PRESCRIPTION DRUG MISUSE AND DRUG DIVERSION
Faculty:
Kristina (Tia) Neu, RN
Kristina (Tia) Neu is a licensed Registered Nurse and author currently developing in-service training for healthcare professionals. She is a National Board-Certified Health & Wellness and Lifestyle Medicine Coach. Her work experience includes work in several areas of the healthcare profession, including psychiatric nursing, medical nursing, motivational health coaching, chronic case management, dental hygiene, cardiac technician, and surgical technician.
Steven Malen, PharmD, MBA
Dr. Steven Malen graduated with a dual degree: Doctor of Pharmacy (PharmD) and Master of Business Administration (MBA) from the University of Rhode Island.
Pamela Sardo, PharmD, BS
Pamela Sardo is a freelance medical writer, pharmacist licensed in 2 states, and the founder/principal at Sardo Solutions. She received her BS from the University of Connecticut and a PharmD from the University of Rhode Island. Pam’s career spans many years in retail, clinics, hospitals, long-term care, Veterans Affairs, pharmaceutical manufacturing, and managed healthcare across broad therapeutic classes and disease states.
Topic Overview
In 2022, 16,416 prescription opioid overdose deaths were reported. This statistic exposes the importance of healthcare professionals remaining alert and assessing for the signs of substance use disorders and drug diversions. Clinicians should be aware of the behavioral characteristics and physical symptoms of a substance use disorder when prescribing, dispensing, and monitoring medications that are often misused. Systems, such as prescription drug monitoring programs, patient presentation, and patient responses to questions, can assist interprofessional teams in the identification of drug diversion and possible substance use disorders. Primary care professionals or specialists should be careful not to become too stringent when it comes to prescribing controlled substances so that patients who have legitimate medical needs are not denied adequate treatment.
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Universal Activity Number (UAN): The ACPE Universal Activity Number assigned to this activity is
Pharmacist 0669-0000-25-025-H08-P
Pharmacy Technician 0669-0000-25-026-H08-T
Credits: 2 contact hour(s) (0.2 CEU(s)) of continuing education credit
Type of Activity: Knowledge
Media: Internet/Home study Fee Information: $6.99
Estimated time to complete activity: 2 contact hour(s) (0.2 CEU(s)), including Course Test and course evaluation
Release Date: March 18, 2025 Expiration Date: March 18, 2028
Target Audience: This educational activity is for pharmacists and pharmacy technicians.
Secondary Audiences: Other healthcare professionals, such as nurses, physicians, or others who may be part of a healthcare team, may be interested in this educational topic. The healthcare team's approaches to patient care are discussed in this activity. No state board or professional organization has evaluated this activity to determine whether it meets the continuing education requirements of nurses, physicians, or other professions not listed under the “Target Audience” described above. Always verify with individual employers or supervisors whether they will accept this educational activity upon completion.
How to Earn Credit: From March 18, 2025, through March 18, 2028, participants must:
Read the “learning objectives” and “author and planning team disclosures;”
Study the section entitled “Educational Activity;” and
Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)
Credit for this course will be uploaded to CPE Monitor®.
Learning Objectives: Upon completion of this educational activity, participants should be able to:
Define prescription drug misuse
Identify patient drug misuse signs and risk factors
Describe common drug diversion tactics
Prepare approaches to reduce misuse or diversion
Disclosures
The following individuals were involved in developing this activity: Kristina (Tia) Neu, Steven Malen, PharmD, MBA, and Pamela Sardo, PharmD, BS. Kristina (Tia) Neu, Steven Malen, and Pamela Sardo have no conflicts of interest or financial relationships regarding the subject matter. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.
© RxCe.com LLC 2025: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.
Educational Activity
Prescription Drug Misuse and Drug Diversion Introduction
The number of people misusing prescription drugs or dying from a drug overdose of prescription and illicit drugs in the United States has reached record highs in recent years. Healthcare professionals can help mitigate this crisis by translating awareness of behavioral and physical signs of prescription drug use disorders or misuse into action. Awareness of drug diversion and implementing steps to detect and address diversion should improve healthcare. While preventing drug diversion or drug misuse is vital, it is also important not to underprescribe.
Prescription Drug Misuse: Definitions and Evolution
Definitions of prescription drug misuse vary. Broadly speaking, prescription drug misuse includes “any medication use at a frequency or dose greater than prescribed or for any reason other than the medical indication for which it was prescribed.”1 Narrower definitions focus on the presence of a substance use disorder or the motive for the drug use.
