Prescription opioid diversion is the transfer of a prescription opioid from a legal supply chain to an illegal channel of distribution or use. Diversion is common, dangerous, difficult to identity, and can occur in palliative care situations (PC).

Why does it happen?
Patients’ drugs can be diverted for many reasons: a patient (1) carelessly shares prescribed opioids to a friend/family to try to help them; (2) intentionally and routinely sells/trades prescribed opioids for personal gain; (3) is the victim of theft or manipulation and diversion the patient’s opioids for personal gain.

Universal risk mitigation:
General strategies to reduce diversion risk can be applied to PC.
• Educate patients and caregivers on diversion risks, emphasizing that prescribed opioids must be used by the patient alone. Examine safe storage and disposal of opioids, including after a patient dies.
• Recommend 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 (morphine, buprenorphine).

Reacting to (suspected) casual sharing diversion
It is identified if a patient or caregiver reports doing this, or if a patient is left without opioids early (it can occur for different reasons !!). Education to the patient/caregiver about the dangers of sharing often is sufficient to address this. Short prescriptions, regular visits, and random pill counts can help.

Reacting to intentional, regular diversion for personal gain
It is often only clearly identified after friends/family report to the clinician that it is happening. Other clues include unexpected refills, 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). It is basic 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; increase patient visits; random pill counts; move the patient to safer opioid formulations if diverted (buprenorphine, abuse-deterrent formulations); encourage and help arrange SUD treatment for patients; help address the patient’s financial needs.

Reacting 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. Alleviation strategies are many, some of them are described in the 2 previous situations. Additionally, the patient usually is a vulnerable adult and appropriate authorities must also be participating.

See reference for more information.

Adapted from Lowry M and Childers J. Voluntary stopping of eating and drinking. Palliative Care Network of Wisconsin. Fast facts and concepts # 484. Internet. Accessed on July 9, 2024.