Labor and sex trafficking (collectively referred to as human trafficking) have been identified as a global problem and occurs in most countries, including the United States. Traffickers use force, fraud and other coercive tactics to lure, exploit, and control victims.1 Youth are especially vulnerable to such tactics, particularly those with risk factors such as prior abuse and runaways.2 This article provides insights into what is currently known about the nature and prevalence of sex trafficking in the United States and provides a roadmap for healthcare and security leaders for identifying and responding to sex trafficking victims that present in healthcare facilities. This article does not address victims of labor trafficking as the methods to identify labor trafficking victims are different from those used to identify sex trafficking victims.
While law enforcement officers are the most likely group to identify victims,3 much attention has been focused on training lodging and transportation industry workers to identify trafficking victims. Such training generally involves educating workers to identify victims through awareness of “red flags” ostensibly associated with traffickers and victims. Because many of the red flags are not supported by evidence-based research and these red flags can be exhibited by non-victims, identification of victims is challenging for workers outside law enforcement. However, research indicates that healthcare workers may be uniquely positioned to identify trafficking victims due to their direct, personal interactions with suspected victims.
The first comprehensive law addressing anti-trafficking in the United States is the federal Trafficking Victims Protection Act of 2000 (TVPA). The TVPA established several protective measures for victims of human trafficking. The law provides for federally funded benefits for trafficking victims, regardless of immigration status. The law also provides additional tools for prosecuting traffickers, including stronger penalties for trafficking crimes and mandated financial restitution to trafficking victims.4
There has been a recent trend in civil lawsuits against hotels and motels alleging that such entities benefited financially from sex trafficking. The basis for such claims stems from the 2003 update to the TVPA which opened the door for civil lawsuits to be filed by human trafficking victims not only against their traffickers, but also against “whoever knowingly benefits, financially or by receiving anything of value from participation in a venture which that person knew or should have known has engaged in an act in violation of this chapter.” It is currently unclear how this provision may apply to healthcare entities treating trafficking victims.
Under the TVPA, human trafficking is defined as the exploitation of a person or persons for sex or labor using “force, fraud, or coercion.”5 The TVPA’s definition of “severe forms of trafficking in persons” includes both sex trafficking and labor trafficking, defined as follows:
Sex trafficking is the recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purposes of a commercial sex act, in which the commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age.
Labor trafficking is the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purposes of subjection to involuntary servitude, peonage, debt bondage, or slavery. 6
According to the National Human Trafficking Resource Center (NHTRC) and the TVPA, the Action-Means-Purpose (A-M-P) model is relevant in establishing whether force, fraud, or coercion was present, indicating the encounter was not consensual. According to this model, human trafficking involves three key elements:
an ‘act’ (recruiting, harboring, transporting, providing, or obtaining an individual)
committed by a ‘means’ (force, fraud, or coercion)
for a ‘purpose’ (sexual or labor exploitation).7
Force, fraud, or coercion is the ‘means’ used by traffickers to compel victim to provide commercial sex acts, labor, or other services.8 It can include threats of serious harm to the victim or their loved ones, as well as actual physical abuse or torture.9 Traffickers may use drugs as a form of control over the victim by impairing a victim’s senses, or by creating or fueling addictions.10 In cases involving children, the ‘act’ and ‘purpose’ elements alone are sufficient to constitute trafficking.11 Minors cannot give informed consent, which makes the ‘means’ element irrelevant in cases involving children.12 13
Sex trafficking is a process crime and a crime of economic benefit. As an economic benefit crime, traffickers exploit victims to maximize profits by minimizing labor costs. “To make [human trafficking] riskier, there must be a measurable risk of economic detriment to committing the crime.”14 This is an important consideration for public policy.
