US Pharm. 2021;46(4):HS-10.

It is estimated that approximately 10% to 15% of healthcare workers will abuse drugs or alcohol during their careers. Benzodiazepines and opiates are the most commonly abused drugs. The environments most frequently associated with drug abuse include specialties such as psychiatry, emergency medicine, and anesthesia. Medical students mainly use drugs and alcohol for recreational use. Attending physicians and residents tend to abuse drugs for treating anxiety, depression, or pain.1 Therefore, the risk of drug diversion among these healthcare workers is prevalent.

Drug diversion occurs when prescription medications are obtained illegally for personal use. Healthcare workers who obtain controlled substances and other prescription drugs put patients at risk. The types of harm can include denial of pain medications to patients, below-average care by an impaired healthcare worker, and risk of infections, such as hepatitis C, if  injectable drugs are tampered.

Drug diversion is the result of addiction to narcotics by healthcare workers.2 Therefore, it is important for institutions to implement a controlled-substance diversion–prevention program (CSDPP) to protect patients from harm, protect the organization from liabilities, and protect the community. Organizations need to adhere to federal, state, and local regulations, depending on which is more stringent. There are several key areas at risk for drug diversion in the inpatient setting, including procurement, preparation and dispensing, prescribing, administration, and waste removal.3

Controlling the Chain of Custody

Federal and state laws and regulations govern the procurement, prescribing, administration, and waste or removal of controlled substances. Other compliance organizations, such as The Joint Commission and the Centers for Medicare and Medicaid Services, provide compliance standards that hospitals can adopt in their policies and procedures. Organization oversight refers to establishing best practices that ensure the chain of custody and the healthcare workers responsible for handling controlled substances are held accountable at all times.3

System-level controls addresses human-resources management, technology and automation, monitoring and surveillance, and investigation and reporting. It is paramount that organizations keep patients safe from harm. If a healthcare worker is suspected of drug diversion or abuse, he or she must be removed from patient care and access to controlled substances immediately until the investigation is completed. Diversion-monitoring software, automated dispensing, and prepackaging devices help with controlled-substance inventory control as well as tracking medication removal, administration, waste, and billing. Surveillance should include verifying perpetual inventory, and auditing should be performed regularly by an assigned pharmacist. Patient-care units, anesthesia, special procedure areas, and the pharmacy are all areas susceptible to drug diversion and abuse.3

Provider Responsibilities

Provider-level controls address the chain of custody, storage and security, internal pharmacy controls, prescribing and administration, returns, waste, and disposal. The CSDPP should define the chain of custody to ensure that only those healthcare workers who are authorized to access the controlled substances are allowed. If the healthcare worker is no longer a part of the organization, then access should be removed promptly. Automated dispensing devices should be accessed with a biometric identification with user identification. Controlled-substance cabinets and carts that are not automated dispensing devices are protected with an electronic lock that requires a badge swipe, biometric identification, or code.3

Implementing policies and practices to best deter, detect, and respond to drug diversions is the goal for healthcare organizations to prevent controlled-substance drug diversion.


1. Baldisseri MR. Impaired healthcare professional. Crit Care Med. 2007;35(2 Suppl):S106-S116.
2. CDC. Drug diversion. Accessed February 28, 2021.
3. American Society of Healh-System Pharmacists. Guidelines on Preventing Diversion of Controlled Substances. Accessed February 28, 2021.

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.

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