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DRUG DIVERSION
TRAINING
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor, professor
of academic medicine, and medical author. He
graduated from Ross University School of
Medicine and has completed his clinical clerkship
training in various teaching hospitals throughout
New York, including King’s County Hospital Center and Brookdale Medical Center, among
others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test
prep tutor and instructor for Kaplan. He has developed several medical courses and
curricula for a variety of educational institutions. Dr. Jouria has also served on multiple
levels in the academic field including faculty member and Department Chair. Dr. Jouria
continues to serves as a Subject Matter Expert for several continuing education
organizations covering multiple basic medical sciences. He has also developed several
continuing medical education courses covering various topics in clinical medicine. Recently,
Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s
Department of Surgery to develop an e-module training series for trauma patient
management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy &
Physiology.
ABSTRACT
As prescription drug misuse becomes more common, medical professionals
are being forced into the role of detective, evaluating every patient — and
coworker — for their potential for drug diversion. Clinicians must be able to
identify characteristics of drug diverters and provided with tools to help
them prevent diversion. Strategies to address the problem of drug diversion
are discussed.
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Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 3 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
Statement of Learning Need
Increasingly, health team members are required to update their knowledge
and practices to recognize and prevent drug diversion. The rise in public
access to information about disease cures and, in particular, by drug
diverters, has led to heightened challenges and surveillance measures.
Current federal and state laws require health administrators to develop drug
diversion prevention programs that include mandatory training by all
employees to recognize and report a substance use disorder in the
workplace.
Course Purpose
To provide knowledge for clinicians expected to be compliant with the
regulation of controlled substances, and to recognize and report the signs of
drug diversion.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC - all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
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1. Most drug diverters will divert drugs from some of the
following categories:
a.
b.
c.
d.
Opiates
Stimulants, Pseudoephedrine and Ephedrine
Central Nervous System Depressants
All of the above
2. True or False: Dextromethorphan is part of a classification of
drugs called antitussives that are found in less than 10
products.
a. True
b. False
3. Prescription Drug Monitoring Programs utilize databases that
do the following except:
a. collect and store information regarding the prescription, dispensing,
and use of prescription drugs
b. collect information regarding the patient, practitioner, and
pharmacy used
c. consistently collect information from prescribers
d. include gaps in process that can cause drug diversion to go
undetected
4. A prescription for a controlled substance must:
a.
b.
c.
d.
be dated and signed by the prescriber on the date issued
include one patient identifier
include only the drug name, strength and number prescribed
none of the above
5. In the past decade, there has been an increase of _____ in the
number of cases related to prescription painkillers.
a.
b.
c.
d.
40%
200%
400%
100%
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Introduction
As prescription drug misuse becomes more common, medical professionals
are being forced into the role of detective, evaluating every patient - and coworker - for their potential for drug diversion. Drug diversion can take many
forms, but the most common types of drug diversion include theft from
family and friends, doctor shopping, and theft from healthcare facilities.1 It is
important for medical clinicians and pharmacists to be aware of the different
strategies for drug diversion as well as the common characteristics of
individuals with a substance use disorder, as this information will help
reduce the incidence of drug diversion.
Drug Diversion And Scope Of The Problem
The National Association of Drug Diversion Investigators provides the
following definition for drug diversion:2
Drug diversion can be defined as any criminal act or deviation that
removes a prescription drug from its intended path from the
manufacturer to the patient. This can include the outright theft of the
drugs, or it can take the form of a variety of deceptions such as doctor
shopping, forged prescriptions, counterfeit drugs and international
smuggling.
Prescription drug misuse and drug diversion is a significant problem that
affects numerous individuals. As the availability and scope of prescription
drugs have expanded to include a range of opiates, non-opiate depressants,
stimulants, and potent cold medicines, so too have the misuse of these
substances and the tendency to use them recreationally. Prescription drug
use is a growing problem that can be difficult to identify. In the past decade,
there has been an increase of 400% in the number of treatment admissions
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related to prescription painkillers, and a significant number or prescription
drug related deaths.3
Approximately seven million Americans misuse prescription drugs, which is
more than the number of individuals addicted to all forms of illegal drugs.4
This study focuses on the jurisdiction of West Virginia as an example of
regional efforts to improve regulation of controlled substances. In West
Virginia, it is reported that the number of individuals that died from
overdosing on prescription drugs is higher than the number of individuals
who have died from overdosing on illicit drugs.5 In fact, prescription drug
misuse is considered a significant problem in West Virginia, as a large
percentage of the population is affected.6
Other state jurisdictions report outcomes, which more or less compare with
those of West Virginia and may be found at the U.S. department of
Substance Abuse and Mental Health Services Administration (SAMHSA)
website: http://www.samhsa.gov/data/2k12/NSDUH115/sr115-nonmedicaluse-pain-relievers.htm. For the purposes of this brief self-study, the focus
will be on West Virginia as a case example within a much broader and
growing national concern about the problem of drug diversion within and
across state borders.
While any type of prescription drug can be diverted, it is most common for
individuals to divert those that are classified as controlled substances as
they tend to have a physical or psychological effect on the body.7 Drug
diversion occurs when patients are addicted to the drugs, which is most
common with those classified as controlled substances. Most drug diverters
will divert drugs from the following categories:8
 Opiates
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 Pseudoephedrine and Ephedrine
 Dextromethorphan
 Central Nervous System Depressants
 Stimulants
Drug diverters do not fall into one specific category. In fact, drug diverters
are categorized based upon the ways in which they divert drugs. The
following is a list of the different types of drug diverters.9
 Individual Drug Diverters
 Patients
 Healthcare workers
 Drug Dealers
 Drug Addicts
 Organizational Drug Diverters
 An Organization with a defined hierarchy (Managers,
Supervisors, Recruiters, Runners)
 Pharmacy Employee
 Pharmacist
 Pharmacy Technicians
 Physicians
 Wholesale Distributors
The list above provides examples of all the types of drug diverters.
However, the most common drug diverters are individuals, healthcare
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workers and pharmacy technicians.10 Therefore, this course will focus
primarily on those groups.
Most Commonly Diverted Drugs
While any type of prescription drug can be diverted, it is most common for
individuals to divert those that are classified as controlled substances as
they tend to have a physical or psychological effect on the body.7 Drug
diversion occurs when patients are addicted to the drugs, which is most
common with those classified as controlled substances. Most drug diverters
will divert drugs from the following categories:8
 Opiates
 Pseudoephedrine and Ephedrine
 Dextromethorphan
 Central Nervous System Depressants
 Stimulants
In 1970, Congress enacted the Controlled Substances Act, which established
a classification system for narcotics. This system follows an established set
of criteria to categorize narcotics based upon the potency of the drug and
the potential for misuse.11 Using these guidelines, the Drug Enforcement
Administration (DEA) established a drug schedule that classifies controlled
substances into five categories based upon the intended use and potential
for misuse.
The following table provides information on categories I through V in the
Drug Enforcement Administration’s Drug Schedule.12 The criteria, drug
categories and prescription type as well as the legal limitations of prescribing
the types of medication are included.
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I
Criteria: High potential for abuses, no accepted medical use in treatment, and
lack of accepted safety for use under medical supervision.
Drugs (Opiates, opiate derivatives, psychedelic substances, depressants, and
stimulants): Include heroin, marijuana (currently approved for medical use in
some states), peyote, GBH, MDMA AKA as “Ecstasy,” LSD, mescaline, and MMDA.
Prescription: None allowed in the U.S.
II
Criteria: High potential for abuse, currently accepted medical use in treatment,
and abuse may lead to severe psychological or physical dependence.
Drugs: Include cocaine, opium, morphine, methadone, Ritalin®, Concerta®,
Focalin®, oxycodone, oxymorphone, fentanyl.
III
Criteria: Potential for abuse less than for schedule I or II drugs, currently
accepted medical use in treatment, and abuse may lead to moderate or low
physical dependence or high psychological dependence.
Drugs: Anabolic steroids, intermediate-acting barbiturates (talbutal),
buprenorphine (Buprenex®), vicodin, dihydrocodeine, ketamine,
hydrocodone/codeine when compounded with an NSAID, marinol, and paregoric.
Prescription: May be directly dispensed by practitioner to user or with written or
oral prescription, with a 6-month or 5-refill limitation without renewal.
