Reduce Criminal Diversion of Prescription Drugs

Introductory Paragraph

Drug diversion is the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber. Inciardi et al. (2006), defines prescription drug diversion as the illegal way of acquiring or distributing controlled medicinal drugs for any use.

Key Information

According to the US Department of Health and Human Services the most common types of drug diversion include:

• Selling prescription drugs;
• Doctor shopping;
• Illegal Internet pharmacies;
• Drug theft;
• Prescription pad theft and forgery;
• Illicit prescribing.

Physicians are in the forefront of managing chronic pain for their patients and play a key role in drug diversion. It is estimated that this may affect 15 percent to 30 percent of the general population of the United States – as many as 70 million individuals. Prevention strategies include training to identify points of diversion, improve drug monitoring, and recognition of signs of drug diversion.

Signs of Diversion

The potential for misuse of opioids and other medications used to treat pain by patients suffering from chronic ongoing pain is high. Patients may abuse their own medication and may divert by obtaining medications under false pretenses or by reselling medications prescribed to them. The American Academy of Family Physicians (AAFP) provides tips on recognizing signs of diversion. These tips from AAFP are as follows-

• Strange stories. Be wary of new patients with stories that don’t seem quite right. Diverters often claim to be traveling through town on business or visiting relatives. Occasionally, they’ll pose as government officials or pharmaceutical company representatives. They may be excessively complimentary about the office facilities or your appearance or medical reputation in the community. They may deliberately request appointments toward the end of the day or may show up just after regular office hours. One common ploy diverters use is to ask to be seen immediately or to be given a prescription right away because they have to “catch a plane” or “get to an important appointment.” They may claim that they have lost a paper prescription, forgotten to pack their medication or had their medication stolen.

• Reluctance to cooperate. Diverters often refuse a physical exam and are unwilling to give permission to access past medical records or allow contact with previous providers. If pressed, they may claim they cannot precisely remember where they were last treated or that the previous clinic, hospital or provider has gone out of business. In many cases, these patients leave the office suddenly if things are not going their way.

• Unusually high (or low) understanding of medications. Be alert when patients appear to be extremely well-informed about specific medications. While it is true that people who have been sick for a long time often learn much about their disease process and know the medications that work best for them, this is also true of diverters. They often appear to have a familiarity with diseases that comes straight from textbooks rather than real life. Some diverters may feign naiveté by deliberately mispronouncing medication names or seeming to be uninformed about their underlying medical condition.

• Strange symptoms. Diverters may exaggerate or feign symptoms. Certain complaints are typical, such as back pain, kidney stones, migraine headaches, toothaches or post-herpetic neuralgia. Some diverters may even attempt to alter urine samples by pricking a finger and putting a drop of blood in the specimen to corroborate their story of renal colic.

• Specific drug requests. Because many diverters are very knowledgeable about controlled substances, they may request specific medication brands and resist any of your attempts to prescribe generic forms and substitutes, stating that they are “allergic” or that a particular alternative has never provided relief for them in the past.

Relevant Research

• The Department of Justice has funded a research summary on diversion titled "Illegal Prescription Drug Market Interventions."

• The Mayo Clinic has documented steps that have been taken to reduce drug diversion by its healthcare workers in a report titled "Diversion of Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention."

Impactful Federal, State, and Local Policies

The Controlled Substances Act (CSA) The CSA is a federal drug law regulating the manufacture and distribution of controlled substances since the 1970s. The CSA requires every person who orders, handles, stores or distributes controlled substances to registered with the DEA. "Registrants must maintain accurate inventories and records, and must have specific security controls and operating procedures in place to guard against theft and diversion." In addition, the CSA requires all prescriptions for controlled substances be issued for a medical purpose by an individual practitioner acting in the usual course of medical practice.

The CSA categorizes drugs into one of five schedules based on each drug’s medical use and its potential for abuse or dependency. The Drug Enforcement Agency(DEA) and the Food and Drug Administration (FDA) have authority to add or remove drugs from the different schedules.The most harmful substances are placed in Schedule I, and the rest appear in descending order accordingly. Included in each schedule are:

• Schedule I: heroin, ecstasy, LSD, marijuana
• Schedule II: morphine, cocaine, methamphetamine
• Schedule III: Vicodin, anabolic steroids
• Schedule IV: Ambien, Soma, Valium
• Schedule V: Lyrica, cough suppressants

The Pharmacist Manual The Diversion Control Division within DEA has published an informational outline of the CSA.

The Affordable Care Act The U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, has published an issue brief titled "Continuing Progress on the Opioid Epidemic: The Role of the Affordable Care Act."

Available Tools and Resources

Fact Sheet The US Department of Health and Human Services has a fact sheet for the prescriber's role in drug diversion.

Drug Diversion Toolkit This guidance by the Center for Medicare and Medicaid Services (CMS) provides more detailed information on how prescribers can prevent drug diversion.

The Office of Diversion Control within the US Department of Justice Drug Enforcement Administration provides a website with current information on drug diversion.

American Society of Health-System Pharmacists (ASHP) provides a website with multiple resources for pharmacy technicians on controlled substances diversion.

Drug Policy Facts is provided by the Real Reporting Foundation, a nonprofit that maintains a website with numerous topics. One extensive "chapter" of their website is devoted to the diversion of prescription drugs.

Promising Practices

The Bureau of Justice Assistance (BJA) has published a call to action and issue brief. It details the justice system use of prescription drug monitoring programs (PDMPs).

Medicaid Drug Diversion. The Center for Program Integrity within the Center for Medicare and Medicaid Services promotes a variety of strategies for states to reduce drug diversion in Medicaid.