As a process crime, sex trafficking is composed of four steps, each of which may occur at several distinct crime scenes and entail numerous underlying offenses. The four steps are:
Deception, or the abduction, or recruitment
In most instances, it is difficult to identify sex trafficking victims. This presents a major challenge for law enforcement and others.16 17 Sex trafficking often involves emotional manipulation, and less frequently, physical abduction. Most often, traffickers use coercion and fraud to maintain power and control over victims.18 Coercion can involve threats, debt, or bondage that fosters a climate of fear and intimidation. Fraud may include false claims of employment, marriage, promises of a better life, or a family.19
As a clandestine crime, sex trafficking is different from other predatory crimes such as robbery. First, robberies are overt crimes and may be seen by witnesses or bystanders, whereas sex trafficking is often invisible to others despite the fact that elements of the crime occur in the open. Second, robbery victims will typically report the crime, whereas sex trafficking victims are less likely to report and may not recognize that they are victims.20 21 In some cases, traffickers may test the “loyalty” of their victims to ensure that they are not trying to seek help.22 For example, a trafficker may send a colleague posing as a police officer to visit the victim to see if he/she reveals any information. Sex trafficking victims may also be reluctant to reveal their exploitation due to a sense of shame, or because they or their families have been threatened with harm.23 In some cases, victims may have bonded with their captors, a condition similar to Stockholm syndrome called “trauma bonding.”24
Sex trafficking and prostitution are often conflated. Prostitution and sex trafficking are not the same.25 While they may look similar, they are quite different. A prostitute makes a choice to provide a service (albeit an illegal service) and keeps all or a significant portion of the proceeds. A sex trafficking victim, on the other hand, is someone who is enslaved and forced to perform a commercial sex act without economic benefit.26 Where prostitution is legal, there is more potential for sex trafficking. Because prostitution in mostly illegal27 in the United States and police actively enforce the laws, “there is no legal veneer under which sex-slave exploitation can take place.”28 In countries where prostitution is legal, brothels may have both prostitutes and sex slaves.
Estimating the prevalence of sex trafficking in the United States has been exceedingly difficult. Much of the existing research has failed to use clear methodologies for producing estimates.29 Moreover, the clandestine nature of sex trafficking makes it a particularly difficult offense to identify and count.30 Traffickers guard their victims closely, and many trafficking victims are hidden in private homes or businesses.31 Victims may also lack any form of identification.32
During the 10-year period from 2007-2017, the National Human Trafficking Resource Center (NHTRC) received 40,200 reports of human trafficking cases in the U.S.33 This number includes both sex and labor trafficking cases. Due to the underreporting of trafficking cases, the actual number of human trafficking cases in the U.S. is likely much higher.
Sex trafficking in Europe and Asia represents up to 45 percent of all human trafficking, while in the United States, the rate is significantly lower at 15 to 20 percent of all human trafficking.34 In the United States, child sex trafficking appears to account for a substantial proportion of all trafficking cases encountered by law enforcement.35 The National Crime Information Center reported that 398,250 minors were missing in the U.S. in 2019.36 However, this figure alone is not a reliable estimate of the scale of commercial child sexual exploitation.37
As discussed earlier, sex trafficking is a process crime with distinct crime scenes.38 First, there is an initial deception, abduction, or recruitment. This may take place anywhere, and a trafficker’s initial contact with victims increasingly occurs online. Second, there is often a need to transport the victim to other locations where he/she is “seasoned,” that is, prepared for commercial sex acts. Transportation may occur on commercial carriers such as airlines and buses. Most often, victims are transported in private vehicles. Third, the exploitation phase requires one or more locations for the commercial sex acts to occur. In the United States, this most often occurs in a private residence. Despite media attention, hotels are not used frequently for sex trafficking because they are not suitable environments as compared to private homes. “Prostitutes who work for pimps or crime networks in hotels are usually former slaves who have accepted a life of prostitution and seek to make as much money as possible. Pimps typically split up to half the payment for sex with hotel prostitutes.”39 Finally, the victim disposal scene may be where the victim was initially picked up, a location near the last place of exploitation, or the victim may be murdered.