IV
Criteria: Low potential for abuse compared to Schedule III drugs, currently
accepted medical use in treatment, and abuse may lead to limited physical or
psychological dependence compared to Schedule III drugs.
Drugs: Include benzodiazepines (Xanax®, Librium®, Klonopin®, Valium®),
benzodiazepine-like drugs (Ambien®, zopiclone, zaleplon AKA Sonata®), longacting barbiturates (phenobarbital), partial agonist opioid analgesics (Talwin®),
butorphanol (Stadol®, stimulant-like drugs (modafinil), pentazocine, and
antidiarrheal drugs (difenoxin).
Prescription: May be directly dispensed by practitioner to user or with written or
oral prescription, with a 6-month or 5-refill limitation without a renewal.
V
Criteria: Low potential for abuse compared to Schedule IV drugs, currently
accepted medical use in treatment, and abuse may lead to limited physical or
psychological dependence compared to Schedule IV drugs.
Drugs: Include cough suppressants with low-dose codeine, antidiarrheals with low
dose opium or diphenoxylate, pregabalin (Lyrica®), dezocine, pyrovalerone, and
centrally-acting antidiarrheals when mixed with atropine (Lomotil®).
Prescription: For medical purposes only.
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Drug diversion can occur with a wide range of drugs. However, it is most
common for diverters to seek out drugs in the categories listed below.
Opioids
Opioids are a group of controlled substances that include a number of the
prescription painkillers on the market.13 Opioids, which are also called
opiates, are either derivatives of opium or a synthetic version of opium,
which are potent prescription painkillers.13 Opiates decrease pain sensations
by binding to the receptors in the brain, thereby interrupting the pain
signal.14 In addition to pain relief, opiates often produce a sensation of
euphoria. This sensation is what often leads to the individual to become
addicted to prescription painkillers.15
In addition to the reduction of pain and the sense of euphoria, opiates can
produce a number of common side effects. The most common side effects
for opiates include the following:7
 Sedation
 Dizziness
 Nausea or vomiting
 Constipation
 Physical dependence
 Tolerance
 Respiratory depression
Opiates are the most misused prescription drugs and they can have a
significant impact on the individual’s physical and mental health.16 Opioids
include those listed below:7
 Fentanyl (Duragesic®)
 Hydrocodone (Vicodin®)
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 Oxycodone (OxyContin®)
 Oxymorphone (Opana®)
 Propoxyphene (Darvon®)
 Hydromorphone (Dilaudid®)
 Meperidine (Demerol®)
 Diphenoxylate (Lomotil®)
Pseudoephedrine and Ephedrine
Pseudoephedrine and ephedrine, which are common ingredients in many
over-the-counter cold medicines, are not typically abused on their own.17
However, they are common ingredients in the manufacture of
methamphetamine.18 Therefore, many individuals attempt to divert large
quantities of these ingredients through the purchase of over-the-counter
cold medicine.
The purchase and use of these ingredients has become a significant
problem.19 Hence, the Drug Enforcement Agency (DEA) has established
guidelines specific to the distribution of pseudoephedrine or ephedrine.20
According to federal regulations, each handler (regulated person) is required
to report to the DEA Special Agent in Charge of the local DEA office such
information as involves any regulated transaction of the following:
 An extraordinary quantity of EPH or PSE, an uncommon method of
payment or delivery, or
 Any other circumstance that the regulated person believes may indicate
that the EPH or PSE will be used in violation of the Controlled
Substances Act.
 Any proposed regulated transaction with a person whose description or
other identifying characteristic the DEA has previously furnished to the
regulated person.
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 Any unusual or excessive loss or disappearance of EPH or PSE under the
control of the regulated person. The regulated person responsible for
reporting a loss in-transit is the supplier.
Further to the above, it is unlawful for any person knowingly or intentionally
to possess or distribute EPH or PSE, knowing, or having reasonable cause to
believe, the EPH or PSE will be used to illegally manufacture
methamphetamine.
Dextromethorphan
Dextromethorphan is a medication that is used to reduce or suppress coughs
associated with common viruses. It is part of a classification of drugs called
antitussives and works by halting activity in the portion of the brain that
causes coughing.21 Dextromethorphan is used in a number of over-thecounter cough suppressants and expectorants. There are approximately
seventy products that contain dextromethorphan.22 It is also used to relieve
sinus congestion, runny noses, sneezing, itching nose and throat, and
watery eyes.21
When consumed in large quantities, dextromethorphan can cause
psychotropic responses in individuals.23 Many individuals will consume an
amount greater than the recommended dosage so that they can experience
the dangerous side effects, as excessive consumption can result in
heightened perceptual awareness, altered time perception, and visual
hallucinations.24 While these products are not physically addicting, they do
pose a problem as many individuals will divert drugs containing
dextromethorphan so that they can experience the side effects listed
above.21
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Central Nervous System Depressants
Central Nervous System Depressants are the category of drugs used to treat
anxiety, panic, sleep disorders, stress reactions, and muscle spasms.25 They
typically work by decreasing brain activity, thereby producing a calming
sensation that helps reduce the anxiety of stress experienced by the
individual.
Many individuals will become addicted to the calming sensation that is
experienced when taking a central nervous system (CNS) depressant.26
Other individuals will experiment with CNS depressants recreationally
without ever taking them as a prescribed drug.27 Therefore, there is a
significant risk of drug diversion with CNS Depressants. Unfortunately, CNS
depressants can be extremely dangerous when combined with other
medications and can cause breathing problems and/or death in the
individual.13 Central nervous system depressants include:10
 Pentobarbital sodium (Nembutal®)
 Diazepam (Valium®)
 Alprazolam (Xanax®)
Stimulants
Stimulants are used to treat Attention Deficit Hyperactivity disorder (ADHD)
and narcolepsy. The stimulants are taken orally and work by stimulating the
central nervous system.28 The stimulant produces a gradual and sustained
increase in the neurotransmitter dopamine. This increase in dopamine
results in a therapeutic effect on the patient, thereby causing a reduction in
the negative symptoms and behaviors associated with the aforementioned
disorders.29 Stimulants produce a calming effect that allows patients with
ADHD to focus, and they are affective in helping prevent narcoleptic
episodes.30
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In individuals who do not have ADHD or narcolepsy, stimulants have the
opposite effect. In fact, stimulants produce effects similar to cocaine, as they
bind to sites in the brain and produce dopamine using specific molecular
targets.28 When individuals ingest stimulants without having one of the
conditions mentioned above, they experience a rush that is similar to that
experienced by cocaine users. This rush is what causes individuals to take
stimulants even if they do not need them for a medical reason.29 Stimulants
include those listed below:15
 Dextroamphetamine (Dexedrine®)
 Methylphenidate (Ritalin® and Concerta®)
 Amphetamines (Adderall®)
Doctor Shopping
Many individuals obtain prescription drugs through doctor shopping. Doctor
shopping occurs when an individual visits a number of different doctors
complaining of specific symptoms or medical conditions, with the goal of
obtaining prescription medications for personal use.31 Doctor shopping is one
of the primary methods of drug diversion and is difficult to track and
prevent.32 Doctor shoppers will visit a variety of doctors to obtain
prescriptions, including physicians, specialists, dentists and veterinarians.33
In some instances, individuals will pay for services and prescriptions out of
pocket, but many doctor shoppers use health insurance to cover their visits
and subsequent prescriptions.34
Individuals will typically visit multiple doctors, thereby costing their health
insurance company tens of thousands of dollars. In one instance, a woman
was found to have visited sixty-nine doctors, which resulted in over $80,000
in health insurance payments.35 While there are individuals who will visit an
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extreme number of doctors to obtain prescriptions, the average numbers of
doctors visited by an individual is between five and ten per year. In these
cases, the typical cost to insurance providers is between $10,000 and
$15,000 per year.31
It is difficult to track patients who engage in doctor shopping, even when
health insurance is used as patients often use viable reasons for their visits.4
Therefore, it is necessary for healthcare providers to accept some
responsibility for monitoring individual patients. The following strategies are
useful when working with patients who may be drug diverters:36
 Communicate with other providers and pharmacies when shopping is
suspected
 Provide better record keeping for controlled substance prescribing
 Employ electronic medical records integrated between pharmacies,
hospitals, and managed care organizations
 Periodically request a report from the state prescription drug monitoring
program on the prescribing of prescription drugs by other providers
Characteristics
Drug diverters can be anyone, but there are some defining characteristics
that can distinguish doctor shoppers from others. Doctor shoppers make
frequent visits to multiple doctors, emergency rooms and pharmacies. They
often complain of multiple ailments that would warrant the prescription of
specific drugs. These include migraines, toothaches, psychiatric disorders,
backaches, and other forms of chronic physical pain.33 In some instances,
diverters will cause self-injury to obtain a prescription from a treating
physician in an emergency department.37
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To circumvent the system, many drug shoppers will claim to be out of town
visitors who have forgotten an important and necessary prescription.8 Other
drug shoppers will claim to have accidentally lost their prescription of to
have accidently destroyed their pills (i.e., dropping them in the toilet).33
Drug shoppers will often become agitated when questioned or challenged.1 If
a drug shopper is unable to obtain a prescription from one doctor, he or she
will find a different doctor and start the process over again.35
Monitoring Systems
Prescription Drug Monitoring Systems have been established to monitor how
controlled substances are prescribed and distributed, with the goal of
reducing drug diversion at the statewide level.32 The following fact sheet
created by the U.S. Department of Justice provides an explanation of the
creation and enforcement of the Prescription Drug Monitoring Program.38
The Prescription Drug Monitoring Program was created by the 2002 U.S. Department of
Justice Appropriations Act (Public Law 107-77). Under this new legislation, Congress
appropriated funding to the U.S. Department of Justice to support the Prescription Drug
Monitoring Program (PDMP). The purpose of the Prescription Drug Monitoring Program is
to enhance the capacity of regulatory and law enforcement agencies to collect and
analyze controlled substance prescription data. The program focuses on providing help
for states that want to establish a prescription drug monitoring program. Resources are
also available to states that wish to expand their existing programs.
