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DRUG DIVERSION TRAINING

NOAH CARPENTER, MD

Dr. Noah Carpenter is a Thoracic and Peripheral Vascular Surgeon. He completed his Bachelor of Science in chemistry and medical school and training at the University of Manitoba. Dr. Carpenter completed surgical residency and fellowship at the University of Edmonton and Affiliated Hospitals in Edmonton, Alberta, and an additional Adult Cardiovascular and Thoracic Surgery fellowship at the University of Edinburgh, Scotland. He has specialized in microsurgical techniques, vascular endoscopy, laser and laparoscopic surgery in Brandon, Manitoba and Vancouver, British Columbia, Canada and in Colorado, Texas, and California. Dr. Carpenter has an Honorary Doctorate of Law from the University of Calgary, and was appointed a Citizen Ambassador to China, and has served as a member of the Native Physicians Association of Canada, the Canadian College of Health Service Executives, the Science Institute of the Northwest Territories, the Canada Science Council, and the International Society of Endovascular Surgeons, among others. He has been an inspiration to youth, motivating them to understand the importance of achieving higher education.

DANA BARTLETT, RN, BSN, MSN, MA, CSPI Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 25 years at a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, written textbook chapters, and done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely on the subject of toxicology and was a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center.

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ABSTRACT Drug diversion can take many forms and there are common ways in which drugs are diverted. As the availability and scope of prescription drugs have expanded to include a range of opiates, non-opiate depressants, stimulants, and potent cold medicines, so too have the misuse of these substances and the tendency to use them recreationally. It is important for all members of the interdisciplinary health team, including prescribers, pharmacists, and nursing staff, to be aware of the different strategies for drug diversion as well as the common characteristics of patients or coworkers with a substance use disorder. There are also preventative measures that healthcare facilities and clinicians may or must use to help reduce the incidence of drug diversion. These include organizational policies mandated by the U.S. Department of Justice and the Drug Enforcement Agency, prescription drug monitoring programs, Federal guidelines for proper storage and security regarding controlled substances, and guidelines for ordering, prescribing, preparation and dispensing of prescription drugs or controlled substances.

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Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. Continuing Education Credit Designation This educational activity is credited for 3 hours at completion of the activity. Statement of Learning Need Increasingly, all members of the interdisciplinary health team are required to update their knowledge and practices to recognize and prevent drug diversion. Current federal and state laws require health administrators to develop drug diversion prevention programs that include mandatory training by all members of the interdisciplinary health team to recognize and report a substance use disorder and suspected drug diversion activities. Course Purpose To provide knowledge for all members of the interdisciplinary health team who are expected to be compliant with the regulation of controlled substances, and to recognize and report the signs of drug diversion. Target Audience Advanced Practice Registered Nurses, Registered Nurses, and other Interdisciplinary Health Team Members. Disclosures Noah Carpenter, MD, Dana Bartlett, RN, BSN, MSN, MA, CSPI, Kellie Wilson, PharmD, William Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures. There is no commercial support.

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Self-Assessment of Knowledge Pre-Test: 1. Drug diversion is best understood as a medical and legal concept

involving the transfer of any legally prescribed substance a. to the intended patient who then misuses it. b. that is on the Controlled Substance schedules. c. from the individual for whom it was prescribed to another person. d. that has no medical purpose.

2. True or False: Dextromethorphan is a medication that is used to

reduce or suppress coughs associated with common viruses. a. True b. False

3. Individual drug diverters may include

a. patients. b. healthcare workers. c. drug dealers and drug addicts. d. All of the above

4. Fentanyl is an ________ and it is frequently diverted.

a. opioid b. stimulant c. benzodiazepine d. depressant

5. ________________________, which are common ingredients in

many over-the-counter cold medicines, are common ingredients in the manufacture of methamphetamine.

a. Opioids b. Stimulants c. Central nervous system depressants d. Pseudoephedrine and ephedrine

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Introduction

The increase in the availability of prescription drugs has led to an increase in diversion. Drug diversion is an illegal act. Drug diversion is a potential threat to patients who are the intended recipients of diverted drugs, individuals diverting drugs, and individuals who receive and misuse the diverted drug. Healthcare professionals who divert drugs are not only at risk of personal, physical harm from misuse of the drugs but they may also suffer loss of a professional license or face criminal prosecution. In order to address this problem, medical professionals need to know what constitutes drug diversion. They also need to know which class of drugs and specific drugs are commonly diverted, how they are diverted, and common profiles of drug diverters. There are prevention strategies that healthcare facilities must or should implement to reduce drug diversion. If a coworker is suspected of diverting drugs, the other team members need to know how to approach the coworker and when they must report drug diversion. Finally, there are recovery programs for healthcare diverters. The goal here is to reduce the incident of drug diversion.

Drug Diversion and the Scope of the Problem

“Drug diversion is a medical and legal concept involving the transfer of any legally prescribed substance from the individual for whom it was prescribed to another person.”1 Prescription drug diversion often involves redirecting controlled substances but diversion may include non-controlled substances.2,3 Diversion of non-controlled substances is rising.2,3

Prescription drug misuse and diversion are serious problems that may affect the intended beneficiaries of drugs, harm the public and cost programs like Medicare significant amounts of money.2 For the healthcare professional, drug misuse and diversion can have a profound impact on the professional’s career. A healthcare professional who is caught diverting drugs may face criminal prosecution, civil liability, as well as suspension or loss of his or her professional license.4

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People have various motivations for drug diversion. Drug diversion certainly occurs when people have a substance use disorder and they want to alter their consciousness but many drug diversions occur for profit or because someone wants relief from physical pain.2

Drug Diversion and the Opioid Epidemic

The opioid crisis in the U.S., has been attributed to aggressive prescribing practices and the prevalence of opioid misuse.5 Drug diversion has played a major role in the opioid epidemic as well. This has led to increases in opioid overdose-related deaths.5

The Substance Abuse and Mental Health Services Administration and

the National Center for Health Statistics reported that during 2016, about 11.5 million people misused prescription opioid pain relievers.6 In spite of the attention to this epidemic, and the efforts to control the misuse of opioids, the data shows that these numbers are continuing to rise.6

Drugs that are Commonly Diverted

There are different classes of drugs that are commonly diverted worldwide. They are benzodiazepines, opioids, stimulants, antipsychotics, anesthetics, and GABA agonists.7 Within these classes, specific drugs are the usual targets of the diverter. These are listed in Table 1.7

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TABLE 1: COMMONLY DIVERTED DRUGS7

Class Drugs

Benzodiazepines all (e.g., alprazolam, diazepam)

Opioids all (e.g., fentanyl, oxycodone)

Stimulants dexamphetamine pseudoephedrine methylphenidate

Antipsychotics olanzapine quetiapine

Anaesthetic drugs ketamine propofol

GABA agonists gabapentin pregabalin

According to the U.S. Drug Enforcement Administration, there are five classes of drugs that are most commonly misused in the United States: opioids, antidepressants, hallucinogens, stimulants, and anabolic steroids.1

Analgesics and antiretroviral drugs are also diverted and misused.8 Other over-the-counter medications are diverted for use in the manufacture of illegal drugs.9

Some classes of drugs play a more prominent role in drug diversion. In some cases, a class of drugs will impact a certain population (e.g., stimulants and adolescents) more than others. Opioids

Opioids are a group of controlled substances that include a number of the prescription painkillers on the market. Opioid abuse is a major driver for individuals to divert prescription drugs. Opioids that are commonly prescribed include fentanyl (Duragesic®), hydrocodone (Vicodin®), oxycodone (OxyContin®), oxymorphone (Opana®), propoxyphene (Darvon®),

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hydromorphone (Dilaudid®), meperidine (Demerol®), and diphenoxylate (Lomotil®).10 The most commonly diverted opioid is fentanyl.1,11 It is also one of the most potent opioids. Fentynal is a leading cause of death due to opioid overdose.1 Other opioids that are diverted and misused include “morphine, oxycodone, methadone, and other hydrocodone combinations.”1 Individuals involved in the diversion or misuse of opioids prefer the immediate-release opioids.12 The immediate-release opioids are popular because they account for most of the U.S., market share, and they are faster acting than the extended-release opioids.12

Benzodiazepines

Benzodiazepines are a class of psychoactive drugs. The U.S. Drug Enforcement Administration provides its list of benzodiazepines that are commonly misused in the U.S. They include alprazolam, clonazepam, and lorazepam.1 Benzodiazepine misuse can lead to adverse health effects and benzodiazepine use disorders; however, it is not common for users to meet criteria for benzodiazepine use disorder.13 Clinicians need to establish screening tools to identify individuals who are misusing benzodiazepines or who may have a benzodiazepine use disorder.13

