JMO, a psychiatrist from Barcelona with more than three decades of clinical experience, received a call two years ago from a pharmacy in Castellón. “They had a client with a ‘dubious’ prescription for Rivotril 2mg made with my supposed signature. They asked if he was my patient. He wasn’t. They had copied a private prescription and ordered a stamp with my name and registration number to falsify everything,” he says.
Spanish pharmacies and surgeries are, involuntarily, one of the two ends of the long chain of illegal trafficking of clonazepam, a powerful anxiolytic also used against epilepsy, whose best-known brand name is Rivotril. The other end is made up of the working-class neighborhoods of Moroccan cities, where the drug is mixed with hashish to make a coveted drug called carkubi.
The profits obtained by the mafias are colossal: a box of 60 two-milligram Rivotril tablets costs 3.12 euros in Spanish pharmacies – much less if the prescription is public – while on the other side of the Strait a single tablet sells for more than 10 euros (more than 600 euros per box). An estimate made by the police for EL PAÍS six years ago calculated that the profit obtained by these organised groups was “more than 100 million euros a year”.
“It has been one of the biggest problems we have faced in recent years,” admits Raquel Martínez, general secretary of the General Council of Colleges of Pharmacists, who details the successive measures deployed. As the use of stolen public health prescription pads was initially common, the Ministry of Health imposed the exclusive use of electronic prescriptions.
The same measure has been adopted for patients of MUFACE civil servants’ mutual funds (and also ISFAS and MUGEJU) who choose to be treated in the public health system. And those who opt for the private system are moving in the same direction: nearly half of the communities have already developed a similar electronic system, while the Ministry of Health has imposed since January 1 that, when there is no electronic prescription, a validation system in person must be complied with in which the patient must “Go to your Provincial MUFACE Service with the paper prescription signed by a certified doctor as well as a report of the latter, and there the validation will be carried out in person,” explains the mutual society’s website.
The Achilles heel of the system remains, as far as control of clonazepam trafficking is concerned, the entirely private prescriptions, although steps are being taken at this level as well. “I no longer work with paper prescriptions, but with a system developed by the College of Physicians [también el de Farmacéuticos] which sends the prescription electronically to the patient with a QR code that ensures that only he can pick it up and that it is single-use,” explains JMO. This system is advancing, albeit slowly, in several provinces.
The illegal trafficking of Rivotril took a turn for the worse in 2016. On January 7 of that year, a routine check by the Civil Guard in Ceuta discovered more than 26,000 2mg tablets of the drug in a car coming from Algeciras. “We were surprised by the size of the stash and that all the pills were the same. Until then, smaller seizures of different drugs had been the norm,” sources from the Civil Guard explained to EL PAÍS. It was a sign that the mafias had set their sights on the drug and that the 2-milligram tablets were their favourites (there are others with less active ingredient, 0.5 and 1 milligrams).
At that time, clonazepam sales in Spain began to skyrocket. In the Community of Madrid alone —with 3,000 of the 22,000 Spanish pharmacies and 14.6% of the country’s population—, sales of Rivotril 2mg rose from 75,000 boxes in 2015 to 160,000 in 2017. That is, they multiplied by 2.1 in just two years without there being any changes in clinical activity to justify it.
The data of the consulting firm specializing in the pharmaceutical sector IQVIAwhich began in 2018, also showed a spectacular jump in the last years of the past decade. Between July 2018 and June 2019, sales in Spain of all presentations of clonazepam amounted to 1.6 million boxes. In the following 12 months, the units served shot up to 3.4 million, 112.5% more in just one year.
Since then, the trend has been slightly upward, with some sharp peaks, but basically stable: 3.6 million in the 12 months prior to June 2021, 3.9 million in 2022, 3.7 million in 2023 and again 3.9 million in the month ending on June 30. In other words, the large increase that occurred between 2015 and 2019 has been halted, but the number has not dropped to previous levels.
“Our perception is that all the measures taken are bearing fruit and that, to a large extent, they are preventing pharmacies from selling units outside the legal circuit. The pharmacist provides all the professional value in custody and dispensing. The slight increase in recent years is probably due more to the increase in population in Spain and the use of psychotropic drugs observed after the pandemic,” says Raquel Martínez. The general secretary of pharmacists is in favour of the universalisation of electronic prescriptions as the best measure to end fraud: “The paper format is much more vulnerable. We think that prescribers should be required to use electronic prescriptions, at least for medicines such as Rivotril.”
Sources from the National Police agree with this assessment. “Organised groups are increasingly having problems getting clonazepam out of pharmacies with false prescriptions. It continues to happen, but it is more complicated, so now they have gone up a notch and put the focus on distribution channels through robberies or other strategies,” these sources say.
The data that reaches the congresses of the sector continues to show, despite the improvements, the persistence of the problem. A study presented by pharmacists of the Superior Corps of Sanitary Inspection of the community of Madrid in the 23rd National Pharmaceutical Congress, held last February in Valenciafocuses on “investigating prescriptions for drugs diverted to non-therapeutic uses”. Between November 2020 and September 2023, the authors detected in the sample studied and by various methods a total of “5,666 prescriptions (339,960 tablets).
The study of prescriptions shows that “doctors are often unaware of the fraudulent use of their data” and that in many cases the prescriptions (the study includes some years prior to the extension of electronic prescriptions) “tend to be stolen and with similar handwriting, which leads one to think of an organized network and illicit marketing that brings great economic benefits.”
Pharmacists are well aware of the modus operandi of groups that, armed with false prescriptions – increasingly better copies of the real ones – try to illegally obtain boxes of clonazepam. “Most of the time you can see them coming by the way they act, how they react when asked for their ID… They arrive in an area and go to several pharmacies,” explains Raquel García Fuentes, president of the College of Pharmacists of Zaragoza. This college is one of the first to have established a protocol on how to act when suspecting that the prescription on the counter is false.
“The pharmacist’s safety comes first, so if the situation may involve any risk, or it is impossible to verify that it is a false prescription at the time, the medication is dispensed and the College is immediately notified, to whom all the data is provided,” explains Raquel García Fuentes. It is then the College that, with all the information, contacts the police to clarify the case and, if necessary, take legal action.
JMO, who has seen his prescriptions falsified five times in the last four years, regrets the burden this places on doctors. “You have to go and file a complaint with the police, give a statement and, in the end, a few months or years later, go to court, which can be in a province hundreds of kilometres away. It is something common among my colleagues. I have always been surprised by the ease with which a person can obtain a stamp with our details and membership numbers without being asked to identify themselves to obtain them,” he concludes.
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