PREVENTING PRESCRIPTON DRUG MISUSE AND DIVERSION

Various actions by healthcare providers can help prevent prescription drug misuse and diversion. These include:

• Educating patients on safe use, storage, and disposal of medications
• Understanding which drugs are commonly misused and/or diverted
• Recognizing aberrant drug-related behaviors (ADRB) (behaviors that may be associated with misuse of prescription opioids)
• Detecting and responding to drug diversion in the workplace

Institutional measures are also an important part of addressing the opioid epidemic, such as:

• Medication formulation and abuse-deterrent formulations
• Prescription drug monitoring programs (PDMPs)
• Surveillance systems

Teaching Safe Use, Storage, and Disposal of Prescription Medications

Educating patients on safe use, storage, and disposal of medications is an essential part of addressing the opioid and drug diversion epidemic. Nurses and prescribers can address the following points with patients who have been prescribed opioids:

SAFE USE

• Before you are prescribed opioids, tell your healthcare provider about all other medications and supplements you are taking.
• Tell your healthcare provider if you or your family has a history of alcohol or drug addiction. There are other pain treatment options that are equally as effective as (or more effective than) opioids and don’t carry the same risks for addiction and overdose.
• Only take opioids prescribed to you and as directed by your healthcare provider.
• Never accept opioids from anyone else.
• Don’t share your medications with others, because they may cause harm to someone else.
• Store prescription opioids in a locked container and out of children’s reach (see below).
• Safely dispose of any unused medication when you are not longer using the medication (see below).
• If you’ve been prescribed opioids, talk to your healthcare provider about your risk for overdose.
• Tell your healthcare provider if you experience changes in your mood, balance, sleep, or pain level, and if you find it difficult to stop or decrease opioid use.
• Discuss with your healthcare provider alternative ways to manage your pain.
  (VA, 2020)

SAFE STORAGE

Opioids are controlled substances, and their possession and use is regulated by state and federal laws. More than 70% of people who misuse prescription opioids obtain them from family and friends. Therefore, it is important that patients safely store their prescription medications. The CDC also recommends that prescribers discuss risks to household members and other individuals if opioids are intentionally or unintentionally shared with others for whom they are not prescribed, including the possibility that others might experience overdose at the same or at lower dosage than prescribed for the patient.

• Store opioids in their original packaging inside a locked cabinet, a lockbox, or other secure location.
• Do not store opioids in obvious places like bathroom cabinets or on kitchen counters where others might find them.
• Note when and how much medication you take in order to keep track of the amount left.
  (AAFP, 2021; Dowell et al., 2022; SAMHSA, 2020)

SAFE MEDICATION DISPOSAL

Prescribers and/or pharmacists often provide specific disposal instructions for unused or expired medicines, and patients are educated to follow those instructions. There are a variety of ways to dispose of medications. The U.S. FDA (2020a) outlines three options for drug disposal according to the type of drug: a take-back site, the flush list, or household trash.

Take-Back Programs

The best way to dispose of most types of unused or expired medicines (both prescription and over the counter) is to immediately drop off the medicine at a drug take-back site, location, or program. Pharmacies, firehouses, or police departments will often “take back” unused medications, particularly opioids. Some areas have specific dates on which they offer this service; other sites will take back medications at any time.

The U.S. Drug Enforcement Agency (DEA) website provides a locator app where the user can search for drug drop-off points within a 10- to 100-mile radius, and each year the DEA sponsors a National Prescription Take Back day (U.S. DEA, 2021a). In 2020, West Virginia collected 5,865 pounds of materials at 94 collection sites throughout the state.

(See “Resources” at the end of this course to locate a disposal location.)

Flushing Disposal

If a drug take-back option or DEA-authorized collector is not available and a medication is on the FDA flush list (see table below), the FDA recommends safely flushing such approved medications down the toilet. The medicines on the flush list are those sought after for their misuse and abuse potential or those that can result in death from one dose if inappropriately taken. For these reasons, the FDA recommends that patients flush them down the toilet to immediately and permanently remove these risks from their home.

The FDA believes that the risk of harm from accidental exposure to these few select medicines far outweighs any potential risk to the environment that may come from disposal by flushing (Khan et al., 2017).