Prescription monitoring programs help prevent and detect the diversion and abuse of
pharmaceutical controlled substances, particularly at the retail level where no other
automated information collection system exists. States that have implemented
prescription monitoring programs have the capability to collect and analyze prescription
data much more efficiently than states without such programs, where the collection of
prescription information requires the manual review of pharmacy files, a time-consuming
and invasive process.
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Program objectives include:
• Building a data collection and analysis system at the state level.
• Enhancing existing programs' ability to analyze and use collected data.
• Facilitating the exchange of collected prescription data among states.
• Assessing the efficiency and effectiveness of the programs funded under this initiative.
Prescription Drug Monitoring Programs (PDMPs) utilize databases that collect
and store information regarding the prescription, dispensing, and use of
prescription drugs. The database collects information regarding the patient,
practitioner, and pharmacy used.39 Unfortunately, many PDMPs do not
consistently collect information from prescribers, and rely heavily on
information obtained from dispensers instead.40 This often causes cases of
drug diversion to go undetected.41
Prescription Drug Monitoring Programs are managed and enforced at the
state level, and each state handles the process differently. The system is not
standardized.39 In some states, the PDMP is utilized heavily to search for and
identify instances of misuse and abuse. However, other states do not rely as
heavily on the system and only use it when they are required to respond to
instances of misuse or abuse.32 While the process and use of the system
varies by state, the majority of states use the PDMP to perform the
following:42
 Prevent and reduce prescription drug abuse
 Identify and investigate potential cases of diversion (i.e., by pinpointing
and tracking possible illegal activity)
 Identify and investigate professional misconduct (identifying
inappropriate prescribing and dispensing)
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 Disseminate educational information (i.e., by alerting the public to
prescription drug use trends or to provide feedback to prescribers and
dispensers)
 Promote public health initiatives (i.e., by monitoring trends and
addressing prescribing and dispensing issues)
 Implement early intervention and prevention programming (i.e., by
identifying those in need of early assessment and treatment or
targeting efforts at certain high-risk populations)
False Prescriptions
Many diverters will obtain prescription drugs using false prescriptions, which
can take the form of forged, altered and fabricated prescriptions. These
prescriptions are often created by individuals who obtain copies of original
prescriptions and alter them more than the amount initially prescribed.43 In
other instances, patients will steal prescription paper and write their own
prescriptions.8 Regardless of the method, false prescriptions are a significant
problem for physicians and can be difficult to identify and track.27
Altered Prescriptions
Many diverters will initially obtain prescription drugs by altering a legitimate
prescription that they have obtained from a physician. Most alterations will
increase the number of pills prescribed or the number or refills allowed. In
other instances, the patient will add other drugs to the prescription, or
change the type of drug altogether.4
The following information, provided by the National Association of Drug
Diversion Investigators, provides descriptions of how individuals alter
legitimate prescriptions:1
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For many years forgers have used correction fluid to blot out the ink
on prescriptions they wanted to change. They would then take this
piece of paper to a photocopier, and produce what appears to be a
blank prescription. The problem with this method is that it requires the
forger to write an entirely new prescription.
The more popular method today is to use fingernail polish remover for
the acetone it contains. Acetone will remove ballpoint pen from paper.
Those involved in criminal drug diversion will use acetone to “wash”
the prescription. This means the chemical is only used to eliminate the
drug they want to change, leaving the doctor’s signature intact. The
sought after drug is then written on the altered prescription, often with
no one the wiser, including the pharmacist who ultimately dispenses
the drugs.
Forged Prescriptions
Forged prescriptions are prescriptions that are fabricated using a medical
provider’s prescription pad or identifying information.3 Forged prescriptions
are becoming a more significant problem now that individuals have access to
high quality copying equipment.34 In most instances, a patient will steal a
prescription pad or one blank prescription from his or her physician’s office
and write prescriptions for various drugs. The patient signs the prescription
and uses the physician’s information.10
False Called-In Prescriptions
Another form of false prescriptions involves calling in prescriptions. In these
instances, an individual will impersonate a medical provider and call-in a
false prescription to the pharmacy. Most false call-ins are conducted when
the physician’s office is closed so that the pharmacy cannot call the
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physician to verify, and the patient often provides his or her own number for
verification.33
Healthcare Staff Drug Diversion And Theft
One of the most common mechanisms of drug diversion is the diversion of
drugs from healthcare facilities such as hospitals and nursing homes.44 This
type of diversion is a direct theft of the drugs. Typically, the theft occurs
when a member of the staff steals the drugs from the facility, and it can
occur in a number of ways. The most common forms of healthcare staff
related theft are highlighted below.45
1) Stealing drugs directly from a patient:
There are a number of ways this can be accomplished. In most
instances, the healthcare provider will substitute the patient’s drugs
with a different substance. It is common for healthcare providers to
replace intravenous drugs with water, or for pills to be switched for
placebo pills. In other instances, the provider will place the blame on
the patient.
2) Stealing drugs from a drug supply cabinet:
Some drug diverters will steal medication directly from the drug supply
cabinet. In these instances, the healthcare worker will fill out
paperwork as if he or she is dispensing medication to a patient. In
other instances, the healthcare worker will replace drugs in the supply
cabinet with placebos.
Drug diversion is common in healthcare settings where there are no
standard procedures in place to monitor how drugs are procured and
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dispensed. In many instances, healthcare workers are individually
responsible for dispensing medication to their patients, which provides ample
opportunity for them to steal prescriptions without being noticed.44
Other Theft
Other prescription drug theft occurs when individuals steal prescription drugs
from those who have a legitimate prescription. This type of theft can take
two forms. In some instances, the individual will steal prescription drugs
from someone he or she knows, which is most often a family member, and
typically someone who is elderly or mentally unable to identify the theft. In
other instances, the individual will steal prescription drugs from strangers or
healthcare facilities through a traditional break in scenario.33
Profiles Of Drug Diverters
It is imperative that medical providers be aware of the warning signs and
common characteristics of drug diverters, as early identification is imperative
in the treatment process. When a patient presents with symptoms that
warrant prescription drugs, the medical provider should conduct an initial
screening for signs of drug addiction and diversion.11 This can be
accomplished through a thorough medical history and intake.
