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.
People of all ages, genders, and backgrounds use illicit or prescription drugs nonmedically. This can include 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).
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).
Most Common Sources of Illicit Drugs
Illicit drugs can be procured in several ways: from family and friends, by doctor shopping, from healthcare providers, through fraud, and via the internet.
Family and Friends
Although we might assume that drug users acquire opioids from street dealers, this is not usually the case. Because pain medications are so commonly prescribed, users may simply look in the medicine cabinet of a family member or friend. As a matter of fact, drug dealers are a relatively small source of illicitly used prescription opioids. Diversion through family and friends is by far the greatest source of illicit opioids (Dixon, 2018).
Doctor shopping occurs when patients seek 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. However, most opioids are obtained by prescription from one physician (Dixon, 2018).
In the early part of the century, doctor shopping was identified as a risk factor for opioid use disorder, overdose, and diversion. Many states, including Rhode Island, have developed PDMP databases to flag patients who doctor shop (Schneberk et al., 2020).
Paradoxically, negative health outcomes can occur when patients are unable to get medications from a doctor and pursue opioids through riskier channels. 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. They may try to fill out a prescription for a fictitious patient on a prescription pad stolen from a prescriber’s office or alter a legitimate prescription.
They may try to change the phone number on a legitimate prescription pad with an altered call-back number or call in a fraudulent prescription and provide the drug abuser’s own call-back number for verification. They may also try to create a fraudulent prescription signed by a fictitious doctor or copy a prescription from a legitimate doctor.
Data suggests 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. They may divert drugs from their patients for their own use.
Healthcare providers can divert controlled substances by replacing a controlled substance with a substitute drug or with saline solution. They may remove a substance from a premixed infusion or from a multidose vial. Additionally, they may:
- Divert and forge a prescription pad.
- Document that a medication has been given, but not administer it to the patient.
- Remove controlled substances from an unsecure waste container.
- Divert an expired controlled substance from a holding area. (Joint Commission, 2019)
Nonclinical healthcare workers can also divert drugs. Shipping-and-receiving personnel often handle drug shipments or returns and may take the drugs for personal use. Housekeeping staff can obtain pain medication by stealing partially filled vials from patient rooms (Fan et al., 2019).
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 the healthcare setting, diversion of controlled substances can be difficult to detect and prevent without a comprehensive controlled substances diversion–prevention program (Joint Commission, 2019).
Case: APNs 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 Rhode Island, 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.
Do you think Jan is behaving appropriately? Is she stealing from the facility? What other ethical issues arise from Jan’s behavior? Do her friends have a legal or ethical duty to report Jan to her employer or perhaps to the state department of health?
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 that 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 large amounts for inadequate safeguards. Hospitals that fail to regulate and report diversion compromise public trust (Fan et al., 2019).
Drugs have been available for sale on the internet for more than fifteen years, but when the first cryptomarket, Silk Road 1, came online in 2011, illicit drugs began to be traded in large quantities. The annual turnover of drug sales conducted through cryptomarkets is estimated to be in the hundreds of millions of dollars, with most transactions involving recreational drugs such as cannabis and ecstasy. Since 2011 cryptomarkets have been analyzed using automated software “crawlers” that collect publicly available data from websites (Martin et al., 2018).
Before 2014 prescription drugs represented slightly less than 10% of all cryptomarket sales. People who buy through cryptomarkets are believed to be predominantly male, young (<25 years), educated, employed, and White (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, especially a repeat prescription. Restrictions had the unintended consequence of a displacement towards 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 cryptomarkets makes 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).
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 1 doctor