Over the past 30 years, there have been sharp increases in prescription drug use disorder and misuse in the US. Misuse continually rose into the late 1990s and then plateaued at just below 3 million initiators yearly.2 The most commonly identified class of prescription drugs to be misused were opioids. From 1992 to 2012, the number of adults misusing prescription opioids increased from 4.9 million to 12.5 million.3 Tranquilizers were the second most misused prescription drug class at 6 million people in 2012, and stimulants were third at 3.3 million individuals. A study at a substance use disorder treatment facility found that 17% of patients misuse antipsychotic medications. The US has the highest reported prevalence of drug misuse, with Canada, New Zealand, and India also among the top countries affected. In Canada, a 2013 study found that 5% of the population misused opioids. In
2012, the number of adults in the population and the number of opioid prescriptions in the U.S. were the same number.3 Around this time, prescriptions for opioids increased significantly in emergency departments. From 2003 to 2013, stimulant use increased, and opioid use decreased among college students.3
Studies on motives for misuse have found a range of reasons for misusing prescription drugs, such as altered neurochemical sensations (“getting high”), pain management, or improved sleep.3 Prescription drug misuse can also refer to medication obtained from an illicit source, i.e., from someone other than a prescriber who prescribed the medication for a valid medical purpose.
Studies found that prescription drug misuse increased in the following populations:3
Native Americans and Caucasians
Younger and unmarried
People with other substance use disorders and psychiatric illness
People living in rural areas
People with exposure to violence
Adolescents with delinquent behaviors
The overall national opioid dispensing rate has declined from 46.8 opioid prescriptions dispensed per 100 persons in 2019 to 37.5 prescriptions per 100 persons in 2023.4 The states with the highest opioid dispensing rates per 100 persons in 2023 are Arkansas (71.5), Alabama (71.4), Mississippi (63.1), and
Louisiana (62.7).4
The Current Prescription Drug Misuse Problem
Prescription drug misuse causes morbidity, mortality, and lowers life expectancy.5,6 Illicit drugs have been combined with prescription drugs, leading to greater overdose deaths.
Overdose Deaths
In 2020, 13,722 deaths were reported from prescription drug overdoses. This number increased to 16,416 deaths from prescription opioid overdoses in 2022.
Prescription drug overdose deaths are part of a bigger picture of deaths from illicit and legal drugs. In 2021, there were 107,622 deaths from drug overdose in the US.5 By 2022, overdose deaths peaked at approximately 108,000.5 A modicum of good news followed, with overdose deaths declining to 105,007 in 2023, marking a 4.0% decrease from 2022.7
In 2023, approximately 72,000 drug overdose deaths, or nearly seven in ten, were estimated to involve fentanyl, which is primarily illegally manufactured.8 Additionally, there has been a reemergence of carfentanil, a fentanyl analog 100 times more potent than fentanyl, which might threaten recent progress in reducing overdose deaths.8
Prevalence of Prescription Drug Misuse
Misuse of prescription drugs continues to be a problem.6 In 2021, approximately five million people in the US reportedly had a disorder relating to prescription opioids.6 Patients 12 or older who may not have had a substance use disorder but reported misusing prescription drugs during 12 months leading up to 2021 were as follows:6
5.1% (~14.3 million) reported misusing prescription psychotherapeutic drugs
1.3% (~3.7 million) reported misusing prescription stimulants
1.7% (~4.9 million) reported misusing prescription tranquilizers or sedatives
1.4% (~3.9 million) reported misusing benzodiazepines
3.1% (~8.7 million) reported misusing prescription pain relievers
Signs of Prescription Drug Use Disorders and Misuse
Healthcare professionals can help reduce the opioid epidemic by recognizing the behavioral and physical signs of substance use disorders and drug misuse and the methods used to obtain prescription drugs for improper use, such as drug diversion, doctor shopping, and doctor hopping, which will be discussed later in this activity.
Behavioral Signs
Substance use disorder is defined as “a chronically relapsing disorder, characterized by the compulsion to seek and take the drug, loss of control in limiting intake, and the emergence of a negative emotional state (e.g., dysphoria, anxiety, irritability) when access to the drug is prevented.”9 The DSM-5 refers to “drug addiction” as a substance use disorder, which can range from mild to moderate to severe.9 The severity of a disorder depends on the number of DSM-5 criteria that apply.9 A full review of the causes and neurobiological aspects of drug misuse is beyond the scope of this course, but it is important to know the behaviors and personality characteristics that flow from or are associated with drug misuse.
Behavioral signs of patients seeking narcotics in the clinical setting may range from fear to anger, depending on their current needs. A physician or advanced practice nurse may have a patient who reports successive physical injuries and asks for a narcotic prescription. Skilled patient interview techniques may reveal inconsistencies or the need for the healthcare professional to evaluate the patient factors more closely.