FDA’s FLUSH LIST

Drug Name	Examples
(U.S. FDA, 2020b)
Drugs That Contain Opioids
Any drug that contains the word buprenorphine	Belbuca, Buavail, Butrans, Suboxone, Subutex, Zubsolv
Any drug that contains the word fentanyl	Abstral, Actiq, Duragesic, Fentora, Onsolis
Any drug that contains the words hydrocodone or benzhydrocodone	Apadaz, Hysingla ER, Norco, Reprexain, Vicodin, Vicodin ES, Vicodin HP, Vicoprofen, Zohydro ER
Any drug that contains the word hydromorphone	Exalgo
Any drug that contains the word meperidine	Demerol
Any drug that contains the word methadone	Dolophine, Methadose
Any drug that contains the word morphine	Arymo Er, Avinza, Embeda, Kadian, Morphabond ER, MS Contin, Oramorph SR
Any drug that contains the word oxycodone	Codoxy, Combunox, Oxadydo (formerly Oxecta), Oxycet, Oxycontin, Percocet, Percodan, Roxicet, Roxicodone, Roxilox, Roxybond, Targiniq ER, Troxyca ER, Tylox, Xartemis XR, Xtampza ER
Any drug that contains the word oxymorphone	Opana, Opana ER
Any drug that contains the word tapentadol	Nucynta, Nucynta ER
Drugs That Do Not Contain Opioids
Any drug that contains the term sodium oxybate or sodium oxybates	Xyrem, Xywav
Diazepam rectal gel	Diastat, Diastat Acudial
Methylphenidate transdermal system	Daytrana

Household Trash Disposal

If a drug take-back program is not available and a medication is not on the flush list, the FDA (2018) provides the following guidance on how to dispose of drugs via household trash:

• Mix medicines (liquid or pills; do not crush tablets or capsules) with an unappealing substance such as dirt, cat litter, or used coffee grounds.
• Place the mixture in a container such as a sealed plastic bag.
• Throw away the container in the household trash.
• Delete all personal information on the prescription label of empty medicine bottles or medicine packaging, then trash or recycle the empty bottle or packaging.

Even after fentanyl patches have been used, a degree of medication remains. These patches should be folded over so the adhesive sticks together and no exposed area that contains the drug remains. It should then be flushed or disposed of per the household trash disposal guidelines.

Since inhalers are dangerous if punctured or if they come in contact with fire, they must be treated with care. Local trash and recycling facilities typically provide information on how to properly dispose of inhalers in their area.

Understanding Commonly Abused/Misused Drugs

The DEA (2020a) recognizes five classes of drugs that are frequently abused: opioids/narcotics, depressants, hallucinogens, stimulants, and anabolic steroids, with opioids being the most commonly misused. The extent to which the drug is reliably capable of producing intensely pleasurable feelings (euphoria) increases the likelihood of that substance being abused.

Three specific classes are most commonly abused and thus most susceptible to diversion for nonmedical use:

• Pain medications/narcotics. Opioid pain relievers (narcotics) are the most commonly diverted controlled prescription drugs. Opioid medications are effective for the treatment of pain and have been used appropriately to manage pain for millions of people, however increased rates of abuse and overdose deaths have raised concerns about proper use of these medications in the treatment of chronic pain.
• Central nervous system (CNS) depressants/sedatives/hypnotics. CNS depressants slow brain activity and are useful for treating anxiety and sleep disorders. Since many patients with pain also experience anxiety or sleep disturbances, increased prescribing of sedative hypnotics has paralleled the increase in prescribing of opioids. Clinicians who add sedative hypnotics to the treatment plan for chronic pain patients may potentiate the risk for patients who are also prescribed opioid medication.
• Stimulants. Stimulants are prescribed primarily for treatment of attention deficit hyperactivity disorder (ADHD) and narcolepsy. They may also be used as an adjunct medication in the treatment of depression. When taken nonmedically, stimulants can induce a feeling of euphoria and thus have a high potential for abuse and diversion. They also have a cognitive enhancement effect that has contributed to non-medical use by professionals, athletes, and other individuals who rely on productivity. Nonmedical use of stimulants poses serious health consequences, including addiction, cardiovascular events, and psychosis.
  (NIDA, 2020)