Despite growing concern about sex trafficking, existing U.S. laws largely focus on reactive enforcement and service provisions for victims. U.S. businesses where victims are transported or exploited are increasingly incorporating sex trafficking into their worker training programs. Such training has largely focused on increasing awareness and understanding of trafficking to identify potential victims and traffickers, and reporting of suspected trafficking activity.40 To date, however, there has been limited evidence-based research exploring the effectiveness of training and other interventions to prevent trafficking and identify potential victims. 41 42
Civil enforcement is largely focused on holding U.S. businesses accountable for preventing sex trafficking occurring on their property using countermeasures which lack empirical support. For example, “hotels and restaurants are being utilized by traffickers to sustain their illegal operations and infrastructure without clear indication of active facilitation by these industries.”43 While private businesses might be an invaluable resource to law enforcement’s trafficking reduction efforts, research has shown that private businesses are, at best, a supplement to the criminal justice system.44
HEALTHCARE-BASED VICTIM IDENTIFICATION
Several studies have shown that over 80% of human trafficking victims interact with the healthcare system in some capacity while they are being trafficked.45 46 47 Sex trafficking victims may visit healthcare facilities for a multitude of emergent medical conditions including sexually transmitted infections and pregnancy-related issues.48 This provides healthcare workers an opportunity to play a significant role in identifying and responding to potential trafficking victims.49 50 51 A victim-centered approach is important, as each trafficking victim and case is unique.52 Some trafficking victims may not be open to assistance and cannot be forced to report against their traffickers.53 Victims may also be reluctant to share their experience out of fear of their traffickers.
Victim identification may be further confounded by the presence of traffickers with the victim as they enter the healthcare facility. In some instances, traffickers will communicate with clinical staff on behalf of the victim.54 55 Healthcare personnel must be cautious when seeking information from a potential victim. If a trafficker becomes aware that a healthcare provider is suspicious of the situation, the victim may be put in physical danger.56
Sex trafficking victim identification, like workplace violence prevention, involves a multidisciplinary approach. An effective program includes victim identification protocols, clinical staff training, screening tools, supplemental screening, clinical indicators, examination, safety considerations, and victim assistance. Privacy, communications, documentation, and legal aspects must also be considered.57
All direct patient care staff should receive trafficking victim identification and response protocol training.58 59 While researchers recommend that healthcare staff receive training in trauma-informed approaches for identifying and managing sex trafficking victims, there has been little research examining the effectiveness of such programs. “Although many training programs and resources are available, most lack any evidence of effectiveness, have not been published in the peer-reviewed literature, and very few have examined behavior changes as a result of training and education.”60
Victim identification may be further enhanced by providing anti-trafficking training to Emergency Medical Service (EMS) workers. These workers are likely to see patients in environments where victims may be living and where they may be trafficked. This affords EMS workers with a unique perspective of assessing not only the patient, but also their environment. Some of the environmental conditions that may be observed by EMS workers include a large number of people living in a small space, sex toys and condoms, and the absence of personal belongings.61 EMS workers also have the opportunity to temporarily load the suspected trafficking victim on the ambulance to confidentially screen the suspected victim outside the presence of others, such as the trafficker.62
Healthcare workers are most likely familiar with screening tools used to identify suicidal patients. In more recent years, healthcare workers have increasingly become accustomed to using homicidal screening tools which identify patients that are at risk of harming others. Similar screening tools can be used to identify potential sex trafficking victims. Only a few trafficking victim screening tools have been validated.63
Vera Institute's Trafficking Victim Identification Tool (TVIT), a validated social service instrument to screen adults for human trafficking, can take 60 min to administer and requires a human trafficking expert for interpretation.64 The Human Trafficking Interview and Assessment Measure (HTIAM-14), a validated screening tool to evaluate for trafficking among the homeless young adult population, can take up to 45 min to administer and also requires an interviewer with human trafficking expertise.65
In a recent paper published by the International Association for Healthcare Security and Safety Foundation, the following screening questions to identify sex trafficking victims were suggested:
Have you been to see a nurse, doctor or other health provider in the last year?
Have you ever broken any bones or had any cuts that needed stitches?
Have you ever been knocked unconscious (“knocked out”)?
Have you ever run away from home or been ‘kicked out’ of your home?
Have you used drugs or alcohol in the last 12 months?
If yes, do you remember how old you were when you first tried alcohol or drugs?
Have you ever had any problems with the police?
Has a boyfriend or girlfriend in a dating or serious relationship ever physically hurt you or threatened to hurt you (hit, pushed, kicked, choked, burned or something else)?
Have you ever had sex of any type?
If yes, when you had sex, what did it involve (vaginal, anal, oral)
Since the first time you had sex, how many partners have you had?