General Profile: Physical and Psychological
The clinician should review the patient’s history for any inconsistencies or
suspicious behaviors that indicate a pattern of substance abuse.36 Clinicians
should also be familiar with the common physical and psychological
behaviors common in drug diverters. The following bulleted lists provide
thorough information regarding the general profile, physical appearance and
psychological characteristics of those that divert drugs:3,16,33
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General Profile
 Patient is reluctant to provide identification, such as driver’s license
 Patient states he/she is a visitor to the area and in need of emergency
medication or has just moved to the area and has no medical clinician
 Patient requests pain medication over the telephone or per email
 Patient requests pain medication when usual clinician is not available,
such as on the weekend when others are covering the practice
 Patient asks for specific drugs by name and is often adamant that other
drugs are ineffective or may claim allergies to other less potent drugs,
such as NSAIDs
 Patient may appear agitated or in a hurry
 Patient maintains eye contact with clinician and may try to take control
of the interview
 Patient appears knowledgeable about medical terminology and
describes needs in medical terms despite lack of medical education
 Patient may be evasive or inconsistent in answers or tell unlikely stories
 Patient may avoid follow-up appointment
 Patient has wounds that inexplicably do not heal
Physical Appearance
 Physical signs of substance use
 Needle tracks on arms or legs
 Itching, scratching excessively
 Burns on fingers or lips
 Pupils abnormally dilated or constricted, eyes watery, eyelids droopy
(may wear dark glasses inside)
 Slurring of speech, slow speech
 Lack of coordination, instability of gait
 Tremors
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 Sniffing repeatedly, rubbing nose, nasal irritation
 Persistent cough
 Rigid movements, muscle cramps
 Weight loss
 Dysrhythmias
 Pallor or flushing, puffiness of face
Psychological Characteristics
 Labile emotions, including mood swings, agitation, and anger (especially
if in withdrawal)
 Inappropriate, impulsive, and/or risky behavior
 Lying
 Missing appointments
 Difficulty concentrating/short term memory loss, disoriented/confused
 Experiences blackouts
 Lethargic, sleepy during daytime
 Insomnia or excessive sleeping
 Poor personal hygiene
 Answers evasively
Healthcare Workers and Job Performance
Healthcare workers who divert drugs will have additional work related
behaviors in addition to the characteristics listed above. In many instances,
the behaviors will be apparent to their coworkers and supervisors.43 It is
important to be familiar with the characteristics specific to health workers to
reduce the incidence of drug diversion in healthcare settings. Some of the
common performance deficiencies that may be seen in health workers are
listed below:44
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Profile of Diverting/Impaired Healthcare Workers
 Chronic absenteeism, often without notification, and use of excessive
sick days.
 Long unexplained breaks or absences from workplace, including taking
frequent trips to the bathroom or medicine room where drugs are
kept.
 Excessive amounts of time spent near a drug supply, such as a cart or
medicine room. Worker may volunteer for overtime or appear at work
when not scheduled.
 Unreliability in keeping appointments and meeting deadlines.
 Work performance varies widely and mistakes may increasingly occur
resulting from inattention, impaired decision-making, and poor
judgment.
 Worker appears confused at times and may exhibit memory loss and
difficulty concentrating or recalling details or instructions. May work
quite slowly.
 Worker’s interpersonal relations with colleagues, staff and patients
suffer.
 Worker rarely admits errors or accepts blame for errors or oversights.
 Worker experience heavy "wastage" of drugs.
 Recording keeping is sloppy, and some falsification of records may
occur along with drug shortages.
 Those with prescriptive authority write inappropriate prescriptions for
large narcotic doses.
 Worker insists on personally administering injections of narcotic drugs
to patients.
 Worker may appear progressively disheveled and lacking in personal
hygiene.
 Changes are evident in handwriting and charting.
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 Worker wears long sleeves in appropriately, such as in very hot
weather.
 Personality changes become evident with mood swings, anxiety,
depression, lack of impulse control, suicidal thoughts or gestures.
 Others, including patients and staff begin to make complaints about the
coworker’s attitude or behavior.
 Worker becomes increasingly isolated from others.
Prevention Strategies
There are a number of prevention strategies that have been implemented to
reduce the number of drug diverters and increase awareness in the medical
community. Many of the prevention strategies have been developed as
pieces of legislation and standard policies that provide strict guidelines for
the preparation, procurement, and distribution of controlled substances.
Organizational Policies
Organizational policies are those enforced by the U.S. Department of Justice
and the Drug Enforcement Agency, and they clearly outline the requirements
of healthcare clinicians. The Prescription Drug Monitoring Program, which
was discussed earlier in this course, is one of the primary mechanisms for
the regulation of drug distribution and the prevention of drug diversion.
An example is that of West Virginia where the Prescription Drug Monitoring
Program is administered as follows:
West Virginia Code Chapter 60A, Article 9 requires that practitioners
with a DEA registration identification number to administer controlled
substances in West Virginia apply for and receive capability to access
the Controlled Substances Monitoring Program (CSMP) database for
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information about patients to whom they are prescribing controlled
substances in schedules II to IV.
Application forms for advance practice nurses to access the CSMP may
be downloaded from the West Virginia Board of Pharmacy or through a
link from the West Virginia board of Examiners for Registered Nursing.
According to WV Code 60A-9-5:
Good faith reliance by a practitioner on information contained in the
West Virginia Controlled Substances Monitoring Program database in
prescribing or dispensing or refusing or declining to prescribe or
dispense a schedule II, III or IV controlled substance shall constitute
an absolute defense in any civil or criminal action brought due to
prescribing or dispensing or refusing or declining to prescribe or
dispense.46
In addition to the Prescription Drug Monitoring Program, there are a number
of federal guidelines in place that provide strict guidelines for the
development and distribution of controlled substances. The following section
provides the federal guidelines related to the storage and security, ordering
and prescribing, preparation and dispensing, and administration of controlled
substances.
Storage and Security
Federal Guidelines for proper storage and security regarding controlled
substances are as follows:
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Required Controls
Title 21, CFR Section 1301.71(a), requires that all registrants provide
effective controls and procedures to guard against theft and diversion of
controlled substances. A list of factors is used to determine the adequacy of
these security controls. Factors affecting clinicians include:
1. The location of the premises and the relationship such location bears
on security needs
2. The type of building and office construction
3. The type and quantity of controlled substances stored on the premises
4. The type of storage medium (safe, vault, or steel cabinet)
5. The control of public access to the facility
6. The adequacy of registrant’s monitoring system (alarms and detection
systems)
7. The availability of local police protection
Clinicians are required to store stocks of Schedule II through V controlled
substances in a securely locked, substantially constructed cabinet. Clinicians
authorized to possess carfentanil, etorphine hydrochloride and/or
diprenorphine, must store these controlled substances in a safe or steel
cabinet equivalent to a U.S. Government Class V security container.
Registrants should not assign an agent or employee access to controlled
substances under any of the following circumstances:
1. Any person who has been convicted of a felony offense related to
controlled substances.
2. Any person who has been denied a DEA registration.
3. Any person who has had a DEA registration revoked.
4. Any person who has surrendered a DEA registration for cause.
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Lastly, clinicians should notify the DEA, upon discovery, of any thefts or
significant losses of controlled substances and complete a DEA Form 106
regarding such theft or loss.47
Safeguards for Prescribers
In addition to the required security controls, clinicians can utilize additional
measures to ensure security. These include the following measures.47
1. Keep all prescription blanks in a safe place where they cannot be
stolen; minimize the number of prescription pads in use.
2. Write out the actual amount prescribed in addition to giving a number
to discourage alterations of the prescription order.
3. Use prescription blanks only for writing a prescription order and not for
notes.
4. Never sign prescription blanks in advance.
5. Assist the pharmacist when they telephone to verify information about
a prescription order; a corresponding responsibility rests with the
pharmacist who dispenses the prescription order to ensure the
accuracy of the prescription.
6. Contact the nearest DEA field office to obtain or to furnish information
regarding suspicious prescription activities.
7. Use tamper-resistant prescription pads.
Ordering and Prescribing
The following are the guidelines for ordering and prescribing controlled
substances.
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Prescription Requirements
A prescription is an order for medication, which is dispensed to or for an
ultimate user. A prescription is not an order for medication, which is
dispensed for immediate administration to the ultimate user (for example,
an order to dispense a drug to an inpatient for immediate administration in a
hospital is not a prescription).
A prescription for a controlled substance must be dated and signed on the
date when issued. The prescription must include the patient’s full name and
address, and the clinician’s full name, address, and DEA registration number.
