Ariel Clark, PharmD
On October 26, 2017, the opioid crisis was officially declared a public health emergency in the United States. Since then, opioid overdoses have failed to decline—CDC’s 2020 data on opioid overdoses demonstrated a 31% increase over 2019.
While multifactorial, drug diversion remains a major contributor to the public health crisis, leading to increased misuse, addiction, and death.
In their 2022 update to the Guide-lines on Preventing Diversion of Controlled Substances, the American Society of Health-System Pharmacists (ASHP) aimed to close some of the gaps from previous guideline editions and add in recommendations from the ASHP Opioid Task Force. These guidelines give providers recommendations on how to build an effective diversion program, including administrative elements, system-level controls, and individual-level controls.
Technology
Automation technology in pharmacy has been increasingly used over the last several decades. Reducing drug diversion using technology can include the use of automated dispensing cabinets, management of inventory, and pre-packaging of drugs that are at risk for diversion. ASHP said that automation can also include electronic surveillance and monitoring—both electronic and manual—through audits and reviews to ensure the health system continues to “meet legal, regulatory, and functionality requirements.”
Investigation and reporting
In cases of suspected diversion, ASHP noted that a “detailed and thorough approach” to the investigation is imperative. Health systems should have a predetermined process in place for any “unresolvable discrepancy” that includes coordination within the system, with outside affiliates—in cases where it is necessary—and which results in a root cause analysis by the drug diversion team.
Tracking, storage, security
Within system tracking of controlled substances is a critical protection against diversion, which also aids a health system in identifying when and where a diversion has occurred. ASHP recommends that tracking parameters be maintained throughout the entirety of the “chain-of-custody,” between departments and individuals.
Another key element in maintaining autonomy over controlled substances is the mechanism of storage and the security of those storage centers, ASHP said. Limiting access, maintaining an electronic record, and ensuring all contents remain under lock-and-key, unless under “the direct physical control of an authorized individual,” will all aid health care practitioners in the prevention of diversion cases.
Pharmacy procurement and dispensing
Drug diversion within the confines of the pharmacy department can occur, and steps should be taken to mitigate these risks. ASHP suggests a variety of methods to reduce this risk, such as limiting access and rotating the health care workers assigned to handle controlled substances, for example. These key principles outlined by the ASHP guideline can help minimize drug diversion within the pharmacy department.
Prescribing, administrating, and wasting
With a shift in technology, prescribers have the opportunity to “write” orders electronically, lowering the risk of potential diversion through prescription pads, which can more easily be falsified. In the updated diversion guidelines, ASHP recommends using order sets whenever possible, as long as they “are supported by clinical evidence.“ ASHP also noted that methods to reduce controlled substance diversion “should not delay patient treatment or compromise patient needs,” helping to ensure that providers are still fully able to care for patients to the best of their ability.
Drugs that are set to be or are in the process of being wasted are highly susceptible to diversion. ASHP recommends designing systems to attempt to reduce waste whenever possible by using unit-dose packaging and avoiding multidose vials. When waste must occur, practitioners should follow guideline recommendations by incorporating witnessing and extensive documentation procedures as defined by federal and state laws.
As pharmacy professionals play their part in helping to end the opioid epidemic, they must also take an active role in preventing drug diversion in their workplace. Using these updated guidelines can set up health care organizations to build their own procedures, improve awareness, and reduce controlled substance diversion. ■