Drug diversion is a medical and legal concept involving the transfer of a legally- prescribed

controlled substance A controlled substance is generally a drug or chemical whose manufacture, possession and use is regulated by a government, such as illicitly used drugs or prescription medications that are designated by law. Some treaties, notably the Sing ...

from the individual for whom it was prescribed to another person for any illicit use. The definition varies slightly among different

jurisdiction Jurisdiction (from Latin 'law' and 'speech' or 'declaration') is the legal term for the legal authority granted to a legal entity to enact justice. In federations like the United States, the concept of jurisdiction applies at multiple level ...

s, but the transfer of a controlled substance alone usually does not constitute "diversion," since certain controlled substances that are prescribed to a child are intended to be administered by an adult, as directed by a

medical professional A health professional, healthcare professional (HCP), or healthcare worker (sometimes abbreviated as HCW) is a provider of health care treatment and advice based on formal training and experience. The field includes those who work as a Nursing, nur ...

(the prescriber). The term is named for "diverting" said drugs from their original, intended, licit medical purpose. In some jurisdictions, drug diversion programs are available to first time offenders of diversion drug laws, which "divert" offenders from the criminal justice system to a program of education and rehabilitation.

Imprecise, Misleading Definition of "Diversion"

The definition of "drug diversion" is not all-inclusive or all-encompassing, in the sense that it does not account for the potential of ''any'' substance, chemical, formulation, molecule, medication, or "drug" in the broadest sense to be diverted from one individual to another; it is not exclusive to controlled substances, as even substances that are not "scheduled" (neither "controlled" per, regulated by, nor listed in the

Controlled Substances Act The Controlled Substances Act (CSA) is the statute establishing federal government of the United States, federal drug policy of the United States, U.S. drug policy under which the manufacture, importation, possession, use, and distribution of ...

or related analogues and derivatives, which are regulated in the United States by the

Federal Analogue Act The Federal Analogue Act, , is a section of the United States Controlled Substances Act passed in 1986 which allows any chemical "substantially similar" to a controlled substance listed in Schedule I or II to be treated as if it were listed ...

. Even medication sold

over-the-counter Over-the-counter (OTC) drugs are medicines sold directly to a consumer without a requirement for a prescription from a healthcare professional, as opposed to prescription drugs, which may be supplied only to consumers possessing a valid pres ...

or behind the counter can be diverted from one individual to another for purposes of

substance abuse Substance misuse, also known as drug misuse or, in older vernacular, substance abuse, is the use of a drug in amounts or by methods that are harmful to the individual or others. It is a form of substance-related disorder, differing definition ...

, often for recreational purposes and/or as a means of self-medicating that have hitherto been improperly or insufficiently treated (perhaps due to not being "taken seriously" by medical providers) or due to a patient's inability to access primary health care services due to not being insured; specific to the U.S., many Americans neither have nor qualify for

health insurance Health insurance or medical insurance (also known as medical aid in South Africa) is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance, risk is shared among ma ...

coverage in any form. Perhaps most commonly, diversion serves to aid

clandestine chemistry Clandestine chemistry is chemistry carried out in secret, and particularly in illegal drug laboratories. Larger labs are usually run by gangs or organized crime intending to produce for distribution on the black market. Smaller labs can be run by ...

and production of

methaqualone Methaqualone is a hypnotic sedative. It was sold under the brand names Quaalude ( ) and Sopor among others, which contained 300 mg of methaqualone, and sold as a combination drug under the brand name Mandrax, which contained 250 mg me ...

glutethimide Glutethimide (brand names included Doriden, Elrodorm, and Noxyrom) is a central nervous system (CNS) depressant drug of the piperidine chemical class, one of many non-barbiturate, "barbiturate-like" GABAergic medications exhibiting general calm ...

, ethinamate, ethchlorvynol, methyprylon. OTC medications that can be misused (used recreationally (depending on one's perspective) include

diphenhydramine Diphenhydramine, sold under the brand name Benadryl among others, is an antihistamine and sedative. Although generally considered sedating, diphenhydramine can cause paradoxical central nervous system stimulation in some individuals, particula ...