Antipsychotics

The U.S. Drug Enforcement Administration provides its list of antipsychotics that are commonly misused in the U.S. They include aripiprazole, ziprasidone, risperidone, quetiapine, and olanzapine.1

Stimulants

Stimulants are frequently prescribed to treat attention deficit hyperactivity disorder (ADHD).14 These ADHD drugs include combination agent amphetamine-dextroamphetamine and methylphenidate.14 Diversion of stimulants prescribed to treat ADHD are a frequent choice of adolescents. Adolescents misuse prescription stimulants because of the high they experience with stimulants.14 Stimulants are also used nonmedically by

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adolescents who seek to increase alertness, improve concentration and school performance, or to enhance highs from other drugs.14 Stimulants are Schedule II drugs, and as such, they have a high potential for abuse.14

Analgesics and Antiretroviral Drugs

People living with HIV are commonly prescribed analgesics and antiretroviral drugs to treat their pain and symptoms. The growth in prescriptions to treat these patients has also provided an opportunity for diversion of these drugs. There is a “high prevalence of prescription drug diversion for analgesics and antiretroviral drugs” among this population.8

Other Medications

Pseudoephedrine and Ephedrine: Pseudoephedrine and ephedrine are common ingredients in many over-the-counter cold medicines. They are not typically misused but they are common ingredients in the manufacture of methamphetamine.9 Therefore, many individuals attempt to divert large quantities of these ingredients through the purchase of over-the-counter cold medicine, and many states require online tracking of pseudoephedrine products and several require identification and signing of a log book before pseudoephedrine- containing products will be sold.15

Dextromethorphan: Dextromethorphan is a medication that is used to

reduce or suppress coughs associated with common viruses. It is part of a classification of drugs called antitussives and works by halting activity in the portion of the brain that causes coughing.16 Dextromethorphan is used in a number of over-the-counter cough suppressants and expectorants, and there are dozens of over-the-counter cough and cold products that contain dextromethorphan.16

When consumed in large quantities, dextromethorphan can cause

psychotropic responses like coma, disorientation, drowsiness, and hallucinations. While dextromethorphan is not generally considered high risk

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for substance use disorder, it is widely misused, and chronic users can develop a withdrawal syndrome.16 Regulation of Other Medications

Because of the potential misuse of over-the-counter medications, the Drug Enforcement Agency (DEA) has established regulations for their purchase and use. The purchase and use of these ingredients has become a significant problem. For example, the DEA has established guidelines specific to the distribution of pseudoephedrine or ephedrine.17 According to federal regulations, each handler (regulated person) is required to report to the DEA Special Agent in Charge of the local DEA office such information as involves any regulated transaction of the following:17

● An extraordinary quantity of EPH [ephedrine] or PSE [pseudoephedrine], an uncommon method of payment or delivery, or

● Any other circumstance that the regulated person believes may indicate that the EPH or PSE will be used in violation of the Controlled Substances Act.

● Any proposed regulated transaction with a person whose description or other identifying characteristic the DEA has previously furnished to the regulated person.

● Any unusual or excessive loss or disappearance of EPH or PSE under the control of the regulated person. The regulated person responsible for reporting a loss in-transit is the supplier.

In addition to the above regulations, it is unlawful for any person

knowingly or intentionally to possess or distribute ephedrine or pseudoephedrine, knowing, or having reasonable cause to believe, ephedrine or pseudoephedrine will be used to manufacture methamphetamine illegally.17

Common Forms of Drug Diversion

Common forms of drug diversion include drug-seeking behaviors, also

called “doctor shopping,” falsified or altered prescriptions, and through theft

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of a patient’s prescription drugs by a family member, friend or other person outside a healthcare facility. Drug diversion may also be accomplished through direct theft of prescription drugs from a healthcare facility by a staff member. Drug-seeking Behavior

One way a patient will obtain prescription drugs to divert or misuse is through a behavior known as “doctor shopping.”18 A patient who doctor shops tries to obtain prescriptions from “multiple prescribers without their coordination or knowledge.”18

A patient may doctor shop to obtain a medication for his or her use. For example, a patient may seek a prescription for a benzodiazepine so he or she may take a higher dose than prescribed to experience a “high” or euphoric feelings.19 This does not fit the definition of drug diversion above because it is not “the transfer of any legally prescribed substance from the individual for whom it was prescribed to another person.”1 This conduct, however, does constitute misuse of a prescribed drug.19

Alternatively, a patient may doctor shop to obtain a prescription drug to

sell illegally or to give to a person other than the patient named in the prescription.19 This conduct constitutes drug diversion.1 One study evaluated insurance claims data to determine if there is a correlation between opioid use disorder and doctor shopping.18 The study found no correlation and the authors suggested that many people who doctor shop may not have an opioid use disorder.18 Does this imply that most people who doctor shop are more likely to divert the drug than use it personally?

Doctor shopping is difficult to track and prevent.20 The difficulty lies partly in the fact that a healthcare professional must try to distinguish between a legitimate need for a medication and the patient who is seeking a prescription for an illegal purpose.20 This problem is particularly difficult when a patient is complaining of acute or chronic pain and is seeking an opioid or other drug to treat the pain. The healthcare professional must be able to understand and identify the signs, symptoms, and treatment of acute or

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chronic pain and distinguish them from the signs and symptoms of a patient who seeks the medication for an illegal purpose.20

Healthcare providers must monitor individual patients in order to control

this form of drug diversion. There are common characteristics that distinguish drug-seekers from other patients. There are also strategies a healthcare provider may use to identify these individuals.

Drug diverters can be anyone but there are some defining characteristics. As mentioned above, people who drug-seek make frequent visits to multiple health providers, emergency rooms and pharmacies: If a drug-seeker is unable to obtain a prescription from one provider, then another provider will be sought and the process will be started again.20 They often complain of multiple ailments that would warrant the prescription of specific drugs.19 These include migraines, toothaches, psychiatric disorders, backaches, and other forms of chronic physical pain; these complaints are often used by drug-seekers because they are subjective and the absence or presence of a true medical or dental condition that is causing these types of pain conditions is not easily verified.19,20

Some drug-seekers will avoid using insurance to pay for a prescription to limit the record of the transaction but one study found utilized insurance databases to determine if there was a pattern for possible opioid shoppers that could be used to identify them.18

There are characteristics common to drug-seekers. They may claim to be in the area visiting friends or relatives. Others who drug-seek or doctor shop will claim their prescription drugs were stolen, or they lost or forgotten them.21 They may claim to have accidentally destroyed their pills21 (e.g., dropping them in the toilet). People who drug-seek will often arrive after office hours or seek an appointment toward the end of regular hours.21

When drug-seekers are at a health provider’s office, they may provide

specific descriptions of symptoms but give a vague medical history; they may provide old medical records or X-rays (often from an out-of-state provider) to

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validate their request; they may decline a physical exam or authorization to acquire past records or to perform diagnostic tests; and they may be unable or unwilling to provide the name and contact information of their regular doctor.21

Furthermore, drug-seekers tend to have an exceptional knowledge of opioid medications. They may claim to be allergic to nonopioid medications or claim that nonopioids provide unacceptable pain control.21 If a healthcare provider challenges or questions patients who give vague, incomplete information, this may cause them to become agitated. They may try to pressure the provider with threats or by eliciting guilt or sympathy.21 False or Altered Prescriptions

Many drug diverters will obtain prescription drugs using altered prescriptions or by calling in a false prescription.22 Common practices include altering a prescription that was issued legitimately, printing prescription pads with a licensed, healthcare provider’s name but using a fake call-back number that is answered by an accomplice when the pharmacy calls to verify the prescription, a patient calling in his or her prescription and using his or her telephone number as the call-back number for verification, or stealing prescription pads from a healthcare provider.22

In addition, a provider may be aware and on guard for the above

schemes a drug diverter may use to obtain prescription drugs illegally but there are also characteristics of false or altered prescriptions. They include:22

● Prescription looks “too good” (i.e., the handwriting of the prescriber is too

legible). ● Medication quantity, directions for use, or dosages vary from usual medical

usage. ● Prescription does not contain acceptable standard abbreviations or

appears too “textbook.” ● Prescription appears to be a photocopy and not an original. ● Directions for use are written out in full with no standard abbreviations.

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Even if a prescription does not appear forged or altered, there are red flags that may indicate that a prescription was not issued for a legitimate medical purpose:22

● Healthcare provider writes significantly more controlled substance

prescriptions (or writes for larger quantities) than other prescribers in the area.

● Patients return to the pharmacy too frequently (i.e., a prescription that should last a month for a legitimate medical purpose is being refilled weekly or daily).

● Health care provider writes for drugs with “antagonistic” effects (i.e., drug abusers often request prescriptions for “uppers and downers” at the same time).

