- Drug Diversion And The Scope Of The Problem Drug Diversion Is A Medical And Legal Concept Involving The Transfer Of Any 1 (162.05 KiB) Viewed 112 times
improved your understanding of drug diversion and how this
knowledge could positively impact your role as a new graduate
nurse.
Drug Diversion and the scope of the Problem "Drug diversion is a medical and legal concept involving the transfer of any legally prescribed substance from the individual for whom it was prescribed to another person. Prescription drug diversion often involves redirecting controlled substances but diversion may include non-controlled substances - Diversion of non-controlled substances is rising.2.3 Prescription drug misuse and diversion are serious problems that may affect the intended beneficiaries of drugs, harm the public and cost programs like Medicare significant amounts of money. For the healthcare professional, drug misuse and diversion can have a profound impact on the professional's career. A healthcare professional who is caught diverting drugs may face criminal prosecution, civil liability, as well as suspension or loss of his or her professional license.
People have various motivations for drug diversion. Drug diversion certainly occurs when people have a substance use disorder and they want to alter their consciousness but many drug diversions occur for profit or because someone wants relief from physical pain? Drug Diversion and the Opioid Epidemic The opioid crisis in the U.S., has been attributed to aggressive prescribing practices and the prevalence of opioid misuse. Drug diversion has played a major role in the opioid epidemic as well. This has led to increases in opioid overdose-related deaths. The Substance Abuse and Mental Health Services Administration and the National Center for Health Statistics reported that during 2016, about 11.5 million people misused prescription opioid pain relievers. In spite of the attention to this epidemic, and the efforts to control the misuse of opioids, the data shows that these numbers are continuing to rise. Drugs that are commonly Diverted There are different classes of drugs that are commonly diverted worldwide. They are benzodiazepines, opioids, stimulants, antipsychotics, anesthetics, and GABA agonists. Within these classes, specific drugs are the usual targets of the diverter. These are listed in Table 1.
According to the U.S. Drug Enforcement Administration, there are five classes of drugs that are most commonly misused in the United States: opioids, antidepressants, hallucinogens, stimulants, and anabolic steroids. Analgesics and antiretroviral drugs are also diverted and misused. Other over-the-counter medications are diverted for use in the manufacture of illegal drugs. Some classes of drugs play a more prominent role in drug diversion. In some cases, a class of drugs will impact a certain population (e.g., stimulants and adolescents) more than others. Opioids Opioids are a group of controlled substances that include a number of the prescription painkillers on the market. Opioid abuse is a major driver for individuals to divert prescription drugs. Opioids that are commonly prescribed include fentanyl (Duragesic), hydrocodone (Vicodin), oxycodone (OxyContin®), oxymorphone (Opana), propoxyphene (Darvon®),
adolescents who seek to increase alertness, improve concentration and school performance, or to enhance highs from other drugs. ** Stimulants are Scredule II druys, and as such, Lley lave aliylı pulential for abuse.** Analgesics and Antiretroviral Drugs People living with HIV are commonly prescribed analgesics and antiretroviral drugs to treat their pain and symptoms. The growth in prescriptions to treat these patients has also provided an opportunity for diversion of these drugs. There is a "high prevalence of prescription drug diversion for analgesics and antiretroviral drugs" among this population. Other Medications Pseudoephedrine and Ephedrine: Pseudoephedrine and ephedrine are common ingredients in many over-the-counter cold medicines. They are not typically misused but they are common ingredients in the manufacture of methamphetamine. Therefore, many individuals attempt to divert large quantities of these ingredients through the purchase of over-the-counter cold medicine, and many states require online tracking of pseudoephedrine products and several require identification and signing of a log book before pseudoephedrine-containing products will be sold as Dextromethorphan: Dextromethorphan is a medication that is used to reduce or suppress coughs associated with common viruses. It is part of a dassification of drugs called antitussives and works by halting activity in the portion of the brain that causes coughing. Dextromethorphan is used in a number of over-the-counter cough suppressants and expectorants, and there are dozens of over-the-counter cough and cold products that contain dextromethorphan." When consumed in large quantities, dextromethorphan can cause psychotropic responses like coma, disorientation, drowsiness, and hallucinations. While dextromethorphan is not generally considered high risk