, doxylamine,

chlorpheniramine Chlorphenamine (CP, CPM), also known as chlorpheniramine, is an antihistamine used to treat the symptoms of allergic conditions such as allergic rhinitis (hay fever). It is taken orally (by mouth). The medication takes effect within two hour ...

dimenhydrinate Dimenhydrinate, also known as diphenhydramine/8-chlorotheophylline salt and sold under the brand names Dramamine and Gravol, among others, is an over-the-counter medication used to treat motion sickness and nausea. Dimenhydrinate is a theocl ...

propylhexedrine Propylhexedrine, sold under the brand name Benzedrex among others, is an alkylamine primarily utilized as a topical nasal decongestant. Its main indications are relief of congestion due to colds, allergies, and allergic rhinitis. Propylhexedr ...

dextromethorphan Dextromethorphan, sold under the brand name Robitussin among others, is a cough suppressant used in many cough and Common cold, cold medicines. In 2022, the US Food and Drug Administration (FDA) approved the combination dextromethorphan/bupropi ...

levmetamfetamine Levomethamphetamine ( INN: levmetamfetamine) is an optical isomer of methamphetamine primarily used as a topical nasal decongestant. Levomethamphetamine is used to treat nasal congestion from allergies and the common cold. It was first used me ...

nicotine replacement therapy Nicotine replacement therapy (NRT) is a medically approved way to treat people with tobacco use disorder by taking nicotine through means other than tobacco. It is used to help with quitting smoking or stopping chewing tobacco. It increases th ...

products, oral

caffeine Caffeine is a central nervous system (CNS) stimulant of the methylxanthine chemical classification, class and is the most commonly consumed Psychoactive drug, psychoactive substance globally. It is mainly used for its eugeroic (wakefulness pr ...

dosage form Dosage forms (also called unit doses) are pharmaceutical drug products presented in a specific form for use. They contain a mixture of active ingredients and inactive components ( excipients), configured in a particular way (such as a capsule she ...

s, vitamins, minerals, and dietary or nutritional supplements. Medication containing the sympathomimetic amines

ephedrine Ephedrine is a central nervous system (CNS) stimulant and sympathomimetic agent that is often used to prevent hypotension, low blood pressure during anesthesia. It has also been used for asthma, narcolepsy, and obesity but is not the preferred ...

and

pseudoephedrine Pseudoephedrine, sold under the brand name Sudafed among others, is a sympathomimetic medication which is used as a decongestant to treat nasal congestion. It has also been used off-label for certain other indications, like treatment of lo ...

can be purchased without a prescription, albeit behind the counter of the pharmacy upon showing ID, signing a log and legal disclaimer, and not exceeding monthly purchase limits, as defined by the Combat Methamphetamine Epidemic Act of 2005. Theoretically, prescription drugs defined as "

controlled substances A controlled substance is generally a drug or chemical whose manufacture, possession and use is regulated by a government, such as illicitly used drugs or prescription medications that are designated by law. Some treaties, notably the Single ...

" (i.e. prescription drugs regulated or "scheduled" by the

) are the most likely to be misused or diverted.

Commonly diverted drugs

Chemical class Chemical classification systems attempt to classify elements or compounds according to certain chemical functional or structural properties. Whereas the structural properties are largely intrinsic, functional properties and the derived classi ...

es of commonly diverted controlled substances include:

Central Nervous System (CNS) Depressants

Benzodiazepines Benzodiazepines (BZD, BDZ, BZs), colloquially known as "benzos", are a class of central nervous system (CNS) depressant drugs whose core chemical structure is the fusion of a benzene ring and a diazepine ring. They are prescribed to treat co ...

, including

diazepam Diazepam, sold under the brand name Valium among others, is a medicine of the benzodiazepine family that acts as an anxiolytic. It is used to treat a range of conditions, including anxiety disorder, anxiety, seizures, alcohol withdrawal syndr ...

and

clonazepam Clonazepam, sold under the brand name Klonopin among others, is a benzodiazepine medication used to prevent and treat anxiety disorders, seizures, bipolar mania, agitation associated with psychosis, obsessive–compulsive disorder (OCD), and ...

are often prescribed to treat

social anxiety Social anxiety is the anxiety and fear specifically linked to being in social settings (i.e., interacting with others). Some categories of disorders associated with social anxiety include anxiety disorders, mood disorders, autism spectrum dis ...

, generalized anxiety,

akathisia Akathisia (IPA: /æ.kə.ˈθɪ.si.ə/) is a movement disorder characterized by a subjective feeling of inner restlessness accompanied by mental distress and/or an inability to sit still. Usually, the legs are most prominently affected. Those a ...

