INDIANAPOLIS - Doctors and pharmacies are coming under the close watch of prosecutors and drug agents who are searching for sources of the pain pills that are fueling opioid addictions and encouraging heroin use in Indiana.

“When you see a problem of this magnitude, you have to act,” said U.S. Attorney Josh Minkler, whose jurisdiction covers two-thirds of Indiana’s 92 counties.

Minkler’s move to put more attention on drug enforcement stems in part from the HIV epidemic emanating from Scott County. The 158 HIV cases reported as of Tuesday have been directly linked to addicts using dirty needles to inject the prescription painkiller Opana.

A report on the Scott County outbreak by the U.S. Centers for Disease Control and Prevention noted the sheer volume of drug abuse there, with addicts shooting up 8 to 10 times a day. Their addictions are fed by painkillers - obtained through doctors or for sale on an underground market - diverted for illegal use.

“It’s gotten our attention,” Minkler said.

The prosecutor said he expects federal civil and criminal penalties to be brought against doctors and pharmacies who violate rules that cover the dispensing of opiate painkillers.

Until now, state investigators and local prosecutors have handled most of the criminal cases. The attorney general has sought to suspend the licenses of 23 doctors accused of over-prescribing painkillers since 2009.

But that’s not been enough, Minkler said.

“We’ll start with education, but if that doesn’t work, we'll turn to civil remedies, and if that doesn’t work, we’ll turn to criminal remedies,” he said.

Minkler said federal drug agents can track the number of prescriptions that doctors hand out and that pharmacies fill to detect who’s generating the most. Unlike local and state investigators, federal agents can reach across state lines to look for sources of prescription pills elsewhere.

State Rep. Steve Davisson, a pharmacist and Scott County native, welcomed Minkler’s plans. Davisson pushed for legislation in 2012 that created tougher rules for physicians prescribing opioids to treat chronic pain. Indiana has seen a 10 percent decrease in opioid prescriptions since then, but Davisson said it’s only put “a dent” in the problem.

“We need a concerted effort between states and feds to stem the flow of it,” he said.

Minkler, a federal drug prosecutor for 20 years before he was named U.S. attorney last year, said he surprised to learn Indiana has ranked among the top 10 states for the number of painkiller prescriptions written and filled.

A CDC analysis found 82 prescriptions written for opioid painkillers for every 100 Americans in 2012. In Indiana, more than 109 painkiller prescriptions were written for every 100 people.

A year later, overdose deaths from prescription drugs hit the 700 mark, according to state health officials. That’s up from about 100 a decade ago.

Heroin deaths are up, too, reported at just over 100 in 2013.

State Public Health Commissioner Jerome Adams, scheduled to testify today (XXX THURSDAY XX) at a Congressional hearing on prescription drug abuse, fears the HIV epidemic in Scott County is masking a larger problem of opioid use.

In written testimony submitted for the hearing, Adams noted officials' “inability to control flow of opioids” into communities like Scott County and the need to improve programs that track prescriptions written by doctors and filled by pharmacies.

He cited the case of a Scott County teenager who was prescribed painkillers for a high school football injury and then became addicted. He’s now 23 and has tested positive for HIV, having shared a contaminated needle with a fellow addict.

“These stories are all too common,” Adams wrote.

Minkler’s decision to narrow the sources of painkillers is also fed by his worries about rising demand for heroin, which has a chemical structure similar to prescription opioids. Prescription painkiller addicts turn to heroin for a cheap and easy high when they can no longer get their hands on pills.

“In small towns in Indiana, painkiller addiction is often the prologue to heroin use,” he said.

Drug agents report an increasing supply of Latin American heroin, shipped from Mexico, passing through the same networks used to distribute other illegal drugs. Street prices of heroin - usually sold in doses of one-tenth of a gram - have fallen as American supplies replace heroin originating in Afghanistan.

In one of the biggest heroin busts in Indiana in recent years, drug agents in March seized 10 kilos of heroin, transported from Mexico.

Pills are more easily tracked. The U.S. Drug Enforcement Administration already has the ability to monitor prescriptions. Indiana Attorney General Greg Zoeller has used that information to go after doctors who take cash to prescribe large amounts of pills.

But Zoeller's powers are often limited to convincing the state Medical Licensing Board to pull the state license of an offending physician. Some of those doctors relocate to other states, he said.

So, Zoeller said he welcomes the attention from federal prosecutors. He's convinced that Indiana will see more overdose deaths from painkillers and heroin, along with more HIV cases in rural communities where opiate abuse is rampant.

“It’s a tidal wave, and we haven’t seen the crest of the wave yet,” he said.

Also welcoming the help is Scott County prosecutor Jason Mounts.

After a series of painkiller overdose deaths in 2011 and 2012, Scott County doctors and pharmacies changed their practices to tightly limit access to painkillers. That pushed users to go doctor-shopping in neighboring counties and states, he said.

“That’s the one piece we’re missing here,” Mounts said. “We can go after the users, but we don’t have the resources locally to go after the doctors and pharmacies handing out these drugs.”

Like Zoeller, Mounts said he worries that an increased crackdown on prescription drugs may lead to increased heroin use.

“I’m sure if we can attack prescription pills, heroin will be our next problem,” he said. “But we have to do something.”

Maureen Hayden covers the Statehouse for CNHI's Indiana newspapers. Reach her at mhayden@cnhi.com.

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