The prescription must also include the following:
 drug name
 strength
 dosage form
 quantity prescribed
 directions for use
 number of refills (if any) authorized
A prescription for a controlled substance must be written in ink or indelible
pencil or typewritten and must be manually signed by the practitioner on the
date when issued. An individual (secretary or nurse) may be designated by
the clinician to prepare prescriptions for the practitioner’s signature. The
clinician is responsible for ensuring that the prescription conforms to all
requirements of the law and regulations, both federal and state.
Who May Issue
A physician, dentist, podiatrist, veterinarian, mid-level practitioner, or other
registered practitioner may issue a prescription for a controlled substance
only when practicing according to the following regulations.48
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 Authorized to prescribe controlled substances by the jurisdiction in
which the practitioner is licensed to practice.
 Registered with DEA or exempted from registration (that is, Public
Health Service, Federal Bureau of Prisons, or military practitioners).
 An agent or employee of a hospital or other institution acting in the
normal course of business or employment under the registration of the
hospital or other institution which is registered in lieu of the individual
practitioner being registered provided that additional requirements as
set forth in the CFR are met.
Preparation and Dispensing
The following are guidelines for the preparation and dispensing of
prescription drugs.
Dispense all drugs in a USP approved tight, light resistant container with a
safety closure. If the patient does not wish a safety closure, a signed release
should be obtained from the patient for the protection of the physician.
Drugs must be properly stored in a location that includes protection from
moisture, freezing and excessive heat, or as directed by the labeling.
Additionally, labeling of medications require specific steps, such as affixing a
label to the outside of the container showing:
 date of filling
 a serial number that refers to a log, prescription, or other record of a
specific order for a specific patient
 dispenser's name and address
 name of the patient
 name of the prescriber
 directions for use
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 name of the drug
 any cautionary statements required by law
If the drug is a controlled substance listed in schedule II, III, or IV, a label
must also be attached stating: Caution: Federal law prohibits the transfer of
this drug to anyone other than to whom prescribed.
All records relating to controlled substances must be readily retrievable and
uniformly maintained. This record must be separate from the patients'
charts.
The physician must dispense the drugs. Although office personnel, including
physician assistants and nurse practitioners, may provide technical
assistance in the preparation or packaging of the drugs, they are not
generally licensed or authorized to dispense medication. Mid level providers
with prescriptive authority should refer to their state licensing board with
regard to license protection involving medication dispensing. In West Virginia
and other state jurisdictions, the physician must be on the premises
whenever drugs are dispensed.48
Inventory Maintenance
The U.S. Department of Justice Office of Diversion Control Practitioner’s
Manual provides the following guidelines for inventory maintenance.
Recordkeeping Requirements
Each clinician must maintain inventories and records of controlled
substances listed in Schedules I and II, separately from all other records
maintained by the registrant. Likewise, inventories and records of controlled
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substances in Schedules III, IV, and V must be maintained separately or in
such a form that they are readily retrievable from the ordinary business
records of the clinician. All records related to controlled substances must be
maintained and be available for inspection for a minimum of two years.
Records should demonstrate that the following standard controls have been
observed relative to the dispersal of controlled medications:49
 A registered clinician is required to keep records of controlled
substances that are dispensed to the patient, other than by prescribing
or administering, in the lawful course of professional practice.
 A registered clinician is not required to keep records of controlled
substances that are administered in the lawful course of professional
practice unless the practitioner regularly engages in the dispensing or
administering of controlled substances and charges patients, either
separately or together with charges for other professional services, for
substances so dispensed or administered.
 A registered clinician is required to keep records of controlled
substances administered in the course of maintenance or detoxification
treatment of an individual.
Each registrant who maintains an inventory of controlled substances must
maintain a complete and accurate record of the controlled substances on
hand and the date that the inventory was conducted. This record must be in
written, typewritten, or printed form and be maintained at the registered
location for at least two years from the date that the inventory was
conducted. After an initial inventory is taken, the registrant shall take a new
inventory of all controlled substances on hand at least every two years.
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Every inventory must contain the following information:
 Whether the inventory was taken at the beginning or close of business
 Names of controlled substances
 Each finished form of the substances (i.e., 100 milligram tablet)
 The number of dosage units of each finished form in the commercial
container (i.e., 100 tablet bottle)
 The number of commercial containers of each finished form (i.e., four
100 tablet bottles)
 Disposition of the controlled substances
It is important to note that inventory requirements extend to controlled
substance samples provided to practitioners by pharmaceutical companies.49
Waste Disposal
The following are excerpts of the federal guidelines for proper disposal of
controlled substances.48
Procedure for disposing of controlled substances:
Any person in possession of any controlled substance and desiring or
required to dispose of such substance may request assistance from the
Special Agent in Charge of the Administration in the area in which the
person is located for authority and instructions to dispose of such
substance. The request should be made as follows:
(1) If the person is a registrant, he/she shall list the controlled
substance or substances which he/she desires to dispose of
on DEA Form 41, and submit three copies of that form to the
Special Agent in Charge in his/her area; or
(2) If the person is not a registrant, he/she shall submit to the
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Special Agent in Charge of a letter stating:
 The name and address of the person
 The name and quantity of each controlled substance to be
disposed of
 How the applicant obtained the substance, if known
 The name, address, and registration number, if known, of the
person who possessed the controlled substances prior to the
applicant, if known
The Special Agent in Charge shall authorize and instruct the applicant to
dispose of the controlled substance in one of the following manners:
(3) By transfer to person registered under the Act and authorized
to possess the substance;
(4) By delivery to an agent of the Administration or to the
nearest office of the Administration;
(5) By destruction in the presence of an agent of the
Administration or other authorized person; or
(6) By such other means as the Special Agent in Charge may
determine to assure that the substance does not become
available to unauthorized persons.
In the event that a registrant is required regularly to dispose of controlled
substances, the Special Agent in Charge may authorize the registrant to
dispose of such substances, in accordance with paragraph
of this section, without prior approval of the Administration in each
instance, on the condition that the registrant keep records of such
disposals and file periodic reports with the Special Agent in Charge
summarizing the disposals made by the registrant. In granting such
authority, the Special Agent in Charge may place such conditions as he
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deems proper on the disposal of controlled substances, including the
method of disposal and the frequency and detail of reports.
This section shall not be construed as affecting or altering in any way the
disposal of controlled substances through procedures provided in laws
and regulations adopted by any State.
Reporting Procedures
Every jurisdiction must publish its own reporting procedures. The following
example of the reporting guidelines specific to West Virginia is instructive in
terms of how a state jurisdiction regulates the reporting of controlled
substances:
In West Virginia, all licensees who dispense Schedule II, III and IV controlled
substances to residents of WV must provide the dispensing information to
the West Virginia Board of Pharmacy (BOP) each 24-hour period basis.
Prescribers and pharmacists authorized to access the patient information,
must certify before each search that they are seeking data solely for the
purpose of providing healthcare to current patients. By providing prescribers
and dispensers access to controlled substance history information at the
point of care it will help them make better prescribing decisions and impact
prescription drug misuse in West Virginia. Any individual who suspects that
another individual or entity has accessed or disclosed patient information in
violation should immediately contact the Administrator or the CSMP
Administrator.
Prescribers, pharmacists and approved officers of law enforcement agencies
whose primary mission involves enforcing prescription drug laws can register
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for a West Virginia Controlled Substance Automated Prescription Program
(C.S.A.P.P.) account to access timely patient prescription controlled
substance reports. The role of the C.S.A.P.P. is to help well-informed
prescribers and pharmacists use their professional expertise to evaluate
their patient’s care and assist in the help and prevention to those patients
who may be misusing controlled substances.46
Prevention Strategies in West Virginia
West Virginia has a number of programs and legislative initiatives in place to
address the issue of drug diversion.
Drug Diversion Prevention Laws in West Virginia
There are five specific prescription drug overdose state laws in West Virginia,
designed to address and control drug diversion activity in the state. These
five laws include:50
 Laws Requiring a Physical Examination before Prescribing
 Laws Requiring Tamper-Resistant Prescription Forms
 Laws Setting Prescription Drug Limits
 Laws Prohibiting “Doctor Shopping”/Fraud
 Laws Requiring Patient Identification before Dispensing
In addition to legislation that is targeted at drug diversion, West Virginia has
established a number of strategies and programs to combat drug diversion.