● Patient presents prescriptions to the pharmacy written for other individuals other than the patient.

● Similar prescriptions from the same health care provider are presented to the pharmacy by a variety of individuals at the same time.

● Patients who are not regular customers, or who do not live in the area, present prescriptions to the pharmacy from the same health care provider.

As can be seen from the above, a patient can be quite creative in his or

her efforts to obtain a prescription drug illegally. Pharmacists in particular need to know the above characteristics of false or altered prescriptions and illegitimate medical purposes that patients or drug diverters may use.22

Other simple prevention techniques may be used in conjunction with

these criteria. For example, it helps if the pharmacist knows the patients who come to the pharmacy. The pharmacist should check the date of the prescription and determine if it has been presented to the pharmacy for filling within a reasonable time frame.22 It is also helpful if a pharmacist knows the prescriber, and is familiar with the prescriber’s signature and DEA registration number.22

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Drug Diversion and Theft from Healthcare Facilities

Another mechanisms of drug diversion is the diversion of drugs from healthcare facilities such as hospitals and nursing homes. This type of diversion is a direct theft of the drugs from the facility.23 According to a American Journal of Health Systems Pharmacists report, theft at healthcare facilities starting at the procurement process through waste removal and disposal.23 These steps in the process can be described as follows:23

● Procurement: Controlled substances are ordered and/or inventoried

incorrectly and then diverted. ● Preparation and dispensing: Controlled substances are replaced with a

similar-appearing product or substance; morphine will be removed from the vial and replaced with sterile saline.

● Prescribing: Prescription altering, prescription forging, or prescriptions written for the clinician.

● Administration: The controlled substance is documented as give but stolen by a staff member.

● Waste and removal: Controlled substances that should be wasted are taken by a staff member.

Drug diversion is easier in healthcare settings where there are weak

procedures in place to monitor how drugs are procured and dispensed. In many instances, healthcare workers are responsible for dispensing medications to their patients, which provides ample opportunity for them to divert prescriptions without being noticed.

One form of theft by healthcare workers involves the automated drug dispensing machines (ADMs) used at healthcare facilities.24 Diversion from ADMs occurs because facility staff (e.g., pharmacy staff) are not alerted to ADM overrides, which allow a clinician to access drugs without proper overview. Healthcare personnel are able to divert drugs from ADMs “by selecting higher doses than ordered for patients or selecting medications not on a patient’s list.”6 If supervisors fail to review ADM reports, they will not be able to determine if diversion were occurring. In some facilities, supervisors

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are not aware of their obligations to review ADM reports, which creates fertile grounds for drug diversion.6

Other Theft

Other prescription drug theft occurs when individuals steal prescription drugs from those who have a legitimate prescription.20 An individual may steal prescription drugs from someone known, which is most often a family member or steal from a pharmacy or facility.20

Profiles of People Who Divert Drugs

Drug diversion is done by people inside and outside the healthcare and pharmaceutical industries. Individual drug diverters include patients, healthcare workers, drug dealers, drug addicts. Organizational drug diverters include individuals within an organization, i.e., managers, supervisors, recruiters, and runners. The profiles for patients who divert drugs and people who divert drugs from within the healthcare industry are discussed separately. Profiles of Patients Who Divert Drugs

It is imperative that medical providers be aware of the warning signs and common characteristics of drug diverters, as early identification is important to the treatment process. As discussed in the section on Drug-seeking Behavior, doctor shopping is one of the ways a patient may try to obtain prescription drugs for an illegal purpose. The characteristics relevant to doctor shopping were covered in that section. Consultation and Screening for Drug Misuse

When a patient presents with symptoms that warrant prescription drugs, the medical provider should conduct an initial consultation and screening for signs of drug use or diversion. This should include screening for a substance use disorder (e.g., signs such as mild tremor, drug odor on breath or clothing, nasal irritation).21

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In addition to these signs, a person who is diverting or misusing drugs may have “atypical responses to standard treatments for chronic diseases such as hypertension or diabetes (for example, blood pressure medicine is not working and glucose levels are not managed on medication).”21 Another sign that a patient may be diverting drugs is when a patient has a prescription for the drug the patient is seeking. The patient is supposedly taking the drug; however, when the provider performs a urine test, the patient tests negative for the drug.20 Even though a urine test indicates the patient is not taking his or her prescription, the patient is seeking a refill. This situation could be occurring in as much as 25% of patients.20 Physical and Psychological Patterns

A clinician should review the patient’s history for any inconsistencies or suspicious behaviors that indicate a pattern of substance use. Clinicians should also be familiar with the common physical and psychological behaviors common in drug diverters.

The characteristics applicable to drug-seeking behavior, discussed above, apply here; for example, a drug-seeker who is diverting drugs will often complain about an ailment that is subjective and where no easily verifiable medical condition is present.

In addition, the clinician should perform a physical examination to look for the indicators of substance use including:25

● Poor personal hygiene ● Significant weight loss or weight gain ● Signs of injection drug use including scars at injection sites (so-called

“track marks”) on the skin ● Signs of drug inhalation including atrophy of the nasal mucosa and

perforation of the nasal septum ● Evidence of acute intoxication or withdrawal – e.g., slurred speech,

unsteady gait, pinpoint pupils, bizarre or atypical behavior, changes in

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the level of arousal (agitation or sedation), tachycardia, conjunctival injection, sweating, watery eyes, runny nose

A patient’s mental status, or psychological characteristics, should be

examined according to the following characteristics:25

● General appearance ● Behavior and interaction ● Speech and voice ● Motor activity ● Mood and affect ● Perceptions ● Thought process ● Thought content (suicidal or homicidal ideation, hallucinations, delusions) ● Insight ● Judgment ● Cognitive functioning These physical and mental examinations are essential to identifying patients who may be diverting or misusing prescription drugs. Consequences of Not Identifying Drug Diverters

Drug diversion causes harm to the public: the intended beneficiary of the drug does not receive his or her prescribed medication. Diversion of drugs that are later misused have caused the death of many due to overdose.7 Drug diversion also costs the medical industry significant amounts of money.7

In addition, healthcare facilities face liability if they do not take reasonable or required steps to prevent drug diversion through doctor shopping or other means. Courts in various states are allowing people to sue prescribers and pharmacists who supplied them medications, even though they broke the law to divert drugs.26 For example, even if a patient admits that he or she acquired the medications by misleading the prescriber, by doctor shopping, or by ingesting greater amounts of the medication than was

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prescribed, the prescriber and pharmacist may still be held liable for the diverter’s injuries.26

Profiles and Warning Signs of Healthcare Workers Who Divert Drugs

Healthcare workers who divert drugs will have additional work related behaviors to those characteristics listed previously. In many instances, the behaviors will be apparent to their coworkers and supervisors. It is important to be familiar with the characteristics specific to health workers to reduce the incidence of drug diversion in healthcare settings.27 The profile of diverting or impaired healthcare workers includes those listed next.27

● Chronic absenteeism, often without notification, and use of excessive sick

days. ● Long unexplained breaks or absences from the workplace, including taking

frequent trips to the bathroom or medicine room where drugs are kept. ● Excessive amounts of time spent near a drug supply, such as a cart or

medicine room. Worker may volunteer for overtime or appear at work when not scheduled.

● Unreliability in keeping appointments and meeting deadlines. ● Work performance varies widely and mistakes may increasingly occur

resulting from inattention, impaired decision-making, and poor judgment. ● Worker appears confused at times and may exhibit memory loss and

difficulty concentrating or recalling details or instructions. May work quite slowly.

● Worker’s interpersonal relations with colleagues, staff and patients suffer. ● Worker rarely admits errors or accepts blame for errors or oversights. ● Worker experience heavy "wastage" of drugs. ● Recording keeping is sloppy, and some falsification of records may occur

along with drug shortages. ● Those with prescriptive authority write inappropriate prescriptions for large

narcotic doses. ● Worker insists on personally administering injections of narcotic drugs to

patients.

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● Worker may appear progressively disheveled and lacking in personal hygiene.

● Changes are evident in handwriting and charting. ● Worker wears long sleeves in appropriately, such as in very hot weather. ● Personality changes become evident with mood swings, anxiety,

depression, lack of impulse control, suicidal thoughts or gestures. ● Others, including patients and staff begin to make complaints about the

coworker’s attitude or behavior. ● Worker becomes increasingly isolated from others.

