“Diversion” means the transfer of a controlled substance from a lawful to an unlawful channel of distribution or use.
Uniform Controlled Substances Act (1994)1
“Diversion” means “Any criminal act involving a prescription drug.”
National Association of Drug Diversion Investigators2
In the United States in 2010, nearly 4 billion retail prescriptions were filled, with sales totaling $307 billion. The medication most often prescribed, 131.2 million times, was the opioid hydrocodone combined with acetaminophen.3
The opioid oxycodone combined with acetaminophen was prescribed 31.9 million times. Although most of these sales resulted in the legitimate, targeted administration of pharmaceutical agents to patients, a fraction of the drugs manufactured and prescribed for patients are diverted for illicit purposes. Most drug prescriptions are for use in the outpatient setting, and, thus, most diversions of drugs occur there. This problem has been well documented in multiple publications and will not be further addressed here.4
Although a relatively small fraction of the nation's drug supply is administered in a health care facility such as a hospital or outpatient surgery center, the nature of these practices provides ample opportunity for drug diversion. This less appreciated form of drug diversion is associated with adverse consequences, the scope of which is incalculable, with harm to the drug diverter and others that is at times horrific. There are no available data that precisely define the extent of drug diversion from the health care facility workplace. However, it is well recognized that anesthesiologists, perhaps more than any other class of physician, have ready access to highly addictive psychotropic medications and have a higher rate of addiction to opioid drugs than physicians in other specialties.5
Furthermore, the drugs most commonly abused by anesthesiologists are obtained through diversion.6
Such data suggest that ready access is a critical component of drug diversion from the health care facility workplace.
The most common drugs diverted from the health care facility setting are opioids. Although other high-value drugs such as antiretroviral drugs, athletic performance–enhancing drugs (eg, erythropoietin and anabolic steroids), and nonopioid psychotropic drugs have been diverted from the health care facility workplace,7
the ensuing discussion focuses on the theft of controlled substances (CSs), defined as medications classified as Schedules II (ie, substances with high potential for abuse) through V (ie, substances with lower potential for abuse than substances in Schedules II, III, and IV), as defined by the federal Drug Enforcement Administration (DEA) and state statutes.8
We do not discuss the topic of theft within the pharmacy setting, which is largely accomplished by other means. Typically, drugs stolen from health care facilities are used to support an addiction of either the health care worker (HCW) or an associate and, less commonly, for sale for financial gain. This theft can be of unopened vials; vials or syringes that have been tampered with, resulting in either substituted or diluted dosages being administered to the patient; or residual drug left in a syringe or vial after only a fraction of the drug that has been signed out was actually administered to the patient. In addition, this theft can be of discarded syringes or ampules that have been properly disposed of in a “sharps” safety container.
In the outpatient setting, there is an elaborate system of checks and balances for prescription, procurement, and dosing of a CS. However, in the health care facility environment, vulnerability to diversion exists when a single provider, out of view of others, is free to engage in drug procurement from central stores, drug preparation, drug administration to patients, and/or disposal of drug waste. Given that CSs are often titrated to a desired effect in patients who may have widely varying drug requirements (eg, as a result of baseline individual variability, acquired habituation, or other factors), in the absence of sufficient controls, it is relatively easy for a single HCW, without the knowledge or collusion of others, to divert drugs intended for patients. It is beyond question that HCW diversion of opioids and other CSs from the health care workplace has occurred since time immemorial.
Recent experience at Mayo Clinic and elsewhere have revealed that such health care workplace drug diversion creates numerous potential victims. Specifically, harm can come not only to drug diverters but also to their patients and co-workers and to the reputation of the health care institution that employs them. A recent devastating example is that of an infected HCW in the Denver, Colorado, area who, in the process of diverting narcotics for self-use, passed on hepatitis C virus to approximately 36 patients.9
Such cases provide graphic examples of why it is essential to reduce or eliminate opportunities for diversion of drugs in the health care facility workplace.
Mayo Clinic has recently expanded its efforts to better educate its staff about the risks of drug diversion and to enhance its methods for detection. With encouragement from institutional physician-executives, we provide details of several instances that are instructive in alerting others to the sub-rosa crimes and harms that are likely occurring in health care systems worldwide. In addition, we define the many potential harms and victims associated with drug diversion. We also review strategies that we have developed, and that continue to evolve, in our efforts to combat diversion.