Background information

Evidence for or history of diversion of controlled substances: The clinician should communicate to patients that drug diversion is a crime and constitutes an absolute contraindication to prescribing additional medications. Because suspicion is subjective and may be based on impression, bias, or prejudice, it is important that providers who suspect diversion base treatment plans on objective evidence. Suspicions may be confirmed by a negative mass spectrometry/liquid chromatography UDT for the substance being prescribed in the absence of withdrawal symptoms in someone who is receiving opioids. A negative UDT for the prescribed opioid could also by itself be a sign of diversion. Signs of diversion may also include frequent requests for early refills or atypically large quantities required to control pain. Routine UDT, however, may not reliably detect synthetic opioids (e.g., methadone, fentanyl, tramadol) or semi-synthetic opioids (e.g., oxycodone, hydrocodone, hydromorphone). When there is evidence that the patient is diverting opioids, discontinue opioids according to Recommendations 14 and 15 and assess for underlying OUD and/or psychiatric comorbidities. Consultation with a pain specialist, psychiatrist, or SUD specialist may be warranted. Also consider consultation with local risk management and/or counsel. For patients with OUD, keep in mind that sudden discontinuation of opioids due to suspected diversion may place them at high risk for illicit opioid use and resulting opioid overdose (see Recommendation 17).

Question: What should the clinician communicate to patients?
Answer: that drug diversion is a crime and constitutes an absolute contraindication to prescribing additional medications

Question: What is a crime and constitutes an absolute contraindication to prescribing additional medications?
Answer: drug diversion

Question: Why is it important that providers who suspect diversion base treatment plans on objective evidence?
Answer: Because suspicion is subjective and may be based on impression, bias, or prejudice

Question: On what kind of evidence should the providers who suspect diversion base treatment plans?
Answer: objective

Question: How to confirm suspicions regarding drug diversion?
Answer: by a negative mass spectrometry/liquid chromatography UDT for the substance being prescribed in the absence of withdrawal symptoms in someone who is receiving opioids

Question: What could also by itself be a sign of diversion?
Answer: A negative UDT for the prescribed opioid

Question: What may not reliably detect synthetic or semi-synthetic opioids?
Answer: Routine UDT

Question: What are some examples of synthetic opioids?
Answer: methadone, fentanyl, tramadol

Question: What are some examples of semi-synthetic opioids?
Answer: oxycodone, hydrocodone, hydromorphone

Question: What to do when there is evidence that the patient is diverting opioids?
Answer: discontinue opioids according to Recommendations 14 and 15 and assess for underlying OUD and/or psychiatric comorbidities

Question: When may consultation with a pain specialist, psychiatrist, or SUD specialist be warranted?
Answer: When there is evidence that the patient is diverting opioids

Question: When to consider consultation with local risk management and/or counsel?
Answer: When there is evidence that the patient is diverting opioids

Question: What to keep in mind for patients with OUD?
Answer: sudden discontinuation of opioids due to suspected diversion may place them at high risk for illicit opioid use and resulting opioid overdose (see Recommendation 17)