Consequences of Drug Diversion in the Workplace First and foremost, patient care suffers when drugs are diverted by medical clinicians. One example is a patient who contracted HCV because a healthcare provider used a discarded needle to inject the patient and personally used the injectable narcotic drug intended for the patient.24 The injectable narcotic drugs were withdrawn from an automated drug dispensing system.24 In addition, the person diverting the drug is susceptible to physical harm from the drug misuse, and is subject to a loss of professional license, as well as criminal liability.24

Prevention Strategies

There are a number of prevention strategies that must or may be

implemented to reduce the number of drug diversions and increase awareness in the medical community. Many of the prevention strategies have been developed through legislation, such as the establishment of prescription drug monitoring systems,19 and by the adoption of standard policies that provide strict guidelines for the preparation, procurement, and distribution of controlled substances. Strategies for Identifying Potential Drug Diversion

The following strategies are useful when working with patients who may be engaging in drug-seeking behavior or diverting drugs:19

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● Education and awareness programs for prescribers and clinicians ● Education and awareness programs for patients ● Diversion monitoring software ● Contracts with patients who use controlled substances ● Improved prescribing practices, e.g., providing the minimum amount

needed ● Closer monitoring of patient use by clinicians ● Prompt reporting of diversion or possible diversion ● Proper and timely disposal of controlled substances ● Communicate with other providers and pharmacies when shopping is

suspected ● Provide better record keeping for controlled substance prescribing ● Employ electronic medical records integrated between pharmacies,

hospitals, and managed care organizations ● Periodically request a report from the state prescription drug monitoring

program on the prescribing of prescription drugs by other providers

Walker, et al. (2017) utilized insurance databases to determine if there was a pattern for possible opioid shoppers that could be used to identify them.18 This information could be useful as an additional effort toward drug diversion prevention. Monitoring Systems

Prescription Drug Monitoring Systems have been established to monitor how controlled substances are prescribed and distributed, with the goal of reducing drug diversion at the state level. The U.S. Department of Justice explains the creation and enforcement of the Prescription Drug Monitoring Program (PDMP), as shown in the table here.28

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The Prescription Drug Monitoring Program was created by the 2002 U.S. Department of Justice Appropriations Act. Under this new legislation, Congress appropriated funding to the U.S. Department of Justice to support the Prescription Drug Monitoring Program. The purpose of the PDMP is to enhance the capacity of regulatory and law enforcement agencies to collect and analyze controlled substance prescription data. The program provides help for states to establish a PDMP, and provides resources to expand programs.. Prescription monitoring programs help prevent and detect the diversion and use of pharmaceutical controlled substances, particularly at the retail level where no other automated information collection system exists. States that have implemented prescription monitoring programs are able to collect and analyze prescription data more efficiently than states without such programs, where the collection of prescription information requires the manual review of pharmacy files, a time-consuming invasive process. Program objectives include: • Building a data collection and analysis system at the state level. • Enhancing existing programs' ability to analyze and use collected data. • Facilitating the exchange of collected prescription data among states. • Assessing the efficiency and effectiveness of the programs funded under this initiative.

A majority of states have PDMPs that are managed and enforced at the state level, and each state handles the process differently. For example, Delaware and Utah requires that providers check the state PDMP based on subjective judgment of inappropriate use while Oklahoma requires providers to check the state PDMP only when administering, dispensing, or prescribing methadone.28

While the process and use of the system varies by state, the basic goals

of PDMPs are the same: 1) Monitor opioid prescribing, 2) Monitor and prevent opioid diversion, 3) Track and prevent opioid misuse, 4) Reduce opioid-related morbidity and mortality, and 5) tracking possible illegal activity.28 These are the basic goals, but they have many discrete and specific applications. These include identifying and investigating professional misconduct (identifying inappropriate prescribing and dispensing), disseminating educational information (alerting the public to prescription drug use trends or to provide feedback to prescribers and dispensers), promoting public health initiatives (monitoring trends and addressing prescribing and dispensing issues), and implementing early intervention and prevention programming (identifying

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those in need of early assessment and treatment or targeting efforts at certain high-risk populations).28

Organizational Policies

Organizational policies are those enforced by the U.S. Department of Justice and the Drug Enforcement Agency, and they clearly outline the requirements of healthcare clinicians. The Prescription Drug Monitoring Program, which was discussed earlier in this course, is one of the primary mechanisms for the regulation of drug distribution and the prevention of drug diversion. West Virginia will be referenced here to show a regional example of the Prescription Drug Monitoring Program:29

West Virginia Code Chapter 60A, Article 9 requires that practitioners with a DEA registration identification number to administer controlled substances in West Virginia apply for and receive capability to access the Controlled Substances Monitoring Program (CSMP) database for information about patients to whom they are prescribing controlled substances in schedules II to IV.

Application forms for advance practice nurses to access the CSMP may be downloaded from the West Virginia Board of Pharmacy or through a link from the West Virginia Board of Examiners for Registered Nursing.

According to WV Code 60A-9-5: Good faith reliance by a practitioner on information contained in the West Virginia Controlled Substances Monitoring Program database in prescribing or dispensing or refusing or declining to prescribe or dispense a schedule II, III or IV controlled substance shall constitute an absolute defense in any civil or criminal action brought due to prescribing or dispensing or refusing or declining to prescribe or dispense.

In addition to the Prescription Drug Monitoring Program, there are a

number of federal guidelines in place that provide strict guidelines for the

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development and distribution of controlled substances. The following section provides the federal guidelines related to the storage and security, ordering and prescribing, preparation and dispensing, and administration of controlled substances. Storage and Security

Federal guidelines for proper storage and security regarding controlled substances are as follows.30-32

Required Controls

All registrants must provide effective controls and procedures to guard against theft and diversion of controlled substances. A list of factors is used to determine the adequacy of these security controls. Factors affecting clinicians include those listed here.

● The location of the premises and the relationship such location bears on security needs

● The type of building and office construction ● The type and quantity of controlled substances stored on the premises ● The type of storage medium (safe, vault, or steel cabinet) ● The control of public access to the facility ● The adequacy of registrant’s monitoring system (alarms and detection

systems) ● The availability of local police protection

Clinicians are required to store stocks of Schedule II through V

controlled substances in a securely locked, substantially constructed cabinet. Clinicians authorized to possess carfentanil, etorphine hydrochloride and/or diprenorphine, must store these controlled substances in a safe or steel cabinet equivalent to a U.S. Government Class V security container.30-32

Registrants should not assign an agent or employee access to controlled

substances under any of the following circumstances:30-32

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● Any person who has been convicted of a felony offense related to controlled substances.

● Any person who has been denied a DEA registration. ● Any person who has had a DEA registration revoked. ● Any person who has surrendered a DEA registration for cause.

Lastly, clinicians should notify the DEA upon discovery of any thefts or significant losses of controlled substances and complete a DEA Form 106 regarding such theft or loss.30-32 Safeguards for Prescribers

In addition to the required security controls, clinicians can utilize additional measures to ensure security. These include the following measures.30-32

● Keep all prescription blanks in a safe place where they cannot be stolen;

minimize the number of prescription pads in use. ● Write out the actual amount prescribed in addition to giving a number to

discourage alterations of the prescription order. ● Use prescription blanks only for writing a prescription order and not for

notes. ● Never sign prescription blanks in advance. ● Assist the pharmacist when they telephone to verify information about a

prescription order; a corresponding responsibility rests with the pharmacist who dispenses the prescription order to ensure the accuracy of the prescription.

● Contact the nearest DEA field office to obtain or to furnish information regarding suspicious prescription activities.

● Use tamper-resistant prescription pads. Ordering and Prescribing

The following are the guidelines for ordering and prescribing controlled substances.

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Prescription Requirements

A prescription is an order for medication, which is dispensed to or for an ultimate user. A prescription is not an order for medication, which is dispensed for immediate administration to the ultimate user (for example, an order to dispense a drug to an inpatient for immediate administration in a hospital is not a prescription).30-32

A prescription for a controlled substance must be dated and signed on

the date issued. The prescription must include the patient’s full name and address, the clinician’s full name, address, and the DEA registration number. The prescription must also include the drug name, strength, dosage form, quantity prescribed, directions for use, and number of refills (if any) authorized.30-32

A prescription for a controlled substance must be written in ink or

indelible pencil or typewritten and must be manually signed by the practitioner on the date when issued. An individual (secretary or nurse) may be designated by the clinician to prepare prescriptions for the practitioner’s signature. The issuing clinician is responsible for ensuring that the prescription conforms to all requirements of the law and regulations, both federal and state.30-32

A physician, dentist, podiatrist, veterinarian, mid-level practitioner, or

other registered practitioner may issue a prescription for a controlled substance only when practicing according to the following regulations.30-32

● Authorized to prescribe controlled substances by the jurisdiction in which the practitioner is licensed to practice.

● Registered with DEA or exempted from registration (that is, Public Health Service, Federal Bureau of Prisons, or military practitioners).

● An agent or employee of a hospital or other institution acting in the normal course of business or employment under the registration of the hospital or other institution which is registered in lieu of the individual practitioner being registered provided that additional requirements as set forth in the CFR are met.