The following list, provided by the West Virginia Summit on Prescription
Drug Use, highlights the numerous prevention strategies that are currently
in place:51
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SBIRT Program
The Bureau for Health and Health Facilities has expanded Screening, Brief Intervention,
Referral and Treatment (SBIRT) to 75 sites throughout West Virginia. Licensed
counselors have completed more than 96,000 substance misuse/abuse screens in
primary care, behavioral health and school-based sites.
Substance Abuse Early Intervention Programs (EIP)
EIP in Mercer and Logan counties are the first of their kind in West Virginia. The
programs target youth, ages 12 to 17, who are in the onset stages of substance abuse.
They are designed to provide increased understanding of substance abuse consequences
and coping skills to resist pressures to engage in substance abuse.
Teen Courts
Teen courts are established in each region of West Virginia with 14 courts providing a
legally binding alternative system of justice that offers young offenders an opportunity to
make restitution for their offenses through community service, educational classes, and
jury service.
Juvenile Drug Courts
Juvenile drug courts currently exist in Brooke, Hancock, Cabell, Lincoln, Boone, Logan,
Mercer, Monongalia, Putnam, Randolph, Wayne and Wood counties. They divert nonviolent youths, ages 10 to 17, who abuse alcohol or drugs from the juvenile court system
into an intensive, individualized outpatient treatment process, probation case
management, compliance monitoring and parent involvement.
Prescription Drug Abuse Quit-line (1-866-WV-QUITT)
The Quit Line was developed specifically to assist individuals in determining their
personal quitting needs. Phone educators are highly trained in crisis and addictions.
A supportive staff member provides professional one-on-one support that increases
chances of quitting successfully through: educational information and self-help materials
regarding drug treatment and abstinence, assistance to family members or loved ones of
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abusers, and comprehensive planning sessions and individual phone education with up to
four (4) follow-up sessions as needed.
Substance Abuse Treatment Services
The Bureau for Behavioral Health and Health Facilities (BHHF) provides funding to
thirteen comprehensive behavioral health centers and other providers statewide
supporting the provision of substance abuse intensive out-patient, residential and
recovery services in various locations. Gender-specific residential long-term treatment,
transitional living and apartments are also available for women and pregnant women
with children.
West Virginia has a comprehensive social marketing campaign to address the culture of
prescription drug sharing. The Take Care West Virginia campaign emphasizes the
message that it is dangerous and illegal to share prescription drugs. The campaign
includes research-based, professionally-produced public service announcements (PSAs).
All television, radio and print PSAs are available to view and download via the multimedia
campaign website at www.takecarewv.org. Also available are the following: campaign
information designed for placement on prescription bags used by pharmacies; resources
for planning community forums; information about proper prescription drug storage and
disposal; and a toolkit for coordinating a local prescription drug Take Back Initiative. The
campaign was initially launched in 2010, and continues on a smaller scale through
community and other implementation.
There have been opportunities for proper disposal of prescription drugs. National and
local efforts to collect unused and expired prescription drugs have taken place across the
state. Important federal and state regulations, however, must be followed when
implementing prescription drug take backs that include controlled substances.
West Virginia Controlled Substance Monitoring Program
The West Virginia Board of Pharmacy recently established a new Controlled Substance
Monitoring Program. As part of this program, prescribers are required to create a profile
in the controlled Substances Automated Prescription Program registration system before
being able to access to reports and other information. The initial registration must be
made by the supervisory Physician, Pharmacist in Charge, or Organizational Head of
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Entities. By registering with the Controlled Substance Monitoring Program, the clinician
affirms that he or she will comply with all requirements of the West Virginia Code,
maintain confidentiality of patient information as required by law, and only share
information in an appropriate investigation involving the prescribing and / or dispensing
of controlled substances.
Responding To Deception
It is important for medical providers to be cautious when responding to
potential deception from a patient. Many patients will become defensive
when challenged by their medical clinicians. The clinician should offer the
patient assistance and refrain from judgmental behaviors.7 A helpful
resource for health professionals when seeking guidance on how to deal with
a challenging case of drug diversion, such as doctor shopping, may be found
at The National Association of Drug Diversion Investigators (NADDI) @
http://www.naddi.org/aws/NADDI/pt/sp/home_page. This resource also
offers informational brochures, posters and FAQs for health administrators
wanting to improve drug diversion recognition and prevention in their
organizations, including a help line that is accessible from any U.S. state
jurisdiction and international partner.
Support For Professionals In Recovery
Healthcare professionals who have engaged in drug diversion will require
special treatment and guidance before returning to work. Since these
individuals will often return to situations where drugs are readily available, it
is important to ensure that the diversion does not occur again when the
temptation arises.
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Treatment
In the state of West Virginia, healthcare workers who divert drugs are
immediately reported to the state board and action is taken against the
licensee. Once a healthcare worker has gone through the initial reporting
stage, he or she will undergo treatment and will be required to commit to a
contract that typically includes work restrictions that are dependent upon
successful completion of a treatment program.
Returning to Practice
Once a healthcare worker has undergone treatment and is determined to be
in recovery, he or she may return to work, but often can only do so with
specific restrictions in place.52 As part of the treatment program, the
following components will be addressed so that the individual is less apt to
begin using drugs again. Since these individuals will be returning to
situations out them in contact with controlled substances, it is imperative
that a number of issues are addressed beforehand.
Healthcare workers will undergo three stages of treatment and monitoring.
They are listed below as:53
 Treatment
 Re-Entry
 Monitoring each stage has specific components that must be addressed
to ensure that the patient can successfully reintegrate into the
healthcare setting without risk of diverting again.
The treatment program should include and/or address the components
discussed in the section below.54
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Treatment
Potential Stressors:
 Long hours, lack of privacy
 Responsibility for life and death decisions
 Disruption of family life
 Managed care, less autonomy
 Litigation stress, increasing malpractice rates
Internal issues and psychiatric concerns:
 Perfectionism, compulsivity
 Difficulties with intimacy, detached from feelings
 Addressing complex family dynamics
Relapse prevention:
 Re-entry stresses
 Access to drugs
 Need for workplace monitoring
 Dealing with Board issues, legal issues
 Planning for treatment of symptoms which initiated self-prescribing
 Chronic pain
 Insomnia
 Exploring career issues
 Developing individualized continuing care and relapse prevention plan
Re-entry
Returning to practice:
 When is the professional ready to re-enter?
 What preparations and/or restrictions are needed prior to re-entry?
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Modifications of practice needed:
 Changing circumstances in work setting
 Access to drugs
 Availability of support at work
 Work site monitoring
 Changing to different work setting
 Changing focus of practice
 Re-training in a new specialty or profession
Monitoring
Monitoring reintegration:
 Documentation of treatment compliance and continuing progress
 Urine drug screens and other testing
 Compliance with prescribed medications
 Hair and nail testing if indicated
 Communication with treatment providers, employers, licensure boards,
etc., as indicated
Summary
Drug diversion is a significant problem in the United States and the effects
are wide reaching. Drug diverters use a number of different strategies to
acquire prescription drugs, including doctor shopping, altering and forging
prescriptions, and theft. In most instances, the diverter is an individual who
is either a patient or healthcare worker, but some diverters can be part of
larger organizations. Drug diversion is costly and has a significant impact on
the health insurance system as many diverters use health insurance to cover
the cost of doctor visits and prescription drugs.
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It is important for medical clinicians and pharmacists to be aware of the
different strategies for drug diversion as well as the common characteristics
of drug diverters, as this information will help reduce the incidence of drug
diversion. To combat the growing problem of drug diversion, a number of
guidelines and laws have been established. These guidelines, along with the
involvement of healthcare workers and pharmacists, will likely reduce the
number of drug diverters.
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1. Most drug diverters will divert drugs from some of the
following categories:
a.
b.
c.
d.
Opiates
Stimulants, Pseudoephedrine and Ephedrine
Central Nervous System Depressants
All of the above
2. True or False: Dextromethorphan is part of a classification of
drugs called antitussives that are found in less than 10
products.
a. True
b. False
3. Prescription Drug Monitoring Programs utilize databases that
do the following except:
a. collect and store information regarding the prescription, dispensing,
and use of prescription drugs
b. collect information regarding the patient, practitioner, and
pharmacy used
c. consistently collect information from prescribers
d. include gaps in process that can cause drug diversion to go
undetected
4. A prescription for a controlled substance must:
a.
b.
c.
d.
be dated and signed by the prescriber on the date issued
include one patient identifier
include only the drug name, strength and number prescribed
none of the above
5. In the past decade, there has been an increase of _____ in the
number of cases related to prescription painkillers.
a.
b.
c.
d.
