Pharmacists Should be Aware of Drug Diversion, How to Prevent it

In an interview with Pharmacy Times® at the American Society of Health-System Pharmacists Summer Meetings and Exhibition, Angela Livingood, PharmD, MHA, BCGP, CPHQ, diversion specialist at Novant Health, discusses what drug diversion is and why it is important for pharmacists to be aware of it.

Q: What is drug diversion and why is it important for pharmacists to be aware of it?

Angela Livingood: drug diversion is the hijacking of medications from its intended use through the medication use process from the manufacturer to the ultimate use or the patient. It can occur anywhere within that process from transport and delivery to the facility to receiving it within the facility to waste. Manipulating the waste process after preparing a dose for patients, so anytime that the drug does not follow the path predicted is drug diversion.

It's important for pharmacists to be aware of because we are the ultimate professional group responsible for how medications are used and stored and secured within institutions, and we carry that responsibility, and it is a high one. We hold many permits related to the management of medications particularly controlled substances, or we are the powers of attorney for the ultimate executive leader that holds that responsibility, and that's a high trust environment that we work in. So, the responsibility is great in making sure that we know where the medications are and what's being done with them.

Also accrediting organizations expect that pharmacist and technicians play a key role in medication management and we are responsible for maintaining those standards, as well as any regulatory agency will be looking to us to have a key role in preventing diversion as well as detecting it.

Q: How does drug diversion differ in a hospital setting compared to a retail setting?

Angela Livingood: Great question because diversion can occur anywhere in any practice setting. So, in an institution like a hospital acute care facility, regardless of size, typically diversion is because the diverter or the teammate taking those medications is planning to use it for personal use, for personal treatment of some condition that they feel they have, or they may actually have a diagnosis of. In smaller cases, it may be that they are going to divert those medications from the patient to use to treat a family member, close relatives, or friends.

In the retail setting, however, most likely, the reason for diversion will be for resale in an alternative market. Not that there cannot be diversion in a retail setting for your personal use nor that resale does not happen in an acute care setting, but that's the key difference institutions where diversion occurs, it's typically for personal use, and in retail, it's typically for resale.

Q: What are effective ways at monitoring inventory, especially with controlled substances?

Angela Livingood: Knowing your inventory, limiting access to who can manipulate those inventories, creating redundancy so you do not have the same people ordering and receiving your inventory, and appropriate witnessing of all functions that require interventions with medications particularly controlled substances. On delivery, making sure that there is a witness to watch the pharmacy teammate receive into the floor stock or into the automated dispensing cabinets, and then checking the reports that you have in your vault, whether it's a manual perpetual inventory or whether it is through some technology. With automated dispensing cabinets that you have, it's monitoring those reports to look for any discrepancies that may appear and that cannot be resolved.

Q: What are some methods pharmacists can take to prevent drug diversion?

Angela Livingood: Number 1, let your teammates know that you do have a drug diversion program and that it's not meant to be a “gotcha.” It's meant to protect patient safety as well as teammates safety. Leverage whatever reporting aspects you have at your facility through your automated dispensing cabinets and pharmacy storage devices, or if it's a manual process, make sure that you're reconciling what you receive with what you give out and what is allotted for patient use, chart review, and use auditing.

Also consider if you are able to have a drug diversion specialist on staff that has training and has developed skills to look for abnormal patterns of use. Finally, it's a team approach. So, listen to your teammates on the frontline for any complaints or gut instincts that they have, and have a good working relationship with your nursing leadership and nursing partners as well as your security or company police. If you have the luxury of having that at your institution, those partners are invaluable in our attempts to prevent drug diversion.

Q: How can the prevention of drug diversion bring awareness to the opioid pandemic?

Angela Livingood: drug diversion prevention programs ensure that the medications obtained by facility follow the medication use process that is expected and that keeps opioids and other substances that could be misused off the streets and out of the public.

Also, drug diversion prevention programs work hand in hand with opioid stewardship programs to make sure that the appropriate amounts of opioids are being prescribed and utilized by our patients and available to their caregivers, so that we minimize the amount of medication available to the public, not as a means of not controlling pain or treating a disorder but just not having extra available that could be tempting to people that have illicit uses in mind.