Compliance with Recommendations for Prevention and Detection of Controlled-substance Diversion in Hospitals

Steven R. McClure; Brian C. O'Neal; Dennis Grauer; Rick J. Couldry; Allison R. King


Am J Health Syst Pharm. 2011;68(8):689-694. 

In This Article

Abstract and Introduction


Purpose. The use of recommended practices for preventing and detecting diversion of prescription controlled substances at U.S. acute-care institutions, as reported by a sample of pharmacy service providers, were characterized.
Methods. A 41-item questionnaire was developed for an online survey of directors of pharmacy regarding strategies to combat controlled-substance diversion at their institutions. The survey questions were based on recommendations presented in a 2007 series of articles in the professional literature focusing on diversion control in three areas (the pharmacy, the operating room, and nursing units). Only institutions that had an accredited pharmacy residency program or were members of the University HealthSystem Consortium (UHC), an alliance of U.S. academic medical centers and affiliated hospitals, were targeted for the survey. Four hundred ninety-nine pharmacists were invited to participate in the survey, and 140 survey responses were received; all respondents did not answer all questions.
Results. The survey responses indicated considerable variation among the institutions in the use of 37 specific recommended practices, as reported by the pharmacy providers. Statistical analysis of comparative data suggested that larger institutions (400 or more licensed beds) were more likely to be using more of the recommended practices.
Conclusion. The results of a survey of directors of pharmacy at a sample of U.S. institutions (hospitals that had pharmacy residency programs or were UHC members) suggest wide variation in facilities' use of recommended practices for the prevention and detection of controlled-substance diversion.


All health care institutions that handle controlled substances are required to develop storage and distribution systems to minimize the risk of diversion. The Drug Enforcement Administration (DEA) estimated that prescription drug diversion in the United States is a "$25 billion-a-year industry."[1] DEA reported that 563,677 methadone dosage units (10 mg/unit) and 226,519 OxyContin (oxycodone) tablets of all strengths were stolen during the period 2001–03, with 23.1% and 28.0% of those thefts, respectively, attributed to employee pilferage.[2,3] Drug addiction among health care workers is well documented. In a survey conducted by Trinkoff et al.,[4] nurses who reported a perception of easier availability were determined to be almost twice as likely as others to divert and use a controlled substance; nurses employed by institutions perceived to have poor workplace control of controlled substances were 1.5 times more likely to use a controlled substance. In another survey, 19% of pharmacists reported use of a controlled substance without a prescription during the preceding 12 months.[5] In a study by Hughes et al.,[6] 17.6% of physicians surveyed reported the use of a minor opiate within the past year; of those, 92.5% cited self-treatment as the reason for use.

Diversion is difficult to detect due to the numerous medication-access points embedded within most hospital distribution systems. Every transfer step throughout the dispensing process (e.g., transfer from point of purchase to pharmacy storage vault) should be assessed for the risk of diversion, and audit processes implemented at the most critical risk points. There are multiple strategies pharmacy departments can employ to prevent and detect diversion. Implementation of automated dispensing hardware and software is critically important to the diversion detection process. The widespread adoption of automated dispensing machines (ADMs) has greatly improved the physical security of controlled substances and enabled electronic documentation of dispensing, waste, and expiration processes. Software systems continue to evolve to meet the need for rapid and accurate identification of personnel with controlled-substance transaction counts that significantly exceed those of peers. Physical controls are also of great importance, as are operational policies that direct personnel to handle controlled substances in a manner that reduces the temptation and ease of diversion; examples include policies for handling of multidose vial waste and policies that ban personal belongings from all medication storage and fill areas.

Currently there are no broadly accepted best practices or guidelines in the literature that institutions can adopt to improve controlled- substance diversion detection systems, but recommendations published in recent years in the professional literature can guide those efforts. A series of articles published in the journal Hospital Pharmacy focused on diversion of controlled substances in the acute-care setting.[7,8,9,10,11,12,13] The series included numerous recommendations to reduce the risk of diversion or aid in its detection at key controlled- substance handling points in the pharmacy, procedure areas, and nursing units. In an effort to ascertain current health-system practices for detection of controlled-substance diversion, we compiled those recommendations into a questionnaire and contacted a national sample of directors of pharmacy to request their participation in an online survey. The primary objective of this research was to determine the prevalence of reported use of diversion detection practices recommended in the aforementioned series of articles. A secondary objective was to provide health-system pharmacists with a listing of these practices as an aid in assessment and improvement of their institutions' diversion detection systems.


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