PRESCRIPTION DRUGS WITH HIGH POTENTIAL FOR DIVERSION/ABUSE

Category	Drugs
(NIDA, 2020)
Opioids	Codeine Fentanyl Hydrocodone or dihydrocodeinone Hydromorphone Meperidine Methadone Morphine Nalbuphine Oxycodone Oxymorphone
CNS depressants	Barbiturates: pentobarbital Benzodiazepines: alprazolam, chlordiazepoxide, diazepam, lorazepam, triazolam Sleep medications (hypnotics): eszopiclone, zaleplon, zolpidem Ketamine (can be classified as an analgesic, centrally acting nonopioid, anesthetic, or antidepressant depending on how it is used; when used appropriately, its primary purpose is sedation)
Stimulants	Amphetamines Methylphenidate

Recognizing Aberrant Drug-Related Behaviors

Some patients who are prescribed opioid pain medication are at increased risk for opioid misuse and diversion. These patients may demonstrate certain misuse behaviors that can provide clues to the clinician. By recognizing what are called aberrant drug-related behaviors (ADRBs), healthcare professionals can respond appropriately and help patients to remain safe.

ADRBs may occur because a patient is experiencing poor pain control or has a fear of uncontrolled pain, which can lead to hoarding of medication. The behaviors may also be attributed to elective use of opioid medication for the euphoric effect or for non-pain-related symptoms such as anxiety, depression, insomnia, and stress.

ADRBs in patients who are prescribed opioids should trigger clinicians to the possibility of addiction. Current literature suggests a range of aberrant drug-related behaviors, with some more predictive of addiction than others. Being aware of the behaviors described in the following box can help guide clinicians who are treating and monitoring patients who are receiving prescription opioid therapy for long-term pain management.

The presence of aberrant behaviors, however, may indicate a range of problems other than misuse or diversion, and the clinician must explore a differential diagnosis. Possible etiologies include addiction, pseudo-addiction, another psychiatric disorder, personality disorder, chronic boredom, mild encephalopathy, withdrawal states, and genuine undertreatment of pain. Therefore, it is important to monitor, document, and communicate any aberrant behaviors using objective means and in a team-based fashion over the patient’s entire course of care. This process will also remove any bias on the part of a single provider.

In the hospital setting, monitoring and responding to ADRBs is important in order to:

• Determine the success or failure of treatment
• Help prevent the transition of chronic pain to opioid dependence and SUD
• Help prevent psychiatric disorders such as anxiety and depression
• Identify undiagnosed SUD
• Identify patients at high risk for diversion
• Identify possible complications of opioid therapy
  (Maumus et al., 2020)

Drug Diversion in the Workplace

The opportunity for diversion of controlled substances from the workplace exists, and diversion of opioids is seen across all clinical disciplines and all levels of an organization, from management to frontline staff.

Despite a lack of comprehensive studies on the topic, one 2020 analysis of publicly reported diversion incidents involving healthcare workers found that diversion occurred in various settings: hospital/medical center/clinic (32%), practice (26%), long-term care (20%), pharmacy (17%), ambulance services (5%), and other (1%). Data on the diverter’s role found doctors to be the most common diverters (36%), followed by nurses (31%), pharmacist/pharmacy tech (13%), executive/owner/operator (9%), paramedic/emergency services (6%), and other (2.5%) (Protenus, 2021). Nurses may be at increased risk for misuse or diversion of prescription medications due to working in environments where frequent and easy access to controlled substances is part of their daily work routine (TJC, 2019; Mumba, 2018).

Diversion may occur with opened or unopened vials, partially used doses of medication that are not wasted, and medication that has been disposed of and left in sharps containers. The drugs most commonly diverted from healthcare settings are opioids, but there is no precise data that defines the extent of drug diversion.

Every healthcare professional plays an important role in drug diversion prevention and should be able to recognize patterns, trends, and behaviors associated with drug diversion in the workplace. These may include:

• Consistently arriving early, staying late, or frequently volunteering for overtime
• Frequent breaks or trips to bathroom
• Heavy wastage of drugs
• Drugs and syringes in pockets
• Anesthesia record does not reconcile with drug dispensed and administered to patient
• Patient has unusually significant or uncontrolled pain after anesthesia
• Higher pain score as compared to other anesthesia providers
• Times of cases do not correlate when provider dispenses drug from automated dispenser
• Inappropriate drug choices and doses for patients
• Missing medications or prescription pads
• Drugs, syringes, needles improperly stored
• Signs of medication tampering, including broken vials returned to pharmacy
• Compromised product containers
• Frequent medication losses, spills, or wasting
• Controlled substances removed without a doctor’s order
• Controlled substances removed on recently discharged or transferred patient
• Controlled substances removed for a patient not assigned to the nurse
• Medication documented as given but not administered to the patient
• Frequent reports of ineffective pain relief from patients
• Frequent unexplained disappearances from the unit
• Incorrect controlled substance counts
• Consistently documenting administration of more controlled substances than other nurses
• Large amounts of narcotic wastage
• Numerous corrections on medication records
• Offers to medicate coworkers’ patients for pain
• Saving extra controlled substances for administration at a later time
• Altered verbal or phone medication orders
• Variations in controlled substance discrepancies among shifts or days of the week
  (NCSBN, 2018; AANA, n.d.; U.S. DEA, 2021c; Brummond et al., 2017)

