Drug diversion is the misuse of scheduled prescription drugs, which are purchased, given to others, or stolen or received as stolen goods. Drugs such as painkilling narcotics are often diverted, as are depressants, stimulants, and other types of medications. Drug diversion can be highly profitable, and diverted scheduled prescription drugs may sell for many times more than what pharmacies charge for a legitimate prescription. Some studies have shown that adolescents who have both attention deficit hyperactivity disorder (ADHD) and conduct disorder or a substance use disorder are more likely to sell or misuse prescribed drugs than other individuals. (An alternate meaning of diversion is to provide special programs such as drug courts to help drug offenders stay out of jail.)

Some specific drugs, such as OxyContin, a narcotic painkiller, and methylphenidate (Ritalin, Concerta, Focalin, etc.), a drug that is often prescribed to children and adolescents who have ADHD, are also diverted. In addition, Darvocet and Tylenol 3, both prescribed analgesics, are drugs of diversion. anabolic steroids are often diverted. Antianxiety drugs such as alprazolam (Xanax) are sometimes diverted.

According to the National Survey on Drug Use and Health, from 2003 to 2004, the nonmedical use of some scheduled drugs increased significantly, such as specific pain relievers including Vicodin or Lorcet (hydrocodone with acetaminophen). Drug abuse in this category increased from a lifetime use of 15.0 percent among adult ages 18 to 25 years old to 16.5 percent in 2004. Other drugs, such as those including oxycodone (Percocet, Percodan, and Tylox), increased in lifetime prevalence from 7.8 percent to 8.7 percent.

Abuse of products containing hydrocodone increased from 16.3 percent to 17.4 percent, and OxyContin abuse increased from 3.6 percent to 4.3 percent. Abuse of products containing oxycodone increased from 8.9 percent to 10.1 percent.

According to the National Survey on Drug Use and Health, in 2004, 6 million people in the United States used prescribed drugs nonmedically, including 4.4 million who abused prescribed pain relievers, 1.6 million who used tranquilizers, 1.2 million who used stimulants, and 0.3 million who used sedatives. Although most street drug abuse decreased among young adults ages 18-25 years over the period 2003 to 2004, the nonmedical lifetime use of prescription drugs showed little change. It was 6.1 percent in 2004 compared to 6.0 percent in 2003 and 5.4 percent in 2002. Clearly, the demand for such drugs remains high, and thus drug diversion is likely to continue.

Some physicians are so concerned about drug diversion that they will not prescribe any scheduled medications, and some experts worry that patients in severe pain may be seriously undermedicated.

Drug diversion essentially includes six primary means of transferring drugs for medical purposes to individuals who use them for abuse, including the following:

- prescription forgery or fraud

- doctor shopping

- Internet pharmacies

- illicit prescribing practices of some physicians

- drug theft

- personal sales of their own legitimately prescribed drugs (often by adolescents or young adults)

Most patients do not forge or alter the prescriptions that they are given for legitimate medical problems, but some patients who are addicted to prescribed drugs, particularly scheduled drugs, will take whatever action they feel is necessary to obtain the drug that they need. Patients may take the prescription that a doctor has written and then change the quantity that the doctor ordered to a greater number than the physician intended. In addition, some individuals steal blank prescription pads or even create their own prescription pads.

Fraud also plays a role in drug diversion. Some patients have attempted to call in their own prescriptions by phone to pharmacies by impersonating physicians.

Pharmacists themselves sometimes become involved in drug diversion and use their database of physicians to "write" prescriptions for drugs that they sell illegally. Pharmacists or pharmacy technicians may also skim off prescriptions, for instance, they give a patient a smaller quantity of pills than were prescribed and then pocket a portion for selfuse or resale. This allows the pharmacy count to be accurate while leaving some patients in difficulty with an inadequate medication quantity. In some cases, physicians, dentists, and other health care workers who have access to scheduled drugs divert the drugs to themselves or others who should not have them.

Some patients who abuse or are dependent on prescription drugs make appointments with several different physicians, seeking a prescription for the same or a similar drug from each doctor, thus obtaining multiple prescriptions. They may go from doctor to doctor seeking a prescription until they find one who will prescribe the drug that they seek. This is known as "doctor shopping."

Because of this and related problems with prescription drug abuse, about half the states in the United States have prescription drug monitoring programs, which capture data on all prescriptions for scheduled drugs. In this way, the monitoring agency can identify patients who are receiving multiple prescriptions of the same drug.

In 2005, President George W. Bush signed the National All Schedules Prescription Electronic Reporting Act of 2005, a new program offering financial grants to states that create or enhance the electronic monitoring of scheduled prescription drugs.

