Drug diversion is the intentional removal of a prescription medication from the legitimate channels of distribution and dispensing. Diversion occurs when family or friends share a prescription medication, when medication is stolen from its intended recipient, or when a prescription medication is otherwise illegally acquired.
Prescription drug diversion, misuse, and abuse is an escalating public health problem. Its impact is associated with a high likelihood of poor healthcare outcomes, increased incarceration cases, and increased mortality. Worldwide, sedatives, analgesics, and stimulants are the drug classes most commonly diverted, misused, and abused (Chibi et al., 2020).
People of all ages, genders, and backgrounds use illicit or prescription drugs nonmedically. This can mean taking a medication in a manner or dose other than prescribed; taking someone else’s prescription, even if for a legitimate medical complaint such as pain; or taking a medication to get high (NIDA, 2020, June).
Most Common Sources of Illicit Drugs
Once a person has made the decision to seek illicit drugs, they can find them in a number of ways: family, friends, doctor shopping, from healthcare providers, through fraud, and via the internet.
Friends and Family
Although we might assume that drug users acquire their prescription drugs from street dealers, this is not usually the case. Because prescription pain medications are so commonly prescribed, often nonmedical users merely look in the medicine cabinet of a family member or friend. Strikingly, drug dealers are a relatively small source of illicitly used prescription opioids. Diversion through family and friends is now the greatest source of illicit opioids (Dixon, 2018).
Patients may request prescription pain medications from more than one physician. The patient does not inform the doctors of the multiple prescribers and fills multiple prescriptions for the same or similar medication at different pharmacies. This is known as “doctor shopping.” However, most opioids are obtained by prescription from one physician (Dixon, 2018).
After prescriptions for opioids nearly quadrupled in the early part of the century, states began efforts to identify individuals most at risk for opioid abuse and overdose. Doctor shopping was identified as a risk factor for opioid use disorder, overdose, and diversion. Many states, including New Jersey, have developed PDMP databases to flag patients who doctor shop (Schneberk et al., 2020).
Paradoxically, negative health outcomes can occur as denied patients pursue opioids through riskier channels or use more lethal forms of opioids. Although there is evidence that PDMPs may reduce overall opioid prescriptions, there is insufficient evidence to determine if PDMPs curtail doctor shopping behavior or reduce negative patient centered outcomes such as opioid overdoses (Schneberk et al., 2020).
Patients who misuse or abuse prescription drugs may try to fill a fraudulent prescription, which come in many forms:
- Filling out a prescription for fictitious patient on a prescription pad stolen from a prescriber’s office.
- Altering a legitimate prescription.
- Changing the phone number on a legitimate prescription pad with an altered call-back number.
- Calling in a fraudulent prescription and providing the drug abuser’s own call-back number for verification.
- Create a fraudulent prescription signed by a fictitious doctor or copied from a legitimate doctor.
Data suggest that about 10% of healthcare workers are abusing drugs. They may become involved in drug diversion by providing drugs to patients engaging in fraud or doctor shopping, or divert drugs for their own use.
Nonclinical healthcare workers may also divert drugs. Shipping-and-receiving personnel often handle drug shipments or returns and housekeeping may encounter partly filled vials in patient rooms. Patients and their families may also divert drugs by, for example, acquiring fentanyl patches from unsecured waste receptacles or tampering with unsecured intravenous infusions (Fan et al., 2019).
Due to the availability of, and access to, medications in healthcare organizations, diversion of controlled substances can be difficult to detect and prevent without a comprehensive controlled substances diversion-prevention program (Joint Commission, 2019).
Some of the ways in which controlled substances are diverted by a healthcare provider:
- Substitute drug is removed and administered while controlled substance is diverted.
- Prescription pads are diverted and forged to obtain controlled substances.
- Volume removed from premixed infusion.
- Multidose vial overfill diverted.
- Prepared syringe contents replaced with saline solution.
- Medication is documented as given but not administered to the patient.
- Controlled substance waste is removed from unsecure waste container.
- Expired controlled substances are diverted from holding area. (Joint Commission, 2019)
Case: Jan and Dora
Jan and Dora are advanced practice registered nurses who specialize in restructuring and rehabbing nursing homes that are on the brink of bankruptcy. They have had success “saving” several large nursing homes in New Jersey, are paid handsomely, and have the respect and gratitude of their employers. When they arrive at a failing facility, it isn’t unusual for them to fire employees who have been engaged in illegal activities such as diversion of controlled substances.
On a visit to their home, a friend noticed a plastic bag filled with pills on a table next to a recliner. The friend, a registered nurse and recovered heroin addict, immediately recognized the drugs as prescription pain pills. She asked Jan where she got the pills and Jan replied that she had retrieved them from a garbage can in her office at the facility she and Dora were currently working to save from bankruptcy. When pressed for an explanation, Jan said that as far as she was concerned, once a drug is thrown into a garbage can, it no longer belonged to anyone and she was free to take possession.
The diversion of controlled drugs from hospitals affects patients, healthcare workers, hospitals, and the public. Patients suffer inadequate pain control and experience substandard care from impaired healthcare providers. Healthcare workers who divert are at risk of overdose and death; they also face regulatory censure, criminal prosecution, and civil malpractice suits (Fan et al., 2019).
Hospitals bear the cost of internal investigations and followup care for affected patients, and can be fined in excess of $4 million dollars for inadequate safeguards. Hospitals that fail to regulate and report when diversion occurs compromise public trust (Fan et al., 2019).
The internet has facilitated the sale drugs for more than fifteen years, but when the first crypto market,* Silk Road 1, came online in 2011, illicit drugs began to be traded in large quantities. The annual turnover of drug sales conducted through crypto markets is estimated to be in the hundreds of millions of dollars, with most transactions involving recreational drugs such as cannabis and “ecstasy” (Martin et al., 2018).
*Crypto markets. Crypto = cyber. Also known as Cryptocurrency exchanges, they are websites where individuals can buy, sell, or exchange cryptocurrencies for other digital currency or traditional currency. The exchanges can convert cryptocurrencies into major government-backed currencies, and can convert cryptocurrencies into other cryptocurrencies.
Before 2014, prescription drugs represented slightly less than 10% of all crypto market sales. Customers of crypto markets are believed to be predominantly male, young (<25 years), educated, employed, and white. Since 2011 crypto markets have been analyzed using automated software “crawlers” that collect publicly available data from websites (Martin et al., 2018).
In 2014, when the FDA rescheduled hydrocodone combination products from schedule III to the more restrictive schedule II, it became harder to get these drugs through a prescription, and especially repeat prescriptions. Restrictions had the unintended consequences of a displacement toward illicit substitutes such as heroin, oxycodone, and fentanyl. It has been suggested that the growing use of heroin and fentanyl in the United States is related to this prohibition, whereby interventions, such as increased enforcement and changes to drug scheduling, lead to illicit markets dominated by higher potency products (Martin et al., 2018).
The access of drugs through crypto markets might make it more difficult to reduce the harms associated with prescription opioids. With the move to an illicit market, it becomes more difficult to track use of prescription opioids gotten illegally and to offer treatment and help to users. Prohibition also suggests that the move to an illicit market is associated with use of increasingly potent drugs (Martin et al., 2018).
Percentages of Users by Source
Sources of prescription pain medication
Free of charge from a relative or friend
From a healthcare provider via prescription or by stealing
From one doctor
Bought or stolen from a relative or friend
Bought from a dealer or stranger
From more than one doctor