A physician, nurse, or pharmacy team may observe a patient becoming agitated when he or she is told there will be a delay in prescribing or dispensing the patient’s medication. A patient who misuses drugs may be easily confused and engage in blame-shifting.10 These are signs and behaviors that may be a sign of a substance use disorder. Adolescent patients with poor school attendance or performance are especially at risk of prescription drug misuse or a substance use disorder.11 Clinicians should not ignore or disregard
these behaviors and personality characteristics, especially when prescribing or dispensing misused medications.
Physical Signs
In addition to emotions, there are some physical symptoms to watch out for, such as opioids causing slurred speech or drowsiness. Stimulants, on the other hand, cause rapid and repetitive speech, overactive, restless agitated, or excitable.12
A patient’s overall appearance may change. The patient may appear with bloodshot eyes, dilated pupils, or pin-point pupils, which may indicate drug use.13 Dilated pupils may mean that a patient is using amphetamines. Pinpoint or constricted pupils (miosis) may mean that a patient is using opioids or barbiturates.13 These symptoms can be easily recognized or assessed in the clinic or pharmacy.
POINT TO PONDER:
What is the policy or procedure if drug misuse or diversion is suspected?
Drug Diversion, Doctor Shopping, and Doctor Hopping
Individuals who use controlled substances for non-medical purposes obtain their preferred prescription drugs from a healthcare professional.14-17 There are many other methods that people use to gain inappropriate access to controlled substances.18 These techniques not only hurt the people who are diverting and misusing drugs, but they also usually result in barriers to care for patients who need these drugs for appropriate medical reasons.
Concerns are raised when a patient frequently seeks to refill a prescription early.14 They may be diverting their prescription, or they may be addicted to the substance. When patients prescribed a controlled substance claim that they lost their prescription, or it happens more than once, this may be a sign of addiction or misuse.
Drug diversion describes the process of transferring prescription drugs to a person who was not prescribed the drug, who then uses it for an illicit purpose.14 Drug diversion can be seen with established patients who sometimes genuinely need medication for pain control but who may sell their extra medications as a way of making money. Some people divert drugs because they have a substance use disorder. These individuals who have access to prescription drugs may sell a prescription drug and use the money to buy a drug they crave. People may divert drugs to others, such as friends or partners. Healthcare professionals, workers, and staff may also divert prescription drugs.19
Doctor shopping occurs when a patient seeks out multiple prescribers to obtain more opioids or other controlled substances than their provider is willing to prescribe and dispense.14-16 Patients who doctor shop often travel great distances to obtain their drugs.14-16 They will even cross state lines to obtain the prescription they seek.15 Some clinicians refer to this behavior as doctor hopping.20 Doctor hopping is “characterized by above average patient- to-prescriber travel distances and patients bypassing nearby prescribers in favor of more distant ones.”15 Doctor hopping is a clear indication of high-risk opioid use and is distinct from and complementary to doctor shopping. Signs
of doctor shopping or hopping do not confirm improper behavior but are indicators of potentially risky behavior.20 Prescription Drug Monitoring Programs may be used to evaluate a patient’s travel patterns and potential misuse.15
Drug Theft and Prescription Forgery
Drug theft can occur anywhere in the prescription drug supply chain, from the manufacturer to the pharmacy. Theft can also happen from relatives or friends with access to the patient's home.20 Prescription pad theft and forgery are common, which has caused states like New York to create laws requiring electronic prescriptions.21 Finally, illicit prescribing or “pill mills” are prescribers who take cash from patients to prescribe large quantities in a prescription.22 These settings, when identified and investigated by boards of medicine, boards of pharmacy, and the Drug Enforcement Agency, are being closed, and “pill mill legislation” has ensued.23 Between 2000 and 2016, this legislation has resulted in an 8.5% reduction in drug-related suicides, which represents a reduction of almost 700 drug-related suicides annually.23
Methods of Detecting Prescription Drug Misuse or Diversion
Systems may be used to detect prescription drug misuse or drug diversion. Healthcare professionals should not rely solely on their intuition but should use the systems set up by the hospital, clinic, or pharmacy. Systems include prescription drug monitoring programs, Morphine Milligram Equivalents calculations, and patient drug testing as part of a controlled substance prescribing agreement.24,25
Identity Drugs Commonly Misused or Diverted
To detect drug diversion systematically, it is important to know which drugs are more likely to be misused and which drugs have the highest demand or “street value.”26 These are the prescription drugs that patients may try to divert.
