Table 6. Common Types of Drug Diversion
Method
Definition
Selling Prescription Drugs
Patients and non-patients sell prescription drugs that were obtained illegally Soliciting multiple prescribers under false pretenses to obtain CS prescriptions
“Doctor Shopping”
Rogue websites under the guise of legitimate pharmacies provide CS to people without prescriptions, evading state licensing requirements, operating across state and international borders May occur at any step of the supply chain (examples: manufacturers, patients, patient’s relatives or friends, HCPs, pharmacists) Printing or stealing prescription pads to write fraudulent prescriptions, altering existing prescriptions to obtain unauthorized quantity Providing unnecessary prescriptions or larger quantities than medically necessary (i.e., “pill mills”)
Illegal Internet Pharmacies
Theft
Prescription Pad Theft and Forgery
Illicit Prescribing
CS = Controlled substances HCPs = Health care providers
Most misused opioids are obtained through diversion. Year after year, the National Survey on Drug Use and Health, conducted annually by SAMHSA, reports that most people who misuse prescription opioids either bought them, were given them, or took them without asking from family members or friends. 88 About a third of people who misuse opioids get them by prescription from one doctor. 88 Leftover pills from acute pain prescriptions are a chief source of diverted and misused opioids. One systematic review found that 42% to 71% of opioids obtained by surgical patients went unused. 89 Leftover CS in medicine cabinets can then become a significant source for diversion. Patients should be counseled never to share opioids or other CS with any other person and to store opioids in a locked area away from other family members and visitors. 44 Certain medications are highly sought for diversion as identified by the DEA and NIDA and shown in Table 7. 25 Some prescription drugs sell on the street for as much as $50 a pill and, unfortunately, some patients sell the drugs prescribed to them as a way of earning money to pay expenses or to
finance their desire to buy street drugs. 17 To be clear, most patients who take opioids for pain do not misuse or divert their pills. 88 However, HCPs should understand that some people who visit a medical facility for pain are actually seeking opioids to divert or misuse and take relevant precautions to prevent diversion as required by the DEA. Some patients may have the disease of OUD and should be managed accordingly. Distinguishing would-be diverters from patients is difficult at best. Although no behavior reliably indicates drug diversion, the chances of detecting such deception increase when HCPs watch for patterns of behavior. The DEA has listed some common behaviors that should not be considered an exhaustive list but that might indicate a person seen in-clinic is seeking drugs to divert or misuse: 24 • Demanding to be seen immediately • Stating that they are visiting the area and need a prescription to tide them over until seeing a local HCP • Appearing to feign symptoms, such as abdominal or back pain or pain from kidney stones or a migraine to obtain opioids
• Claiming non-opioid analgesics do not work • Requesting a particular opioid • Complaining that a prescription has been lost or stolen and needs replacing • Requesting more refills than originally prescribed • Using pressure tactics or threatening behavior to obtain a prescription • Showing visible signs of drug abuse, such as track marks Clinical practices to minimize the potential diversion when seeing patients include: 25 • Caution when prescribing to patients who request combinations of drugs that may enhance effects, such as opioids with benzodiazepines • Thorough documentation when prescribing or choosing not to prescribe opioids • Keeping a DEA registrant or license number confidential unless disclosure is required • Protecting access to prescription pads • Ensuring that prescriptions are written clearly to minimize the potential for forgery
Table 7. Drugs with Highest Potential for Diversion and Misuse
Drug Class
Examples
Anabolic Steroids
Methyltestosterone Testosterone
Depressants
Barbiturates: pentobarbital Benzodiazepines: alprazolam, diazepam
Hallucinogens
Ketamine
Opioids
Diphenoxylate Fentanyl Hydrocodone Hydromorphone Meperidine Methadone Morphine Oxycodone Oxymorphone
Stimulants
Amphetamine Dextroamphetamine Methamphetamine Methylphenidate
Centers for Medicare and Medicaid Services. Partners in Integrity: What is a Prescriber’s Role in Preventing the Diversion of Prescription Drugs? https://www.pharmacy.umn.edu/sites/pharmacy.umn.edu/files/prescriber_role_in_preventing_diversion.pdf Accessed Sep 17, 2021.
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