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Preparation and Dispensing

The following are guidelines for the preparation and dispensing of prescription drugs.

All drugs should be dispensed in a USP approved tight, light resistant container with a safety closure. If the patient does not wish a safety closure, a signed release should be obtained from the patient for the protection of the physician.30-32 Drugs must be properly stored in a location that includes protection from moisture, freezing and excessive heat, or as directed by the labeling. Additionally, labeling of medications require specific steps, such as affixing a label to the outside of the container showing the following details:30-

32

● Date of Filling ● A serial number that refers to a log, prescription, or other record of a

specific order for a specific patient ● Dispenser's name and address ● Name of the patient ● Name of the prescriber ● Directions for use ● Name of the drug ● Any cautionary statements required by law

If the drug is a controlled substance listed in schedule II, III, or IV, a label must also be attached stating: Caution: Federal law prohibits the transfer of this drug to anyone other than to whom prescribed. All records relating to controlled substances must be readily retrievable and uniformly maintained.30-

32 This record must be separate from the patients' charts.

The physician must dispense the drugs. Although office personnel, including physician assistants and nurse practitioners, may provide technical assistance in the preparation or packaging of the drugs, they are not generally licensed or authorized to dispense medication. Mid level providers with prescriptive authority should refer to their state licensing board with regard to license protection involving medication dispensing.30-32

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Inventory Maintenance

The U.S. Department of Justice Office of Diversion Control Practitioner’s Manual provides the following guidelines for inventory maintenance.30

Recordkeeping Requirements

Each clinician must maintain inventories and records of controlled substances listed in Schedules I and II, separately from all other records maintained by the registrant. Likewise, inventories and records of controlled substances in Schedules III, IV, and V must be maintained separately or in such a form that they are readily retrievable from the ordinary business records of the clinician.30 All records related to controlled substances must be maintained and be available for inspection for a minimum of two years.

Records should demonstrate that the following standard controls have been observed relative to the dispersal of controlled medications:30 ● A registered clinician is required to keep records of controlled substances

that are dispensed to the patient, other than by prescribing or administering, in the lawful course of professional practice.

● A registered clinician is not required to keep records of controlled substances that are administered in the lawful course of professional practice unless the practitioner regularly engages in the dispensing or administering of controlled substances and charges patients, either separately or together with charges for other professional services, for substances so dispensed or administered.

● A registered clinician is required to keep records of controlled substances administered in the course of maintenance or detoxification treatment of an individual.

Each registrant who maintains an inventory of controlled substances

must maintain a complete and accurate record of the controlled substances on hand and the date that the inventory was conducted. This record must be in written, typewritten, or printed form and be maintained at the registered location for at least two years from the date that the inventory was conducted.

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After an initial inventory is taken, the registrant shall take a new inventory of all controlled substances on hand at least every two years. Every inventory must contain the following information:30

● Whether the inventory was taken at the beginning or close of business ● Names of controlled substances ● Each finished form of the substances (i.e., 100 milligram tablet) ● The number of dosage units of each finished form in the commercial

container (i.e., 100 tablet bottle) ● The number of commercial containers of each finished form (i.e., four 100

tablet bottles) ● Disposition of the controlled substances Waste Disposal

The DEA has published regulations regarding the proper disposal of controlled substances by a registered practitioner and non-registered individual who is in lawful possession of controlled substances. A condensed version of the regulations are as follows:33

(a) Practitioner inventory. Any registered practitioner in lawful possession of a controlled substance in its inventory that desires to dispose of that substance shall do so in one of the following ways: (1) Promptly destroy controlled substances in accordance with subpart C of this part using an on-site method of destruction. (2) Promptly deliver controlled substance to a reverse distributor's registered location by common or contract carrier pick-up or reverse distributor pick-up at the registrant's registered location. (3) For the purpose of return or recall, promptly deliver controlled substance by common or contract carrier pick-up or pick-up by other registrants at the registrant's registered location to: the registered person from whom it was obtained, the registered manufacturer of the

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substance, or another registrant authorized by the manufacturer to accept returns or recalls on the manufacturer's behalf; or (4) Request assistance from the Special Agent in Charge of the Administration in the area in which the practitioner is located. (i) The request shall be made by submitting one copy of the DEA Form 41 to the Special Agent in Charge in the practitioner's area. The DEA Form 41 shall list the controlled substance or substances which the registrant desires to dispose. (ii) The Special Agent in Charge shall instruct the registrant to dispose of the controlled substance in one of the following manners: (A) By transfer to a registrant authorized to transport or destroy the substance; (B) By delivery to an agent of the Administration or to the nearest office of the Administration; or (C) By destruction in the presence of an agent of the Administration or other authorized person. (5) In the event that a practitioner is required regularly to dispose of controlled substances, the Special Agent in Charge may authorize the practitioner to dispose of such substances, in accordance with subparagraph (a)(4) of this section, without prior application in each instance, on the condition that the practitioner keep records of such disposals and file periodic reports with the Special Agent in Charge summarizing the disposals. (b) Non-practitioner inventory. Any registrant that is a non-practitioner in lawful possession of a controlled substance in its inventory that desires to dispose of that substance shall do so in one of the following ways: (1) Promptly destroy that controlled substance in accordance with subpart C of this part using an on-site method of destruction

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(2) Promptly deliver that controlled substance to a reverse distributor's registered location by common or contract carrier or by reverse distributor pick-up at the registrant's registered location (3) For the purpose of return or recall, promptly deliver that controlled substance by common or contract carrier or pick-up at the registrant's registered location to: the registered person from whom it was obtained, the registered manufacturer of the substance, or another registrant authorized by the manufacturer to accept returns or recalls on the manufacturer's behalf; or (4) Promptly transport that controlled substance by its own means to the registered location of a reverse distributor, the location of destruction, or the registered location of any person authorized to receive that controlled substance for the purpose of return or recall as described in paragraph (b)(3) of this section. (i) If a non-practitioner transports controlled substances by its own means to an unregistered location for destruction, the non-practitioner shall do so in accordance with the procedures set forth at §1317.95(c). (ii) If a non-practitioner transports controlled substances by its own means to a registered location for any authorized purpose, transportation shall be directly to the authorized registered location and two employees of the transporting non-practitioner shall accompany the controlled substances to the registered destination location. Directly transported means the substances shall be constantly moving towards their final location and unnecessary or unrelated stops and stops of an extended duration shall not occur. (c) Collected controlled substances. Any collector in lawful possession of a controlled substance acquired by collection from an ultimate user or other authorized non-registrant person shall dispose of that substance in the following ways:

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(1) Mail-back program. Upon receipt of a sealed mail-back package, the collector shall promptly: (i) Destroy the package in accordance with subpart C of this part using an on-site method of destruction; or (ii) Securely store the package and its contents at the collector's registered location in a manner consistent with §1301.75(c) of this chapter (for practitioners), or in a manner consistent with the security requirements for Schedule II controlled substances (for non-practitioners) until prompt on-site destruction can occur. (2) Collection receptacles. Upon removal from the permanent outer container, the collector shall seal it and promptly: (i) Destroy the sealed inner liner and its contents; (ii) Securely store the sealed inner liner and its contents at the collector's registered location in a manner consistent with §1301.75(c) of this chapter (for practitioners), or in a manner consistent with §1301.72(a) of this chapter (for non-practitioners) until prompt destruction can occur; or (iii) Securely store the sealed inner liner and its contents at a long-term care facility in accordance with §1317.80(d). (iv) Practitioner methods of destruction. Collectors that are practitioners (i.e., retail pharmacies and hospitals/clinics) shall dispose of sealed inner liners and their contents by utilizing any method in paragraph (a)(1), (a)(2), or (a)(4) of this section, or by delivering sealed inner liners and their contents to a distributor's registered location by common or contract carrier pick-up or by distributor pick-up at the collector's authorized collection location. (v) Non-practitioner methods of destruction. Collectors that are non-practitioners (i.e., manufacturers, distributors, narcotic treatment programs, and reverse distributors) shall dispose of sealed inner liners and their contents by utilizing any method in paragraph (b)(1), (b)(2), or (b)(4) of this section, or by delivering sealed inner liners and their contents to a distributor's registered location by common or contract carrier or by distributor pick-up at the collector's authorized collection

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location for destruction. Freight forwarding facilities may not be utilized to transfer sealed inner liners and their contents.

By following the above organizational guidelines and requirements throughout the life cycle of controlled substances from procurement to disposal, healthcare organizations can reduce the diversion of prescription medications.