, and

anxiety Anxiety is an emotion characterised by an unpleasant state of inner wikt:turmoil, turmoil and includes feelings of dread over Anticipation, anticipated events. Anxiety is different from fear in that fear is defined as the emotional response ...

related to, or stemming from, obsessive-compulsive disorder (OCD) (such as compulsive decluttering);

lorazepam Lorazepam, sold under the brand name Ativan, Tavor among others, is a benzodiazepine medication. It is used to treat anxiety (including anxiety disorders), insomnia, severe agitation, active seizures including status epilepticus, alcoh ...

and

alprazolam Alprazolam, sold under the brand name Xanax among others, is a fast-acting, potent tranquilizer of moderate duration within the triazolobenzodiazepine group of chemicals called benzodiazepines. Alprazolam is most commonly prescribed in the ...

are often utilized to treat symptoms of

and

panic disorder Panic disorder is a mental disorder, specifically an anxiety disorder, characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath ...

, acute

panic attack Panic attacks are sudden periods of intense fear and Comfort, discomfort that may include palpitations, otherwise defined as a Tachycardia, rapid, Arrhythmia, irregular Heart rate, heartbeat, Hyperhidrosis, sweating, chest pain or discomfort, s ...

s, and

;

temazepam Temazepam, sold under the brand name Restoril among others, is a medication of the benzodiazepine class which is generally used to treat severe or debilitating insomnia. It is taken by mouth. Temazepam is rapidly absorbed, and significant hypn ...

, flurazepam,

triazolam Triazolam, sold under the brand name Halcion among others, is a central nervous system (CNS) depressant tranquilizer of the triazolobenzodiazepine (TBZD) class, which are benzodiazepine (BZD) derivatives. It possesses pharmacological properti ...

, and sodium clorazepate are utilized for the treatment of treatment-resistant"">treatment-resistant insomnia">treatment-resistant"

insomnia Insomnia, also known as sleeplessness, is a sleep disorder where people have difficulty sleeping. They may have difficulty falling asleep, or staying asleep for as long as desired. Insomnia is typically followed by daytime sleepiness, low ene ...

by virtue of their status as sedative-hypnotic, calming, and soporific (sleep-inducing) agents; and

midazolam Midazolam, sold under the brand name Versed among others, is a benzodiazepine medication used for anesthesia, premedication before surgical anesthesia, and procedural sedation, and to treat psychomotor agitation, severe agitation. It induces ...

is frequently utilized for

muscle relaxation Muscle contraction is the activation of tension-generating sites within muscle cells. In physiology, muscle contraction does not necessarily mean muscle shortening because muscle tension can be produced without changes in muscle length, such as ...

and easing of muscle spasms). *

Opioids Opioids are a class of Drug, drugs that derive from, or mimic, natural substances found in the Papaver somniferum, opium poppy plant. Opioids work on opioid receptors in the brain and other organs to produce a variety of morphine-like effects, ...

(

analgesic An analgesic drug, also called simply an analgesic, antalgic, pain reliever, or painkiller, is any member of the group of drugs used for pain management. Analgesics are conceptually distinct from anesthetics, which temporarily reduce, and in s ...

s for relief of chronic, severe pain in cases of broken bones and cancers), including

codeine Codeine is an opiate and prodrug of morphine mainly used to treat pain, coughing, and diarrhea. It is also commonly used as a recreational drug. It is found naturally in the sap of the opium poppy, ''Papaver somniferum''. It is typically use ...

morphine Morphine, formerly also called morphia, is an opiate that is found naturally in opium, a dark brown resin produced by drying the latex of opium poppies (''Papaver somniferum''). It is mainly used as an analgesic (pain medication). There are ...

hydrocodone Hydrocodone, also known as dihydrocodeinone, is a semi-synthetic opioid used to treat pain and as a cough suppressant. It is taken by mouth. Typically, it is dispensed as the combination acetaminophen/hydrocodone or ibuprofen/hydrocodone fo ...

oxycodone Oxycodone, sold under the brand name Roxicodone and OxyContin (which is the extended-release form) among others, is a semi-synthetic opioid used medically for the treatment of moderate to severe pain. It is highly addictive and is a commonly ...

, tapentadol,

hydromorphone Hydromorphone, also known as dihydromorphinone, and sold under the brand name Dilaudid among others, is a morphinan opioid used to treat moderate to severe pain. Typically, long-term use is only recommended for pain due to cancer. It may b ...

, and

fentanyl Fentanyl is a highly potent synthetic piperidine opioid primarily used as an analgesic (pain medication). It is 30 to 50 times more Potency (pharmacology), potent than heroin and 50 to 100 times more potent than morphine. Its primary Medici ...

