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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.

Policy Statement

This activity has been planned and implemented in accordance with the policies of and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of 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.

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.

1. Most drug diverters will divert drugs from some of the following categories:

a. Opiates

b. Stimulants, Pseudoephedrine and Ephedrine

c. Central Nervous System Depressants

d. 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. be dated and signed by the prescriber on the date issued

b. include one patient identifier

c. include only the drug name, strength and number prescribed

d. 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. 40%

b. 200%

c. 400%

d. 100%

Introduction

As prescription drug misuse becomes more common, medical professionals are being forced into the role of detective, evaluating every patient - and co-worker - 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 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: . 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

• 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 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.

|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®), long-acting 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. |

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®)

• 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.

• 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-the-counter 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

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

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 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

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. |

| |

|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)

• 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

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 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 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

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

• 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

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.

• 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 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:

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.

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.

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

• 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

• 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 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.

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

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 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 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

| |

|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 non-violent 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 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 . 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 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) @ . 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.

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

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?

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.

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.

Please take time to help course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.

1. Most drug diverters will divert drugs from some of the following categories:

a. Opiates

b. Stimulants, Pseudoephedrine and Ephedrine

c. Central Nervous System Depressants

d. 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. be dated and signed by the prescriber on the date issued

b. include one patient identifier

c. include only the drug name, strength and number prescribed

d. 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. 40%

b. 200%

c. 400%

d. 100%

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. illegal

b. prescription

c. opiates

d. painkillers

7. Which of the following individuals is a common source of drug diversion?

a. wholesale distributors

b. hospital management

c. runners

d. healthcare workers

8. Individuals become addicted to prescription opiates because of

a. the pain relief.

b. the sensation of euphoria.

c. the sedative effect.

d. their low cost.

9. A common side effect of opiates includes

a. sedation.

b. euphoria.

c. nasal congestion.

d. muscle spasms.

10. Pseudoephedrine and ephedrine, which are common ingredients in many over-the-counter cold medicines,

a. are used to manufacture methamphetamine.

b. are a depressant.

c. are typically abused on their own.

d. are a Category I drug.

11. Many individuals will become addicted to the calming sensation that is experienced when taking

a. methamphetamines.

b. oxymorphone (Opana®).

c. a central nervous system (CNS) Depressant.

d. 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. altered time perception

b. rush

c. euphoria

d. 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. Stimulants

b. Marijuana

c. Dextromethorphan

d. Opiates

15. A patient who diverts drugs may fall into the following general profile:

a. Agitated or angry.

b. Abnormal pupils.

c. Burns on fingers or lips.

d. Patient asks for a specific drug by name.

16. Long-acting barbiturates are a ______________ on the DEA’s Drug Schedule.

a. Category II

b. Category I

c. Category IV

d. Category III

17. A patient who diverts drugs may fall into the following psychological characteristic(s):

a. mood swings

b. lying

c. agitation

d. 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. patient takes control of the provider’s interview.

b. dysrhythmias.

c. poor personal hygiene.

d. All of the above.

20. Diazepam is a central nervous system depressant commonly known by the trade name ___________.

a. Darvon®.

b. Xanax®.

c. Valium®.

d. Vicodin®.

21. It is difficult to track patients who engage in doctor shopping, even when health insurance is used because

a. patients give valid reasons for their visits.

b. patients make the appointments.

c. providers do not care if patient is doctor shopping.

d. the patient is in charge of his or her care.

22. Common performance deficiencies of healthcare workers who divert drugs

a. long unexplained breaks.

b. frequent trips to the bathroom.

c. chronic absenteeism.

d. 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. Schedules I and II

b. Schedule I

c. Schedules I through III

d. 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. Schedules I and II

b. Schedule I

c. Schedules I through III

d. Schedules I through V

26. A prescription for a controlled substance may be issued by which of the following?

a. An employee at a hospital

b. Pharmacist

c. Veterinarian

d. A registered nurse

27. Healthcare workers who are misusing or diverting drugs may have which of the following:

a. suicidal thoughts.

b. lack of impulse control.

c. complaints from patients and coworkers.

d. All of the above.

28. Which of the following is prescription drug preparation and dispensing guideline for drug containers and storage?

a. It MUST have a safety closure, no exception.

b. An outside label showing, among other things, date filled.

c. It MUST be refrigerated.

d. 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. seven years

b. one year

c. two years

d. six months

30. If health professionals who have engaged in drug diversion return to work they may

a. NOT work where drugs are stored.

b. change to different work setting.

c. NOT return to the same work setting.

d. None of the above.

31. Healthcare workers undergo specific stages related to their return to work:

a. Treatment, re-entry and monitoring.

b. Discipline and treatment.

c. Reporting, discipline and treatment.

d. Discipline and monitoring.

32. A drug diversion treatment program should include and address the following component:

a. Discipline.

b. Restrictions for re-entry.

c. Potential Stressors, i.e., disruption of family life.

d. Access to drugs.

33. A drug diversion re-entry program should include and address the following component:

a. Lack of privacy.

b. Modifications to drug access.

c. Psychiatric concerns, i.e., compulsivity.

d. 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. discipline program.

b. re-entry program.

c. treatment program.

d. monitoring program.

35. A successful relapse prevention program will include

a. addressing re-entry stresses.

b. dealing with Board issues, legal issues.

c. exploring career issues.

d. All of the above.

Correct Answers:

| d |c |a |a |

|b |b |d |c |

|c |d |a |b |

|a |a |a |d |

|c |d |a |d |

|b |c |c | |

|d |d |d | |

|b |b |b | |

|a |b |c | |

|a |c |b | |

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. Drug Diversion: The Scope of the Problem [Internet]. Available fro

2. National Association of Drug Diversion Investigators [Internet]. Available from:

3. Office Of National Drug Control Policy. Epidemic: Responding to America’s prescription drug abuse crisis. Pharm. Mark. 2011 p. 10.

4. Hertz JA, Knight JR. Prescription drug misuse: a growing national problem. Adolesc. Med. Clin. 2006;17:751–769; abstract xiii.

5. Substance Abuse in West Virginia [Internet]. Available from:

6. Drug Trends West Virginia [Internet]. Available from: Virginia

7. Holmes D. Prescription drug addiction: the treatment challenge. Lancet. 2012 Jan 7;379(9810):17–8.

8. Maxwell JC. The prescription drug epidemic in the United States: a perfect storm. Drug Alcohol Rev. 2011 May;30(3):264–70.

9. 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.

10. 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.

11. 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.

12. DEA / Drug Scheduling [Internet]. Available from:

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. T. P, E.P. K. The impact of federal pseudoephedrine regulations on methamphetamine exposures. Clin. Toxicol. 2010. p. 616.

20. Advisories to the Public - NOTICE - Ephedrine and Pseudoephedrine Drug Products are used in Illicit Methamphetamine Manufacture [Internet]. Available from:

21. 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.

22. Darboe MN. Abuse of dextromethorphan-based cough syrup as a substitute for licit and illicit drugs: a theoretical framework. Adolescence. 1996;31:239–45.

23. Miller SC. Dextromethorphan psychosis, dependence and physical withdrawal. Addict. Biol. 2005. p. 325–7.

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