Responding to Drug Diversion in the Workplace When a coworker is found to be diverting drugs at the facility, the coworker who discovers the activity has an obligation to the patient, the facility and all of its employees, and the drug diverter, to report the incident. It is important to confront drug diversion through the organization’s policies for drug diversion. Drug diversion puts patients at risk because the coworker who is diverting may be impaired, the patient is not receiving adequate treatment or pain relief, and the patient’s records are inaccurate.6 This exposes the patient to adverse results, such as exposure to infectious diseases from contaminated needles.6 Mandatory Reporting Requirement

Under Federal law, a healthcare organization and its employees are mandated to report any incident of drug diversion within the organization. This mandate is found in Title 21 Code of Federal Regulations, Part 1301.90. Support for Professionals in Recovery

Healthcare professionals who have engaged in drug diversion will

require special treatment and guidance before returning to work.34-37 Since these individuals will often return to situations where drugs are readily available, it is important to ensure that the diversion does not occur again when the temptation arises.

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Treatment

Most states require health professionals to report an impaired healthcare worker. Healthcare workers who divert drugs are immediately reported to the state board and action is taken against the licensee. Once a healthcare worker has gone through the initial reporting stage, the individual will undergo treatment and will be required to commit to a contract that typically includes work restrictions that are dependent upon successful completion of a treatment program.34,35 Returning to Practice

Once a healthcare worker has undergone treatment and is determined to be in recovery, the individual may return to work, but often can only do so with specific restrictions in place.35-37 As part of the treatment program, the following components will be addressed so that the individual is less likely to begin using drugs again. Since these individuals will be returning to situations where there are controlled substances, it is imperative that a number of issues are addressed beforehand.35-37

Healthcare workers undergo three stages of treatment and monitoring. They include treatment, re-entry, and monitoring. Each stage has specific components that must be addressed to ensure that the patient can successfully reintegrate into the healthcare setting without risk of diverting again. Treatment is individualized but typically involves addiction counseling, psychotherapy and if needed, medication. Once the acute phase of treatment is completed, a return to work can be planned.

A return to work can be started if there is documented, sustained

abstinence, acceptance of the diagnosis of a substance use disorder, and a demonstrated ability to understand and manage stress triggers that lead to substance use. The legal and licensure requirements must be met and there must be a workplace monitoring program in place.34 After returning to work ongoing monitoring should be in place and restrictions to access and

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administer controlled substances must be observed. Periodic drug testing may be required and there should be an at-work support system available.35-37

Literature Review: Deception and Drug Diversion

The following literature review focused on patient deception and drug

misuse that is an influencing factor related to most recent policies guiding clinical practice in the area of drug diversion in the United States.38

As already discussed in preceding sections, fraud, unethical prescribing

practices, and other methods of illicit drug acquisition have caused medical prescribers to be more vigilant in the determination of whether a patient has an authentic health need or is drug-seeking for the purpose of diversion or misuse. Doctor shopping, described previously, involves attempts to obtain prescriptions from multiple physicians that often corresponds with exaggeration, and may involve malingering traits or feigning symptoms in order to have a drug. The authors of this review reported that doctor shopping appears widespread and is a major concern of physicians.38

Identifying drug diverters can be a difficult task. The authors of this review noted that “relatively healthy individuals may be efficient deceivers, well-versed in fabricating or inflating symptoms to obtain pharmaceuticals for themselves, to sell to others, or both.”38 Without an effective prescription drug monitoring program it is difficult to determine medications previously prescribed. Unfortunately, physicians who suspect a patient is doctor shopping or attempting to divert drugs may undertreat patients when there is a legitimate concern.38

The authors further indicated that most research examining patient-

based drug diversion tends to neglect to assess physician deception. They stated that most studies “rely on case or cohort studies, retrospective self-reports of identified heavy users, or secondary analysis of records, and thus cannot give an accurate estimate of attempted deception in the general population nor detail the proportion of these individuals who are successful at obtaining medications.”38

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Studies have shown that patients seeking prescriptions for economic reasons were generally more likely to succeed than those only concerned with obtaining a drug because of a drug craving or substance use disorder.38 Individuals motivated by a substance use disorder and economic reasons had lower odds of successfully obtaining a prescription than those motivated by economic reasons alone. Individuals who sought a prescription to sell, or, both to sell and to use, were found to have significantly greater odds of successfully obtaining a prescription than those motivated only by the desire to use. The chance of success to deceive a prescriber differed depending on the patient’s motive and prior experience to divert a substance.38

The authors stated successful deception was more likely among

individuals who reported recreationally using pharmaceuticals in the past. Patients who reported being prescribed Adderall/Ritalin or antidepressants during their life were more likely to successfully deceive a prescriber as compared to those who were never prescribed either of these medications.38 On the other hand, those who reported poor health, were diagnosed with attention deficit/hyperactivity disorder, or prescribed opioids in their past were reportedly no more likely to obtain a sought prescription than those not reporting these.38

Demographic characteristics involving race/ethnicity were found to

correspond with successful attempts to deceive and divert drugs. Caucasian patients reportedly had significantly more success than non-Caucasian respondents. However, males from affluent families (earning >$100,000 per year), and self-identified LGBT individuals were no more or less likely to successfully obtain a prescription.38 A weakness of this study was that, while the authors were able to report patient and demographic characteristics that corresponded with successful deception and drug diversion, the reasons for each were not well explained.38 Discussion38

The authors explored patient characteristics that tended to correlate

with successfully obtaining an unneeded prescription. They found that those

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who had financial motives were overwhelmingly likely to have successful deception as compared with others who sought prescriptions solely for a substance use disorder. Successful deceivers “were also more likely to have been legitimately prescribed medications sometime in the past. This suggests that greater odds of success may be attributable to experiential knowledge making it easier to feign appropriate symptoms.”38 They stated that future research to investigate multiple dimensions of success, including frequency of both successful and failed attempts at prescriber deception are needed.38

Effective, operational prescription drug monitoring programs could

make a difference for prescribers to detect patients that have been frequenting multiple physicians, receiving medication, and consequently which patients may be attempting to use or divert medication. The authors indicated that successful deceivers were more likely to be Caucasian than any other race/ethnicity. Success was neither related to gender or sexual orientation. These reported demographic differences require further study for improved validity.38 The authors stated it cannot be determined with certainty that individuals enrolled in studies were accurately reporting intent to obtain prescriptions for substance use. Also, prescriber characteristics would have a significant role in whether patient attempts to deceive are successful or not.38

Future research should also attempt to gather information on both the

patient and the prescriber. The difficulty is that some groups may be perceived by prescribers as more suspicious with heightened scrutiny by the prescriber while those deserving of scrutiny may be overlooked.

Research that assesses factors associated with successful acquisition of

prescription drugs is needed. Clinicians need to be greater aware of doctor shopping tactics, especially successful ones. The demand for prescription drugs is increasing, thus placing physicians at risk of pharmaceutical diversion and raising the stakes to prevent successful diversion tactics.38

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Case Study: Heroin Substance Use

The following case study was obtained through a PubMed search in which the authors reported on a 19-year old single male patient with a personal history of heroin drug use.39

The patient’s work and social history showed that he had graduated from

secondary school and trained as a hairdresser. The patient had used heroin for four years. In the patient’s history, there were no medical illness, mental disorder and history of previous surgery

In February 2018, the patient was admitted due to intravenous (IV)

buprenorphine (BNC) and oral pregabalin misuse. He was evaluated to be depressed, and expressed feelings of hopelessness and pessimism about not being able to recover from heroin use.

Laboratory tests showed that his complete blood count, liver and kidney

function test results were normal. Hepatitis and human immunodeficiency virus (HIV) markers were negative. A urine toxicology screen showed buprenorphine was positive, and other drug use parameters were negative.

The BNC dose was regulated to be 8 mg/day and quetiapine to 200

mg/day after the patient was admitted. He reported having an intense craving to pregabalin, and was observed to be experiencing symptoms of heroin withdrawal. Carbamazepine 400 mg/day and buspirone 20 mg/day, were added to the medical treatment for the control of craving to pregabalin, anxiety and impulsivity. However, the patient refused treatment after two weeks of hospital stay and wanted to be discharged. Treatment therefore had failed.

BNC Treatment

BNC 10 mg/day was started and continued for 26 months. Mention was made the patient thought the dose was not enough, and an intravenous infusion of BNC 10 mg daily from the intravenous route over the last 6 months,

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dissolving it in drinking water under non-sterile conditions, was initiated. During the 26-month treatment, BNC generally finished earlier than the prescription time, therefore the patient used pregabalin (at a dose of 600–2,400 mg/day), provided in several ways to reduce deprivation. Discussion39

The use of BNC in the treatment of opioid use is reportedly increasing

daily, and there are more cases of misuse of BNC. Since 1995 when BNC was used for opioid use in Europe, the illegal use and misuse of BNC is well documented in the literature. The authors noted that one study reported that 20% of BNC patients injected the drug intravenously.

