Drug diversion is a critical issue that affects the general population of the United States, as well as the healthcare industry. This phenomenon involves the unauthorized distribution or usage of prescription medications — most commonly analgesics and psychoactive drugs — in ways that were not intended by the prescriber (1). Examples of drug diversion include the theft of prescription medications from individuals or healthcare institutions; the fabrication of symptoms to gain access to particular medications; and altering information on prescription slips (2). Drug diversion poses a significant public health problem in two spheres: the general population and the healthcare industry.
In the general population, thousands of individuals are estimated to illegally gain access to prescription medications every year (3). However, drug diversion in the general population is difficult to trace, as the most common route is stealing or taking medications from family or friends with prescriptions, followed by fabricating symptoms, “doctor shopping,” and purchasing illegally from dealers or online pharmacies (1, 3, 4). However, it is assumed that drug diversion heavily contributes to the opioid epidemic in the United States, as an average of 44 individuals died every day in 2020 from prescription drug overdoses and a significant proportion of these deaths have been linked to unauthorized use (1, 5).
In the healthcare industry, drug diversion poses a problem to healthcare workers and their patients. Like the general population, healthcare workers can illegally gain access to medications by faking prescriptions or taking from family and friends, but they can also steal from healthcare resources and their patients. Altering or forging patient prescriptions is one common route of gaining illicit access, exemplified by the fact that 8% of medication transactions in US hospitals between 2018 and 2021 showed characteristics that signaled unauthorized or unintended usage (6). Highly addictive, dangerous opioids and benzodiazepines such as fentanyl, midazolam, and morphine comprised the bulk of these suspicious prescriptions, which demonstrates a connection between drug diversion and the prescription drug overdose crisis (6).
In addition to falsifying prescriptions, the practice of replacement is another problem, which entails the theft of prescription drugs and the substitution of the corresponding amount of a non-active agent, typically saline (7). For example, in 2022, a nurse extracted the fluids from vials of analgesic prescriptions used in surgical procedures and replaced them with saline, resulting in patients being unmedicated for their surgeries (8). Another route of drug diversion, self-injecting or tampering with patient prescriptions, carries the additional risk of bloodborne pathogen exposure, as exemplified by the six outbreaks of bloodborne diseases between 2000 and 2013 that were caused by hospital workers who tampered with drug syringes prescribed for their patients (9). Drug diversion in the healthcare field also remains difficult to trace, but the consequences of it directly harm patients, as well as the healthcare workers themselves.
Preventing drug diversion requires executing several strategies. To minimize risk in the general population, experts recommend completing a full evaluation of the patient, requesting a report from the state prescription drug monitoring program, screening for substance abuse characteristics, and prescribing heavily controlled substances only when alternative options do not offer adequate symptom relief (2). In the healthcare field, prevention strategies include incorporating technologies such as automatic dispensing cabinets, implementing procurement and disposal procedures, installing security cameras, and monitoring inventory and waste (10). Noting suspicious behaviors in patients — such as reporting strange symptoms or requesting specific medications — and in healthcare workers — such as frequently failing to document prescription waste or requesting supplemental prescriptions — also helps monitor drug diversion (7, 11). Implementing these strategies can help limit this dangerous practice, which can benefit and even save the lives of individuals who divert drugs.
References
1: Wood, D. 2015. Drug diversion. Australian Prescriber, vol. 38(5). DOI: 10.18773/austprescr.2015.058.
2: Health and Human Services (HHS). 2016. “Drug diversion: what is a prescriber’s role in preventing the diversion of prescription drugs?” Health and Human Services Guidance. URL: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/DrugDiversionFS022316.pdf.
3: Ford, J., Pomykacz, C., Szalewski, A., McCabe, S. and Schepis, T. 2020. Friends and relatives as sources of prescription opioids for misuse among young adults: The significance of physician source and race/ethnic differences. Substance Use and Addiction Journal, vol. 41(1). DOI: 10.1080/08897077.2019.1635955.
4: Inciardi, J., Surratt, H., Kurtz, S. and Cicero, T. 2007. Mechanisms of prescription drug diversion among drug-involved club- and street-based populations. Pain Medicine, vol. 8(2). DOI: 10.1111/j.1526-4637.2006.00255.x.
5: Centers for Disease Control and Prevention. 2022. Prescription opioid overdose death maps. CDC Drug Overdose. URL: https://www.cdc.gov/drugoverdose/deaths/prescription/maps.html.
6: Kaltwasser, J. 2022. “Many cases of potential drug diversion go uninvestigated: report.” Managed Healthcare Executive. URL: https://www.managedhealthcareexecutive.com/view/many-cases-of-potential-drug-diversion-go-uninvestigated-report.
7: Nyhus, J. 2021. “Drug diversion in healthcare.” American Nurse Journal. URL: https://www.myamericannurse.com/wp-content/uploads/2021/04/an5-DrugDiversion_Fresenius-414.pdf.
8: Murphy, J. 2023. “Nurse who stole painkillers, replacing them with saline and putting surgical patients at risk, sentenced to four years.” Drug Enforcement Administration. URL: https://www.dea.gov/press-releases/2023/05/22/nurse-who-stole-painkillers-replacing-them-saline-and-putting-surgical.
9: Schaefer, M. and Perz, J. 2014. Outbreaks of infections associated with drug diversion by US healthcare personnel. Mayo Clinic Proceedings, vol. 89(7). DOI: 10.1016/j.mayocp.2014.04.007.
10: Knight, T., May, M., Tyson, D., McAuley, S., Letzkus, P. and Enright, S. 2022. Detecting drug diversion in health-system data using machine learning and advanced analytics. American Journal of Health-System Pharmacy, vol. 79(16). DOI: 10.1093/ajhp/zxac035.
11: Cole, E. 2001. Recognizing and preventing medication diversion. Family Practice Management, vol. 8(9). URL: https://www.aafp.org/pubs/fpm/issues/2001/1000/p37.html.