. *

Z-drug Nonbenzodiazepines (), sometimes referred to colloquially as Z-drugs (as many of their names begin with the letter "z"), are a class of psychoactive, depressant, sedative, hypnotic, anxiolytic drugs that are benzodiazepine-like in uses, such as f ...

s, including

zolpidem Zolpidem, sold under the brand name Ambien among others, is a medication primarily used for the short-term treatment of sleeping problems. Guidelines recommend that it be used only after cognitive behavioral therapy for insomnia and after beh ...

(Ambien) and

eszopiclone Eszopiclone, sold under the brand name Lunesta among others, is a nonbenzodiazepine medication used in the treatment of short-term and long-term insomnia. It holds the distinction of being one of the few FDA-approved hypnotic medications with ...

(Lunesta) – prescription sleep medications *

Stimulant Stimulants (also known as central nervous system stimulants, or psychostimulants, or colloquially as uppers) are a class of drugs that increase alertness. They are used for various purposes, such as enhancing attention, motivation, cognition, ...

s (CNS stimulants, psychostimulants, "uppers") including

amphetamine Amphetamine (contracted from Alpha and beta carbon, alpha-methylphenethylamine, methylphenethylamine) is a central nervous system (CNS) stimulant that is used in the treatment of attention deficit hyperactivity disorder (ADHD), narcolepsy, an ...

methylphenidate Methylphenidate, sold under the brand names Ritalin ( ) and Concerta ( ) among others, is a central nervous system (CNS) stimulant used in the treatment of attention deficit hyperactivity disorder (ADHD) and narcolepsy. It may be taken Oral adm ...

– prescribed to treat

ADHD Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by symptoms of inattention, hyperactivity, impulsivity, and emotional dysregulation that are excessive and pervasive, impairing in multiple ...

narcolepsy Narcolepsy is a chronic neurological disorder that impairs the ability to regulate sleep–wake cycles, and specifically impacts REM (rapid eye movement) sleep. The symptoms of narcolepsy include excessive daytime sleepiness (EDS), sleep-r ...

, and

obesity Obesity is a medical condition, considered by multiple organizations to be a disease, in which excess Adipose tissue, body fat has accumulated to such an extent that it can potentially have negative effects on health. People are classifi ...

. According to the

United States Department of Justice The United States Department of Justice (DOJ), also known as the Justice Department, is a United States federal executive departments, federal executive department of the U.S. government that oversees the domestic enforcement of Law of the Unite ...

, "Most pharmaceuticals abused in the United States are diverted by doctor shopping, forged prescriptions, theft and, increasingly, via the Internet." To reduce the occurrence of pharmaceutical diversion by doctor shopping and prescription fraud, almost all states have established prescription monitoring programs (PMPs) that facilitate the collection, analysis, and reporting of information regarding pharmaceutical drug prescriptions.

Registration of drug suppliers

21 U.S.C. § 823 of the

provides for registration of manufacturers and distributors of controlled substances. The criteria for registering manufacturers of Schedule I and II drugs are particularly strict and call for "limiting the importation and bulk manufacture of such controlled substances to a number of establishments which can produce an adequate and uninterrupted supply of these substances under adequately competitive conditions for legitimate medical, scientific, research, and industrial purposes." The

Attorney General In most common law jurisdictions, the attorney general (: attorneys general) or attorney-general (AG or Atty.-Gen) is the main legal advisor to the government. In some jurisdictions, attorneys general also have executive responsibility for law enf ...

must make a positive determination that the registration would be "consistent with the public interest." For manufacturers of other drugs, and for drug distributors, the regulations are substantially less strict: "The Attorney General shall register an applicant… unless he determines that the issuance of such registration is inconsistent with the public interest." The criteria for both manufacture and distribution is somewhat biased in favor of established industries, favoring "past experience" and a record of compliance with drug laws The Controlled Substances Act also provides for the registration of medical practitioners (i.e., physicians, dentists, veterinarians, etc.), pharmacies and hospitals that prescribe, administer, or dispense controlled substances directly to patients, as well as individuals conducting approved research involving controlled substances. This category also includes narcotic treatment programs that administer and dispense primarily

methadone Methadone, sold under the brand names Dolophine and Methadose among others, is a synthetic opioid used medically to treat chronic pain and opioid use disorder. Prescribed for daily use, the medicine relieves cravings and opioid withdrawal sym ...

for narcotic addiction treatment.