The patient in this case also misused pregabalin in addition to IV BNC. Multiple drug misuse is not uncommon, which places patients at risk of treatment failure. The patient in this case completed BNC before the prescribing time and non-adherent to treatment plan for BNC use. He used Pregabalin 2,400 mg per day to compensate for not using opiates, and eventually left treatment at his own discretion.

The authors referenced another study where 27% of IV drug users used

BNC by injection and 37% were diagnosed with polysubstance use. The patient in this case also used intravenous BNC along with pregabalin. And additional study was raised where the use liability of IV BNC was compared to buprenorphine/naloxone, which revealed that “formulations with larger absolute naloxone may be less abusable because of precipitating a greater degree of withdrawal.”39

A 35-year old female patient with a history of drug use was referenced

in a case study by Filipetto, et al. She reportedly used pregabalin for pain control and required referral to a detoxification center due to withdrawal symptoms from pregabalin cessation (600 mg/day, maximum daily dose recommended). Grosshans, et al. referenced a 47-year old male patient with co-occurring pregabalin, cannabis and alcohol use.

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The authors discussed an existing focus on street demand for illegal BNC, raising an approach to increase the availability of BNC. By reducing market cose through greater usability, the use of care services may increase; hence, potentially lowering the demand for illegal BNC. BNC is a drug with a risk of misuse, yet BNC has also proven to be clinically effective to treat opioid use disorder, and BNC is typically used to treat opioid use disorder worldwide as the first choice of treatment. Patients using BNC may use inappropriately, for example dosing and route (inhalation or injection).39

Illegal sales of BNC have the potential to grow and become more

dangerous. Access to treatment for individuals with a drug use problem is important to prevent dangerous use. Treatment options alongside an increase for follow-ups and controls are critical to successful rehabilitation. The authors suggest a need for increased research on the misuse of BNC and motivational methods to adhere to treatment.

Summary

The increase in the availability of prescription drugs has created an environment in which medical professionals must be more vigilant in evaluating patients, and attending to co-workers who may be diverting prescription drugs. There are drugs that are commonly diverted. There are also common ways in which drugs are diverted, such as “doctor shopping,” using falsified or altered prescriptions to obtain drugs, direct theft of prescription drugs from a healthcare facility by a staff member, and theft of a patient’s prescription drugs by a family member, friend or other person outside a healthcare facility. It is important for all members of the interdisciplinary health team to be aware of the different strategies for drug diversion as well as the common characteristics of individuals with a substance use disorder. There are also preventative measures that healthcare facilities and clinicians should implement. Understanding the manner of diversion, the characteristics of individuals who divert drugs, and the preventative measures that are mandated or available can help a healthcare clinician and facility reduce the incidence of drug diversion.

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Self-Assessment of Knowledge Post-Test:

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement.

1. Drug diversion is best understood as a medical and legal concept involving the transfer of any legally prescribed substance

a. to the intended patient who then misuses it.b. that is on the Controlled Substance schedules.c. from the individual for whom it was prescribed to another person.d. that has no medical purpose.

2. True or False: Dextromethorphan is a medication that is used to reduce or suppress coughs associated with common viruses.

a. Trueb. False

3. Individual drug diverters may include

a. patients.b. healthcare workers.c. drug dealers and drug addicts.d. All of the above

4. Fentanyl is an ________ and it is frequently diverted.

a. opioidb. stimulantc. benzodiazepined. depressant

5. ________________________, which are common ingredients in many over-the-counter cold medicines, are common ingredients in the manufacture of methamphetamine.

a. Opioidsb. Stimulantsc. Central nervous system depressantsd. Pseudoephedrine and ephedrine

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6. True or False: Prescription drug diversion only involves redirecting controlled substances.

a. Trueb. False

7. People who ____________ visit a number of medical providers in order to obtain prescriptions to divert or misuse.

a. steal prescriptionsb. use illegal drugsc. doctor shopd. are uninsured

8. A prescription for a controlled substance

a. must be typed or written by the prescriber.b. must be signed by the prescriber.c. may be signed using a pre-printed signature.d. All of the above

9. Antipsychotics that are commonly misused in the U.S., include

a. gabapentin.b. bupropion.c. ziprasidone.d. All of the above

10. It is often difficult to know if a patient is doctor shopping because when a patient claims to be in pain,

a. the provider must take the patient’s word that it is true.b. the provider does not always have time to objectively evaluate the

claim.c. providers are obligated to treat the condition with medication.d. a legitimate complaint is not easily distinguished from an illegal

purpose.

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11. True or False: When a patient presents with symptoms that warrant prescription drugs, the medical provider should conduct an initial consultation and screening for signs of drug use or diversion.

a. Trueb. False

12. There is a high prevalence of prescription drug diversion for __________________ prescribed to people living with HIV.

a. analgesics and antiretroviral drugsb. pseudoephedrine and ephedrinec. stimulantsd. anesthetics or depressants

13. Which of the following drugs is an opioid?

a. Dextroamphetamineb. Alprazolamc. Meperidined. Dextromethorphan

14. A patient who diverts drugs may fit into the general profile of a diverter, which involves

a. claiming to be from out of town, visiting friends or relatives.b. never missing an appointment.c. requesting an appointment early in the day.d. offering the name and contact information of his or her primary

physician.

15. A sign that a patient may be diverting drugs is when a patient is given a urine test in which the patient tests

a. positive for the drug.b. reveal the patient is taking a masking agent.c. negative for the drug that the patient is supposedly taking.d. positive for a medical condition.

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16. Stimulants are a ______________ on the DEA’s Drug Schedule.

a. Schedule IIb. Schedule Ic. Schedule IVd. Schedule III

17. People are motivated to divert drugs because they

a. have a substance use disorder.b. are seeking to profit from the sale of the diverted drugs.c. want relief from physical pain.d. All of the above

18. A patient who diverts drugs may have the following physical characteristic(s):

a. poor personal hygiene.b. significant weight loss.c. significant weight gain.d. All of the above

19. True or False: Dextromethorphan use carries a high risk of developing into a substance use disorder because patients who stop taking the drug experience withdrawal syndrome.

a. Trueb. False

20. When evaluating whether a patient may be diverting or misusing drugs, the patient should be examined for which of the following psychological characteristics?

a. Cognitive functioningb. Offering to work overtimec. Atrophy of the nasal mucosad. A loquacious character

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21. A prescriber or pharmacist may not be held liable for a diverter’s injuries if it is proven that the diverter

a. lied to the prescriber or pharmacist.b. was doctor shopping.c. ingested more of the medication than was prescribed.d. None of the above

22. The profile of diverting or impaired healthcare workers includes

a. refusing to work overtime.b. frequent trips to the bathroom.c. a loquacious character.d. the worker becoming more engaged with patients and others.

23. Which of the following is a prescription drug preparation and dispensing guidelines for drug containers and storage?

a. It MUST have a safety closure, no exception.b. It MUST have an outside label showing, date filled, etc.c. It MUST be refrigerated.d. It must be a clear, see-through container.

24. An inventory of controlled substances must be complete, accurate and maintained at the registered location for at least __________ from the date that the inventory was conducted.

a. seven yearsb. one yearc. two yearsd. indefinitely

25. True or False: States are not allowed to have a prescription drug monitoring program (PDMP) because this is a federal program that preempts the states’ ability to have one also.

a. Trueb. False

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26. A health professional, who engaged in drug diversion, goes through the following stages as part of his or her return to work:

a. Treatment, re-entry and monitoring.b. Discharge, discipline and treatment.c. Reporting, discipline and treatment.d. Discipline, demotion and monitoring.

27. A registered practitioner who is in lawful possession of a controlled substance may dispose of it by

a. recycling the substance through an onsite dispensary.b. disposing the substance in the same manner as hazardous

materials.c. promptly and properly destroying the controlled substance using

an on-site method of destruction.d. returning it to the prescribing clinician.

28. False and altered prescriptions may be difficult to detect but there are red flags and characteristics of false and altered prescriptions, which include

a. a prescription from a physician who rarely prescribes controlled substances.

b. the handwriting on the prescription being too legible (good).c. the prescription uses abbreviations.d. the directions for administration are not written out.

29. Diversion of drugs by a healthcare worker from an automated drug dispensing machines (ADMs) occurs because

a. facility staff are able to override ADM dispensing.b. a healthcare worker may select a higher dose than what was

ordered for the patient.c. there are no reports generated for ADMs.d. All of the above

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30. Prescription monitoring programs help prevent and detect the diversion of controlled substances, particularly at the ________ level where no other automated information collection system exists.

a. manufacturingb. shippingc. retaild. disposal

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Reference Section The References below include published works and in-text citations of published works that are intended as helpful material for further reading. 1. Pellegrini CA. Joint Commission focuses on strategies to detect,

prevent drug diversion. Bulletin of the American College of Surgeons. Published June 1, 2019. Retrieved from http://bulletin.facs.org/2019/06/joint-commission-focuses-on-strategies-to-detect-prevent-drug-diversion/

2. Staff. Office of Inspector General (OIG). Ensuring the Integrity of Medicare Part D (OEI-03-15-00180). An OIG Portfolio. June 2015. Retrieved at https://oig.hhs.gov/oei/reports/oei-03-15-00180.pdf.

