__________________________________________________ Responsible Prescribing of Controlled Substances
language, an interpreter is required. Interpreters can be a valu- able resource to help bridge the communication and cultural gap between patients and practitioners. Interpreters are more than passive agents who translate and transmit information back and forth from party to party. When they are enlisted and treated as part of the interdisciplinary clinical team, they serve as cultural brokers who ultimately enhance the clinical encounter. In any case in which information regarding treat- ment options and medication/treatment measures are being provided, the use of an interpreter should be considered. Print materials are also available in many languages, and these should be offered whenever necessary. IDENTIFICATION OF DRUG DIVERSION/ SEEKING BEHAVIORS Research has more closely defined the location of prescribed opioid diversion into illicit use in the supply chain from the manufacturer to the distributor, retailer, and the end user (the pain patient). This information carries with it substantial public policy and regulatory implications. The 2024 National Survey on Drug Use and Health found that 7.6 million indi- viduals misused prescription opioids in the past year. Among persons 12 years of age or older, 42.3% obtained their prescrip- tion opioids from a friend or relative. Of this, 31.3% got them through a friend or relative for free, 6.9% bought them from a friend or relative, and 4% took them from a friend or relative without asking. Another 40.5% got their opioids through a prescription from one doctor. Less frequent sources included a drug dealer or other stranger (7.6%) and theft from a doctor’s office, clinic, hospital, or pharmacy (1.3%) [49]. The term diversion is defined as “any criminal act or deviation that removes a prescription drug from its intended path from the manufacturer to the patient” [50]. Due to ease of access, drug diversion is particularly likely to occur in healthcare set- tings, with some researchers estimating that as many as 10% to 15% of all healthcare workers divert drugs at least once in their careers. The most common drug diverted from health- care facilities is fentanyl (an opioid), although other opioids, anti-anxiety drugs, sedatives, stimulants, and sleep aids are at higher risk of diversion. Diversion in the healthcare setting can occur through several mechanisms, including [50]: • False documentation (e.g., stating in a patient’s medical record that the worker gave the patient the drug without doing so, or falsely listing a medication as wasted) • Scavenging wasted medication (e.g., removing residual medication from used syringes or trash) • Theft by tampering (e.g., substituting or diluting medication with a similar looking substance, such as saline)
Signs of drug diversion among healthcare workers include delays between obtaining drug from the pharmacy or auto- mated dispensing cabinet (ADC) to patient administration of drug; frequent ADC overrides or irregular ADC reports; and wasting large amounts of drugs or not properly documenting drug waste. In addition, patients reporting high pain scores or complaining of pain after being administered pain medication may also be a sign of drug diversion by healthcare workers. In the healthcare setting, the following factors are considered contributors to controlled substance diversion [50; 51]: • Excess ordering • Unsupervised access to drug storage areas • Unverified verbal orders • Flexible ordering and administration • Forgery and/or falsification of patient documentation • Compounding and repackaging • Typical doses smaller than stocked drugs • Poor verification of dispensing to clinical units • Reduced pharmacy oversight of dispensing with introduction of technology (e.g., automated dispensing cabinets) • Loopholes in the intended use of or poorly configured automated dispensing cabinets • Prepared drugs are unsupervised and unsecured • Unsupervised access to drug stock in patient care areas • Visual confirmation of or falsification of witnessing wasting • Falsification of drug expiration • Presence of partially administered drugs on clinical units • Unsecured waste receptacles Many of these same factors contribute to the theft of controlled substances from healthcare facilities by patients, visitors, ven- dors, and various other opportunists. As discussed, UDTs can give insight into patients who are mis- using opioids. A random sample of UDT results from 800 pain patients treated at a Veterans Affairs facility found that 25.2% were negative for the prescribed opioid while 19.5% were posi- tive for an illicit drug/unreported opioid [52]. Negative UDT results for the prescribed opioid do not necessarily indicate diversion but may indicate the patient halted his/her use due to side effects, lack of efficacy, or pain remission. The concern arises over the increasingly stringent climate surrounding clini- cal decision-making regarding aberrant UDT results and that a negative result for the prescribed opioid or a positive UDT may serve as the pretense to terminate a patient rather than guide him/her into addiction treatment or an alternative pain management program; the CDC states that “clinicians should not dismiss patients from care on the basis of a toxicology test
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