for substance use disorder, it is widely misused, and chronic users can develop a withdrawal syndrome. Regulation of Other Medications Because of the potential misuse of over-the-counter medications, the Drug Enforcement Agency (DEA) has established regulations for their purchase and use. The purchase and use of these ingredients has become a significant problem. For example, the DEA has established guidelines specific to the distribution of pseudoephedrine or ephedrine. 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:17 • An extraordinary quantity of EPH [ephedrine) or PSE (pseudoephedrine), 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. In addition to the above regulations, it is unlawful for any person knowingly or intentionally to possess or distribute ephedrine or pseudoephedrine, knowing, or having reasonable cause to believe, ephedrine or pseudoephedrine will be used to manufacture methamphetamine illegally."> Common Forms of Drug Diversion Common forms of drug diversion include drug-seeking behaviors, also called "doctor shopping," falsified or altered prescriptions, and through theft
of a patient's prescription drugs by a family member, friend or other person outside a healthcare facility. Drug diversion may also be accomplished through direct theft of prescription drugs from a healthcare facility by a staff member. Drug-seeking Behavior One way a patient will obtain prescription drugs to divert or misuse is through a behavior known as "doctor shopping. *** A patient who doctor shops tries to obtain prescriptions from multiple prescribers without their coordination or knowledge." A patient may doctor shop to obtain a medication for his or her use. For example, a patient may seek a prescription for a benzodiazepine so he or she may take a higher dose than prescribed to experience a "high" or euphoric feelings. This does not fit the definition of drug diversion above because it is not "the transfer of any legally prescribed substance from the individual for whom it was prescribed to another person." This conduct, however, does constitute misuse of a prescribed drug. ** Alternatively, a patient may doctor shop to obtain a prescription drug to sell illegally or to give to a person other than the patient named in the prescription. This conduct constitutes drug diversion. One study evaluated insurance claims data to determine if there is a correlation between opioid use disorder and doctor shopping. The study found no correlation and the authors suggested that many people who doctor shop may not have an opioid use disorder. Does this imply that most people who doctor shop are more likely to divert the drug than use it personally? Doctor shopping is difficult to track and prevent. 20 The difficulty lies partly in the fact that a healthcare professional must try to distinguish between a legitimate need for a medication and the patient who is seeking a prescription for an illegal purpose. 2* This problem is particularly difficult when a patient is complaining of acute or chronic pain and is seeking an opioid or other drug to treat the pain. The healthcare professional must be able to understand and identify the signs, symptoms, and treatment of acute or
Healthcare providers must monitor individual patients in order to control this form of drug diversion. There are common characteristics that distinguish drug-seekers from other patients. There are also strategies a healthcare provider may use to identify these individuals. Drug diverters can be anyone but there are some defining characteristics. As mentioned above, people who drug-seek make frequent visits to multiple health providers, emergency rooms and pharmacies: If a drug-seeker is unable to obtain a prescription from one provider, then another provider will be sought and the process will be started again.20 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; these complaints are often used by drug-seekers because they are subjective and the absence or presence of a true medical or dental condition that is causing these types of pain conditions is not easily verified.18.20 Some drug-seekers will avoid using insurance to pay for a prescription to limit the record of the transaction but one study found utilized insurance databases to determine if there was a pattern for possible opioid shoppers that could be used to identify them. There are characteristics common to drug-seekers. They may claim to be in the area visiting friends or relatives. Others who drug-seek or doctor shop will claim their prescription drugs were stolen, or they lost or forgotten them. They may claim to have accidentally destroyed their pills (e.g., dropping them in the toilet). People who drug-seek will often arrive after office hours or seek an appointment toward the end of regular hours. When drug-seekers are at a health provider's office, they may provide specific descriptions of symptoms but give a vague medical history, they may provide old medical records or X-rays (often from an out-of-state provider) to
validate their request; they may decline a physical exam or authorization to acquire past records or to perform diagnostic tests; and they may be unable or unwilling to provide the name and contact information of their regular doctor.21 Furthermore, drug-seekers tend to have an exceptional knowledge of opioid medications. They may claim to be allergic to nonopioid medications or claim that nonoploids provide unacceptable pain control. Ir a healthcare provider challenges or questions patients who give vague, incomplete information, this may cause them to become agitated. They may try to pressure the provider with threats or by eliciting guilt or sympathy."