Which of the following best describes you? (Heterosexual (straight), Homosexual (Gay or Lesbian), Bisexual, Transgender, Not sure
Have you ever had any sexually transmitted infections, like herpes, gonorrhea, chlamydia or trichomonas?
Have you ever traded sex for money, drugs, a place to stay, a cell phone, or something else?
Has a boyfriend, a girlfriend or anyone else ever asked you, or forced you to have sex with ANOTHER person? (If asked, did you have to actually do it?)
Has anyone ever asked or forced you to do some sexual act in public, like dance at a bar or a strip club? (If asked, did you have to actually do it?)
Has anyone ever asked you to pose in a sexy way for a photo or a video? (If asked, did you have to actually do it?)66
Likewise, clinical workers should be cognizant of physical indicators during their questioning of suspected victims. While these indicators are often exhibited by non-victim patients, coupled with the screening questions above and the physical examination described below, they may supplement the trafficking victim identification protocol. The indicators include:
Inconsistent history or a history that appears coaxed. May be difficult to determine if a language barrier is present.
Resistant to answer questions about the injury or incident.
Avoids eye contact, is nervous, fearful of touch.
No idea of address or general area where they live.
No control over their finances and lacks decision-making capacity.
Accompanied by a controlling companion or family member that refuses to let the patient speak for themselves or be alone for care or insists on being the translator.
Exhibits bizarre, hostile behavior. Resistant to care and assistance. May have initially consented but changes mind after asked to undress for an exam.
No identification or the companion has it in their possession.
Under age 18 and involved in a commercial sex act.
Tattoos or branding signs. Markings may say "daddy" "for sale," imply ownership, or read as an advertisement for a product.
Multiple sex partners.
Inappropriate attire for the environmental conditions of the area.
Attempt to reason away bruises or ligature marks by claiming a bruising or rare blood disorder.
Silent, afraid to speak, cringes at the sound of a loud voice.
Uses trafficking "lingo" such as "the life" or other words common in the commercial sex industry.
Has addiction issues such as opioids.
Admits to a forced sexual encounter or being forced into sex acts.
Has a cover story to avert suspicion, but details may vary or be inconsistent with a query. Law enforcement may refer to this as a "legend."67
Clinical workers should also be looking for mental health indicators exhibited by potential trafficking victims, such as such as depression, suicidal ideations, self-mutilation injuries, anxiety, post-traumatic stress disorder (PTSD), and feelings of shame or guilt. Such indicators can be missed or associated with other mental health disorders, so behavioral red flags such as adopting third party viewpoints, emotional numbness, and detachment may be survival mechanisms.68 Potential victims may also present with addiction issues, as traffickers can use addiction to control their victim. Victims may also fuel their addictions to cope with their circumstances.69
Supplemental Screening Techniques
As in cases of intimate partner violence, providers can create opportunities to separate patients from a family member or controlling individual and provide opportunities for them to report trafficking crimes. For example, providers can notify the individuals accompanying the patient that it is hospital policy to interview and examine all patients alone.70 Providers can also ensure patients are unaccompanied by controlling individuals when going to radiology scans or to a bathroom for urine samples.71 A staff member trained in human trafficking should be available to accompany the patient. 72
The healthcare facility can also implement tools to encourage victims to give non-verbal signals. For example, signage in patient-only bathrooms can instruct victims to flip a sign over, affix a colored dot to a urine collection cup, leave a note, etc. Such signals can indicate to staff that the patient should be screened in a safe area.73 Healthcare providers can also develop triggers for screening when patients exhibit health symptoms common among trafficking victims, such as urinary tract infection, pelvic or abdominal pain, suicide attempt, or psychogenic nonepileptic seizures during the health assessment.74
Unless a potential victim leaves the healthcare facility against medical advice or before triage, a head-to-toe physical examination, without the trafficker present, will take place. This element of the victim identification program is critical for identifying victims and provide an opportunity to interview the victim in private. Clinical staff should ask direct and open-ended questions and avoid accusatory questions.
Once the physical examination is underway, the following conditions may arouse suspicions, but alone, may not be sufficient to accurately identify a victim:
Bruising; old, healing or new lacerations; hematomas; signs of acute or chronic head trauma or a headache; missing hair or bald spots.
