny than at present (Cooper et al., 1993). The risk of such a policy is that fewer doctors, drugs workers, and pharmacists would be prepared to deal with drug misusers, and fewer drug misusers would seek treatment. Those who use diverted prescription drugs without the benefit and advice of treatment services take health risks. The combinations of substances polydrug users consume—particularly those which include benzodiazepines and dexamphetamine sulphate—can result in aggressive, paranoid, and reckless behaviour (Klee et al., 1993; Edmunds et al., 1996). Some drug misusers add to the substances to which they are addicted by their use of diverted prescription drugs, and some use therapeutic dosages—particularly benzodiazepines (Seivewright et al., 1993). Other risks are methadone overdose (Newcombe, 1996); the injection of formulations meant for oral use (Ruben and Morrison, 1992); and the introduction of methadone into the drug-using repertoires of young drug users (Lavelle et al., 1991). In addition, the wide variety and high dosages of drugs obtained from some private doctors can involve a patient in a cycle of increas-
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ing consumption, followed by overscripting and diversion in order to pay the fees. It has been suggested that those buying diverted prescription drugs are engaging in self-treatment (Spunt et al., 1986). However, the term should be used with reservation: it suggests that such users are mimicking the therapeutically-based decisions of treatment services, whereas the combinations and high dosages some of them use would not be available to them from legitimate sources. Nevertheless, some have assimilated the harm reduction advice emanating from drug treatment services and disseminated by the drug users’ grapevine. Ironically, the knowledge that illicit drugs and injecting are dangerous increases demand for the ‘safer’ prescription drugs (Bulla, 1993). If drug misusers in treatment — particularly those with no income and a marginal position in society—generate funds to pay for their preferred drugs by selling those they are prescribed, they are less likely to commit other acquisitive crimes (Burr, 1983). Further, as diverted prescription drugs are cheaper than illicit drugs on the illicit market, successful diversion control would mean that they would have to raise more money than at present. Whilst obtaining prescription drugs from treatment services only to exchange them for preferred drugs can be viewed as irrational, both buyers and sellers are responding rationally to a situation where they are dissatisfied with the drugs and/or the dosages prescribed by treatment services. However, the option of prescribing the preferred drugs—heroin, in particular — has been the subject of controversy for many years (Strang et al., 1994b), although trials are currently being conducted (Uchtenhagen et al., 1996). A policy which seeks to minimise diversion means striking a balance between over-prescribing (and the possibility of contributing to the supply of drugs to the illicit market) and ensuring that drug misusers in treatment are sufficiently satisfied to discourage ‘topping up’ from the illicit market. The examples above illustrate that the diversion of prescription drugs has costs and benefits, both of which impact on treatment options and the drug-using repertoires of drug misusers whether in or out of treatment. Any policy on diversion
control has the difficult task of balancing these positive and negative impacts, whilst also considering whether it is more concerned with treating drug misusers than preventing a minority selling their prescribed drugs.
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