Essential organizational steps to address drug diversion in the workplace include:

• Prevention. Healthcare facilities must have systems in place to guard against theft and diversion of controlled substances. It is important that all staff understand and comply with these protocols, and act in ways to minimize unauthorized access or opportunities for tampering and misuse.
• Detection. Systems can include video monitoring of high-risk areas, active monitoring of pharmacy and dispensing record data, and training staff to be aware of and alert for behaviors and other signs of potential diversion activity.
• Response. Appropriate responses include establishing a just culture in which reporting drug diversion is encouraged, assessing harm to patients, consulting with public health officials when tampering with injectable medication is suspected, and promptly reporting to enforcement agencies.
  (TJC, 2019)

Institutional Measures to Prevent Prescription Drug Misuse

Institutional measures are also an important part of addressing the opioid epidemic. Several such measures are discussed below.

MEDICATION FORMULATION

Manufacturers of prescription drugs continue to work on new formulations of opioid medications, known as abuse-deterrent formulations (ADFs), which include technologies designed to prevent people from misusing them by snorting or injection. Abuse-deterrent formulations have been shown to decrease the illicit value of drugs. Several ADF opioids are on the market, and the FDA has called for the development of ADF stimulants.

Abuse deterrent strategies currently being used include:

• Physical or chemical barriers that prevent the crushing, grinding, or dissolving of drugs
• Agonist/antagonist combinations that cause an antagonist (which will counteract the effect of the drug) to be released if the product is manipulated
• Aversive substances that are added to create unpleasant sensations if the drug is taken in a way other than directed
• Delivery systems such as long-acting injections or implants that slowly release the drug over time
• New molecular entities or prodrugs that attach a chemical extension to a drug that renders it inactive unless taken orally

The development of effective, nonaddicting pain medications is also a public health priority. Researchers are exploring alternative treatment approaches that target other signaling systems in the body, such as the endocannabinoid system, which is also involved in pain (NIDA, 2020).

PRESCRIPTION DRUG MONITORING PROGRAMS

Prescription drug monitoring programs (PDMPs) are statewide electronic databases that gather information from pharmacies on controlled substances. Growing recognition that PDMPs are a vital tool for clinicians to address the prescription drug epidemic has led to increased public and private funding to support widespread expansion of these programs. All U.S. states, Washington, D.C., and U.S. territories have operational PDMPs and share data via the Prescription Monitoring Information Exchange (PMIX) National Architecture (PDMP TTAC, 2021).

SURVEILLANCE SYSTEMS

Prescription Behavior Surveillance System (PBSS) is a public health surveillance system that uses PDMP data to monitor trends in prescribing behaviors for controlled substances at the state or county level. In 2010, PBSS began using PDMP data from participating states to report on a variety of indicators of prescribing behavior, including prescribing rates by patient age, sex, drug type, dose, and source of payment. Although data on clinical indication is not collected, the system tracks various controlled substance indicators of possible misuse, including cash payment for prescriptions and “multiple-provider episodes,” in which a person uses multiple prescribers and pharmacies within specified periods to obtain controlled substances.

PBSS collects data on prescriptions of controlled substances to provide indicators of possible inappropriate medical use to both federal and state collaborators. PBSS has developed approximately 43 prescription behavior measures, including:

• Prescription rates by drug class and individual drug
• High daily opioid dosages (≥90 morphine milligram equivalents [MME]/day)
• Average daily opioid dosage
• Overlapping opioid prescriptions and opioid-benzodiazepine prescriptions
• Multiple-provider episode (MPE) rates by drug schedule or class, payment sources
• Indicators of possible inappropriate prescribing and dispensing

PBSS database can detect changes in prescribing patterns earlier than other administrative health data (e.g., Medicaid claims data) (Strickler et al., 2020).