3. Staff. Office of Inspector General (OIG). Questionable Billing and Geographic Hotspots Point to Potential Fraud and Abuse in Medicare Part D (OEI-02-15-00190). HHS OIG Data Brief. June 2015. Retrieved from https://oig.hhs.gov/oei/reports/oei-02-15-00190.pdf

4. Berge KH, Dillon KR, Sikkink KM, Taylor TK and Laniera WL. Diversion of Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention. Mayo Clin Proc. 2012 Jul; 87(7): 674–682.

5. Clark DJ and Schumacher MA. America's opioid epidemic: Supply and demand considerations. Anesth Analg. 2017;125(5):1667-1674.

6. Bland AC and Wichmann CB. Two Lessons Learned: Preventing drug diversion in your organization. The Joint Commission. Healthcare Executive. 2019. Reprinted with permission. Retrieved from https://www.jointcommission.org/assets/1/6/MA19_IPC_reprint_Drug_Diversion.pdf

7. Wood D. Drug diversion. Aust Prescr. 2015; 38(5):164–166. Published online 2015 Oct 1. doi: 10.18773/austprescr.2015.058 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4657309/

8. Chibi B, Torres NF, Sokhela ZP, Mashamba-Thompson TP. Prescription drug diversion among people living with HIV: a systematic scoping review. Public Health. 2019; Volume 177; Pages 26-43.

9. Hattingh HL, et al. Evaluation of pseudoephedrine pharmacy sales before and after mandatory recording requirements in Western Australia: a case study. Subst Abuse Treat Prev Policy. 2015;11(1):30.

10. Kaye AM, Kaye AD, Lofton EC. Basic Concepts in Opioid Prescribing and Current Concepts of Opioid-Mediated Effects on Driving. Ochsner J. 2013 Winter; 13(4): 525–532.

11. Drug diversion and impaired health care workers. The Joint Commission. Quick Safety. Issue 48. April 2019. Retrieved from www.jointcommission.org/assets/1/23/Quick_Safety_Drug_diversion_FINAL2.PDF.

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12. Nalamachu SR and Shah B. Abuse of immediate-release opioids and current approaches to reduce misuse, abuse, and diversion. Postgrad Med. 2018;1-7.

13. Biano C, et al. Prevalence and correlates of benzodiazepine use, misuse, and use disorders among adults in the United States. J Clin Psychiatry. 2018; 79(6). pii: 18m12174. doi: 10.4088/JCP.18m12174.

14. Epstein-Ngo, QM, McCabe, SE, Veliz, PT, Stoddard, SA, Austic, EA, Boyd CJ. Diversion of ADHD Stimulants and Victimization Among Adolescents. J Pediatr Psychol. 2016; 41(7): 786–798.

15. Mazerolle L, et al (2017). Pharmaceutical sales of pseudoephedrine: the impact of electronic tracking systems on methamphetamine crime incidents. Addiction; 112(3):468-474.

16. Anderson IL (2018). Dextromethorphan. In: Olson KR, Anderson IB, Benowitz NL, Blanc PD, Clark RF, Kearney TE, Kim-Katz S, Wu AHB, eds. Poisoning & Drug Overdose, 9th ed. New York, NY: McGraw-Hill Education;215-217.

17. U.S. Drug Enforcement Agency. Advisories to the Public. NOTICE. Ephedrine and Pseudoephedrine Drug Products are Used in Illicit Methamphetamine Manufacture. Retrieved from http://www.deadiversion.usdoj.gov/chem_prog/advisories/ephedrine.htm

18. Walker AM, Weatherby LB, Cepeda MS, Bradford D, Yuan Y. Possible Opioid Shopping and its Correlates. The Clinical Journal of Pain. November 2017; Volume 33:Issue 11.

19. Worley J. Prescription drug monitoring programs, a response to doctor shopping: purpose, effectiveness, and directions for future research. Issues Ment. Health Nurs. 2012;33(5):319–328.

20. Preuss CV, Kalava A, King KC. Prescription of Controlled Substances: Benefits and Risks. StatPearls Publishing. 2019. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK537318/

21. American College of Preventive Medicine (ACPM). Use, Abuse, Misuse, and Disposal of Prescription Pain Medication Time Tool Clinical Reference. 2011. Retrieved from http://www.acpm.org/?UseAbuseRxClinRef

22. Gabay M. Federal Controlled Substances Act: Dispensing Requirements, Electronic Prescriptions, and Fraudulent Prescriptions. Hosp Pharm. 2014; 49(3): 244–246.

23. Brummond PW, et al. ASHP Guidelines on Preventing Diversion of Controlled Substances. Am J Health Syst Pharm. 2017;74(5):325-348.

24. Henry N, et al. Hepatitis C Virus Potentially Transmitted by Opioid Drug Diversion from a Nurse — Washington, August 2017–March 2018. MMWR Morb Mortal Wkly Rep. 2019; 68(16): 374–376. doi: 10.15585/mmwr.mm6816a3

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25. Karen L Dugosh, KL, John S Cacciola, JS. Clinical assessment ofsubstance use disorders. Uptodate. October 2019. Retrieved fromhttps://www.uptodate.com/contents/clinical-assessment-of-substance-use-disorders?search=signs%20and%20symptoms%20of%20substance%20use%20disorder%20opioid&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4

26. Tug Valley Pharm. v. All Plaintiffs in Mingo County, 2015 BL 148172,W.Va. No. 14-0144 (W.Va. 2015)

27. US Drug Enforcement Agency. Drug Addiction in HealthcareProfessionals. Retrieved fromhttps://www.deadiversion.usdoj.gov/pubs/brochures/drug_hc.htm.

28. Finley EP, et al. Evaluating the impact of prescription drug monitoringprogram implementation: a scoping review. MC Health Serv Res.2017;17(1):420.

29. WV Code Chapter 60A Article 9. 2017. Retrieved fromhttp://www.overdosepreventionstrategies.org/wp-content/uploads/2016/09/WV-Code-Chapter-60A-Article-9.pdf

30. U.S. Department of Justice - Prescription Drug Practitioner’s Manual.Retrieved from

https://www.deadiversion.usdoj.gov/pubs/manuals/pract/index.html.

31. Government Publishing Office. 1307.21 Procedure for disposing ofcontrolled substances. Retrieved fromhttps://www.gpo.gov/fdsys/pkg/CFR-2011-title21-vol9/pdf/CFR-2011-title21-vol9-sec1307-21.pdf.

32. Environmental Protection Agency. Federal Register. EPA.2019;Vol.84,No.36.

33. U.S. Federal Register. Title 21 Code of Federal Regulations, Part 1317:Disposal. Retrievedfromhttps://www.deadiversion.usdoj.gov/21cfr/cfr/1317/subpart_a.htm

34. Merlo L, Teitelbaum S, Thompson S. Substance use disorders inphysicians: Epidemiology, clinical manifestations, identification, andengagement. UpToDate. 2019. Retrieved fromhttps://www.uptodate.com/contents/substance-use-disorders-in-physicians-epidemiology-clinical-manifestations-identification-and-engagement?search=physician%20drug%20abuse&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

35. American Association of Nurse Anesthetists. ReentryRecommendations and Resources. AANA. 2019. Retrieved fromhttps://www.aana.com/practice/health-and-wellness-peer-assistance/About-AANA-Peer-Assistance/substance-use-disorder-workplace-resources/re-entry-recommendations-and-resources

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36. Milenkovich N. The impaired pharmacist: Rehabilitation, regainingdignity and licensure. Mental Health Clinician. 2013; Vol.3, No.6:pp.313-315.

37. American Medical Association. Physician Re-entry. State MedicalLicensure Requirements and Statistics. AMA. 2013. Retrieved fromhttps://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/med-ed-products/physician-reentry-regulations_0.pdf

38. Sanders A, Eassey J, Stogner J, Miller B. Deception and DrugAcquisition: Correlates of “Success” Among Drug-Seeking Patients. JPrim Care Community Health. 2016;7(3):175–179.

39. Kulaksizogiu B, Kara H, Bodur B, Kulogiu M. Intravenousbuprenorphine/naloxone and concomitant oral pregabalin misuse: acase report. Neuropsychiatr Dis Treat. 2018; 14: 3033–3035.

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