Why Stopping Drug Diversion Matters

Written by Benjamin Mandel
June 1, 2022

Drug diversion is a serious issue in hospital environments throughout the U.S. and in other countries around the world. The issue not only affects healthcare professionals involved in drug diversion activities, but puts patients at risk as well. Identifying and preventing drug diversion is filled with challenges.

The Centers for Disease Control and Prevention (CDC) estimates that ‘over 70% of overdose deaths in 2019 alone were caused by opioids’.[1] Awareness and acknowledgement of the problem of drug diversion in every hospital is essential for taking steps in prevention, as is a greater focus on hospital pharmaceutical waste disposal processes. Diligence is key in reducing the risk of ruined careers, criminal penalties, outbreaks of infectious diseases, and harm or death to patients – and to healthcare professionals responsible for their care.

Alarming statistics of drug diversion among nurses emphasizes the need for stronger programs, better pharmaceutical disposal processes, and education in order to reduce the risk of such incidents from happening in your hospital or medical facility.


Overview of the problem of drug diversion in hospitals


Drug diversion implies unauthorized and illegal use of a prescription medicines – most commonly opioids – by those not prescribed those medications. The National Association of Drug Diversion Investigators (NADDI) states the drug diversion definition as “the transfer of a controlled substance from a lawful to an unlawful channel of distribution or use.” Such behavior by healthcare professionals in a hospital environment not only increases the potential of addiction among nurses or physicians, but places the patients and the hospital’s reputation at risk.

How often does drug diversion occur in hospitals throughout the U.S. and what impact does it have on healthcare professionals, patients, and health organizations as a whole? Consider that nearly 77% of physicians and nurses diverted nearly 148 million doses of prescription medications in 2020 alone.[2] Roughly half of such incidents occur in a hospital environment or a physician’s practice.

According to the Centers for Disease Control and Prevention (CDC) drug diversion by nurses or other healthcare professionals in a hospital setting increases the risk of:[3]

  • Patients not being given pain management treatments
  • Substandard patient care by nursing staff or nursing support staff
  • Increased risk of spreading infections such as Hepatitis C (HCV) or other bacterial pathogens in the situations where injectable drugs are stolen
  • Physician or nursing staff addiction to certain opioids

Studies of drug diversion outbreaks in patients in hospital scenarios have seen multiple Hepatitis C as well as gram-negative bacteremia, Serratia marcescens bacteremia, and Sphingomonas paucimobilis bacteremia (among others) at hospitals throughout the country.[4]

Drug diversion among nurses is also a challenge. According to Nurseline, drug diversion in the healthcare field is ‘substantially underestimated, undetected, and underreported’.[5]

Why, when and how does it happen?

Determination of why drug diversion occurs points to several issues that include stressful healthcare environments, long shifts, physical and emotional pain, and extreme fatigue, all of which are contributing factors as to why a physician or nurse might be tempted by a number of controlled substances in the hospital environment.

Nursing and physician staff typically have relatively easy access and availability to drugs and medications. Theft of a physician’s prescription pad is another way in which nursing or other staff may facilitate access to drugs. In one scenario, it might not be difficult for a nursing staff member passing medications on the hospital floor to be able to slip some meds into a pocket. Failure to destroy medication left behind following a patient’s discharge or death might occur if medication counts and handovers from one shift to another are not properly conducted.

It has also been reported that a nurse might document that a medication has been given in the patient’s chart even though that medication was taken for personal use. According to NADDI, approximately 41.7% of drug diversion activity occurs among doctors, while 34.7% occurs from nursing staff.[6]

The most common opioids diverted in hospital environments include Oxycodone, Hydrocodone, and Fentanyl. Morphine and its derivatives are also popular. While processes to more closely monitor controlled substances has proven somewhat effective in recent years, not all ‘drug transactions’ between healthcare provider and patient are monitored.

Challenges in identifying drug diversion

Identifying and dealing with drug diversion in a hospital environment is challenging. According to a 2019 publication (“Improving Drug Diversion Detection and Prevention in Healthcare – An NIH National Study”) the seriousness of the problem is staggering. For example, in a 500-bed hospital, the study states that anywhere from 25 to 75 people may be involved in drug diversion![7]

A primary challenge is recognizing a problem even exists and the fact that in many cases, drug diversion is underreported or undetected until something ‘bad’ happens.

