On November 23, 2016, the CDC published a report describing the preliminary results of a program to reduce the misuse and diversion of prescription drugs by providing drug arrest records to medical professionals. Prescription drug misuse and diversion are a part of the nationwide epidemic of opioid overdose. Prescription drug diversion, the unlawful channeling of regulated pharmaceuticals from legal sources to the illicit marketplace, occurs at various points within the medical distribution system — via wholesale distributors, medical offices, retail pharmacies, or patients themselves. Although they are not the only source, physicians are the leading source of prescription painkillers for people at high risk for painkiller overdose.
Medical professionals are ideally positioned to intervene with patients who struggle with addiction and could more effectively do so if given tools and resources that help them identify and respond to vulnerable patients (i.e., those who are at risk for overdose or who are illegally diverting prescription medicines).
Although federal efforts to limit prescription opioid misuse are substantial and span several federal agencies (e.g., Substance Abuse and Mental Health Services Administration, Health Resources and Services Administration, Drug Enforcement Agency), there has not yet been a systematic approach to linking health system and law enforcement efforts as a means to more effectively address prescription drug abuse and diversion.
Diversion Alert, a unique online tool aimed at reducing misuse and diversion of prescription drugs, was established in 2009 by a community coalition in northern Maine. Diversion Alert aims to: (1) provide medical professionals with a source of information to identify patients who are at risk for overdose, in need of addiction treatment, or engaged in illegal pharmaceutical distribution; (2) increase attentiveness to prescribing practices; and (3) increase use of prescribing practices that help reduce abuse and diversion of prescription drugs. The core components of Diversion Alert are: (1) monthly drug arrest reports from the previous month, consisting of public drug arrest data organized by geographic region (i.e., by county and by state); (2) an online, mobile-friendly, searchable drug arrest database containing an 11-month historical record of public drug arrest data submitted to Diversion Alert and accessible to registrants any time; and (3) research-based educational resources to assist in responding to patients charged with prescription drug or illegal drug crimes.
Diversion Alert provides access to prescription (schedule II-IV) and illegal drug charge data for medical professionals (actively licensed pharmacists, prescribers, and medical office staff authorized to participate on behalf of prescribers or pharmacists), so they can respond to patients in need of intervention.
Significantly, Diversion Alert distributes drug charge data rather than conviction data. There are two types of drug charges: an arrest and a summons. An arrest gives notice to a person that he or she is being charged with a crime. The person who is arrested is detained and kept in custody until he or she can post bail or the criminal charges are resolved. A summons gives notice to an individual that he or she is being charged with a crime, but the individual is not detained. In contrast, a conviction is a formal determination by a court that a person has been found to have committed a crime. The State must prove a person’s guilt beyond a reasonable doubt to obtain a conviction. The fact that a person has been arrested or received a summons does not guarantee that the person will be convicted of a crime.
Provision to prescribers of drug charge data, rather than conviction data, may be a point of concern; however, there are three keys points to consider. First, in Maine it takes from 12 to 18 months for a person charged with a drug crime to be convicted. Because individuals are generally released shortly after an arrest, there is a long period from charge to conviction during which a person could be putting himself or others at risk as a result of an untreated addiction or undetected diversion of pharmaceuticals. Therefore, it may be safer to use drug charge data as soon as they are available (within a few weeks of the date of charge) rather than to use conviction data. Second, anecdotal evidence from discussion with law enforcement in Maine suggests that more than 90% of drug charges end in a conviction. Additionally, a study conducted by the Bureau of Justice Statistics found that 93% of drug defendants adjudicated during 2006 were convicted.
Most importantly, Diversion Alert is intended to be used as a resource to improve patient care and not as a punitive measure against patients. When a medical professional discovers a patient on a Diversion Alert report, that discovery is an indication both that something may be occurring and that additional work should be done (e.g., talking to the patient and to other professionals who share the patient’s treatment, checking the prescription drug monitoring program) to get a more complete picture of what is going on with the patient.
As a public health intervention, Diversion Alert is based on the public health model, which demonstrates that problems arise through relationships and interactions among an agent, a host, and the environment. That is, in some instances prescription drug abuse and diversion arise from the interactions among the patient, the prescriber, and the prescribing environment within the medical system.
In accordance with the Transtheoretical Model of behavior change, health care providers who begin using Diversion Alert will transition from being unaware of the extent of prescription drug abuse in Maine to a point at which they will be ready to change prescribing behaviors in response to patients they discover abusing or diverting prescriptions or to prevent future diversion and abuse. The specific prescribing behaviors the program seeks to increase are practices recommended in the literature (e.g., urine drug screens, random pill counts, frequent use of prescription drug monitoring programs) for reducing abuse and diversion of prescription drugs for any person prescribed schedule II through IV controlled substances. By providing information to prescribers that aims to change prescriber perceptions and behaviors, patient addiction and diversion may be more effectively addressed and prevented, and fewer pharmaceuticals may be illegally diverted into communities.
