Reduce Criminal Diversion of Prescription Drugs

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Introductory Paragraph

"Drug diversion is the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber."[1]   Inciardi et al. (2016), defines prescription drug diversion as the illegal way of acquiring or distributing controlled medicinal drugs for any use.[2]   

Key Information

According to Health and Human Services the most common types of drug diversion include:[3]

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

Physicians are in the forefront of managing chronic pain for their patientsand 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.[4]
 

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.[5]  The American Academy of Family Physicians provides tips on recognizing signs of diversion.  These tips from AAFP are as follows-

Signs of Diversion include:

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.

Other aspects to be highlighted beyond signs of drug diversion include identifying points of diversion, prevention strategies, drug monitoring and training.


Controlled Substances Act[6] The Controlled Substances Act (CSA) is a federal drug law regulating he 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.[7]

The CSA categorizes drugs into one of five schedules based on each drug’s medical use and its potential for abuse or dependency. The most harmful substances are placed in Schedule I, and the rest appear in descending order accordingly.[8] 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 suppressants16

The Drug Enforcement Agency(DEA) and the Food and Drug Administration (FDA) have authority to add or remove drugs from the different schedules.

Relevant Research

  • The Department of Justice Research on Illegal prescription drug market and interventions.[9]
  • Diversion of Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention[10]

Impactful Federal, State, and Local Policies

Diverson of Prescription Drugs- Drug Policy Facts[11]

28 National Alliance for Model State Drugs, State Laws/Regulations Requiring Hospitals, Nursing Homes, and Pharmacies to Report the Theft or Loss of Controlled Substances, April 4, 2016.[12]

U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Continuing Progress on the Opioid Epidemic: The Role of the Affordable Care Act, January 11, 2017[13]

The Controlled Substance Act[14]

Available Tools and Resources

Department of Justice/Drug Enforcement Administration Resources and office of Diversion control[15]

Health and Human Services Drug Diversion & Prescribers role fact sheet[16]

Center for Medicare and Medicaid Services (CMS)- A Drug Diversion Toolkit[17]

Controlled Substances Drug Diversion Pharmacy Technician Toolkit[18]

Promising Practices
 

Prescription Drug Monitioring Programs[19] Department of Justice Systems brief on the use of prescription drugs and drug monitoring

Medicaid Drug Diversion- Strategies for reducing drug diversion in Medicaid.[20]

Sources

  1. https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/MedicaidIntegrityProgram/downloads/drugdiversion.pdf 
  2. Inciardi JA, Surratt HL, Kurtz SP, Burke JJ. The diversion of prescription drugs by health care workers in Cincinnati, Ohio. Subst Use Misuse. 2006;41(2):255–264. [PubMed] [Google Scholar]
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2879025/
  4. Krames ES, Olson K. Clinical realities and economic considerations: patient selection in intrathecal therapy. J Pain Symptom Manage. September1997;14(suppl 3):S3–S13
  5. https://www.aafp.org/fpm/2001/1000/p37.html
  6. https://www.dea.gov/drug-information/csa
  7. https://cdn.ymaws.com/www.iahss.org/resource/collection/48907176-3B11-4B24-A7C0-FF756143C7DE/2018_Methods,_Trends_and_Solutions_for_Drug_Diversion.pdf
  8. https://www.deadiversion.usdoj.gov/schedules/
  9. https://www.ojp.gov/pdffiles1/nij/grants/248905.pdf
  10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538481/
  11. https://www.drugpolicyfacts.org/chapter/diversion
  12. https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-046)(EO-DEA154)_Pharmacist_Manual.pdf
  13. https://aspe.hhs.gov/pdf-report/continuing-progress-opioid-epidemic-role-affordable-care-act
  14. https://www.dea.gov/drug-information/csa
  15. https://www.deadiversion.usdoj.gov/
  16. https://www.deadiversion.usdoj.gov/
  17. https://www.cms.gov/files/document/drugdiversion022316pdf
  18. https://www.ashp.org/pharmacy-technician/about-pharmacy-technicians/advanced-pharmacy-technician-roles-toolkits/controlled-substances-drug-diversion-pharmacy-technician-toolkit?loginreturnUrl=SSOCheckOnly
  19. https://www.ojp.gov/ncjrs/virtual-library/abstracts/call-action-and-issue-brief-justice-system-use-prescription-drug
  20. https://www.cms.gov/medicare-medicaid-coordination/fraud-prevention/medicaidintegrityprogram/downloads/drugdiversion.pdf