Other challenges include but are not limited to:

  • Time needed to properly investigate drug diversion
  • Slow process for internal data analysis/anomalous usage reports
  • Lack of use of automated systems that detect diversion
  • Ineffective ‘alerts’ resulting in false positives
  • Ignoring data, i.e Automated Dispensing Cabinets
  • Slow detection (up to 30 days behind reported anomalous usage)

Such obstacles emphasize the need to adopt drug diversion as soon as possible, and employ disposal methods that focus on prevention. Development and placement of safe and effective disposal processes as near to the point of origin as possible might also be effective in reducing the temptations and risks of drug diversion in medical facilities and in home environments where controlled substances are used for treatments and/or pain management.

Disposal challenges with current solutions

Because Americans have increased their drug consumption over the years (over 4.5 billion to date in 2021)[8], concerns regarding safe and compliant drug disposal processes have increased. This includes disposal processes that in the past have included simply flushing unused medications down the sink or toilet. Such practices are still prevalent in households around the country.

The Food and Drug Administration (FDA) provides a list of drugs that contain opioids that can be flushed when local ‘take-back’ drug site options are not available. The FDA also published a paper reporting a negligible risk to the environment, stating that the risk of such opioids being consumed if not destroyed is higher and more dangerous over the risk of environmental damage.[9]

In addition, many municipal sewage treatment facilities are ill-equipped to remove pharmaceutical compounds from the water, which can also end up in rivers, lakes, and the ocean. While the levels of drugs reaching our rivers and lakes has decreased, it is still a concern.

Focus on improvement of hospital pharmaceutical waste disposal processes

Improving hospital pharmaceutical waste disposal processes can benefit hospitals in numerous ways, especially in employee and patient safety, reduction of civil liability issues, compliance with Drug Enforcement Agency (DEA) and regulatory compliance with the Centers for Medicare and Medicaid Services (CMS), among others.

Current processes such as employee screening and identification of illicit activities by employees is not consistent. The DEA’s Conditions of Participation [§482.13(c)(2)] state that hospitals must protect vulnerable patients and identify and evaluate problems and patterns of incidents’. Additional conditions [§482.25(a)(3)] include that:

  • Current and accurate records must be kept of the receipt and disposition of all scheduled drugs and that all records must be maintained and any discrepancies reconciled in a prompt manner.
  • The hospital must be able to promptly identify a loss or diversion of controlled substances and determine its extent.
  • The facility must have procedures and policies in place that minimize diversion of controlled substances.

The long-term damages in reputation and potentially huge fines for non-compliance for improper pharmaceutical waste disposal or drug diversion activities in a hospital is compounded by the monetary losses organizations face due to diverted drugs. The cost to organizations in 2019 amounted to $183 million.[10]


Awareness is key, as are improved hospital pharmaceutical waste disposal processes, such as use of specially designed and placed containers that destroy unused pharmaceuticals on-site that can be used in hospitals, pharmacies, or even home settings. Proper and compliant medical and pharmaceutical waste disposal processes can aid to circumvent diversion. So too can collaboration among all hospital departments in regard to use of secure disposal containers placed where controlled medicines are dispensed.

Training, education, and accountability are essential in reducing drug diversion in hospitals and other healthcare facilities. Dispose of unused pharmaceutical waste immediately. Recognize that every facility that prescribes, dispenses, or administers a controlled substance is at risk for drug diversion and take steps to eradicate such activities.

[1] https://www.cdc.gov/opioids/data/index.html
[2] https://www.naddi.org/reports/2020-protenus-diversion-digest/
[3] https://www.cdc.gov/injectionsafety/drugdiversion/index.html
[4] Ibid.
[5] https://www.myamericannurse.com/drug-diversion-in-healthcare/
[6] https://www.naddi.org/reports/2020-protenus-diversion-digest/
[7] https://ihfda.org/wp-content/uploads/presentations/2019/ImprovingDrugDiversionDetectionPrevention.pdf
[8] https://www.statista.com/statistics/261303/total-number-of-retail-prescriptions-filled-annually-in-the-us/
[9] https://www.fda.gov/drugs/disposal-unused-medicines-what-you-should-know/drug-disposal-fdas-flush-list-certain-medicines
[10] https://www.naddi.org/reports/2020-protenus-diversion-digest/