The rise of prescription drug abuse and drug diversion

As prescription drug abuse has grown in the US and Europe, the diversion of such treatments from legitimate sources has also increased. Ben Hargreaves speaks to an expert in the area to learn how drug diversion occurs, and how it can be countered.

Drug diversion is the channelling of prescription drugs from a medical source into the illegal market. The problem is growing as abuse of prescription treatments, such as opioids, stimulants, and sedatives also increases, making the diversion of such treatments increasingly profitable or necessary to fuel addiction. More specifically, the rise in the use of prescription opioids in the US and, increasingly, in Europe is also a major contributor to the issue.

The opioid epidemic in the US has been unfolding over the last three decades. It began in the 1990s with increased use of prescription opioids, with lawsuits from this period still being resolved to this day. From 2010 to 2016, deaths from heroin overdoses increased rapidly, as those in the healthcare community understood the risks of opioid painkillers and reduced the number of prescriptions. From the period of 2013 until the present, a third wave of the crisis struck, which saw synthetic opioids, such as fentanyl, cause a greater number of deaths.

As the crisis rumbles on, there is a risk of greater levels of drug diversion, which requires a counter strategy on the part of the healthcare care industry and regulators. In Europe, the European Monitoring Centre for Drugs and Drug Addiction outlined its strategies on preventing diversion of opioid products, which includes the supervision of doses, the development of misuse-deterrent formulations, and education activities aimed at ensuring quality of care. In the US, a high degree of focus has been placed on developing abuse-resistant opioids and countering the wider issues of addiction that has driven the opioid epidemic to such an extent.

Why drug diversion represents a challenge

Though drug diversion within the overall healthcare industry represents a small portion of pharmaceuticals, it is a significant issue because of the potential harm it poses to individuals, with the likelihood of addiction and overdose in the case of opioids. However, it is also detrimental to the healthcare system itself, as costs are incurred through the loss of therapies that could otherwise be used to treat patients.

There have also been numerous outbreaks of infections that stem from drug diversion activities by healthcare providers who tampered with injectable drugs. The US Centers for Disease Control and Prevention list the most recent outbreaks, which outlines numerous issues that have occurred in the last decade caused by drug diversion. For example, there were 12 HCV infections associated with an emergency department nurse at a hospital in Washington in 2018, and 25 gram-negative bacteremia infections in 2011 that emerged in Minnesota.

Meg Flynn, clinical workflow specialist, pharmaD, at Imprivata, spoke with pharmaphorum about where the issues with drug diversion arise and what action can be taken to counter the issue. Flynn stated that the most common opportunity that is taken to divert drugs is the period between when a nurse or provider acquires the medicine until the treatment is either administered or destroyed.

“Whether a patient legitimately no longer needs to receive a dose of medication that has already been pulled from the automated dispensing cabinet (ADC) or only a partial vial is administered, there is potential for substitution or tampering of the medication between the time that the drug is pulled from the ADC and the wasting event is documented,” Flynn added.

Not only is a potentially dangerous prescription medicine then removed from the healthcare system, before eventually falling into the wrong hands, there is also the risk of how the medicine is diverted from the environment. Flynn outlined one example of how drugs are diverted by describing how injectable opioids, such as morphine, are replaced with saline solution. This means that patients who should be receiving painkilling medication could be receiving inadequate doses, allowing unnecessary suffering to take place.

Known unknowns

One issue with generating effective action against drug diversion is achieving a full understanding of the issue itself. There is not a huge amount of data available, which makes tracking its prevalence and the particular geographical areas of concern challenging. Flynn told pharmaphorum that, although the area is attracting more attention in recent years, healthcare organisations have typically been reactive to the issue, rather than proactive in terms of monitoring for drug diversion.

Flynn explained why this leads to drug diversion going undetected: “It’s frequently said in the drug diversion community that if you’re not finding drug diversion, you’re not looking for it. Unfortunately, not all healthcare facilities have a comprehensive drug diversion monitoring program. Even the ones that do are largely relying on manual audits of disparate software systems and random cycle counts of medications. This is often error prone and time consuming for an already overworked healthcare staff. As a result, a lot of drug diversion goes undetected.”

Tracking drug diversion is challenging because acquiring data on the issue from individual hospitals is often difficult. This is due to the clandestine nature of the activity, and the culture in place in certain healthcare institutions where diversion is left undiscovered or unreported, states one report into the issue.

What can be done

If drug diversion is going undetected, then the key challenge to address the issue is to identify how to be more effective at identifying potential diversion. Current methods of tracking involve having strict chain-of-custody policies, such as having two clinicians signing off on waste destruction. Many hospitals also rely on historical reporting from ADCs, which involve monthly anomalous usage reports or daily discrepancy reports. However, these types of system can be subverted by those wishing to hide their activity.

As a result, Lynn recommends employing more sophisticated systems, particularly by leveraging technologies, such as AI and machine learning. This type of technology can review massive amounts of data from ADC reports, patient pain scales, medication administration, and more in order to detect anomalies or suspicious behaviour.

“With AI advancing at a rapid rate, there are software options for healthcare facilities to efficiently analyse data, prescribing behaviour, and prevent and address drug diversion. With more attention being directed to monitor drug diversion in recent years, this technology is slowly becoming more widely adopted, though there is a long road ahead,” Lynn said.

In terms of lower-tech solutions, Lynn recommends that health systems should also have a multi-disciplinary team dedicated to diversion reduction. The reason for a broad team is that drug diversion itself is a multi-faceted issue, requiring a team effort to address, prevent, and remediate.