Trouble hearing; damage to the auditory canal or eardrum; signs of trauma to the oropharynx such as lacerations or burns, blood in the mouth, ulcerations, tooth decay, broken teeth, gingival irritation, tongue abnormalities; signs of anemia or dehydration in the oral mucosa.
Visual defects, sudden or of gradual onset; tattoos or brands in the hairline or on the neck; signs of strangulation such as bruising.
Signs of chest trauma, murmurs; cigarette burns; tattoos that imply ownership; bruising in various stages of healing; signs of stress-related cardiovascular issues such as arrhythmias or high blood pressure.
Respiratory issues that would indicate inhalation injuries from chemical exposure, toxic fume exposure, asbestos exposure, or mold exposure.
Signs of tuberculosis such as night sweats, coughing up blood, fever, weight loss.
Signs of stress-related respiratory or gastrointestinal problems.
Damage to lung tissue due to prolonged exposure to chemicals or pesticides, aspiration pneumonia or other inhalation injuries; meth lab exposure can produce burning to the eyes, nose, and mouth, chest pain, cough, lack of coordination, nausea, and dizziness.
Hypothermia or hyperthermia from environmental exposure from working in damp, cool, poorly insulated factories or buildings; mold exposure signs/symptoms.
Signs of gastrointestinal issues such as nausea, vomiting, diarrhea, constipation, or abdomen pain; rectal pain, itching, trauma or bleeding; parasites in the feces or signs of abdominal trauma.
Bruising to the back or scarring; tattoos that imply advertisement, ownership, or are sexually explicit in the pubic hair.
Obstetrical and gynecological complaints such as sexually transmitted infections or recurrent STI’s (An STI, especially if recurrent, in a minor may be the first and only sign of sexual abuse; repeated unwanted or unplanned pregnancies or forced abortions; anogenital trauma; evidence of retained foreign bodies such as in the vagina from packing during menstruation, vaginal bleeding, discharge, rashes, itching, signs of injury or forced sex.
Number of sexual partners; condom use; genitourinary symptoms present such as burning, frequency, odor, dark urine or history of frequent urinary tract infections.
Signs of bruising or lower back scarring from repeated beatings; musculoskeletal issues such as signs of
repetitive trauma; work-related injuries or injuries such as back problems from wearing heels for hours walking
the streets or neck and jaw problems from frequent, forced oral ses.
Fractures, old or new, any contractures. Cigarette or scald burns. Ligature marks/scars around ankles or wrists.
Signs of scabies, infestations (scalp or body). Impetigo. Fungal infections.
Signs of nutritional deficits such as Vitamin D deficiencies from lack of exposure to sunlight, anemia, mineral deficiencies, brittle or fine hair.
Signs of anorexia, bulimia, loss of appetite, malnutrition, severe electrolyte abnormalities.
Children may have growth and development abnormalities and dental cavities or misaligned poorly formed teeth.
Neurological issues such as seizures, pseudo-seizures, numbness or tingling, migraines, inability to concentrate, vertigo, unexplained memory loss, seizures.
Insomnia, nightmares, waking up frequently.
Signs of opioid or other addiction.75 76
Once a victim is suspected or identified, safety protocols should be implemented for both healthcare workers and the trafficking victim. The healthcare facility likely has similar protocols for domestic violence and child abuse patients. In the latter instances, the domestic partner or parent/guardian may be present and may become violent. For trafficking victims, the trafficker or his/her surrogate may have brought the trafficked person to the healthcare facility and may remain on-site during the medical examination.
Security Officers should be notified immediately to implement enhanced safety protocols. Security Officers should first determine if the suspected trafficker is on-site or expected to return. Trained clinical staff should continue to be the primary people to communicate with the victim, not security.