40%
200%
400%
100%
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6. Drug diversion can be defined as any criminal act or deviation
that removes _________ drugs from their intended path from
the manufacturer to the patient.
a.
b.
c.
d.
illegal
prescription
opiates
painkillers
7. Which of the following individuals is a common source of drug
diversion?
a.
b.
c.
d.
wholesale distributors
hospital management
runners
healthcare workers
8. Individuals become addicted to prescription opiates because of
a.
b.
c.
d.
the pain relief.
the sensation of euphoria.
the sedative effect.
their low cost.
9. A common side effect of opiates includes
a.
b.
c.
d.
sedation.
euphoria.
nasal congestion.
muscle spasms.
10. Pseudoephedrine and ephedrine, which are common
ingredients in many over-the-counter cold medicines,
a.
b.
c.
d.
are
are
are
are
used to manufacture methamphetamine.
a depressant.
typically abused on their own.
a Category I drug.
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11. Many individuals will become addicted to the calming
sensation that is experienced when taking
a.
b.
c.
d.
methamphetamines.
oxymorphone (Opana®).
a central nervous system (CNS) Depressant.
methylphenidates (Ritalin®).
12. True or False: More Americans are addicted to illegal drugs
compared to the number of Americans who abuse
prescription drugs.
a. True
b. False
13. Stimulants produce a ________________ when given to
patients with ADHD or narcolepsy.
a.
b.
c.
d.
altered time perception
rush
euphoria
calming effect
14. _____________ produce(s) effects similar to cocaine, as
it/they bind(s) to sites in the brain and produce dopamine
using specific molecular targets.
a.
b.
c.
d.
Stimulants
Marijuana
Dextromethorphan
Opiates
15. A patient who diverts drugs may fall into the following
general profile:
a.
b.
c.
d.
Agitated or angry.
Abnormal pupils.
Burns on fingers or lips.
Patient asks for a specific drug by name.
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16. Long-acting barbiturates are a ______________ on the DEA’s
Drug Schedule.
a.
b.
c.
d.
Category
Category
Category
Category
II
I
IV
III
17. A patient who diverts drugs may fall into the following
psychological characteristic(s):
a.
b.
c.
d.
mood swings
lying
agitation
All of the above.
18. True or False: Products with dextromethorphan are physically
addicting.
a. True
b. False
19. A patient who diverts drugs may fall into the following
physical appearance/condition:
a.
b.
c.
d.
patient takes control of the provider’s interview.
dysrhythmias.
poor personal hygiene.
All of the above.
20. Diazepam is a central nervous system depressant commonly
known by the trade name ___________.
a.
b.
c.
d.
Darvon®.
Xanax®.
Valium®.
Vicodin®.
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21. It is difficult to track patients who engage in doctor shopping,
even when health insurance is used because
a.
b.
c.
d.
patients give valid reasons for their visits.
patients make the appointments.
providers do not care if patient is doctor shopping.
the patient is in charge of his or her care.
22. Common performance deficiencies of healthcare workers who
divert drugs
a.
b.
c.
d.
long unexplained breaks.
frequent trips to the bathroom.
chronic absenteeism.
All of the above.
23. Each practitioner must maintain inventories and records of
controlled substances listed in ____________, separately
from all other records maintained by the registrant.
a.
b.
c.
d.
Schedules I and II
Schedule I
Schedules I through III
Schedules I through V
24. True or False: An individual (secretary or nurse) may be
designated by the clinician to prepare prescriptions for the
clinician’s signature.
a. True
b. False
25. Each clinician must maintain inventories and records of
controlled substances listed in ____________, separately
from all other records maintained by the registrant.
a.
b.
c.
d.
Schedules I and II
Schedule I
Schedules I through III
Schedules I through V
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26. A prescription for a controlled substance may be issued by
which of the following?
a.
b.
c.
d.
An employee at a hospital
Pharmacist
Veterinarian
A registered nurse
27. Healthcare workers who are misusing or diverting drugs may
have which of the following:
a.
b.
c.
d.
suicidal thoughts.
lack of impulse control.
complaints from patients and coworkers.
All of the above.
28. Which of the following is prescription drug preparation and
dispensing guideline for drug containers and storage?
a.
b.
c.
d.
It MUST have a safety closure, no exception.
An outside label showing, among other things, date filled.
It MUST be refrigerated.
It must be a clear, see-through container.
29. An inventory of controlled substances must be complete,
accurate and maintained at the registered location for at least
__________ from the date that the inventory was conducted.
a.
b.
c.
d.
seven years
one year
two years
six months
30. If health professionals who have engaged in drug diversion
return to work they may
a.
b.
c.
d.
NOT work where drugs are stored.
change to different work setting.
NOT return to the same work setting.
None of the above.
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31. Healthcare workers undergo specific stages related to their
return to work:
a.
b.
c.
d.
Treatment, re-entry and monitoring.
Discipline and treatment.
Reporting, discipline and treatment.
Discipline and monitoring.
32. A drug diversion treatment program should include and
address the following component:
a.
b.
c.
d.
Discipline.
Restrictions for re-entry.
Potential Stressors, i.e., disruption of family life.
Access to drugs.
33. A drug diversion re-entry program should include and address
the following component:
a.
b.
c.
d.
Lack of privacy.
Modifications to drug access.
Psychiatric concerns, i.e., compulsivity.
Less autonomy.
34. When a healthcare worker returns to work after discipline for
drug diversion, urine drug screens and other testing may be
part of a
a.
b.
c.
d.
discipline program.
re-entry program.
treatment program.
monitoring program.
35. A successful relapse prevention program will include
a.
b.
c.
d.
addressing re-entry stresses.
dealing with Board issues, legal issues.
exploring career issues.
All of the above.
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Correct Answers:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
d
b
c
a
c
b
d
b
a
a
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
c
b
d
a
d
c
d
b
b
c
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
a
d
a
a
a
c
d
b
c
b
31.
32.
33.
34.
35.
a
c
b
d
d
References Section
The References below include published works and in-text citations of published
works that are intended as helpful material for your further reading.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Drug Diversion: The Scope of the Problem [Internet]. Available
frohttp://naddi.org/aws/NADDI/asset_manager/get_file/3143
National Association of Drug Diversion Investigators [Internet].
Available from: http://www.naddi.org/aws/NADDI/pt/sp/home_page
Office Of National Drug Control Policy. Epidemic: Responding to
America’s prescription drug abuse crisis. Pharm. Mark. 2011 p. 10.
Hertz JA, Knight JR. Prescription drug misuse: a growing national
problem. Adolesc. Med. Clin. 2006;17:751–769; abstract xiii.
Substance Abuse in West Virginia [Internet]. Available from:
http://www.wvsma.com/Portals/0/SubstanceAbuse10.pdf
Drug Trends West Virginia [Internet]. Available from:
http://www.usnodrugs.com/drugtrends.htm?state=West Virginia
Holmes D. Prescription drug addiction: the treatment challenge. Lancet.
2012 Jan 7;379(9810):17–8.
Maxwell JC. The prescription drug epidemic in the United States: a
perfect storm. Drug Alcohol Rev. 2011 May;30(3):264–70.
Hernandez SH, Nelson LS. Prescription drug abuse: insight into the
epidemic. Clin. Pharmacol. Ther. American Society of Clinical
Pharmacology and Therapeutics; 2010 Sep;88(3):307–17.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com
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10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
McCabe SE, Teter CJ, Boyd CJ. Medical use, illicit use, and diversion of
abusable prescription drugs. J Am. Coll. Health. Routledge; 2006
Jan;54(5):269–78.
Brown ME, Swiggart WH, Dewey CM, Ghulyan M V. Searching For
Answers: Proper Prescribing of Controlled Prescription Drugs. J.
Psychoactive Drugs. Routledge; 2012 Jan;44(1):79–85.
DEA / Drug Scheduling [Internet]. Available from:
http://www.justice.gov/dea/druginfo/ds.shtml
Spiller H, Lorenz DJ, Bailey EJ, Dart RC. Epidemiological trends in
abuse and misuse of prescription opioids. J. Addict. Dis. Routledge;
2009 Jan;28(2):130–6.
Larance B, Degenhardt L, Lintzeris N, Winstock A, Mattick R. Definitions
related to the use of pharmaceutical opioids: extramedical use,
diversion, non-adherence and aberrant medication-related behaviours.
