Mitigating drug diversion: Safeguard patients, providers, and healthcare organizations by implementing best practices

Best practices for combating drug diversion are based on protecting both inpatient and outpatient settings with an emphasis on using electronic prescriptions for controlled substances (EPCS) and prescription drug monitoring programs (PDMPs).

“The people who are doing these diversions in the hospital are our friends, our colleagues. It’s our diligence, it’s our duty to watch for this and help them get out of it as quickly as possible.”

- Jason Potts, from the Imprivata webinar, Best practices for combating drug diversion.

Over the last few years, drug diversion rates have continued to rise, and despite the rate of substance use disorders significantly rising during the COVID-19 pandemic, it was shown that many healthcare organizations reduced budgets and support for measures combating this issue.

Like the cybersecurity world, drug diversion is always evolving. As programs are put in place, diverters look for new ways to get around them. The problem is also multifaceted: drug diversion was historically thought of as an outpatient problem, and regulations were put in place to help combat that; however, recently, we’ve started to see that healthcare workers are the new diverters, which means focus should expand to encompass all ways controlled substances are currently being misused.

The state of outpatient drug diversion

As drug diversion continues to rise, more effective measures are needed to combat it. In the outpatient space, a great amount of effort has been directed towards using regulations to prevent drug diversion, both on the state and federal level.

Implementing the Electronic Prescriptions for Controlled Substances (EPCS) and the Prescription Drug Monitoring Program (PDMP) has helped make significant progress in drug misuse on the outpatient side. These have both gained momentum in the last five to seven years due to state and federal legislation. New York was the first state to mandate using EPCS and PDMP in 2016 with the I-STOP law, which requires all providers to check the PDMP before prescribing medications, and requires all medications to be prescribed electronically. This created a domino effect, with other states enacting similar legislation for EPCS and PDMP. More than 30 states have an EPCS requirement today.

On a federal level, The Support Act will soon come out, introducing initiatives to address the opioid epidemic, such as requiring all controlled substances prescribed to patients through Medicare Part D to be prescribed electronically.

These regulations have proven effective for combating drug diversion on an outpatient level. The Office of the National Coordinator for Health Information Technology (ONC) recently released a brief that found 71% of physicians used EPCS in 2021, with 78% of physicians indicating they checked their state’s PDMP before prescribing controlled substances to a patient for the first time.

However, there's still room to grow and achieve higher adoption rates of both technologies. In the same study, 25% of providers indicated they rarely or never use EPCS, reflecting a need for better adoption. Usability challenges for providers continue to be the primary obstacle to adoption, with technologies needing to be easily accessible and easy to integrate into the provider's typical workflow.

These challenges are present due to the balancing act of patient care and ease of use. Providers want to provide the quality care patients need, and to do that, technology must be easily accessible and seamlessly integrated into the provider's typical workflow.

The state of drug diversion in inpatient settings

On the inpatient side of drug diversion, access is easier, with controlled substances more frequently used and available. Healthcare providers are the group most affected in this setting, often diverting medications for their own personal use. The downstream effects start with the diverter, but go on to affect others, including:

  • Patients not getting the care they need when their medication is diverted
  • Providers in an altered state are unable to provide the level of care needed in each situation
  • Adulteration of drugs may lead to infection risks for patients, as diverters may dilute the drugs they are taking by replacing the lost volume with water
  • The financial impact of diversion can be massive, as well as the reputational damage to the organization when patients are made aware of the situation

Being equipped to combat drug diversion

Once you have a better understanding of the problem of drug diversion, it is easier to see what steps are needed to combat this pressing issue.

Adoption of technologies

Regulation drives the adoption of technologies, but it is on healthcare organizations to find a solution that causes as little disruption as possible to providers giving care to their patients. Implementing an EPCS solution is challenging, and provider adoption can be difficult. Organizations must go through the DEA guidelines to determine the best approach to meeting regulations without disrupting clinical workflows.

As state laws and Medicare Part D regulations go into effect, healthcare organizations must look at their EPCS process from two perspectives:

  1. Do we meet the requirements of the DEA, and can we prove it in an investigation?
  2. Do our providers have the best workflow in as many scenarios as possible to ensure adoption of the EPCS process?

On the inpatient side, technology utilizing AI and machine learning can help review data points, alerting organizations to potential cases of risk. Manual, random sampling audit methods leave potential risk unnoticed, which puts organizations out of compliance with regulatory reporting standards.

The right AI and machine learning technology can also allow organizations to observe trends within the data, identifying risky behaviors. Examples include users pulling a controlled substance at a much higher percentage than their peers, or accessing cabinets and then canceling that transaction at a higher rate.

Getting leadership involved

Leadership involvement is crucial when spearheading adoption of technologies and policies to mitigate drug diversion. Discussing regulatory requirements, DEA fines for not meeting those requirements, and fines for cases of drug diversion, can help show leadership the importance of investing resources to combat this issue.

On the inpatient side, reviewing the ASHP guidelines for drug diversion can direct the discussion and ensure your organization is meeting those standards. Getting support for building a drug diversion management committee can drive the development of policies and procedures, manage performance improvement, and provide overall direction for developing a robust drug diversion program.


Most diverters are caught by being turned in by patients or other healthcare workers. Educating staff on the signs and symptoms commonly found in healthcare workers who are involved in drug diversion, as well as providing a safe, anonymous way to report suspicious activities, can greatly help to drive down diversion cases.

It’s also important to keep in mind that drug diverters are friends and colleagues within the organization. Though reporting isn’t always easy, it is necessary. It’s up to the diligence of others to notice and mitigate drug diversion as soon as possible.

Next steps

Conquering internal and external drug diversion requires adhering to regulatory requirements without diminishing patient care.

Some next steps towards implementing best practices for drug diversion mitigation include:

  • Taking note of current processes and regulatory developments to stay ahead of violations and implement solutions in the right way
  • Ensuring your organization is looking at processes and technologies that don't hinder clinical workflows to support successful adoption among staff members
  • Reviewing your EPCS process to ensure full compliance with regulatory requirements and address any workflow gaps that could lead to diversion
  • Starting a drug diversion committee to review and manage these processes to ensure all areas within the organization are heard
  • Educating staff on the risks of drug diversion, how to spot it, and how to report it
  • Spending time reviewing the data used to audit internal access to ensure accuracy and provide the best outcomes from technology solutions

Drug diversion is a growing problem, but shining a light on the effects it has on patients, providers, and organizations can further drive initiatives to decrease these cases and keep everyone safe.

To learn more about Imprivata solutions for mitigating drug diversion, check out our webinar, Best practices for combating drug diversion.