Examples

This activity can occur in many venues: ''

The Cincinnati Post ''The Cincinnati Post'' was an afternoon daily newspaper published in Cincinnati, Ohio, United States. In Northern Kentucky, it was Product bundling, bundled inside a local edition called ''The Kentucky Post''. The ''Post'' was a founding publi ...

'' has reported on its frequency. John Burke, an expert on the issue, was quoted as saying, "Pharmaceutical diversion is kind of funny because it's going on in every community, but it appears not to exist unless you go after it purposely."

DEA investigation into oxycodone diversion

According to the US Justice Department, in 2011 CVS pharmacies in

Sanford, Florida Sanford is a city and the county seat of Seminole County, Florida, United States. It is located in Central Florida and its population was 61,051 as of the 2020 census. It is part of the Orlando–Kissimmee–Sanford Metropolitan Statistical ...

, ordered enough painkillers to supply a population eight times its size. Sanford has a population of 53,000 but the supply would support 400,000. According to the

Drug Enforcement Administration The Drug Enforcement Administration (DEA) is a Federal law enforcement in the United States, United States federal law enforcement agency under the U.S. Department of Justice tasked with combating illicit Illegal drug trade, drug trafficking a ...

(DEA), in 2010 a single CVS pharmacy in Sanford ordered 1.8 million oxycodone pills, an average of 137,994 pills a month. Other pharmacy customers in

Florida Florida ( ; ) is a U.S. state, state in the Southeastern United States, Southeastern region of the United States. It borders the Gulf of Mexico to the west, Alabama to the northwest, Georgia (U.S. state), Georgia to the north, the Atlantic ...

averaged 5,364 oxycodone pills a month. DEA investigators serving a warrant to a CVS pharmacy in Sanford on October 18, 2011 noted that "approximately every third car that came through the drive-thru lane had prescriptions for oxycodone or hydrocodone." According to the DEA, a pharmacist at that location stated to investigators that "her customers often requested certain brands of oxycodone using street slang," an indicator that the drugs were being diverted and not used for legitimate pain management. In response, CVS in a statement issued February 17 in response to opioid trafficking questions from ''

USA Today ''USA Today'' (often stylized in all caps) is an American daily middle-market newspaper and news broadcasting company. Founded by Al Neuharth in 1980 and launched on September 14, 1982, the newspaper operates from Gannett's corporate headq ...

'' said the company is committed to working with the DEA and had taken "significant actions to ensure appropriate dispensing of painkillers in Florida." In February 2012, Joseph Rannazzisi, chief of the

’s Office of Diversion Control, issued immediate suspension orders against

Cardinal Health Cardinal Health, Inc. is an American multinational health care services company, and the 14th highest revenue generating company in the United States. Headquartered in Dublin, Ohio, the company specializes in the distribution of pharmaceuticals ...

's supply of

to suspected pill mills. Deputy Attorney General James M. Cole then called Rannazzisi to a meeting at Justice Department headquarters where Cole warned him “it made good sense to listen to what Cardinal had to say”. Rannazzisi was fired from the drug diversion office in August 2015. Cardinal was never fined. Cardinal, alongside

McKesson Corporation McKesson Corporation is a publicly traded American company that distributes Medication, pharmaceuticals and provides health information technology, Medical device, medical supplies, and Health administration, health management tools. The company ...

and

AmerisourceBergen Cencora, Inc., formerly known as AmerisourceBergen, is an American drug wholesale company and a contract research organization, that was formed by the merger of Bergen Brunswig and AmeriSource in 2001. It is one of the largest pharmaceutica ...

, spent $13 million lobbying Congress to pass Congressman Tom Marino's "Ensuring Patient Access and Effective Drug Enforcement Act". The bill, which increases the burden of proof enforcers need to show against drug distributors, was signed into law by President

Barack Obama Barack Hussein Obama II (born August 4, 1961) is an American politician who was the 44th president of the United States from 2009 to 2017. A member of the Democratic Party, he was the first African American president in American history. O ...

in April 2016., 114th Cong. (2015).

References

External links

Controlled Substances Act – U.S. Drug Enforcement Administration
{{DEFAULTSORT:Drug Diversion Illegal drug trade Drug control law United States criminal law Medical law

Imprecise, Misleading Definition of "Diversion"

Commonly diverted drugs

Central Nervous System (CNS) Depressants

Registration of drug suppliers

Examples

DEA investigation into oxycodone diversion

See also

References

External links