Researchers used a quasi-experimental research design to compare survey data in Maine with those of neighboring states (New Hampshire and Vermont, 2013 and 2014). In 2013, 1,811 respondents participated in the pre-evaluation, and 782 respondents participated in the 2014 postevaluation. Posttest respondents and their professional grouping indicated that most responders were prescribers, and 10% to 20% were pharmacists. Less than 9% identified as “medical office staff” or “other.”
In 2013, 87% of Maine survey respondents reported yes to the item, “There is a prescription abuse/diversion problem in my local area.” One year later, 98% agreed. By 2014, nearly all respondents in Vermont believed that there was a prescription abuse/diversion problem in their local area (96%). In New Hampshire, 76% agreed. The percentages increased by more than 10% between 2013 and 2014 for Maine and Vermont, but not for New Hampshire.
For the item, “In the past 6 months, I have become aware of patients in my care arrested for prescription drug possession or diversion,” 49% of Maine respondents said yes in 2014, significantly more than either New Hampshire (21%) or Vermont (29.6%).
With regard to communicating with health care providers who share a patient’s treatment plan, Maine respondents increased from 2013 to 2014 more than the other states (0.46 on a 4-point scale [1 = never, 2 = somewhat, 3 = a lot, and 4 = all the time] compared with 0.04 for New Hampshire and 0.01 for Vermont). Communicating with law enforcement decreased from 2013 to 2014 for Maine respondents (−0.25 on 4-point Likert scale compared with −0.05 for Vermont and +0.04 for New Hampshire). By 2014, Maine respondents were more likely to have changed several of their prescribing practices than were respondents in New Hampshire or Vermont.
In Maine, at posttest, respondents were asked how they used Diversion Alert. Eighty-four percent attributed to Diversion Alert improved attentiveness to prescribing. More than half (59.3%) said they used it as a way to intervene with patients who were abusing or diverting prescriptions, and 40% used it as tool to screen new patients. Respondents were also asked to report the number of patients they discovered on a Diversion Alert report; 52% discovered at least 1 patient, with an average of 2.5 patients discovered per yes response.
It is noteworthy that Maine respondents increased their communications with others involved in the treatment of their patients but decreased their communications with law enforcement. This supports the idea that Diversion Alert is a tool for health care decision-making, not for law enforcement and legal action. Vermont also showed a significant decrease in communication with law enforcement whereas New Hampshire increased on this item. The absence of the prescription drug monitoring program (PDMP), and information provided by it, in New Hampshire may be associated with a higher degree of interaction with law enforcement as the basis for obtaining information about patients who may be involved in illegal activity. This point should be tested, because New Hampshire launched its PDMP in October of 2014.
In Maine, significant improvements were realized on communication and collaboration with patients through contracts, screening to garner additional information to guide prescribing and treatment decisions, and more conservative prescribing procedures to limit illegal use and diversion for patients who have been arrested. Moreover, Maine providers significantly decreased discharging patients who had been arrested, suggesting that they sought to provide needed health care to all patients while also attending to alternative prescribing for those who have been involved in illegal substance activity.
Compared with their counterparts in New Hampshire and Vermont who did not use Diversion Alert, prescribers and pharmacists in Maine who used Diversion Alert increased their communication with patients and other providers involved in their patients’ care, became aware of patients arrested for prescription drugs possession or diversion, used best practices associated with prevention or detection of addiction and diversion more frequently, and attributed positive changes in their prescribing practices to Diversion Alert. In combination with other state and federal programs, Diversion Alert may be an effective tool to help prevent the misuse of opioid medications.
See the CDC Report
See also Medical Law Perspectives, January 2014 Report: Prescription Painkillers: Risks for Patients, Pharmacists, and Physicians
See also Medical Law Perspectives, May 2013 Report: Drugs, Dosage, and Damage: Physician Liability for Prescribing or Administering Medication
See also Medical Law Perspectives, November 2012 Report: Liability for Electronic and Other Medical Record Information Disclosure
See the Medical Law Perspectives February 16, 2015, Blog: Pharmacy Owes Duty To Patient Not To Fill Excessive Prescriptions for Opioids
See the Medical Law Perspectives October 8, 2014, Blog: Opioid Pain Pill Abusers Switch to Heroin; Heroin Overdose Deaths Double