It should be noted that sometimes patients who experience severe pain, such as caused by cancer or chronic serious illnesses, consult two or more doctors because they are undertreated for pain and seek adequate pain relief. As a result, it should not be assumed automatically that individuals who see several doctors for the same complaint are invariably seeking drugs for abuse. However, sometimes even patients who have legitimate medical complaints divert drugs. In one highly unusual case reported in Arizona, a genuinely ill patient consulted physicians in several states and was prescribed an estimated 8,000 pills in one year, which were then sold on the street in Maryland.

Although a few legitimate pharmacies offer pharmacy services over the Internet, requiring a prescription from a medical doctor, there are also many Web sites that offer virtually every drug, including Schedule II drugs such as OxyContin, hydrocodone, and other narcotics, to consumers without a prescription. Often all these sites require to order their prescribed drugs is a valid credit card, and they then send the drugs directly to the consumer. Some adolescents have ordered illegal drugs through the Internet, usually using a parent's credit card. It is difficult to control this form of drug diversion; however, federal and state agencies are seeking solutions to this problem.

Although most doctors do not overprescribe scheduled drugs to their patients, there are some physicians who will write a prescription for scheduled drugs for nearly any patient and who often fail to monitor the drug use of these patients.

This is very risky behavior for the doctor, who usually will eventually attract the notice of the Drug Enforcement Administration and/or other federal and state agencies. Doctors stand to lose their right to prescribe scheduled drugs or even to lose their medical licenses. In some cases, physicians have been jailed for prescribing very large quantities of scheduled drugs, with little or no oversight. Some physicians have been indicted for knowingly participating in Internet pharmacy sales of controlled drugs for illegal purposes.

According to data from Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in the U.S., 16 percent of the pharmacists who were surveyed said that doctors who "knowingly divert controlled prescription drugs" were the primary cause of drug diversion.

Some individuals steal scheduled drugs, whether from pharmacies, clinics, or individuals who are patients with legitimate prescriptions. Drugs are also stolen from pharmaceutical warehouses, and in some cases, replaced with counterfeit drugs, although the extent of this problem is unknown. Some drugs that have been stolen from pharmacies have been OxyContin, Darvocet, and Soma (carisprodol). Sometimes drugs are stolen from veterinarians or dentists.

Some pharmacies in supermarkets or other locations refuse to carry the medications that they believe are the most likely to be stolen, such as some narcotics.

It is also true that some individuals raid the bathroom medicine cabinets of their parents, relatives, or clients, seeking drugs that they can abuse or sell. Selling narcotics can be particularly profitable for some individuals willing to risk the high probability of arrest. Individuals who take narcotics for pain management should not keep these drugs in the medicine cabinet but should locate them elsewhere, preferably in a locked location.

Some adolescents and young adults sell or trade their own scheduled drugs with others. In addition, studies have shown that some students who have attention deficit hyperactivity disorder who take stimulants, particularly Ritalin, report that other individuals sometimes forcibly take their medications from them.

In some cases, patients receiving Medicaid, a medical program for low-income adults and children who qualify for it, may legally obtain their prescriptions at very low or no cost, then sell them on the street.

References:

Kraman, Pilar. Prescription Drug Diversion. Lexington, Ky.: The Council of State Governments, April 2004.

McCabe, Sean Esteban, et al. "Non-Medical Use of Prescription Stimulants among US College Students: Prevalence and Correlates from a National Study." Addiction 100, no. 1 (January 2005): 96-106.

McCabe, S. E., C. J. Teter, and C. J. Boyd. "The Use, Misuse and Diversion of Prescription Stimulants among Middle and High School Students." Substance Use and Misuse 39, no. 7 (2004): 1,095-1,116.

National Center on Addiction and Substance Abuse (CASA) at Columbia University. Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in the U.S. New York: National Center on Addiction and Substance Abuse at Columbia University, July 2005.

Office of Applied Studies, Substance Abuse and Mental Health Services Administration. Overview of Findings from the 2004 National Survey on Drug Use and Health. Rockville, Md.: Department of Health and Human Services Publication Number SMA 05-4061, September 2005.

Poulin, Christiane. "Medical and Nonmedical Stimulant Use Among Adolescents: From Sanctioned to Unsanctioned Use." Canadian Medical Association Journal 165, no. 8 (2001): 1,039-1,044.

Zacny, James, et al. "College on Problems of Drug Dependence Taskforce on Prescription Opioid Non-Medical Use and Abuse: Position Statement." Drug and Alcohol Dependence 69 (2003): 215-232.

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