Drug Diversion in the United States
Laura A. Stokowski, RN, MS Medscape
Drug diversion, broadly defined, is when the legal supply chain of prescription analgesic drugs is broken, and drugs are transferred from a licit to an illicit channel of distribution or use. This definition, however, doesn't specify the who, what, when, where, how much, and for what purpose drug diversion occurs. These are questions that must be answered if we are to maintain the integrity of the opioid prescription drug supply to benefit patients with pain that does not respond to lesser means.
When opioid-related deaths receive intense media attention, people are quick to assign blame to prescribers, even though numerous routes of prescription drug acquisition are available. Media reports can exacerbate fears about medical use of prescription drugs among patients with pain and increase concerns about regulatory scrutiny among legitimate prescribers and dispensers. Rarely do such reports focus on the true nature of prescription drug diversion.
Who Is to Blame?
A major obstacle to ending drug diversion, according to David Joranson, MSSW, Senior Science Director, PPSG, University of Wisconsin School of Medicine and Public Health in Madison, is the widespread belief that the full responsibility for the integrity of the drug supply chain rests with the prescriber. Joranson argues that it is time to distribute fairly the responsibility for the problems of drug diversion and prescription drug abuse within a new paradigm. This paradigm takes a public health approach, rather than an exclusive law enforcement approach, to the complex problems of opioid abuse, addiction, and diversion.
Parallel to the increase in the use of opioid analgesics for pain management in recent years is a rise in the use of these drugs for nonmedical purposes. Opioid analgesic mortality has been attributed to more aggressive pain management. The relationship between increased opioid prescribing and the misuse of opioids is not clear, however, and efforts to end diversion by restricting legitimate pain management are misguided. If we mistakenly believe that drug diversion and abuse stem only from inappropriate prescribing, our view of the medical treatment of pain will be "distorted through the lens of substance abuse." Sources of drug diversion must be tackled head on, without impeding the legal availability of opioid analgesics, medical practice, or patient care.
Mechanisms of Drug Diversion
Drug diversion occurs at every point in the drug supply chain. According to Joranson, a primary route of opioid diversion takes place at the wholesale level of manufacturing and distribution and includes the theft of medications in transit. The next layer of diversion occurs at the retail level, where the theft of drugs by employees and others takes place from hospitals and pharmacies. Nurses, the largest group of healthcare professionals pilfering opioid analgesics from hospital supplies, represent a group of impaired health professionals who need assistance to cease these actions. Although legitimate Internet pharmacies exist, diversion also occurs through the use of stolen or forged prescriptions and the sale of controlled substances without prescriptions. At the patient level, inappropriate prescribing ("pill mills" and "script docs") and the seeking of prescription drugs under false pretenses ("doctor shopping") can be routes of drug acquisition for nonmedical purposes. Theft, sale, or improper disposal of legitimately prescribed medications also contributes to the pool of diverted drugs.
The demand for prescription drugs for illicit use is undeniably powerful. People obtain and consume unprescribed drugs for many reasons. Although some divert drugs for monetary gain, abusers, addicts, and impaired healthcare professionals may take the illegally acquired drugs themselves. Other nonmedical uses of prescription drugs include taking for recreational reasons/getting high; taking compulsively for addiction; self-medicating for mood, sleep, or pain; or taking to alleviate withdrawal symptoms.
Scope of Drug Diversion
When controlled substances are lost or stolen, pharmacists, manufacturers, and distributors must report these occurrences to the US Drug Enforcement Administration (DEA). DEA data reveal that in the 4-year period from 2000 through 2003, nearly 28 million dosage units of all controlled substances were diverted by theft or loss from lawful channels, of which 24% were opioid analgesics. Thefts, primarily from pharmacies, occurred in 12,894 separate incidents and involved hydrocodone, oxycodone, morphine, methadone, meperidine, hydromorphone, and fentanyl. Diversion of all drugs except morphine increased between 2000 and 2003. This is clear evidence that a considerable volume of drugs is being diverted through criminal actions from the drug distribution chain before being prescribed.
Approximately 6500 pharmacy thefts occur annually in the United States, or about 17 per day. Many of these are armed robberies or nighttime break-ins. These numbers indicate that pharmacy theft is nearly as common as the 7400 yearly, or 20 per day, bank robberies that take place in the United States. We rarely read or hear about pharmacy theft, yet it suggests a viable avenue for stopping drug diversion.
The health implications of drug diversion are too important to leave entirely to law enforcement. Efforts to prevent drug diversion must be evidence-based. The remedy for drug diversion will not be found in tightening prescription requirements for opioid analgesics because although prescribing is part of the problem, it is not the whole problem. Preventing drug diversion will require a long-term public health initiative, because an issue of even greater importance to public health is the inadequate treatment of patients with serious pain disorders.