The following drugs fall into these categories, and they should be flagged in the system for special attention:26
Methyltestosterone, testosterone
Pentobarbital, alprazolam, diazepam
Ketamine, diphenoxylate
Fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone
Amphetamine, dextroamphetamine, methamphetamine, and methylphenidate.
Creating policies and procedures regarding consistent approaches to early prescribing or early refills may prevent drug diversion. Rural geographies, facility location, conditions treated, and patients served may be considerations.
Prescription Drug Monitoring Programs
The prescription drug monitoring program (PDMP) is the first and most important system for detecting diversion.16,27 This online database and documentation system records the controlled prescriptions that a patient has filled within participating states.16 The database is comprehensive and records prescriptions purchased with insurance or cash. If your state and institution participate, check the PDMP every time a controlled prescription is being processed and act whenever there are any ‘red flags.’ The red flags can include doctor shopping, doctor hopping, multiple pharmacies, or recurring early refills.16
Information from PDMPs can identify patients who may be at risk for overdose or who are using several providers to fill narcotics for them and provide potentially lifesaving information and interventions. State PDMPs may differ in implementation and enforcement, leading to different levels of effectiveness.28 These differences can be partly overcome by integrating access to the PDMP in the patient’s electronic health records.28 A study found that integrating access to the PDMP in the patient’s electronic health records
increases the number of PDMP queries among primary care physicians, physician assistants, and nurse practitioners.29 Prescription drug monitoring program data can provide important information during care transition to a new primary care provider, especially when a patient's medication history is unavailable.
Illegal internet-based ‘pharmacies’ attempt to evade state licensing requirements by operating across state and international borders. They provide controlled prescriptions to patients without requiring a prescription.30,31 If a patient is not flagged on the PDMP but shows troubling signs of misuse or diversion, the healthcare professional may consider whether the patient is trying to evade state law by using an illegal online internet pharmacy.
POINT TO PONDER:
Do you know how to access PDMP in your State? If not, contact your state board of pharmacy or state medical board.
Morphine Milligram Equivalents
The Morphine Milligram Equivalents (MME) system is a great program that is automatically calculated in the PDMP.16,28,32 Because a broad number of pharmaceuticals can alleviate pain, and institutions and insurance companies vary in their preferred formularies, a morphine milligram equivalent refers to the amount of morphine that an opioid dose is equal to when prescribed. The number of morphine milligram equivalents is often used as a reference or standardized gauge of a medication’s potential to be abused, possibly resulting in an overdose. The MME system provides the information needed to calculate the total amount of opioids someone is prescribed, regardless of the specific opioid. For example, 30 mg of oral immediate- release morphine is equal to 30 mg of oral hydrocodone but equivalent to 7.5 mg of oral hydromorphone.33 The calculation is standardized and based on
ingredient potency.16,34 This calculation reveals trends of prescribed dose equivalents.21,34 This number also helps stratify patients based on their risk of overdose.16 For instance, when a patient takes more than 50 MME/day, the patient is two to approximately 4 times as likely to overdose compared to dosages of less than 20 MME/day.34 This stratification is a good tool to uncover which patients may benefit most from naloxone.35 Stratification allows focus on the patients with the highest chance of being addicted. When drugs are diverted, they are usually in large doses to make the diversion worthwhile.
Morphine Milligram Equivalent Resources
| Morphine Milligram Equivalents (MME) Calculator | https://www.mdcalc.com/calc/1017 0/morphine-milligram-equivalents- mme-calculator |
Morphine Equianalgesic Dose Chart in the Emergency Department (contains PowerPoint file and equianalgesic chart) | https://pmc.ncbi.nlm.nih.gov/article s/PMC10332699/#app1-jetem-7-3- l1 |
Controlled Substance Prescribing Agreement and Drug Testing
Physicians, nurse practitioners, and professionals with prescribing authority may require patients to enter into a controlled substance prescribing agreement, which may include drug testing, e.g., a urine drug test.24,25,36 These agreements are made before starting opioid pain treatment. Regular monitoring through drug testing can help curb opioid misuse. The urine test can show whether or not the patient is taking the prescribed drugs or possibly diverting them.
