Background: Prescription opioid diversion is the transfer of a prescription opioid from a legal supply chain to an illegal channel of distribution or use (1). Diversion is common, dangerous, difficult to identity, and can occur in palliative and hospice care settings (2-8). This Fast Fact presents expert opinion guidance on mitigating opioid diversion in palliative and hospice care settings. See also Fast Fact #312.

Why are opioids diverted?  Patients’ drugs can be diverted for many reasons: a patient casually shares prescribed opioids to a friend/family to try to help them; a patient intentionally and even routinely sells/trades away prescribed opioids for personal gain (e.g., money or another drug of abuse); a patient is the victim of theft or exploitation (often by a caregiver) who diverts the patient’s opioids for personal gain. In this last scenario, a patient may not know it is happening, or may not have the power to address the theft due to health-related vulnerability.

Universal risk mitigation: Universal strategies to reduce diversion risk can be applied to palliative care settings (9,10). A Diversion Risk Scale exists; however, it has not been validated widely let alone in palliative and hospice care settings (11). The clinical utility of urine drug testing (UDT) has not been validated, although is recommended by experts (10,17,18) 

• Educate patients and caregivers on diversion risks, emphasizing that prescribed opioids must be used by the patient alone. Discuss safe storage (e.g., a lockbox) and disposal of opioids (12-14), including after a patient dies. The patient should limit the number of people who know they have opioids at home. 
• Review the prescription drug monitoring program (PDMP) with each prescription. Enact clear refill protocols including expected date of next refill. Prescribe only the quantity of drug needed until the expected next refill. Preferably use opioids that are less commonly diverted (such as morphine or buprenorphine) or which have abuse-deterrent formulations.

Responding to (suspected) casual sharing diversion: Typically, this is only identified if a patient or caregiver reports doing this, or if a patient runs out of opioids early (which can occur for many different reasons). Providing clear education to the patient/caregiver about the dangers of sharing often is sufficient to address this. Patients should understand a clinician’s professional obligation to treat a patient’s pain does not mean the clinician can continue to prescribe opioids they know are being used dangerously, even if a patient is experiencing significant pain. Very short prescriptions, regular visits, and random pill counts can help.

Responding to intentional, regular diversion for personal gain: This is also difficult to identify clinically, and often only is clearly identified after friends/family report to the clinician that it is happening. Other hints include unexpected refills or suspicious PDMP activity; absence of the drug on UDT; and the patient not needing the opioid as expected when hospitalized. A patient’s motivation to do this may be strictly financial (and sometimes done out of utter financial desperation), or it may be to fund a substance use disorder (SUD). In managing this, clinicians need to decide whether there is any indication at all for opioid prescribing, and if that indication outweighs the grave harm to the community diversion causes. Discontinuing opioid prescribing entirely is often an appropriate response; if a patient is not using the opioid, then obviously opioid withdrawal or pain escalation will not occur. If opioid prescribing is necessary for the patient’s well-being, strict protocols should be in place: limit the length of the prescription to the shortest duration your practice can manage; increase patient visits (e.g., weekly or every other week; some of these visits may be nurse visits for pill counts); regular UDT; random pill counts; transition the patient to opioid formulations which are safer for the community if diverted (e.g., buprenorphine, abuse-deterrent formulations); enlist a caregiver if available to be responsible for and to manage the opioids. Encourage and help arrange SUD treatment for patients with comorbid SUD. Work with your social workers and financial counselors to help address the patient’s financial needs.

Responding to patient victimization: Patients with cognitive impairment or dependence in activities of daily living are at high risk of this form of diversion. Usually this is identified because the patient or other person reports it to the care team; occasionally a health professional will witness signs of the diversion during home visits. A patient may know the diversion is occurring but choose to not report it due to being reliant on the person stealing their medication for their day-to-day survival. Other hints include unexpected early refills, or the patient not needing the opioid as expected when hospitalized. Mitigation strategies are many. Rotation to a more difficult to divert medication such as transdermal patches can help. Especially if a patient is receiving homecare or hospice, nursing staff can monitor the presence of the patch, and participate in some patch changes. Other strategies include greatly limiting the amount of medication released to the patient at any time, helping the patient or a trusted caregivers set up a lock-box system at home, transferring the patient out of the home setting to a facility (if possible).

In these scenarios the patient is being victimized, sometimes by a trusted and otherwise essential caregiver, and identification of theft or exploitation of medications can set off a social crisis (e.g., patient at risk of losing housing or essential caregiving; family discord and relational pain). Involvement of social work is critical from the moment this form of diversion is suspected. Additionally, in these situations the patient usually is a vulnerable adult and appropriate authorities must also be involved.  

