Prescriber and Pharmacist Practices

Prescribers can play an important role at the front end to prevent drug addiction and drug diversion. Clinical protocols regarding pain management can help reduce the overall number of controlled substance prescriptions.22 Prescriber guidelines prepared by the CDC recommend against the use of opioids as first-line or routine therapy for chronic pain. Instead, providers should start with alternative therapies, such as anti- inflammatories and muscle relaxers, to help patients relax and ease their pain. When opioid treatment is started, providers should begin with lower doses of immediate-release opioids, prescribe no more than what is needed for acute pain, and regularly follow up with patients to reevaluate the risk of harm.23

Pharmacists also play a vital role in combatting drug addiction and diversion. When a prescription is presented by a patient or doctor’s office, a pharmacist is not obligated to fill it.24 The pharmacist first has the responsibility under the CSA to ensure that the prescription is legitimate.25 The DEA has identified numerous red flags for potential diversion, including:

  • Numerous customers receiving the same combination or strength of prescriptions
  • Many customers paying cash for their prescriptions
  • Many customers with the same diagnosis codes written on their prescriptions
  • Individuals driving long distances to visit physicians and/or fill prescriptions
  • Customers coming to the pharmacy in groups to fill the same prescriptions written by the same physician
  • Prescriptions for controlled substances written by physicians not associated with pain management26

Hospital Responses to Suspected Drug Diversion

Hospitals should have a clear plan in place to respond to suspected drug diversion or discrepancies in controlled substance inventory. Many hospitals have a centralized diversion response team with well-defined roles that include investigations, communications and reporting. Each suspected drug diversion incident must be thoroughly investigated to determine if federal or state regulations have been violated and if the healthcare worker has committed a crime.

The organization must also determine whether its own internal policies and procedures were violated. The employee may be required to undergo a drug screen and may be suspended pending the conclusion of the investigation. If diversion is confirmed, the hospital must assess the seriousness of the employee’s violation, the position of responsibility held by the employee, the employee’s record of employment, and other relevant factors in determining whether to suspend, transfer, terminate or take other action against the employee.27

The hospital must report drug diversion incidents to all relevant federal and state agencies. The DEA must be notified immediately in the event of the theft or significant loss of a controlled substance. State laws vary, but reporting is mandatory in a majority of states. Often, reporting is made to the state Board of Medicine, Board of Pharmacy or other state regulatory body.28 The DEA also recommends that hospitals immediately notify local law enforcement, since missing controlled substances might be disseminated in the community.29

(22) U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, What is a Prescriber’s Role in Preventing the Diversion of Prescription Drugs?,January 2014.
(23) U.S. Department of Health and Human Services, Centers for Disease Control & Prevention, National Center for Injury Prevention and Control, CDC Guideline for Prescribing Opioids for Chronic Pain, CDC Morbidity & Mortality Weekly Report, March 15, 2016, http://www.cdc.gov/drugoverdose/prescribing/guideline.html (accessed December 15, 2017)
(24) U.S. Department of Justice, Drug Enforcement Administration, Office of Diversion Control, DEA Trends and Update, August 13, 2017, https://www.deadiversion.usdoj.gov/mtgs/pharm_awareness/conf_2017/aug13_2017/carrion.pdf (accessed January 25, 2018).
(25) 21 CFR 1306.04(a)
(26) 21 CFR 1306.04(a)
(27) 21 CFR 1301.92
(28) National Alliance for Model State Drugs, State Laws/Regulations Requiring Hospitals, Nursing Homes, and Pharmacies to Report the Theft or Loss of Controlled Substances, April 4, 2016, http://www.namsdl.org/library/A6E61ABB-F923-A510-F44FA458B898567B/ (accessed January 22, 2018).
(29) U.S. Department of Justice, Drug Enforcement Administration, Office of Diversion Control, DEA Trends and Update, August 13, 2017.