Blog by Mark Wolfe, Customer Account Representative, GrandView Pharmacy

I recently had a conversation with a Director of Nursing of a skilled Nursing Facility who asked for assistance in protecting against drug diversion. She does not have a problem within her facility, but she is keenly aware of the need to be aware and diligent in preventing such a problem. This got me to thinking about the scope of drug diversion within the long-term care setting. I concluded that all long-term care facilities need to have an awareness of the potential of such a problem, how to prevent, detect and respond to suspected institutional diversion of controlled substances.

Diversion of drugs from legitimate to illicit use is being recognized with increasing frequency in the United States. Although the full extent of diversion from health care facilities is unknown, and probably unknowable, our experience makes clear that it is a considerable and ongoing problem. Addicted Health Care Workers (HCW) who are diverting drugs from the health care facility workplace pose a risk to their patients, their employers, their co-workers and themselves. It is essential that all health care institutions have a robust system in place to identify and investigate suspected diversion as rapidly and efficiently as possible and that they implement policies and procedures that enable a standardized and effective response to confirmed diversion. (1)

First, lets discuss the scope of the problem. Reliable statistics on the prevalence of drug diversion by nurses is not fully available. But it is known that drug diversion occurs throughout an array of healthcare settings, clinics, hospitals, rehab centers, long-term care facilities, just to name a few. The reason why reliable statistics are not available is that, by its nature, diversion is a behind the scenes activity, a secret or concealed action by health care workers. In addition to that, if a HCW is detected facilities do not want the adverse publicity, or they fear involvement by state and national agencies which casts a negative perception of the facility. Many times, administrators are unsure about the requirements of reporting, and do not know if simply terminating the HCW is a sufficient punishment.

So, who are the possible suspects? Any HCW that has access and availability to controlled substances.

Most HCWs divert for personal use and are extremely secretive about it (2). A business can protect itself by use of Pre-employment drug screening ad criminal background checks. But in the interview process one simple question should be utilized more than it is…” Have you ever been disciplined, terminated, or allowed to resign, or been denied employment because of mishandling of a controlled substance or drug diversion issue?”

It seems like a huge problem so much so that it can be overwhelming. So, start your program looking for thee common items.

INJECTABLES: Hydromorphone, Fentanyl, Propofol
PILLS AND LIQUIDS: Hydrocodone, Oxycodone

Methods of Diversion:

  • Removing Fentanyl patches, removing patches too often
  • Increased frequency of PRN controlled substances, especially on 2nd or 3rd
  • Residents not receiving a full or complete dose as prescribed

Diversion of drugs can lead to patient harm… that is, the patient does not get relief from pain or a patient’s quality of life is affected. However, drug diversion does not always lead to patient harm, so you should be aware of the following.

  • Diversion of scheduled doses, even non-prn doses
  • Documentation of pain at the time that medication is diverted
  • Evidence of substitution and tampering, including transmission of infection
  • Impairment resulting in patient harm or reckless endangerment

Drug diversion by HCWs violates the core value that the needs of the patient come first. Clearly, if we are to optimize our approach to inpatient drug diversion and its consequences, we must look at such diversion not as a victimless act but as a multiple-victim crime.

The writer hopes that you have found this interesting and intriguing enough to do more investigating of the topic on your own. Sadly, a blog format does not allow for more in-depth study of this problem in healthcare today. The citations below are a good start.


  1. Berge KH, Dillon KR, Sikkink KM, Taylor TK, Lanier WL. Diversion of drugs within health care facilities, a multiple-victim crime: patterns of diversion, scope, consequences, detection, and prevention. Mayo Clin Pro)
  2. Institutional Diversion, Prevention, Detection and Response, Kimberly New, HCCA Clinical Practice Compliance Conference, 2015c. 2012;87(7):674-82.
  3. ASHP Guidelines on Preventing Diversion of Controlled Substances, Dec 22, 2016: Phillip W Brummond, David F. Chen, etal


About the Author

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