Controlling Prescription Drug Misuse without Denying Patients Proper Treatment
Confronting the opioid crisis and misuse of prescription drugs is crucial; however, there is a concern that healthcare providers may overreact and
underprescribe pain medications that patients medically need. This requires a delicate balance. For example, healthcare professionals must balance the need to reduce prescription drug misuse (and a reduction in prescribing opioids) with the legitimate role opioids and other prescription drugs may have in providing proper patient care and legitimate drug prescribing.16 Some patients with substance use disorders may also need pain medications. These patients should not be denied treatment for their pain, but healthcare providers need to handle these patients differently. There is also evidence that race and ethnicity may play a role in prescribing and dispensing pain medications, leading to adverse health outcomes for these populations.22
The harm of overprescribing opioids carries significant risks of a substance use disorder, overdose, and injury or death. However, underprescribing can also cause harm to a patient.28,37 In fact, some researchers state that underprescribing for pain may have contributed to the emergence of the opioid crisis.28 This is in contrast to the opinion that the tremendous increase in opioid prescriptions drove the opioid crisis.3
In either case, undertreatment of pain is a concern and may be contributing to the opioid crisis.28 First, patients who are not given enough pain medication by their prescriber may seek pain relief by resorting to doctor shopping and doctor hopping, as discussed above.14-16 Patients may look to illegal drug markets to get the drugs they want.38
Healthcare professionals must consider underserved populations that may be at greater risk for opioid misuse.39 Reports of disparity in pain management are most notable in the African American community.39-41 Statistically, White patients are more likely to misuse opioids than Blacks and more likely to be prescribed opioids as well. One study found that PDMPs appear to reduce opioid dispensing more in Black patients than White patients.40 A 2018 study found a decline in reports of discrimination from African American patients and no change in reports from data that included Latinos.42
Summary
There is good news. Overdose deaths declined in 2023. Before starting and periodically during the continuation of opioid therapy, healthcare professionals should evaluate the risk for opioid-related harms and discuss the risk with patients. Healthcare teams should work with patients to incorporate strategies to mitigate risk into the management plan, including offering naloxone. Shared decision-making should be incorporated into the care plan, and healthcare professionals should be aware of the behavioral and personality characteristics of a patient with a substance use disorder. In addition to emotions, physical symptoms may manifest.
Drug diversion necessitates the use of the PDMP system. Communication among healthcare professionals, shared decision-making, and possible solutions should result in improved outcomes when a potential issue is identified. Preventing drug diversion or drug misuse is essential; however, it is important not to underprescribe.
Course Test
Which of the following is included in the definition of “prescription drug misuse”?
The patient forgot to take their prescribed medication.
The patient sleeps better when they take their prescribed medication.
The patient enjoys the way they feel when taking their prescribed drug.
Medication is used at a frequency or dose greater than prescribed or for any reason other than the medical indication for which it was prescribed.
Drug diversion is when prescription drugs are transferred to a person who
is a first-time patient.
pays for a prescription without insurance.
is not a healthcare worker.
was not prescribed the drug, who then used it for an illicit purpose.
Studies found that prescription drug misuse increased in the following populations:
Older, married persons
Patients on naturopathic therapies
Adolescents with delinquent behaviors
People living outside of rural areas
Prescription drug monitoring programs (PDMPs) can tell an authorized user
what controlled substance prescriptions a patient has filled using insurance or cash in a participating state.
whether a patient purchased fentanyl on the street from a dealer.
whether a patient has a criminal record.
the patient’s motive for taking prescription drugs.
The Morphine Milligram Equivalents (MME) system provides a clinician with the information needed to
compare narcotic medications to non-narcotic treatment options.
calculate the total amount of opioids someone is prescribed.
know if a patient has been labeled a “doctor shopper.”
know if a prior prescriber has determined that the patient has a substance use disorder.
A patient arrives at a clinic or pharmacy with dilated pupils and appears to be under the influence of a drug. Which of the following drug classes causes dilated pupils?
Amphetamines
Opioids
Barbiturates
Antifungals
is when a patient bypasses nearby prescribers in favor of more distant ones and travels above-average distances to their prescriber.
Dispensing
Transitioning
Doctor hopping
Overprescribing
Behavioral signs of patients seeking narcotics in the clinical setting include a patient who
has to be accompanied to medical appointments.
reports successive physical injuries and asks for a narcotic prescription.
is always on time for medical appointments.
is not outgoing or talkative.
When deciding to prescribe or dispense a prescription for a controlled substance, healthcare professionals should
only trust their gut feelings about possible prescription drug misuse since their intuitions are usually right.
first access the prescription drug monitoring program (PDMP) to see if there are any red flags.
dispense the medication but monitor the patient more closely.
dispense the medication but notify the primary care physician.
Which of the following statements describes the best approach to dispensing controlled substances to reduce prescription drug misuse or drug diversion?
It is better to underprescribe pain medications even if it is medically needed by a patient.
Patients with substance use disorders should not be prescribed pain medications.
The primary care physician should be the only clinician determining if a patient misuses prescription drugs.
Healthcare professionals should utilize the PDMP database, utilize controlled substance prescribing agreements, communication with each other, and shared decision-making.
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