Local police should also be notified so they can respond prior to discharging the patient victim.77 Police have greater resources to protect the victim’s family if they have been threatened by the trafficker.78 If the patient victim must be discharged or refuses to await law enforcement, healthcare workers can assist the victim in locating a safe place to go upon discharge and provide the victim with the National Human Trafficking Hotline.79 80
A social worker should take the lead in assisting the victim once medically cleared.81 Victims will likely have immediate needs that social workers can source, such as external resources which provide housing, food, mental health services, and legal services.82 The National Human Trafficking Resource Center (NHTRC) also has resources that the social worker can draw upon to assist the victim.83 It is important to remember that the clandestine and transitory nature of trafficking will likely mean that the victim is not from the local area, whereas social workers have local contacts that can assist trafficking victims at local rape crisis centers, women's shelters, homeless shelters, addiction centers, and churches.84
Communications between healthcare providers and potential trafficking victims should focus on establishing a rapport and building trust with the victim. The U.S. Department of Health and Human Services as part of their Rescue and Restore Campaign in 2016 created a resource called Messages for Communicating with Victims of Human Trafficking to assist healthcare providers in promoting a trusting environment and building a rapport with victims.85 It is also important to create a safe, private environment that builds trust and gives the victim a sense of power and control.86 Behavioral tools such as eye contact, a calm demeanor and a measured tone can also help put the victim at ease.87
Privacy and Legal Considerations
A patient’s privacy rights under the Health Insurance Portability and Accountability Act (HIPAA) must be considered before reporting to the NHTRC. With limited exceptions, a healthcare provider must get permission from an adult trafficking victim before releasing any protected health information (PHI) or personally identifiable health information.88
Once a patient discloses that they are a victim of human trafficking, there may be legal reporting requirements.89 For minor sex trafficking victims under age 18, mandatory state reporting laws for child abuse and institutional child abuse policies should be followed.90 91 Each state has different mandatory reporting laws that generally require providers to report any minors suspected of being trafficking victims, or risk being in violation of the law.92 Healthcare providers and security professionals should be aware of the mandatory reporting laws in their respected state and understand how they relate to human trafficking identification and response. 93
Conspiracy laws can also potentially put healthcare providers and hospitals at risk for failing to identify trafficking victims.94 The 2008 updates to the TVPA specified that civil lawsuits may be filed against anyone who “knew or should have known” that sex trafficking occurred and financially benefited.95 Courts have stated that businesses that knowingly witnessed or financially benefitted from a crime can be liable, though it is currently unclear how these statutes may apply in a healthcare setting.96
As evidenced by the research summarized in this article, healthcare and security leaders have a role to play in reducing the volume of sex trafficking in the United States. Healthcare facilities should develop Human Trafficking Identification and Response Programs using available resources from The Joint Commission,97 the U.S. Department of Health and Human Services,98 the American Hospital Association,99 and the International Association for Healthcare Security and Safety Foundation.100
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Natasha Jouk, Ivana Capin, Jordan Greenbaum, and Dana Kaplan, Recognizing Suspected Human Trafficking in the Pediatric Intensive Care Unit, Journal of Human Trafficking (2021), DOI: 10.1080/23322705.2020.1862614
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Nic McKinley, Founder of Deliver Fund, from Cleared Hot with Andy Stumph Podcast, Episode 171, March 8, 2021.
Quincy C. Miller, Kristina Todorovic, Christina O. Perez, Amy L. Capparelli, and Kamala London, Laypeople’s Knowledge and Misconceptions of Sex Trafficking Influenced by Training Formats, Journal of Human Trafficking, (2021) DOI: 10.1080/23322705.2020.1865767
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Karim H. Vellani
Karim H. Vellani is the President of Threat Analysis Group, LLC, an independent security consulting firm. Karim is Board Certified in Security Management (CPP), a Board-Certified Security Consultant (CSC), has over 26 years of security management, crime analysis, and forensic security consulting experience, and has a master’s degree in Criminal Justice Management. He is the author of two books, Applied Crime Analysis and Strategic Security Management (1st and 2nd Editions), and has contributed to a number of other security related books and journals. Contact Karim at (281) 494-1515 or [email protected].
Tina S. Kristof, Esq.
Tina S. Kristof, Esq., is a healthcare attorney in Houston, TX. Tina earned her JD with a health law specialization from Boston University School of Law and is admitted to practice law in TX, CA, and MA. She has served as Assistant General Counsel for Walmart Stores, Inc., Staff Attorney at Donoghue, Barrett & Singal, and Health Policy Manager at Wellpoint Health Networks. Kristof has authored two research papers for the IAHSS Foundation: Issues and Trends in Health Care Security Litigation and Methods, Trends and Solutions for Drug Diversion. Contact Tina at [email protected].