References:  

1. U.S. Department of Health and Human Services. Drug Diversion in the Medicaid Program: State Strategies for Reducing Prescription Drug Diversion in Medicaid. Baltimore: Centers for Medicare & Medicaid Services; 2012: https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/MedicaidIntegrityProgram/downloads/drugdiversion.pdf 
2. Markotic F, Jurisic D, Curkovic M et al. Sharing of prescription analgesics amongst patients in family practice: Frequency and associated factors. Eur J Pain. 2018 Apr;22(4):716-27. 
3. Beyene KA, Sheridan J, Aspden T. Prescription medication sharing: a systematic review of the literature. Am J Public Health. 2014 Apr;104(4):e15-26. 
4. Colliver JD, Gfroerer JC. Motive for nonmedical use of prescription pain relievers in the national survey on drug use and health. J Pain. 2008:9: 487-489. 
5. Harris S, Nikulina V, Gelpí-Acosta C et al. Prescription Drug Diversion: Predictors of Illicit Acquisition and Redistribution in Three U.S. Metropolitan Areas. AIMS Public Health. 2015 Dec 2;2(4):762-783. 
6. Ware OD, Cagle JG, McPherson ML, Sacco P, Frey J, Guralnik J. Confirmed Medication Diversion in Hospice Care: Qualitative Findings from a National Sample of Agencies. J Pain Symptom Manage. 2021 Apr;61(4):789-796.  
7. Centers for Disease Control and Prevention. Vital signs: Overdoses of prescription opioid pain relievers – United States, 1999-2008. Morbidity and Mortality Weekly Report. Published November 4, 2011. Accessed December 2, 2023. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm 
8. Hall AJ, Logan JE, Toblin RL, Kaplan JA, Kraner JC, Bixler D, Crosby AE, Paulozzi LJ. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA. 2008:300: 2613-2620 
9. Dale R, Edwards J, Ballantyne J. Opioid risk assessment in palliative medicine. J Community Support Oncol. 2016 Mar;14(3):94-100. 
10. Lau J, Mazzotta P, Whelan C et al. Opioid safety recommendations in adult palliative medicine: A North American Delphi expert consensus. BMJ Support Palliat Care. 2022 Mar;12(1):81-90. 
11. Jones T, Moore TM, Meske DS, Passik SD. Preliminary validation of the Diversion Risk Scale (DRS): Using environmental and individual factors to predict opioid-related diversion events. J Opioid Manag. 2023 Jan-Feb;19(1):35-42.  
12. Schäfer WLA, Johnson JK, Wafford QE, Plummer SG, Stulberg JJ. Primary prevention of prescription opioid diversion: a systematic review of medication disposal interventions. Am J Drug Alcohol Abuse. 2021 Sep 3;47(5):548-558.  
13. Ware O, McPherson ML, Barclay JS et al. Recommendations for preventing medication diversion and misuse in hospice care: A modified delphi study. J Pain Symptom Manage. December 2021; JPSM 62(6):1175-1187 
14. Cosgrove JC. Preventing Drug Diversion: Disposal of controlled substances in home hospice settings. Washington DC: United States Government Accountability Office; 2020: https://www.gao.gov/assets/gao-20-378.pdf 
15. Pacheco S, Nguyen LM, Halphen JM et al. Adherence to opioid patient prescriber agreements at a safety net hospital. Cancers. 2023 May 27;15(11):2943. Doi: 10.3390/cancers15112943. 
16. Philpot LM, Ramar P, Elrashidi MY, Mqangi R, North F, Ebbert JO. Controlled substance agreements for opioids in a primary care practice. J Pharm Policy Pract. 207;10:29.  
17. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep. 2022;71(No. RR-3):1–95.  
18. Arthur JA, Haider A, Edwards T et al. Aberrant Opioid Use and Urine Drug Testing in Outpatient Palliative Care. J Palliat Med. 2016 Jul;19(7):778-82.  
19. Mutter R, Black J, Iwanicki J. Changes in the street prices of prescription opioids during the COVID-19 pandemic. Psychiatric Serv. 2023;74:63-65.  

Authors’ Affiliations: University of Pittsburgh Medical Center, Pittsburgh, PA.
Conflicts of Interest: The authors have disclosed no relevant conflicts of interest. 
Version History: Originally electronically published in May 2024; originally edited by Drew A Rosielle MD.