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As a Prescriber, What is Your Role in Preventing Prescription Drug Diversion?

Diversion of prescription medications is a major part of the epidemic of substance abuse in the United States. Clinicians who prescribe opioids and other controlled substances have an important role to play in preventing drug diversion, through maintaining good records and secure prescription pads, communicating with patients and other prescribers, and monitoring compliance with urine drug testing.

It’s not just opioids that are being diverted, according to Jack Kain, PharmD, Director, Medical Science Liaison, Prescription Drug Monitoring & Toxicology for Quest Diagnostics. Although opioids are among the most commonly diverted drugs, other drug classes are also subject to diversion, including central nervous system depressants such as barbiturates and benzodiazepines, stimulants such as amphetamines and methylphenidates, and anabolic steroids such as testosterone and its derivatives. “Diversion of each of these is a major problem,” Dr. Kain says.

In a report titled “Partners in Integrity,” the Centers for Medicare and Medicaid Services (CMS) notes that “physicians and other providers may be involved in drug diversion activities unknowingly, because it is not always clear when a patient is seeking drugs under false pretenses.” One important tool for identifying patients who may be diverting prescription medications is the state Prescription Drug Monitoring Program (PDMP), which every state now employs, which tracks filled prescriptions for controlled substances. As a clinician, it is important to use your state’s PDMP to determine whether your patient may be filling multiple prescriptions from different providers, a key sign of potential diversion activity.

“Physicians and other prescribers often have the first opportunity to identify, control, and report drug diversion,” according to the report. “If a prescriber suspects that drug diversion has occurred, the activity should be documented, and a report should be made.”

Beyond this, there are multiple best practices to use in your clinic to reduce the risk of diversion. “Recommended clinical practices include protecting access to prescription pads, adhering to strict refill policies, and thoroughly documenting when prescribing narcotics,” the report says. “Prescribers can also curb drug diversion by adhering to prescribing principles for opioids and other controlled substances,” especially those put forward by the Centers for Disease Control and Prevention.

Other important tips the report offers include:

  • Exercise caution when patients request a combination of drugs, such as benzodiazepines and opioids
  • Ensure prescriptions are written clearly, to avoid forgery, and move toward electronic prescribing so that paper prescriptions are not required
  • Refer patients with extensive pain management needs to a specialty clinic
  • Communicate with pharmacists or other providers, and pharmacy benefit managers, and collaborate with them when suspicious behavior is observed

Clinical drug monitoring is an important tool for helping to detect diversion, Dr. Kain adds. “The state PDMP can tell you if your patient has filled your prescription, but not if he or she is diverting the drug to friends, family, or strangers. Clinical drug monitoring can help you with detecting that, if it shows the absence of the prescribed drug in the specimen.”

Such a finding provides the objective information you need to begin a conversation with your patient, Dr. Kain says. “Diversion is a serious problem, and it is one of many challenges the clinician who is prescribing controlled substances must grapple with. With the right tools, the clinician can reduce the risk that the patient will divert his or her medications, and receive the benefit of the prescribed treatment.”