Drug Alcohol Rev. 2011 May;30(3):236–45.
McCabe SE, Cranford JA, West BT. Trends in prescription drug abuse
and dependence, co-occurrence with other substance use disorders,
and treatment utilization: Results from two national surveys. Addict.
Behav. 2008;33(10):1297–305.
Sellers EM, Johanson C-E, Compton WM, Volkow ND. Abuse of
prescription drugs and the risk of addiction. Drug Alcohol Depend.
2006;83:S4–S7.
Hendrickson RG, Cloutier RL, Fu R. The association of controlling
pseudoephedrine availability on methamphetamine-related emergency
department visits. Acad. Emerg. Med. 2010;17:1216–22.
Callaghan RC, Liu L-M, Lattyak WJ, Tong D, Li H-Y, Cunningham JK.
Changing over-the-counter ephedrine and pseudoephedrine products to
prescription only: Impacts on methamphetamine clandestine laboratory
seizures. Drug Alcohol Depend. 2012. p. 55–64.
T. P, E.P. K. The impact of federal pseudoephedrine regulations on
methamphetamine exposures. Clin. Toxicol. 2010. p. 616.
Advisories to the Public - NOTICE - Ephedrine and Pseudoephedrine
Drug Products are used in Illicit Methamphetamine Manufacture
[Internet]. Available from:
http://www.deadiversion.usdoj.gov/chem_prog/advisories/ephedrine.ht
m
Shin E-J, Lee PH, Kim HJ, Nabeshima T, Kim H-C. Neuropsychotoxicity
of abused drugs: potential of dextromethorphan and novel
neuroprotective analogs of dextromethorphan with improved safety
profiles in terms of abuse and neuroprotective effects. J. Pharmacol.
Sci. 2008;106:22–7.
Darboe MN. Abuse of dextromethorphan-based cough syrup as a
substitute for licit and illicit drugs: a theoretical framework.
Adolescence. 1996;31:239–45.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com
52
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
Miller SC. Dextromethorphan psychosis, dependence and physical
withdrawal. Addict. Biol. 2005. p. 325–7.
Amaladoss A, O’Brien S. Cough syrup psychosis. CJEM Can. J. Emerg.
Med. care = JCMU J. Can. soins medicaux d’urgence. 2011. p. 53–6.
Monheit B. Prescription drug misuse. Aust. Fam. Physician. 2010
Aug;39(8):540–6.
Hall PB, Hawkinberry D, Moyers-Scott P. Prescription drug abuse &
addiction: past, present and future: the paradigm for an epidemic. W.
V. Med. J. 2010 Jan;106(4 Spec No):26–32.
McCabe SE, Boyd CJ, Teter CJ. Subtypes of nonmedical prescription
drug misuse. Drug Alcohol Depend. 2009;102:63–70.
DuPont RL. Prescription stimulant abuse. Pediatr. Ann. 2006. p. 534,
536–7.
Kroutil LA, Van Brunt DL, Herman-Stahl MA, Heller DC, Bray RM, Penne
MA. Nonmedical use of prescription stimulants in the United States.
Drug Alcohol Depend. 2006;84:135–43.
WILENS TE, ADLER LA, ADAMS J, SGAMBATI S, ROTROSEN J,
SAWTELLE R, et al. Misuse and Diversion of Stimulants Prescribed for
ADHD: A Systematic Review of the Literature. J. Am. Acad. Child
Adolesc. Psychiatry. 2008;47(1):21–31.
Weiner SG, Griggs CA, Mitchell PM, Langlois BK, Friedman FD, Moore
RL, et al. Characteristics of “Doctor-Shopping” Patients in the
Emergency Department. Ann. Emerg. Med. Elsevier; 2013 Oct
1;62(4):S92.
Worley J. Prescription drug monitoring programs, a response to doctor
shopping: purpose, effectiveness, and directions for future research.
Issues Ment. Health Nurs. Informa Healthcare New York; 2012 May
30;33(5):319–28.
Vukmir RB. Drug seeking behavior. Am. J. Drug Alcohol Abuse.
2004;30:551–75.
Ford JA, Lacerenza C. The relationship between source of diversion and
prescription drug misuse, abuse, and dependence. Subst. Use Misuse.
Informa Healthcare New York; 2011 Jan 8;46(6):819–27.
Worley J, Thomas SP. Women Who Doctor Shop for Prescription Drugs.
West. J. Nurs. Res. 2013 Oct 28;0193945913509692–.
Lien CA. A need to establish programs to detect and prevent drug
diversion. Mayo Clin. Proc. 2012 Jul;87(7):607–9.
Collins GB, McAllister MS. Combating abuse and diversion of
prescription opiate medications. Psychiatr. Ann. 2006;36:410–6.
Bureau of Justice Assistance - Prescription Drug Monitoring Program
[Internet]. Available from:
https://www.bja.gov/ProgramDetails.aspx?Program_ID=72
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53
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
Yokell MA, Green TC, Rich JD. Prescription drug monitoring programs.
JAMA. American Medical Association; 2012 Mar 7;307(9):912; author
reply 912–3.
Feldman L, Williams KS, Coates J, Knox M. Awareness and utilization of
a prescription monitoring program among physicians. J. Pain Palliat.
Care Pharmacother. Informa Healthcare New York; 2011 Jan
29;25(4):313–7.
Gugelmann HM, Perrone J. Can prescription drug monitoring programs
help limit opioid abuse? JAMA. American Medical Association; 2011 Nov
23;306(20):2258–9.
BJA Center for Program Evaluation and Performance Measurement What Are Prescription Drug Monitoring Programs? [Internet]. Available
from: https://www.bja.gov/evaluation/program-substanceabuse/pdmp1.htm
El‐Aneed a., Alaghehbandan R, Gladney N, Collins K, Macdonald D,
Fischer B. Prescription drug abuse and methods of diversion: The
potential role of a pharmacy network. J. Subst. Use. 2009;14:75–83.
Berge KH, Dillon KR, Sikkink KM, Taylor TK, Lanier WL. Diversion of
Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of
Diversion, Scope, Consequences, Detection, and Prevention. Mayo Clin.
Proc. 2012;87(7):674–82.
Inciardi JA, Surratt HL, Kurtz SP, Burke JJ. The Diversion of Prescription
Drugs by Health Care Workers in Cincinnati, Ohio. Informa UK Ltd UK;
2009 Jul 3;
West Virginia Code > Chapter 60A > Article 9 - Controlled Substances
Monitoring :: Lawserver [Internet]. Available from:
http://www.lawserver.com/law/state/west-virginia/wvcode/west_virginia_code_chapter_60a_article_9
US Department of Justice - Prescription Drug Practitioner’s Manual SECTION III [Internet]. Available from:
http://www.deadiversion.usdoj.gov/pubs/manuals/pract/section3.htm
US Department of Justice - Prescription Drug Practitioner’s Manual SECTION V [Internet]. Available from:
http://www.deadiversion.usdoj.gov/pubs/manuals/pract/section5.htm
US Department of Justice - Prescription Drug Practitioner’s Manual SECTION IV [Internet]. Available from:
http://www.deadiversion.usdoj.gov/pubs/manuals/pract/section4.htm#
disposal
CDC - State Rx Drug Laws - Poisoning - Home and Recreational Safety
- Injury Center.
West Virginia Summit on Prescription Drug Use [Internet]. Available
from: http://wvs.fd.org/CJA/WVSummitonDrugAbuse.pdf
Dekker AH. What is being done to address the new drug epidemic? J.
Am. Osteopath. Assoc. 2007;107:ES21–S26.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com
54
53.
54.
Berge KH, Dillon KR, Sikkink KM, Taylor TK, Lanier WL. Diversion of
drugs within health care facilities, a multiple-victim crime: patterns of
diversion, scope, consequences, detection, and prevention. Mayo Clin.
Proc. 2012 Jul;87(7):674–82.
Ziegler PP, Compton P, Goldenbaum DM. Prescription Drug Abuse and
Diversion in Clinical Practice: What can be Learned from Regulatory
Sanction Data. J. Addict. Nurs. Informa Healthcare Stockholm; 2011
Mar 23;22(1-2):13–8.
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